Dear Respected One

Carlos pulled his dark blue suit out of the suitcase where it had been since the day after his father's funeral. He shook it out, examined it for holes and stains, and found it to be in great condition. The mice that had eaten whole chunks out of his sweaters during the summer had not made their way to the suitcase, and he wondered if it was the moth balls that had kept the mice away. The suit smelled strongly of camphor and Carlos considered hanging it somewhere to air out, but he didn't really know where in his Brooklyn apartment there would be good enough ventilation, and in the end he decided that it didn't matter. He didn't want to waste any more time.

He dressed quickly. White shirt, red tie, the blue suit. The shirt collar was yellowish and turned up at the corners, but all the stains were well covered by the jacket and the tie. He could not find any dress socks and did not own any dress shoes so he wore his white sneakers instead. He pulled his hair into a ponytail and shaved carefully around his moustache. He could have used a shower but doused himself with after shave instead.

Before heading out he checked his emails one more time. His heart jumped when he saw that there was a new email from Mr. M., but he did not open it. Instead, he checked again his black nylon shoulder bag to make sure he had packed the folder with the printouts of all the other emails. And yes, there it was, with all 20 pages of his correspondence with Mr. M. He grabbed the shoulder bag, put his Yankees cap on, and headed out.

The trip was short and uneventful, and Carlos arrived at the Nigerian Consulate in under an hour. He walked to the building and was stopped by a security guard at the door. "I need to see the Consul" said Carlos.

"Do you have an appointment?"

"No, but it's a very urgent matter".

The guard took a step back and looked at him carefully. "What is this matter you are speaking of?"

"I cannot tell you! I will only speak to the Consul about it."

"Can I see your identification please".

He rummaged through his bag and took out his Uruguayan passport, his American Citizenship certificate, his Medicaid card and his Senior Center ID. He handed them over to the security guard. His hands trembled a bit.

"Um...Mr...Gomez? Thank you. I will now have to ask you to wait out here while I consult with our head of security inside"

"But why? I told you I need to see the Consul!"

"Well, Mr. Gomez, Sir, this is the Nigerian Consulate and generally Nigerian nationals come here, by appointment, to renew their passports or file important paperwork. You are not Nigerian, and will not declare the reason for your presence here, so..."

The security guard stepped inside without finishing his sentence. Another guard came to replace him. Carlos took out his cellphone and checked his missed calls just to keep himself busy. The new security guard was humming some unrecognizable song. Finally the first one returned and told him that he could not, under any circumstances, see the Consul.

Carlos was not pleased. "I will not move from here until I do", he said, and planted himself firmly on his legs, feet apart, hands on his hips. "Call the cops if you want, I will not move".

The security guards exchanged a look and said something in a foreign language. The second guard snickered, then went back inside.

Carlos stood in front of the door. The guard asked him again to leave, and he continued to refuse. His stomach growled. The guard's walkie-talkie buzzed, and after a short exchange he sighed and said "All right, Mr. Gomez, it looks like our Consul can see you after all. Please come this way."

The Consul was surprisingly young. He extended his hand and greeted Carlos with a smile, asked him to sit down. Carlos did not sit down. Instead, he paced back and forth in front of the Consul's desk, and said the speech he had prepared.

"A Nigerian national owes me a substantial sum of money, which I have come to legally, and he will not pay me what is owed, so I am here to make a formal complaint. I'm sure that you will be able to help me obtain my money."

The Consul swallowed, cleared his throat, and asked for some more information. Carlos pulled out the folder and handed it to the Consul. "Here's everything there is to know". The Consul began to read.

"Dear Respected One:
GREETINGS,

I am Imun M.; the only Son of late Mr and Mrs Henry M. My father was a very wealthy in Nigeria before he was killed to death. We are also motherless. Before the death of my father He secretly called me on his bedside and told me that he has a sum of $25.500.000 (Twenty Five Million, five hundred thousand dollars) and that I should seek for a God fearing foreign partner in a country if my choice where I will transfer this money.

I got your contact from the International web site directory. I prayed over it and selected your name among other names due to it's esteeming nature.

Sir, we are honourably seeking your assistance in the following ways.

