Camille Drach Hojaij: Stein and Empathic Fulfilment
Barry Blackwell’s comment
I approached Camille Hojaij’s essay on empathy fulfillment in pleasurable anticipation but was disappointed to find a somewhat sterile philosophical dissertation devoid of clinical reality.
The degree I earned from London University on the completion of my psychiatric training at the Institute of Psychiatry and Maudsley Hospital in 1966 was a Diploma in Psychological Medicine (DPM). Many years later the university converted it to a Master of Philosophy (M.Phil). This transition pleased me since the acronym DPM in America was a Doctorate in Podiatric Medicine; at the wrong end of the body to convey my interests.
But the name change raises important questions about the relationship between philosophy and psychiatry; empathy is an excellent starting point. In pure philosophical terms Camille explains the term in the “Emergence of the Experience” (p.5). As described by Stein: “It is possible for one to be aware of the hidden profiles of these three dimensional objects. When I look at the table (including its underside and legs) they are also grasped by me. The table’s hidden sides are con-primordial to the side of it which appears; all its sides share the same originality and thus are given to me all at once.”
This is a remarkably concrete and mundane metaphor for a human experience defined in the OED as “The ability to understand and share the feelings of another”; from Greek em;in+ pathos;feeling. Now we are in the domain of psychiatry, indeed all mental health professionals in their patient encounters.
In these encounters patient feelings are sometimes openly shared, but often inferred as (like the table) below the surface. Hidden sometimes by shame or fear of sharing and occasionally because the patient lacks an emotional vocabulary due to another Greek derived word, “alexithymia”; no words for feelings, often due to emotionally deprived, abusive or neglectful upbringing. Occasionally the feelings are translated into physical sensations or concerns manifested as psychosomatic or hypochondriacal complaints. Sometimes the patient remains silent and the therapist infers an association or subtly acknowledges it in a metaphor. Bringing these feelings to the surface and dealing with them requires skill and tact (Blackwell 1992,1996).
In my 2012 memoir, Bits and Pieces of a Psychiatrist’s Life, there is a Piece (Chapter) on “The Bread and Butter of Psychiatry” that includes a selection of clinical vignettes and poems chosen to portray that “while I prescribed modern medicines, the essential ingredient to whatever success ensued was clothed in talk. Not always an hour long, but sometimes brief and sequential; in my office, at a bedside, on the streets, in the clinic or in prison.” During my career the wheel of psychiatry turned full cycle. First it was all therapy, then mostly medicine and finally we mingled chemistry with words, dabbling in soma and psyche. The latter involves empathy, sometimes declared, sometimes inferred, deflected, deferred or metaphorically expressed. Some of these nuances of empathy are present in the vignette below.
He was rummaging through some papers on his desk, waiting for Sophie, when she marched briskly though the open door and plumped herself down on the sofa. She had on a silver fox-fur cape, topped by a scarlet beret that matched her lipstick. Before he could close the door to his office or sit down himself, she announced emphatically, “I’m a whore.”
He paused a second or so before inviting her in a deliberately neutral voice to “say some more.”
She did. “It’s disgusting, don’t you think, for a seventy-five-year-old woman to be going with two eighty-year-old men at the same time?
“Two?” he asked innocently, knowing about Max from earlier sessions. Sophie had taken up with Max soon after her husband died. He balanced her checkbook, chauffeured her to the grocery store, and snored next to her in the movies. Early in therapy, when she began the anti-depressants, she had complained her orgasms were inhibited, After the dose was lowered, she said no more. Twice, he tried to stop the drug but each time, the grayness descended and all her pleasures dwindled.
