Dave was one of my two best friends. He lit a wooden kitchen match by striking the match head across the zipper of his pants. That, in itself, was a bold act for the schoolyard. We were in fourth grade and it was forbidden to have matches at school.

He said, looking at the flame, “See, it’s burning once. Right?”

“Yup,” I replied, acting bored.

Dave asked, “Do you want to see me make it burn again?”

“Sure, but I bet you can’t do it,” came my reply.

“Are you really sure you want to see it burn again?”

“C’mon, show me,” I said impatiently.

“Just remember, you asked me to do this. That was once.” He blew out the match. “This is twice.” He then ground the still hot match head into the back of my hand. “See, I made the match burn twice,” he said with an evil-looking grin.

I thought that it had burned three times, actually. The third, and most painful, was the burning confusion in my mind as I tried to figure out how a friend of mine, that I trusted and liked a lot, could trick me, burn me, and then smile about it. Nonetheless, I loved David until the day he died.

Earlier this week, I went to court with a friend of mine; we will call her Stella. I was there for moral support and transportation. She was there because her live-in boyfriend of several years had used her as a punching bag. Unlike the several previous times that he had beat her, that day she pressed charges against him. We went to court so that she could testify about being assaulted.

She hoped he would go to jail. He had done this before to her and others. He had been arrested a number of times for other offenses. In fact, he was already on probation for one of those crimes. Surely, she thought, with that history and the intensity of the beating that she had suffered, he would go to jail.

She had shown me the smashed toilet in her apartment. A big chunk of porcelain lay on the floor. Matter of factly, she told me he broke it when he tried to punch her, as she lay curled up on the floor. Or, maybe it happened when he was kicking her. She couldn’t be sure. In any case, his swing was wild and he missed his mark, hitting the toilet bowl instead. The landlord was going to take the cost of replacing the toilet out of her security deposit, she said blankly.

After the assault, fearing that she had broken ribs and a punctured lung, she went to the hospital. Fortunately, there were no severe injuries. She was badly bruised and in a lot of pain.

Then, torn between the love she had for this man, the sadness that came from knowing the relationship was over, the pain that coursed throughout her injured body, the anger she felt at being abused, and fear that he might hurt her again, she filed charges against him. The police duly arrested him. She eventually went home alone.

Nobody from the police or the court contacted her after she reported that crime. She learned through the man’s family that he would be in court last Monday. She wanted to make sure that she could feel safe again, that he would learn from this episode and not beat her or anybody else in the future. She wanted to testify, in both the legal and religious sense, to all that.

She asked if I could take her to the courthouse. Her car wasn’t running. I asked what time and she said she didn’t know. It was Sunday and there was nobody we could call to find out when the court would be open. I looked on the internet but couldn’t seem to find the information. I suggested we drive by and see if there were hours posted on the door.

“8 – 4:30″ was stenciled on the courthouse door. Back in my car, we agreed that I’d pick her up at 7:30 the next morning. That would get us there when the court opened. If his case was one of the first to be heard, we’d be on time. I drove her home, watched her unlock the front door of the apartment building and then I left.

We got to the parking lot near the court about 15 minutes early on Monday morning. It was cold and windy outside. We waited in the car with the heat running on high. With the windows cracked slightly open, we smoked cigarettes in silence till a few minutes before 8:00. Then we headed to the courthouse.

As the alarm bell sounded, the officer at the metal detector barked at the woman in front of me. “You’re not listening real good this morning.” He had her walk through the machine a second time after she removed her silver bracelets. When she made it through successfully, he turned and said to me, “Keep moving.” Showing him that I am a good listener, I walked into the court building.

I am not a novice when it comes to courthouses. When I was much younger, I wanted to be a lawyer. I volunteered with the RI Public Defenders Office when I was in high school. I worked my way through two graduate school degrees as a litigation assistant at one of the world’s biggest and best-known law firms. I have a good sense of direction and I speak English fluently. I figured that finding the right courtroom would be a breeze.

I was mistaken.

We went to the Information Desk. No one was there. We waited anxiously for five minutes. Still nobody came. One of us suggested that we should look elsewhere.

We roamed the different floors of the building looking for someone or something to show us the way to the right courtroom. On the second floor, there were several rooms with workers behind the counter. They were encased by what I guessed was bulletproof glass. Stella went to the window and waved timidly at some women who were talking to each other at the back of the room. She tried this several times. Though facing in our direction, the women gave no indication that they saw us. Eventually, we moved away.

On one of the other floors, papers were thumb tacked onto corkboard beside the courtroom doors. These were lists of the cases to be heard in each room that day. We scoured the pages. Neither Stella’s name as plaintiff nor her ex-boyfriend’s name as defendant could be found.

There was a column in the middle of the hall. I saw a paper scotch taped to the column. It was a list of the victim resource contact people for each of the counties in the state. I used my cell phone to call the number for Providence County. I asked for the woman named on the paper. I was told that she was probably in room 4F. Stella and I felt a ray of hope and went to 4F.

The room across from 4F had the words “Workers Compensation” in large letters above the door. People bustled in and out of that room. Attorneys negotiated their cases with each other in the hall outside of the Workers Compensation court. Another lawyer called his office and asked what medications so-and-so had been on from July to October.

There was no sign above 4F and nobody was inside that courtroom. We waited until it was clear that we were wasting our time.

We went downstairs once more. This time, a woman was standing behind a window. Above her head, the sign read: “Domestic.” Bingo, we thought. Stella went up and explained her situation. The woman said we needed to go to a different area; she had no information about that case.

We went back to the window where we had first started and waited. About five minutes later, another woman appeared behind the glass. Stella asked where the trial of her ex-boyfriend would be held. She was told we should go to room 4F and wait until 9 a.m. when that court would begin its session.