1) To provide a Bank account where this money would be transferred to.

2) To provide your Social Secuirty number for the sincere purpose of my peace of mind that you are indeed the Esteemed individual your references qualify you as.

3) To provide your address where the correspondence can be sent which is not safe to send by email.

Sir, we are willing to offer you 45% of the sum as compensation for, effort in transfer of this Fund to your designate account overseas.

Anticipating to hear from you soon.
Thanks and God Bless.
Best regards.
Mr. Imun M. "

The Consul closed his eyes, rubbed the bridge of his nose, sighed.

Away

I saw her again after several months in which she could not be convinced to come to my office. The last time she was there, she thought my name was 'Ribaldina' and noted her failing memory with some distress.

This time she thought she was at her doctor's office, remembered my face but had no recollection of my name, or of having visited my office, weekly, for over a year. She looked the same except that her hat was on inside-out, and she was not wearing any makeup. She had on long, very pretty dangly earings that she said were a gift from her new boyfriend. She has no new boyfriends, and in fact her old boyfriend has been so frightened by her memory loss that he stays away more than he visits.

She thought the year was 2007, which isn't so bad, but then said that she was 32 years old, and single, and had no children. This confused her some as she did remember having a newborn granddaughter, but the confusion was short-lived and she broke into a fit of giggles saying that life sure is strange.

I know I will not see her again. There is nothing I can do for her at this point, and besides, she does not feel depressed or even anxious. Any memory she might have had of our sessions together has been erased, and I wonder now what the point really was. It was always difficult for me to see her, painful to the point that I would feel physically tired after our session ended at 11am, with little strength left for my other patients. But I usually told myself that it was all worth it if it helped her. Now she wears her hat inside-out, and thinks I'm her doctor -who is a man, and waits for a boyfriend she will never have.

Sometimes I wonder how much longer I can do this job.

Dressed like a Mexican

E. was my first patient today. She handed me a piece of paper: "Fax this letter to my child's school for me".

E had enrolled the child in school A, went the first day, didn't like it, pulled the child out, enrolled the child back in the school she had attended the year before, or school B. However, she didn't notify school A of the change. Her rationale was that since school A administrators did not pay my patient enough attention when she showed up with her child on the first day, she would exact her revenge by not notifying them of the withdrawal. Naturally, school A had been calling her every day to find out where this child was, and finally threatened to call the authorities if she did not provide proof of enrollment somewhere else.

So here she was today in my office, offended and annoyed by school A's unreasonable request, but willing to give in and send the letter. She had obtained the letter of attendance from school B where the child currently is, and that's how she came to hand it to me this morning, a gesture accompanied by a 'fax this to School A for me'. No question mark, no please, no thank you.

I wondered why she didn't ask the person who wrote her the letter to also fax it to school A and she answered 'I didn't want to bother them'.

Next!

S. was patient #2. S. came with her home attendant, as she does every week. S. is demented and the home attendant helps me understand what is or is not going on in S.'s life, since S. herself is often confused. Besides the fact that it is not possible to do any kind of psychotherapy with someone this impaired, sitting with her for a session is a sad, disheartening experience. She has no memory and no short-term memory in particular, so we'll talk about something and shortly after she'll want to talk about it all over again, having forgotten all about the first talk. For example, she'll say 'My daughter hasn't visited me in years'. She'll look really distraught and I'll help her remember that yes, her daughter does visit her twice a week, and S. will smile, reassured. Then five minutes later she'll say 'My daughter hasn't visited me in years' and so on.

It's like watching Memento, which gave me panic attacks even as a movie.

And every week is a bit different, since dementia apparently has its ups and downs, good days and bad. Today S. complained that she was tired and could not remember my name, which was frightening to her. "What's happening to me?" she wanted to know.
Before I could intervene in any way, the home attendant decided to cut the tension by telling me that there was another lady in the waiting room that also couldn't remember my name! How funny! The other lady was apparently mumbling to herself 'what's her name? miguelina? magdalena? mariaclara?...' The home attendant thought it was a hoot that nobody seemed to remember who I am today, and S said: "I remember your name now! You're Ribaldina!". Which I'm not sure it's even a name, let alone mine. But S. felt better.