Taking her therapist’s knowledge of Max for granted, Sophie told him about the second man in her life. It was an old flame, rekindled. “His name’s Sid. He asked me to marry him in 1929, but I told him no because I wanted to work. Sid said I could work and he’d quit but the Depression came. We both had to find jobs. Now he lives in Cincinnati and his wife’s in a nursing home with Alzheimer’s or something. She doesn’t even know his name.” Sophie paused to reflect on this and then added, “I’m glad all of my husband’s died suddenly.” Ignoring this digression he prompted Sophie to say more about Sid. In the past month Sid had become ardent, driving his Lincoln Mercury fifty miles to Dayton several times a week and often arriving unannounced. Like a timid teenager from sixty years earlier, Sophie strove to keep her two suitors apart. This caution of hers eased a nagging concern that his chemical tinkering might have tipped Sophie from sadness into an erotic mania of insatiable urges and unchecked impulses. She told him that Sid was chairman of the board for a large paper corporation.
Like each of her husbands, and like Sophie herself, Sid was successful and self-made. Once Sophie recovered from her earlier depression and she regained her purpose she was a match for anyone. Sophie played demonic bridge, entertained lavishly, and insisted on credit for the senior citizens’ courses she enrolled in at the university. When an instructor at the YMCA questioned her wisdom in joining an aerobics class she produced a certificate from her internist to prove she was in shape.
As her therapist, he wasn’t sure what Sophie needed from him now. She surely wasn’t having doubts about the wisdom of sex after seventy. For Sophie, sex was simply not sinful. It was a practical matter. Earlier in therapy, she told him of how she had been driving to a party with her first fiancé when she realized they hardly knew each other. Sophie ordered him to turn the car around and take her to bed. That must have been the man she married instead of Sid.
Nor did Sophie seem to need help with strategy. He recalled the courting of third husband, a distinguished professor in the English department at the university. They had met soon after he became a widower. Instantly smitten, the professor declared his interest but coupled it with the intention to remain in mourning for a year. Sophie was sympathetic. She understood the need for the delay but saw no reason to deny themselves sex. They were married two months later.
Often in therapy there were doubts about what his patients wanted. Only a few had wild psychoses or aberrant chemistry that taxed his training. More often, like Sophie, they came for advice, absolution, or an opportunity to iron out an ambivalence or two. He met all these needs like a bartender sworn to secrecy, a minister without a collar, or a friend whose only obligation was to listen and nod. When he was down on himself, he complained to his wife that all he ever did was to sell solace and that it had as little to do with doctoring as work in a massage parlor had to do with a degree in physical therapy.
His mind drifted back to Sophie sitting on the sofa, and his own thoughts merged with her predicament. An image crystalized in his mind. After all these years of living with three husbands and now confronted with two suitors she must feel like an empty house, up for sale. He shared the metaphor with Sophie, wondering what she would make of it. Sophie stayed silent for a long time. A sheen of sorrow spread across her eyes. When he saw the tears glisten he asked how she felt. “Used up. But it’s true I’m available. So what do I have to offer?
Offer? he echoed, wondering if Sophie saw in herself only what she thought the world would see. A widow turned seventy proffering sex?
The thought was mirrored in his own mind. A doctor turned therapist prescribing drugs? He knew that danger well. It was both the product and producer of sad thoughts, spiraling down to depression.
When Sophie answered, it affirmed his fear that she was dwelling on the dark side. “My daughters will think it’s disgusting. At my age.”
Intuitively he sidestepped her statement. Instead he used the time left to gently remind Sophie of the things she did so well and the companionship she had to offer.
At the end of the hour, he asked, according to ritual, if she needed another prescription. Sophie said no, not this time. When she left she seemed calmer than when she came. As he wrote his notes in her chart he looked forward to seeing her again in a month’s time when he knew this self-sufficient woman would have made a wise decision.
These thoughts and feelings, illustrated by Sophie’s story, are from a lost era. Now that so many psychiatrists restrict their practice to insurance ordained “med-checks” there is reason to ponder at what cost to the nuances of empathy and its fulfillment in such brief encounters?
Blackwell B. Sick role susceptibility. Psychotherapy and Psychosomatics.1992; 58:79-90.
Blackwell B. Patients with somatic preoccupation in primary care. Wisconsin Medical Journal. 1996; 840-50.
Blackwell B. Bits and Pieces of a Psychiatrist’s Life. XLibris, 2012; 380-82.
February 13, 2020