Into the elevator and back to the fourth floor we went. We sat outside the empty courtroom for a while as a small crowd began to build. At 9:00, one of the sheriffs unlocked the doors. We entered and took a seat.

Eventually, a man and a woman came in and sat at the prosecutor’s table. A woman soon sat at the defense table. The public defender called out a few names. She then went into the hallway with the people she was to defend that morning. The prosecutors continued talking to each other. A woman seated behind me said, with a disgusted tone, “This judge is always late.”

Around 9:15, the judge arrived. After taking her seat behind the bench, the judge began to take attendance. She called out the names of each of the defendants. The list was lengthy and it was not until the very end that she called out Stella’s ex-boyfriend’s name. The court clerk responded that he was “in lock-up.” Finally, we had our first official notification that we were indeed in the right courtroom.

The judge began with a few cases that had “gone formal.” After those were done, there was a break while the judge read off instructions to the defendants in the courtroom. The rest of us were released for the next twenty minutes. The two prosecutors started to walk out toward the hallway.

Stella rushed over to them and introduced herself. The female attorney said that she would talk with her in the hall for a few moments. During that three or four minute conference, Stella gave a brief history of the relationship, the beatings and the man’s criminal history. My friend said that she wanted him incarcerated and was willing to testify. The attorney thanked her for the information and pointed her toward the victim’s advocate, who was about to get on the elevator.

Stella jogged over to the advocate. Introductions were made again. The advocate interrupted Stella’s description of the case and said that she did not need to know the facts. If Stella is called to testify, then the advocate would stand beside her as Stella gave her testimony. The advocate got into the elevator and had no further advice for my friend.

I asked Stella if the prosecutor gave her any idea about what sentence they would seek. Stella sighed and said no. Then she asked me why the advocate said “if” Stella had to testify. She said that was the whole point of being there. In a worried voice, she asked if I thought that they weren’t going to have her testify. I told her I didn’t know what to think. It was all very confusing to me.

We went back into the courtroom. We sat through a couple of hours of mind-numbing procedures. Most people pled nolo contendere to the charges against them. I did learn that the fine for the fourth offense of driving on a suspended license is $450 and a warning not to do it again. I also learned that a plea of guilty or nolo could negatively affect someone’s immigration status. Many times, for no apparent reason, the process seemed to stop abruptly. The judge turned to her day planner. The public defender left the room. The prosecutor reorganized the files on his desk. And on and on it went.

Several times, I looked over at Stella. Sometimes, she was nervously looking at her shoes. Sometimes, she was napping.

Toward the end of the morning session, the sheriff spoke softly into his walkie-talkie and asked that the defendants in lock-up be brought to the courtroom. Some more time passed, slowly, and then four men in restraints entered into the room. The last one in line was Stella’s assailant.

I glanced at Stella and saw tears stream down her face. I looked away quickly. She continued to cry silently. Once in a while, an involuntary sob escaped from her chest. I briefly put my hand on her knee as the only solace I could offer.

Meanwhile, the public defender crouched in front of the now seated prisoners. One by one, in a hushed voice, she talked to them about plea bargains. So much for attorney-client privilege, I thought. After each agreement to a plea, the public defender went back to the prosecutor’s table and told them of the deal. When Stella’s ex said yes to his bargain, the public defender informed the prosecutor. The female prosecutor then called out Stella’s name.

Stella and the prosecutor went out into the hallway to discuss what had just happened. Stella left the court with an expectant smile. She returned to the room about a minute later and she was in tears.

“We don’t have to stay here any longer, Mike. Let’s go.” She gathered her coat from the chair and hurriedly left the court, still crying.

Here is what she told me about the conversation with the prosecutor.

Stella begins explaining that she wants to feel safe, wants him to learn not to do this again and is willing to testify. The prosecutor cuts her off and tells her that he already agreed to a plea bargain. In return, two of the three charges he is facing will be dropped. He will plead guilty or nolo to domestic assault against Stella. The sentence will be one year of probation. If he violates his probation, he will serve a year in jail. The prosecutor informs her that he will behave himself now because he won’t want to violate probation and return to jail.

Stella disagrees and interrupts. She says that this is only a slap on the wrist. He is already on probation with a year to serve. But that certainly did not stop him from beating her. And why isn’t he going to jail for violating that probation? She says that this deal today won’t prevent him from hurting her yet again. Stella, for the last time, says that she is willing to testify.

The prosecutor smiles at Stella. She tells Stella that she is brave but the deal is already done. Stella will not be testifying today; she can leave now if she would like.

Stella says she cried and tried to get the prosecutor to change her mind. But it was useless. Soon the prosecutor turns to go back to the courtroom. As she passes Stella, the prosecutor says that she will be sure to tell the judge that Stella was very cooperative.

Stella thinks this was a crazy thing to say. Cooperative? What? Stella says she is the victim, not the defendant. Why would the prosecutor tell the judge that Stella was very cooperative?

She had many other questions. She asked me why she could not talk to the judge. Why is he going to be released? How can she be safe now? Why don’t they care that she was beaten? She was the victim, why didn’t her vote about his sentence count? There were many questions. Not one of which could I answer.

The ex-boyfriend did not know that matches can burn more than once. I had met him once before. The subject of hitting Stella came up. He said sometimes Stella acted like a fucking bitch and deserved it. He would stop hitting her when she stopped acting like a fucking bitch. It was just that simple.

I suggested that it was his duty to keep the woman whom he loved safe. He told me that he had been to war. Stella, he asserted, did not know shit about fear and not being safe. You only learned that in war.