My third patient's first words to me were: you are dressed like a Mexican. I happened to be wearing a long summer skirt from India, with pieces of mirror and lots of colorful embroidery. Third Patient stared at it with a look of disapproval.

Oh, but the lady with dementia? She said one wise thing. We were discussing how she has been forgetting to eat, and she giggled -inappropriately- and said "I may forget to eat but I'm hungry when I'm angry!"

To which I absolutely, most definitely can relate.

Home sick

Today I am home sick. I woke up this morning with a sore-throat so bad that it was a real effort to talk. So I called the office and spoke to the person in charge about coverage and about which of my patients should be called first and what they should be told about my absence.

This is probably the second sick day I have taken since the beginning of the year, and I know I must have sounded pretty under the weather on the phone, raspy voice and all. However, all the person at the other end of the line managed to say was 'I guess I'll see you tomorrow' and then we hung up. I was inordinately upset by the exchange, to the point that, finding myself home alone, I burst into tears.

This was not a completely unexpected reaction as I am not quite at my best, emotionally speaking, when I'm ill. I tend to feel bereft and vulnerable and left to take care of myself while being completely unprepared to do so. None of which is true, and all of which is residual from a childhood of covert neglect and lack of, well, love. I have processed my feelings of abandonment and anger and the very deep sadness that stems from knowing, as a child, that I was not cherished, and that when I was ill I was more of a nuisance than usual.

That said, sometimes when I'm feeling sick and my defences are down, the adult in me gives way to a 5 year old girl, who is feeling unwell and has no clue what to do. It's not fun. It's also funny that after so much analytic work on myself and after having so nicely shelved my past and having recovered from it, a simple bad sore throat can still bring on this intense longing for someone to bring me soup and crackers and comic books, someone to make sure I'm tucked in nicely and comfy on the couch. That is what I wanted when I was a child when instead I got spoonfuls of codeine-laced cough-syrup thrust down my throat to make me drowsy. Neglect negates your existence, and triggers fears of annihilation. When I feel the way I did earlier today, much of the work I have to do is to soothe this little kid in me who is panic-stricken.

Patients tend to think that we are perfect people living perfect lives. And it should be that way, so therapists can be the famous blank slate and patients can project what they need onto it.

It is through this wonderful, fascinating process that in my current practice working with the elderly I end up being the mother figure to 80 year olds who, much like me today, still wait for that soft kiss on the forehead that tells them that yes, they are loved and yes, they will be okay.

Not anything a 5 year old kid would be able to provide.

Not today.

Today

This morning I woke up feeling out of sorts, a mix of bereft, vulnerable and angry. The last thing I wanted to do was going to work. In fact, I really, truly, very strongly wanted to stay in bed. When I twisted my ankle on my way to the subway I decided to take it as a sign that I should turn around and go back home. But I didn't. It's hard to take a day off when there are a bunch of people who depend on you being there for them. Twisted ankle and incredibly sad mood and all the other little things that make me human and that they will never know about, I hobbled to work.

And this was my day:

My first patient did not show, and did not call. She does this all the time. See previous blog on 'how to drive your therapist crazy'. I did not call her. Instead, I went to the cafeteria and got breakfast. Two egg-whites, swiss cheese, turkey bacon on whole-wheat toast. I inhaled it at my desk.

My second patient talked about her physical therapy and how she had forgotten to do her shoulder stretches this morning. She explained that she needs to do ten stretches every day, and showed me how. She tried a couple of times and then realized she might as well get her exercise in. "one, two, three...". I watched her in astonishment "four, five...". She stopped stretching and said "how many did I do?"

"I don't know, I wasn't counting"

"You weren't?"

My third patient discussed her plan to buy her son a birthday gift. The son is a 20 year old good-for-nothing drug dealer who only calls his mother to demand money, which she does not really have. She's been known to sell or pawn her jewelry to find money for her son. 'He's my baby', she'll say. And I understand. Really, I do. But my understanding doesn't help her when she has no money left for rent, because she gave it all to her baby. So this time she looks really happy and tells me that she has decided to buy the son a new coat and to save herself some money she will go to this store that sells stolen merchandise. Aren't I proud of her, she wants to know.