I said that he still did not get it. War, the horror that it is, was not the same as what he did to Stella. It would only be the same if, the night before, he had made love with the people trying to kill him the next day.

He looked at me as if I was an ignorant, arrogant asshole.

Nope, matches burn once and only once for him.

As Stella continued to ask me questions, I wondered who taught that prosecutor how to make matches burn twice. The whole experience at court last Monday showed me that everybody there-from the officer at the metal detector to the missing worker at the information desk to the public defender and the prosecutors and the judge-knows that trick. They are experts, in fact.

The brutal assault was the first burn, the fact that it came from her lover was another burn, and the failure of the court to protect and serve her was yet one more burn. And that is how you make a victim suffer more than once from the same crime.

A couple of days after I wrote the above, I coincidentally learned a few things that might throw some light on the outcome in my friend’s case.

Rhode Island, like many other states, is facing a huge budget problem. One of the ways that RI is trying to cut costs is to decrease the number of inmates in the prisons. The Adult Correctional Institution for men has reduced its capacity by 100 and closed three units. In addition, recent changes in the law allow for reducing the time spent in jail. All prisoners who are able to go thirty days without incident get ten days off their sentence. In addition, evidently, there is a push to minimize the number of people sentenced to jail time.

The Providence Journal, it turns out, had a recent article on this. They reported that: “It has alleviated the strain on our operational system caused by overcrowding, saved taxpayer money and makes good overall correctional sense,” (corrections Director A.T.) Wall said of the earned-time changes in his introduction to the 2009 report. “As I write this, our inmate census is in the 3,500s, after hitting an all-time high of 4,000 just two years ago.”

That is a 12.5 percent decrease in the number of prisoners in two years.

Whether or not this makes good social policy, I do not know. However, I am sure that it would have helped Stella to know some of the larger reasons behind the plea bargain, why it was unnecessary for her to testify and why her assailant was not given a jail sentence. Instead, the short shrift that she was given led her to consider the wisdom of pressing charges, how much society valued her, and other disturbing puzzles.

A few moments of explanation by the victim advocate, the prosecutor or even the judge would have gone a long way to minimizing the re-injury she experienced in the court that day. Instead, they let the match burn deeper.

When I was 15, I played on my school’s soccer team. I had only average skills. Nevertheless, I loved the game.

That year, the school’s girl’s athletic association invited the boys on sports teams to a roller-skating party. I didn’t have a girlfriend at the time. It sucks to be 15 and not have a girlfriend. The roller-skating party seemed like a good chance to try to impress one of the girls.

As the party drew closer, it assumed more and more importance for me. I was pretty good at roller-skating and thought the party was a good place to show off. By the night of the party, I was excited and anxious.

For reasons I no longer remember, my parents were less enthusiastic about me going to the party. I recall a lot of bargaining on my part. They relented and drove me to the roller-skating rink.

By the time I got there, many of the other boys and girls were already skating. I quickly rented a pair of skates, put them on, and headed to the rink. After three steps, I fell backward.

It hurt, a lot. I had never before broken a bone. However, as I lay on the floor I knew with a clear certainty that I had broken my right wrist. Embarrassment and shame competed with pain for first place in my head.

Cautiously but quickly, I got up and headed for the snack bar. It was important that I try to get out of there with as little fanfare as possible. I asked the woman behind the snack bar for ice. She didn’t have any. She gave me a cup of soda and suggested that I put that on my arm. The woman did have a phone, though. I called my parents and asked them to pick me up really fast. They were on the way out to a party and were frustrated that they had to cancel their plans.

I removed my skates with my left hand and returned them for my sneakers. I waited for my parents in a corner by the snack bar. My right arm was on the counter, the now warm cup of soda pressed up against my wrist. Just stand here and try not to let anyone notice you, I thought to myself.

Jenny, a long time friend, skated up behind me and playfully hip checked me against the counter. My right arm was pushed into the cash register. What was a barely tolerable, throbbing pain became a shrieking lightning bolt of agony.

Trying to remain cool, I told Jenny that my arm was busted and that she was hurting me. There, my secret was out. Damn. Jenny was good about it. She apologized for hurting me and asked if she could help me.

Just then, my parents arrived. I said good-bye to Jenny and quickly left with my parents. My arm hurt like hell. I wanted to stop somewhere, anywhere and buy ice. My parents thought it would be best to get to the hospital first and get ice there.

In the emergency room, I tried to hold on to my tattered dignity. The nurses and doctors were nice. I tried to be polite and to wait patiently. My arm was eventually x-rayed. Even I could make out the fracture of my right wrist in the x-ray. The doctor said that the fracture needed to be set before putting on a cast.

I never liked getting an injection. Nonetheless, the nurse brought the doctor a tray of syringes and Novocain. My teeth clenched as he injected the anesthetic into several spots around the fracture. The doctor said that it would take a few minutes for the stuff to work. He’d come back in 10 minutes to set the fracture and give me a cast.

My parents were in the exam room with me. We spoke idly until the doctor’s return. My pain was lessening but my fear of “setting the bone” grew. I didn’t know what that meant. However, I did know that I didn’t want anybody to touch my wrist.

The doctor came back. I put on my brave face and said that I was ready. He took my wrist in his hands and squeezed.

The polite and somewhat preppy boy on the exam table suddenly became something out of The Exorcist. My parents were strict about swearing. So, of course, behind their backs I had mastered that art. At the top of my voice, I put together the crudest string of words I could muster. If I could have spun my head around 360 degrees and then hurled projectile vomit into the doctor’s face, I would have.

The tone in the small room changed dramatically. It seems that doctors don’t appreciate being cursed out. He told the nurse to take my parents to the waiting room. I got scared again.

A second nurse unbuckled my belt and pants and told me to roll over. I heard the doctor ask the nurse for Demerol. Great, another shot. This time in the butt. I was grateful that the pain in my arm was now so intense because I did not even notice the next injection.

The doctor and nurse left the exam room and told me they would be back soon.

In what seemed to be a remarkably short time, I started to feel good; very good. There was no pain in my arm. All my anxiety and fear left me. Being in that exam room was quite nice. The colors and lights seemed warm, embracing. I smiled. Who cared if I fell and busted my arm in front of every pretty girl jock in my school? Who needed a girlfriend anyway? I was happy. It was good to have a broken wrist and Demerol coursing through the bloodstream.

By the time the doctor returned, I was high. Flying. The doctor set the bone quickly. The warmth of the ace bandage soaked in plaster was soothing as the doctor wrapped my hand, wrist and forearm. He could have done anything at that point. My hatred of the doctor from a few moments ago now was a warm friendship. Just as long as he kept the Demerol flowing.

I don’t remember much about the ride home. I do recall feeling at peace with the world. That night, sleep came easily. The next day, the Demerol was gone and my physical and emotional pains returned.

All these years later, this memory is what I turn to when I begin to lose empathy for any of my patients who have addiction problems. A drug, Demerol in my case, had taken me to a fine and great place. It evaporated all my pains, physical and emotional. The experience was effortless. I knew for the first time that a drug could change every aspect of how I thought and felt. Bliss was only an injection away.

Just as I instantly knew that my arm was broken, I knew immediately after the Demerol that I could be an addict. No matter what else I did in my teens and twenties, I never went close to an opioid.

In my thirties, I severely herniated the disc between C5 and C6. The pain was nauseating. I slept sitting in a chair for six months because I could not tolerate the pain when I lay down. My doctor asked if I wanted something for pain. Due to the intensity of the pain and the length of time before physical therapy was completed, he explained, there was a good chance that I’d become dependent upon a narcotic. He said that over the course of several months, I’d gain tolerance to the drug and he would have to increase the dose to get the same effect. In the end, I’d have to go through withdrawal. I remembered the sweet rapture of Demerol and said no thanks.

Very, very easily, at any point along the way, I could have made a different decision about opioids and me. I just think I was lucky. After the Demerol, I was acutely aware of my vulnerability to the drug. The place that Demerol took me to was seductive and intoxicating. It scared me. It still scares me.

It could be me on the couch in somebody’s office talking about my urges and cravings; how the drugs take everything away, even if for only one night. However, I had fear of losing myself in the drugs. And I am just lucky. With any small shift in fate, I could have made an impulsive decision and ultimately wound up in somebody’s office, a jail cell or a grave. A number of my friends and some relatives have traveled those other lonely and tragic paths.

These are some of the thoughts help me recover my rapport with the patient and get back into the therapeutic alliance.

Out of the corner of my eye, I saw a neatly dressed, cute, young black girl walking toward me. She was maybe 8 or 9 years old. I didn’t recognize her and wondered why she was looking at me.

She walked right up to me. In a clear, matter-of-fact voice, she said “You’re the man who grabbed me and held me on the floor at the hospital!”

It felt like everything stopped in the bakery and all eyes turned on me.

The girl was right, of course. I remembered her as soon as she said that I had restrained her. Her statement was a fair representation of what had happened.

That didn’t help my situation much. A pretty, young girl, with no malice, had just introduced me to the patrons and staff of the bakery as the man who grabbed her and held her down on the floor.

My hair is long and runs 3/4 of the way down my back. That morning, I was in a rush. I hadn’t taken the time to put my hair into a ponytail. I was in the process of renovating my house and was dressed in torn sweat pants and a grungy t-shirt. I was unshaven and sweating in the heat of the day. In short, I looked pretty much like a mess. That day I was more interested in running errands and working on the house than in making good first impressions.

Given what the girl said to me and my appearance, I couldn’t really blame anybody in the bakery if they thought I was a dangerous creep.

I squatted down a bit to get more towards eye-level with the girl. I asked her how she was since the last time we met. She told me that she felt a little happier. I asked if the hospital had helped her and she said not really. I said that I was glad to see her and hoped that things got better for her. We spoke for a few more moments.

By then it was my turn to order. I got a coke and a calzone. I got it to go instead of eating at one of their tables.

Let me offer a little bit of history. I worked in a psychiatric hospital for about 15 years and much of that was spent in the emergency room, or patient assessment service as it is now called. This girl was brought in for an evaluation. I did the initial assessment of her. At the end, she asked me if I thought she needed to be there. I said that I thought the hospital could help her. She did not like that response and tried to elope from the evaluation room. The room that we were in had doors that opened to a hallway and to the ambulance entrance. To stop her, I restrained her until other staff came and helped.

The girl was quickly admitted to the hospital and I did not see her again until maybe a year later in the bakery.

As part of my duties at that hospital and in various other of my jobs, I have been in more restraints than I can now count. While not commonplace, restraints happened with regularity. Usually, I did not think much about them afterward. To my knowledge, none of people I restrained was ever physically injured. I got hurt only twice. Except for those two instances, I didn’t see much point in thinking about the restraints after they were over. Although I will admit that for years, I watched my rearview mirror on the drive home, sat facing the entrance in restaurants, and took similar precautions. A fair number of people that I restrained or was involved in involuntarily hospitalizing made threats about what they planned to do once they left the hospital.

Clearly, this girl had a different attitude about the restraint. She was frightened, in a strange place against her will. The hospital was filled with strangers and she only wanted to go home. I physically stopped her from that. I can’t say for sure, but I believe it was the first time any professional had ever restrained her. So, for her, the event was unique, novel and wholly unwanted.