I feel suddenly very, very tired. I want nothing more than to close my eyes and fall asleep.

My third patient has a concern and wants my clinical opinion. This is a rare occurrence and I am instantly very alert. He says that he has been hearing voices again, but only in the morning, when he's still asleep. He hears children's voices telling him that he is going to be ok. The voices disturb his sleep and he wakes up. They disappear once he's awake. I wonder if this may be a case of parasomnia, a type of hallucinations that happen in the phase between sleep and alertness, basically just before we wake up. They are benign and fairly common. I ask the patient how he feels about the voices, and he says that he finds them disturbing. Why? Because he thinks they are spirit voices. Apparently, he has been praying before bed, and his church frowns upon bed-time prayer because it opens the soul to the spirit world. I ask him if he thinks he can do something other than praying before bed, like maybe listen to the radio. He smiles and claps his hands and thanks me for my great idea.

I have a cup of soup for lunch.

My fourth patient talks about one of her sons who is wanted by the police for parole violation. There's a warrant out for his arrest. He recently called her to tell her that he is fine but she has no idea where he is, and he won't visit her. Which is just as well because the cops have taken to showing up at her door at 5am with a search warrant, looking for him. He hasn't been there in months, but they still search the house down to the bathroom cabinet where she keeps her anti-depressants. He is not a midget and it's unclear why they feel compelled to check her medicine-cabinet looking for him. Anyway. She wonders how it happened that all three of her children ended up being drug users. Her 43 year old daughter had 10 children, all of whom were toxicology positive at birth and have now been adopted by their foster families. My patient has no idea where any of her 10 grandchildren might be. Her daughter is living in a shelter and continues to do drugs. Her other son, who recently stopped doing drugs and is now on anti-psychotic medication, recently told my patient that his new girlfriend is pregnant with his child. She is 52. My patient laughs and laughs until she cries.

My fifth patient is angry because her landlord insists that she pay her rent. She feels that the landlord should not expect her to pay. It's unclear why. I try to explore this issue but we get nowhere. This has been going on for months. Mostly, what she says is that the landlord is Jewish and 'you know these Jews, all they want is money'. I want to yell at her.

Fast-forward to patient number seven, also called The Last Patient of the Day!

Yay.

So patient number seven comes in 20 minutes late and starts talking about how much she spent on her daughter's school supplies. She goes on to describe each purchase in detail. I learn the size and color of binders, the thickness of paper reams, the number of pencils acquired, and so on. What she does not tell me is the result of her gyn visit. As of last week, she thought she might be pregnant. At 46. By a man that she doesn't care for. Last week she cried desperately just thinking how she does not want a baby, how she would rather die than tell her teenage children that she is pregnant. She was so anxious that she had not slept in a week, just anticipating the doctor's appointment that would determine whether she was pregnant or not. She was too anxious to even take a home pregnancy test. But today she won't talk about it. And normally I wouldn't ask. It's not how psychotherapy works. The patients have center stage and can talk about whatever crosses their minds. It's a fairly basic rule. Except that I'm tired, and I have had a hard day, and I stop monitoring my impulses for a split second, long enough to hear myself say 'Did you see your gyn?'. Startled, my patient looks at me for a second, then giggles and says "Oh. Right. I'm not pregnant".

And then I came home.

How to drive your therapist crazy in 10 easy steps

Psychotherapy, like all relationships, has its ups and down. So for those dull therapy moments when you find yourself getting bored with your own self, and wonder whether your therapist really loves you, or you just want to spice things up a bit, here's a quick and easy guide on how to do drive your therapist crazy.

I broke it down into points, though they are not steps in the common sense, and can be followed in any order. Also, you do not need to follow all of them. Chances are you will begin to see results after only 3 or 4, it all depends on you perseverance and focus.

I should add that this list has been compiled based mostly on my 9-5 clinic patients, who have a different view of psychotherapy than, say, your average private patient, and who generally think of me as their social worker rather than their psychotherapist.