And that’s how she remembered me. I was the guy who grabbed her and held her on the floor in the hospital. She wasn’t angry with me. I don’t think she held a grudge because we chatted fairly easily for a few moments in the bakery. Yet it seems fair to say that she didn’t think I was a nice person.

She did not remember me as the clinician who spent an hour gently talking with her about her life. For her, I was not the man who suggested that the hospital could keep her safe and help her to feel better. Her memory of me was not one of jointly finding her strengths and trying to build her sense of self-confidence and optimism. All that is, however, what I remember of the time we spent together in the hospital’s ER.

In the bakery, I was in a strange place filled with strangers. She seemed quite at ease there. Maybe she lived in the neighborhood. I guessed so at the time because she was not accompanied by an adult. When she said that I had grabbed her, I felt ashamed, embarrassed and afraid. I did not know how the other people in the bakery would react. I feared a scene or worse. In addition, I felt badly because she seemed not to understand my situation in the bakery or at the hospital. I greatly wanted to turn and run out of there.

All in all, this was a very neat reversal of positions, courtesy of fate.

A number of years ago, the hospital made a policy that all restraints are reviewed with the patients once they become safe. But that could be done by staff that were on a different shift and had only second hand information about the restraint. I never reviewed that restraint with the young girl. She was sent to the children’s unit and I assume staff went over the event with her some time later. However, only she and I knew firsthand what happened in the room. Just the two of us knew the emotional bond that formed during the hour-long evaluation and was ruptured by the restraint.

Her memory of me remained as the guy who grabbed her and put her on the floor.

As I say, I left the hospital several years ago. I have no knowledge of their current policies on helping patients process being restrained. Perhaps they have included at least one of the staff actually in the restraint into the review with the patient. That would be a good thing, I think.

Why does this memory surface again now? There is no chance that I am aware of that I’ll be in a restraint any time soon. I don’t think it’s because it’s a similarly hot and humid day in early Fall. I do know that I am about to use a different type of coercion with a current patient. That’s something that I don’t like to do at all. However, I can’t come up with another option to keep him safe. Perhaps this memory has come to try to help me see my plan from his perspective. Alternatively, maybe I’ve been in a position of power with somebody else recently and pushed it too quickly out of awareness. Whatever event that was, the memory could be prompting me to pay more attention to it.

I’m not sure at the moment.

Today, I will start to explain the difference between an anaclitic depression and anxiety guarding against a depressive episode. We will open with a beginner’s introduction to object relations theory.

For this post, it’s not necessary to have read the previous posts. If you’d like, you can read the fifth post for a bit of background. However, again, that is not a requirement for understanding this post.

To understand anaclitic depressions, it is quite helpful to know a bit about object relations theory.

Right from the start, let me acknowledge that I have difficulty writing about object relations theory in a simple, conversational style. For me, it is like conveying the experience of a warm sunny day while using the language of quantum field theory. Nevertheless, if we are to explore how anaclitic depression may relate to anxiety as a defense against depression, then we need some object relations theory.

To try to save us all some hardship with this topic, I will use a metaphor. Granted this metaphor is limited. For a more technical and historical explanation of object relations theory, you can start with a nice review by Sam Vaknin, Ph.D. Scroll down the page a bit and start at “XV. Narcissism and Schizoid Disorders – Melanie Klein.” For further information, you can also read Wikipedia’s entry for object relations theory and Victor Daniel’s website.

Imagine a large amphitheatre. On the stage is Robert. More accurately, Robert’s ego is on the stage. Behind him, instead of scenery and curtains, is the real world where he interacts with other real people. In front of him, the seats are occupied by all of the people with whom he has had significant experiences in the past. These are not the actual persons but are his representations of them. For example, his first grade teacher actually may have cared deeply for him and been a good teacher. However, in Robert’s experience, she was scary and hard to please. Therefore, his representation of her is frightening. This audience consists of the memories of his life.

To his left are the warm, loving people. It is from them that Robert gets self-soothing, guidance, support, etc. In the center are neutral figures. On the right is where the harsh, critical, angry and destructive persons sit.

To complicate things a bit more, the same person can have multiple representations. Robert’s mother can be seated on the left based on the time when she calmed him after a nightmare. But she can also occupy a seat on the right. This would be an unintegrated memory of the time that she wrongly accused him of a theft and punished him unjustly.

Depending on what is happening between Robert and the real world, the audience can shift. Some people will move their seat to the other side, some stay where they are, some may even leave the theater.

In a reciprocal fashion, and this is important, how the audience is arranged in the seats influences the way that Robert interacts with the real world and stores new memories of his experience.

Sometimes the audience is polite and accepting. They don’t interrupt Robert. They wait for him to address them or to recall them in memory. Consider this as a Zen moment. His object relations are in alignment with his experience of the world and criticism is suspended.

Other times, the audience can be intrusive. Out of the blue, a rotten tomato is thrown at Robert’s head. A torrent of unexpectedly harsh criticisms of his performance interrupts his dealings with the real world. Or, perhaps, a gentle, soothing sense of acceptance and love sweeps over him as he reads a novel late at night.

On still other occasions, the audience may start arguing among themselves.

Now the members of the audience may not all be exactly human. Granted, the most advanced of them look completely human. These patrons are well known to Robert and he sees them as reliable and fairly predictable. He has known them through good times and bad. Robert knows these patrons well. He sees them as reliable and fairly predictable.

Some in the audience look only mostly human. Their features are somehow not quite fully developed. Robert only knows one side of them. This part of the crowd can be confusing and unpredictable to Robert.

Then we have gooey, blob-like creatures. They are the least advanced persons in attendance. These are the raw, primitive introjects. Some are scarier than Frankenstein. Others are purely and exquisitely pleasurable and intoxicating. Even the gratifying blobs can be dangerous, though. There is a threat that they can consume you in their gooeyness. (Think of the allure of an urge to regress back to being a coddled, dependent child in times of high conflict.)

In our metaphor, the more psychologically advanced a person becomes, then the more that the audience will look fully human. It is likely that the psychologically mature person will not have multiple representations of significant persons. Instead, the mature person will have integrated the various experiences with, say, his mother into a coherent whole.

If Robert regresses or if a person is psychologically immature, then the audience begins to look more like the gooey blobs. There will be multiple representations of the same person, split off from each other. The blobs can unexpectedly shift positions depending on what is happening either in the real world or in the audience itself.

This should be adequate for our current purposes. There are many elements left out of this metaphor. For instance, I did not mention the drives interacting with the audience. Nor did I get into how object relations mesh with the various structures of the mind, e.g., the superego or the id. (Hints: gooey blobs are raw expressions of the drives in the id, but some might also be in the superego, and usually they are part object (as opposed to whole object) representations. Well-formed humans are in the superego or ego ideal. The left side is fueled by the libido and the right side is powered by the aggressive drive. Those in the middle either are decathected or are unrelated to the current experience with the world.) As I said, this stuff gets complicated fast. For now, we’ll leave this metaphor as it stands.

For quick reference, I made a pictorial representation of this metaphor. You can view it here.

We will now briefly leave object relations theory. In the next post, I will move on to anaclitic depressions.

Julia and Robert have come to my office. We are discussing their desire to elope.

I’ve just asked Julia if there is any way that her parents would agree to delay her return to their home island in Portugal.

Julia: I tried to get my father to delay my trip. He went crazy on me. This is exactly what he said: “You’re going to São Miguel. And if you don’t go on your own, I’ll drag you there. You disgust me, you little bug! You worthless girl!”

I cried and cried. I said, “Father, I’m begging you on my knees, be patient and listen to me say just one thing.”

He just wouldn’t listen. He went on and on. “Forget about you, you worthless girl! You disobedient wretch! I’ll tell you what. Go to the airport on Thursday or never look me in the face again. Don’t say anything. Don’t reply. Don’t talk back to me.

“I feel like slapping you. Wife, we were cursed when we had her. She disgusts me!”

My mother and my assistant tried to help me. It was useless. The longer he yelled, the angrier he got. His last words to me were:

“If you don’t act like my daughter, you can beg, starve, and die in the streets. I swear on my soul, I will never take you back or do anything for you. Believe me. Think about it. I won’t break this promise.”

Then my father stormed out of the room.

Me: What did you do then?

Julia: I begged my mother and my assistant for help. I said, “Mother, don’t throw me out! Delay this trip for a month. Or, if you don’t delay, make my travel plans to my grave.”

Me: Did you mean that? Do you want to die instead of returning to São Miguel?

Julia: Yes, of course I mean it! How can I marry Robert if that happens? I’d rather die than live without him! If everything else fails, at least I have the power to take my own life.

Me: But what if they insist that you leave on Thursday or get thrown out of the house?

Julia: I have a plan for that.

Me: Can you share your plan with me?

Julia: Well, it’s not really my plan. I went to the parish priest after the fight with my parents. He’s from the islands and I thought he might have a solution for me.

Me: What did you say to him?

Julia: I said, if you who are so wise can’t help, please be kind enough to call my solution wise. Then, I showed him my knife. I told him, I’ll solve the problem now with this knife. Love joined my heart to Robert’s. Before I go to São Miguel and am married to another man, I’ll kill myself. You are wise and you have so much experience. Give me some advice. I want to die if what you say isn’t the solution to how I can be with Robert.

Me: What was his plan?

Julia: This is what he told me to do. He said:

“Tomorrow night make sure that you are alone. When you’re in bed, take this vial, mix its contents with liquor, and drink. Then a cold, sleep-inducing drug will run through your veins, and your pulse will stop. Your flesh will be cold, and you’ll stop breathing. The red in your lips and your cheeks will turn pale, and your eyes will shut. It will seem like you’re dead. You won’t be able to move, and your body will be stiff like a corpse. You’ll remain in this deathlike state for forty-two hours, and then you’ll wake up as if from a pleasant sleep.

“Now, when your father comes to get you out of bed on Thursday morning, you’ll seem dead. Then, as tradition demands, you’ll be dressed up in your best clothes, put in an open coffin, and carried to the church. Meanwhile, Robert will come here, and we’ll keep a watch for when you wake up. Then we’ll seal the coffin and nobody will be know that you’re not in it. That night, Robert will take you away to New York City. This plan will free you from your shameful situation as long as you don’t change your mind, or become scared like a silly woman and ruin your brave effort.”

Me: (I look at Robert) You know about this plan? What do you think?

Robert: I trust the priest. We’ve both known him forever. If this is what he thinks is best, then I’m willing to try.

Me: But suppose the medicine is too strong? Suppose Julia doesn’t wake up from the coma or suppose that she dies instead?

Robert and Julia together: It will work.

Me: But the priest is not a doctor. Suppose something goes wrong. Robert, how would you feel if something bad happened to Julia?

Robert: Well, I’d be the one to find her. So I’d just drink the same poison, and kiss Julia good-bye. That way I’d die with a kiss.

There’s no other way. Either we do what the priest suggests or she leaves the country next Thursday.

Me: (to Julia) You know about his plan to suicide if you die? Do you approve of it?

Julia: I wouldn’t say that I “approve” but I can understand it. I’m not worried, I’m not going to die so he won’t have to either.

Me: Suppose we try to come up with a different plan. If we could find one, would you agree not to take the priest’s advice?