HOW TO DRIVE YOUR THERAPIST CRAZY IN 10 EASY STEPS:

1. If you don't feel like keeping an appointment, remember not to call and cancel.

2. When your therapist calls YOU to find out whether you are still alive after you have missed three consecutive appointments, try not to answer the phone. Or, if you must answer, make sure to have a TV on in the background. It doesn't matter what channel it's on, as long as it's loud. If your therapist can still hear you, turn the volume up, or walk closer to the tv. Oh, and don't forget to mumble.

2a. A fun alternative to #2 is to answer the phone and pretend not to be home. "Who? Maria? Nooooooo. She's not here. What do you mean I sound like her! SHE IS NOT HERE!"

3. After you've missed several sessions, return to therapy driven by a firm refusal to discuss any psychological reasons for your absence, but be prepared to resume your conversation where you last left it, 5-6 weeks prior. Good opening sentences in this case might be: "That letter never came", or, "That letter arrived", or "Did you write me that letter?".

4. When you are presenting a complicated situation involving several people of the same sex, make sure to use pronouns only, as in 'He told him that if he ever did that again he would call him up and then he would know what he was talking about!'.

5. If you weigh over 300lbs and have multiple weight-related medical conditions so that your doctor and your therapist are on a first name basis with each other, make sure that whenever your therapist attempts to explore your relationship with food you answer: "I don't know why I'm fat. I never eat!". Ideally, you should try to have potato chip or cookie crumbs on your person when you say that.

6. Ask your therapist to make phone calls for you to settle your unpaid utility bills and make sure to say that this is because you do not feel like wasting the minutes on your pre-paid phone.

7. If your therapist insists that you make the calls yourself provided she/he lends you their own office phone, make sure to sneeze or cough into the receiver.

8. Take off your shoes to show your weird and potentially smelly foot fungus.

9. Ask for help obtaining obscure entitlements such as government-issued blocks of cheese. They do exist.

10. If your therapist has never heard of goverment cheese, or balks at your request to use his/her phone for your personal calls, or cracks open a window while you air out your smelly feet, make sure to look outraged and say "But aren't you a social worker?!"

WWFD?

Another patient decides to bring a child to her session. This is a grandmother and the child is 7 years old. She really wants me to meet this kid because, she explains with pride, he is her favorite grandson and she loves him more than she does his sister. And with that, the introductions are done.

He's a cute chubby kid in a blue Yankees shirt and purple crocs. On his grandmother's insistence he kisses me hello on the cheek, then sits down next to her, looks around the room and before I have a chance to offer him paper and crayons to draw, yells 'I love predators!'.

What am I supposed to say to that? What kind of predators, exactly? I make a non-committal sound that he appears to take as a sign of encouragement, and proceeds to list his favorite predators. To my relief, he means animals. To my dismay, the list is long. He moves from birds to fish to mammals, from extinct to fantasy to myth. That would be the Lockness Monster. Apparently, it is also a predator. And lives in Scotland. This leads him to the topics of pipe-playing and men wearing 'skirts'. The kid free-associates beautifully.

Meanwhile grandma, who is not very fluent in English, watches him adoringly and winks at me as if to say 'isn't he wonderful'. In fact, she does say it. She recognizes random animal names but reallly has no idea what he is talking about, and to be honest, neither do I.

Grandma makes an effort to provide some context: 'He likes that show with Mindy'. Only she says 'Ee likes dat chow'.

The kid stops his list long enough to say 'Who's Mindy?'

'Dat girl wid de chow wid all dee animals'

'That's Bindi, and I don't like her.'

Grandma says that Mindy is very cute. He rolls his eyes and moves on to different species of lizards and giant iguanas. We only have 35 minutes left and there are plenty of predators still unmentioned.

Grandma doesn't mind. 'I feel much less depressed now that he's staying with me', she whispers so as not to interrupt the child's list of snakes. 'He makes me so happy'.

'I like rattle-snakes!' says the kid.

Soon I will have to put a stop to this latest wave of kids joining my patients for their sessions. I know I have to. But my patient was so happy to show off her grandson....and he clearly needed someone to list his predators to.

What Would Freud Do?

He'd probably turn on the TV and watch Bindi.