Robert: For me, I’m in favor of our plan. We’ve already discussed it. We both think it’s our only option and that it will work. No offense, but I trust my priest more than I trust you.

Me: Julia, what do you think?

Julia: I agree with Robert.

Me: Julia, you mentioned your assistant. She seems to know about your situation. What does she say?

Julia: Well, she was helpful in the beginning. But then she agreed with my parents. She said, “Since things are the way they are, I think the best thing to do is leave for São Miguel.”

Me: So you don’t think that she could help us come up with an alternative to your plan?

Julia: No.

Me: There’s nothing, then, that can replace your current plan?

Julia: No.

Robert: Can’t think of anything.

Me: Well, to be honest, this plan makes me nervous. It sounds too close to a suicide pact. Or that’s what could happen, anyway, if even the smallest thing goes wrong.

Robert: (talking over me) Well, it’s our only way to be together and we’re both willing to take the risk.

Me: Oh, gee, I forgot to tell my receptionist something. I’m really sorry but I need to step out for a second. I’ll be right back.

I go to the receptionist and ask her to call 911 for me. I tell her that the couple has a suicide pact and needs to go to the hospital for evaluation.

When I go back into the room, I going to explain what I’ve just done. Both of them are very angry. They threaten to bolt from the office. I explain that the police will be here before they get to the street. I also explain my rationale for calling the police and rescue. Their pact was too dangerous. My duty is to preserve their health and well-being. Therefore, I had to call the police. I offer to continue treatment after they are safe and stabilized.

Julia breaks into uncontrollable sobs. They make all sorts of objections and threaten to sue me for violating their confidentiality.

After a few more minutes, there is a knock on my door and the rescue team comes into my office.

It will surprise no one that I am not as bright as Shakespeare. Try as I would, I could not resolve the dilemma that Shakespeare created for Romeo and Juliet with a smooth therapeutic move. Just as in the play, the resolution could only come from drastic measures.

The Chorus tells us this in the opening Prologue: “For the next two hours, we will watch the story of their doomed love and their parents’ anger, which nothing but the children’s deaths could stop.”

This was not my intended treatment outcome. However, I have no alternative. I tried several versions of this post. I used every way that I could think of to solve their dilemma without involuntary hospitalization. None of it, though, rang true to the situation or the dialogue from Romeo and Juliet.

Their circumstances are too acute and progressed. Neither of them, in my opinion, can be trusted not to act on their plan. They might even devise a more risky, impulsive course.

As Robert says, they trust the priest more than me. Our therapeutic alliance is in its nascent stage and still weak. Their thinking is concrete and action-oriented. Interpretations of their situation and plan do no good in this case. For instance, I might try to point out to Julia that her plan has at least as much to do with parental rejection as it does with love for Robert. She plans to do to herself what her father threatened. Instead of his threat that she “beg, starve, and die in the streets,” she was planning a death in her own bed. Julia would laugh at me for that interpretation. The therapy has not progressed to the point where she could use such an explanation.

Furthermore, even on a more concrete plane, they reject my offer to help problem-solve and find other options.

Neither of them can identify a trustworthy external support. That is, of course, except for their parish priest. And he designed the plan to enter a drug-induced coma.

I have found few internal resources that either of them has to self-sooth or to improve their judgement and insight. They are both overwhelmed.

Their anxiety is fueled by a fear of losing one another. Additionally, for Robert, the fear of a return to deep depression is intense. The anxiety is propelling them toward ever more dangerous and hastily conceived actions.

Even though their plan stems from anxiety and is in itself intensely anxiety provoking, it keeps their hope alive. Seeing their plan as foolhardy would leave them without hope. And that would place them on the threshold of depression. So, rather than see the reality of their situation and cope with it accordingly, they lunge into anxiety and near irrationality.

I do not want to give the impression that all cases of anxiety guarding against depression lead to such an outcome. Recall Donovan Campbell; he certainly did not meet the criteria for psychiatric hospitalization.

Hospitalization could go either way for Robert and Julia. It might make them more emotionally and cognitively available for treatment. Or, they may lose their trust in therapists and shun any further therapy. At the least, the families will find out about their plans to wed. Any immediate repercussions of that can be handled in the safety of the hospital.

If any readers can suggest a viable alternative to involuntary hospitalization, I’d be appreciative.

I want again to acknowledge that the overwhelming majority of the dialogue for Robert and Julia comes verbatim from No Fear Shakespeare’s modern translation of Romeo and Juliet.

As a refresher, this is a “case study” of Robert. He is a single male in his early twenties. Robert was recently in a Major Depressive episode and now presents with anxiety. The precipitant to the depression was Robert’s unrequited love for a woman. The anxiety came in the context of falling in love at first sight with a second woman. Robert is seeking treatment to help him plan an elopement with the second woman, Julia.

Robert’s situation is a mess. For the past two days, Robert has acted impulsively. He was not using good judgement or insight. Julia has plans to return to São Miguel, a Portuguese island, and may marry a man there. Both Robert’s and Julia’s families intensely dislike each other. None of their parents would approve of the marriage. Further, Robert is at high risk for a relapse back into Major Depression. Ominously, Robert says that he would rather kill himself than live without Julia. However, today there is no inclination to suicide and he anxiously anticipates happy days in the near future.

We are still in Robert’s initial evaluation. I am about to present him with treatment options. In the last post, I ruled out offering him help in problem solving his elopement.

There is possibly another way to meet Robert’s request for a speedy resolution to his anxiety symptoms and improving his ability to plan the elopement. That would be a referral for a psychiatric medication evaluation.

I could suggest to Robert that he see a psychiatrist. He can ask about medication for the anxiety and the depression. An anxiolytic might provide relief from most of the anxiety symptoms within a half-hour of ingesting it. Freed of the anxiety, he could think more clearly. Robert could then probably figure out for himself how to marry Julia. The anti-depressant, on the other hand, would take 4 to 6 weeks before having an effect.

Perhaps, though, the anxiety serves more masters than we have seen so far. Symptoms can have a pig pile of underlying motivations. More formally stated, Robert’s anxiety might be overdetermined. That is, the ego is trying to satisfy a number of demands on it through the one symptom of anxiety. We have already seen that Robert’s anxiety is a defense against a return to depression and the possibility that time and events (e.g., Julia’s return to São Miguel) would prevent him from marrying the woman he loves. Let’s see if there might be other factors in his anxiety.

Robert says that he is anxious in large measure because he wants to be married as quickly as possible. He can then be with the woman he loves. He says that he wants it so badly that he cannot think straight. However, one potential subconscious purpose that the anxiety may serve is exactly the effect it is wreaking. Maybe one point of the anxiety is specifically to disrupt or prevent Robert’s elopement.

There are many reasons why Robert might subconsciously use anxiety to derail his marriage plans.

In Freud’s “The Ego and the Id,” he writes “…the ego seeks to bring the influence of the external world to bear upon the id and its tendencies, and endeavors to substitute the reality principle for the pleasure principle which reigns unrestrictedly in the id.” The reality confronting Robert stands directly opposed to marrying Julia. Robert is aware of this. His desire to elude reality accounts for some large measure of his haste to wed. Robert’s ego could use the anxiety as a means to bring reality to bear on his impulses.

Furthermore, the marriage would bring parental disapproval and rejection. The anticipation of this disapproval and rejection may cause some anxiety. He can also anticipate his own guilt feelings about breaking their rules. Expecting guilt in the future produces anxiety as well.

Freud puts it this way in “The Ego and the Id:”

“As a child grows up, the role of father is carried on by teachers and others in authority; their injunctions and prohibitions remain powerful in the ego ideal and continue, in the form of conscience, to exercise moral censorship. The tension between the demands of conscience [what Robert knows he ought to do in the eyes of his parents and society] and the actual performances of the ego [Robert's scheme to marry Julia without his parents' blessing or knowledge] is experienced as a sense of guilt.”

After all, his parents do seem concerned about him and love him. His father has said: “If we could only find out why he’s sad, we’d be as eager to help him as we were to learn the reason for his sadness.” (Act 1, Scene 1, Page 8 ) His mother also expressed concern for him: “Oh, where’s [Robert]? Have you seen him today? I’m glad he wasn’t here for this fight.”(Act 1, Scene 1, Page 7) We can reasonably assume that hurting his parents would cause guilt for Robert. Therefore, the anxiety would be protecting him against hurting his parents and the guilt that he would experience for bringing suffering to them.

We could hypothesize a number of other subconscious uses for the anxiety. But we’ll leave it here for the time being.

There are many instances where it is desirable to remove or reduce severe anxiety as quickly as possible. In those cases, anxiolytic medications are very useful. I think, though, that Robert is better off without the immediate introduction of medications. Removing the anxiety removes some of the emotional barriers to carrying out his impulse-ridden plans. That is, in my judgement, it is in Robert’s best interests not to elope in the next few days.

Getting some Klonopin or Xanax or another anxiolytic today would be roughly the same as helping him problem solve the marriage today. For the same reasons I ruled out helping him problem solve the elopement, and the reasons mentioned here, I would not want him to get the medicines now.

Some bad situations have unseen benefits. In Rhode Island, the state where I practice, it takes about six to eight weeks for a new patient to get in to see a psychiatrist. Usually that is thoroughly undesirable. But not this time. Such a lengthy wait means that I can refer Robert to a psychiatrist today. However, he won’t get an appointment any time soon. That, in this case, is a good thing. It will buy some time to work through the complexities of his crisis.

Now I can tell Robert his diagnosis: Panic Disorder without Agoraphobia. I provide him with some information about this illness. In addition, I give him the names and phone numbers of several psychiatrists.

I then have to tell him to expect about a two-month delay before he can get an appointment.

Obviously, Robert does not like this recommendation. He sees time as an enemy. Two months is far too long to delay his elopement. For one thing, Julia will be out of the country by then. There will be no wedding if that happens. Depression lurks there.

Honestly, I agree with Robert. Two months is too long to wait for a remedy to his problems. He is in a lot of emotional pain and turmoil. I also agree that the situation is complex. It needs to be broken down into its component elements and sorted out. Moreover, there is another person involved, Julia. And in her, I find an option that might satisfy everyone.

I suggest to Robert that we schedule another appointment, as soon as can be arranged. If I get a cancellation, the appointment can be as soon as tomorrow.

I also propose that he bring Julia to the next appointment. We can get her point of view. After all, it is her elopement/wedding, too. At the least, a couples session would give the two of them a chance to look rationally at their situation and to get to know one another better.

In the short-term, my goal is going to try to find an alternative to an abrupt elopement. Perhaps Julia can defer her trip to Portugal. Or maybe between the two of them, they can identify the parent or another authority figure who is most likely to be sympathetic to their situation. We could then try to enlist that person as an ally to the couple. Potentially, that third person could come in at the third session. At this point, I am not sure what assistance Julia can be. But starting couples counseling is the best option I can think of at this point.

In the long-term, I want to provide Robert with treatment to address his vulnerability to both depression and anxiety. Providing successful short-term couples counseling around the elopement may be the best way to engage him in therapy.

In the next post, I plan to take a brief look at another possible explanation of Robert’s anxiety: adult anaclitic depression.