Intensive Therapy Part 5

Dr. Speller's eyes widened. "Me?"

"Yes, it was definitely you. It was one of those bakeries where you see past the end of the counter into the kitchen. I had come to buy sugar cookies. The person behind the counter said, 'Wait a moment, they're just coming out of the oven.' You were the baker. Only, I could see just your face, which cracked me up because you looked like a bobblehead. When I asked why you were there, you said in your clinical mode, 'We need to look into your feelings about this.'"

"Clinical mode?"

"Of course."

"What are you talking about?"

"You must be kidding. You don't know?" He shook his head. "How can you not know?" Victoria laughed. "You have two ways of operating, which you bounce back and forth between. In clinical mode, you sound detached. I like it much better when you're relaxed and conversational. Your voice is sweeter. I can't be the only person who's told you this."

Dr. Speller's face went from pink to red. "Well ... You know ... Someone once said-"

"I didn't mean to upset you."

"I'm not upset," he countered, like the character in Hamlet who protested too much. After a moment, he smiled. "I get it. You just did with me what you did with your friend-saying directly how you feel. Good for you. I can stand the feedback."

"Then you still like me?" Victoria half-joked.

"Yes, I like you."

"This is good," Victoria said as she left, feeling playful and happy for the first time since she had begun therapy.

11.

Friday, November 19, 2004

Jonas Speller had long accepted he would never be a professional violinist-lectures and courtroom appearances had become his recitals. He'd rehea.r.s.ed and performed the day's opus, "The Psychiatric Expert in Mental Damage Cases," many times.

After his morning panel, Jonas lunched with Eddie and his partner, Pete Bodenheim. Pete had been Jonas's fraternity brother in college, and Jonas had introduced him to Eddie. Pete, an all-Ivy backcourt standout, and Eddie, a huge college basketball fan, hit it off immediately. When Pete finished law school, Eddie recommended him for a.s.sociates.h.i.+p at his firm. Later, they founded the law firm bearing their name. Nowadays, Pete and his wife, Beth, and Eddie and Margo Speller spent nearly every holiday together with Jonas and Jennie, the three sets of children like brothers and sisters.

Jonas lounged comfortably with many of the lawyers for whom he often testified, until Eddie retrieved him shortly before his main performance. "Time to make sure the audiovisuals are locked and loaded," Eddie said on the way to the Esquire ballroom. "It's show time."

"It's just not that complicated," Jonas began his presentation. "Mental damage cases are like those with any other type of injury."

Jonas took his audience through what to expect when collaborating with mental health professionals. "When it comes to your expert," he said, "pick someone who doesn't patronize the jury or use jargon. Otherwise, no one will believe their testimony."

Jonas kept the technical parts of the talk entertaining, presenting a series of color-enhanced brain scans to demonstrate the difference in brain functioning between a normal person and a psychologically traumatized September 11th victim. "Technology is revolutionizing psychiatry. For decades defendants have argued that mental damage doesn't really exist because no one could see it. Those days are gone," he said, stressing each syllable as he pointed a laser at the X-rays projected on the screen. "Now we can see and measure brain activity like never before.

"And be sure to get medical records from every doctor your client has seen, not only his psychiatrist or psychologist. Get job evaluations and employment physicals, too, anything that doc.u.ments baseline levels of functioning.

"I leave you with the case that taught me the most. I had a great mentor, Paul Fremont. Some of you may have been fortunate enough to know him. Paul coached me to make eye contact and read the jury's body language, but the best thing he impressed upon me was the importance of having your expert read every doc.u.ment in the medical record word for word. It is so tempting to scrimp on record reviews. Don't do it.

"I testified for Paul in a multi-million-dollar case in which a borderline mentally r.e.t.a.r.ded twenty-six-year-old woman nearly died in a car accident. At issue was whether the accident rendered the woman-we'll call her Carmen-who had been able to make do on her own prior to the accident, totally disabled. Everyone a.s.sumed she had been so traumatized by her near death experience.

"The defense engaged a highly regarded inst.i.tution's department of psychology-note, not psychiatry-for expert testimony; the important distinction being that psychiatrists have medical training. Their report a.s.serted that Carmen's pre-accident IQ was so low that the experience could not have made her functioning level any worse.

"I dissected the report word by word. Same with the medical records-five loose-leaf notebooks so thick they looked like the operating manual for the s.p.a.ce shuttle!

"When I examined Carmen at the nursing home, she was totally bewildered. She remembered nothing of the accident or the hospital, not even what she ate for breakfast that morning. Her capacity to make new memories had been entirely wiped out. She could dress and feed herself only if her clothes and food were prepared for her. I contended that psychological trauma was not the critical issue. The plaintiff's team had missed Carmen's short-term memory deficits, something psychiatrists routinely screen for.

"I'll never forget that courtroom scene," Jonas went on. "The reflection off the defense attorney's bald head looked like it could pierce t.i.tanium. 'Doctor,' he turned on me scornfully. 'How can you tell us that the accident caused the plaintiff's deficits? Look how poorly she functioned for her entire life.'

"I measured my words carefully before I spoke. 'The medical record indicates that prior to the accident this woman could function on her own. When I examined her after the accident I found that she had no short-term memory. No mentally r.e.t.a.r.ded individual, even borderline r.e.t.a.r.ded, with short-term memory loss can subsist without round-the-clock care. Six weeks in a coma with a fractured skull damaged this woman's brain. I'm certain of it.'

"'And where does it say that the plaintiff suffered a fractured skull, Dr. Speller?' the attorney pressed.

"'It's in the medical record,' I responded.

"'Exactly where in the medical record?' he sneered. 'We found no such mention.'

"'She did have a fractured skull, didn't she?' I wondered to myself. If I was mistaken, it would have undermined the credibility I'd worked so hard to establish.

"So, there we were: me rustling through binder number five trying to find a skull X-ray report. I looked everywhere, with no luck. But then, like a lighthouse beacon on a foggy night, the answer appeared before me.

"'It's right here,' I said, and I showed him the CT scan.

"The attorney said, 'I see nothing about a skull fracture.'

"I read aloud. 'Twenty-six-year-old comatose female with CSF leakage from the nose. That's it.'

"'What do you mean, "That's it?" What does CSF have to with anything?'

"I turned to the jury. 'CSF stands for cerebrospinal fluid, the liquid that bathes the brain and spinal cord. CSF leakage through the nose after head trauma is always the result of a fracture of the bones in the base of the skull.'

"The attorney's face turned beet red. He'd broken the first commandment: Never ask a question you don't know the answer to. 'No more questions.' he mumbled quickly.

"The records were key. The cerebrospinal fluid leakage registered in my mind subconsciously. I'm sure of it. And even if the plaintiff's team had reviewed the records as diligently, they missed the short-term memory defect and the subtlety about the skull fracture, not having studied neuroanatomy and radiology, something every medical student-including students of psychiatry-learns. If you need a medical record review, get a medical doctor. P.S.: We won. Big time. Thanks for listening. I'll be around if anyone has questions."

Through the applause, Eddie and Pete smiled broadly. "Jesus, what a performance," Eddie said when the three shared a private moment. "It's like Mark Twain Tonight. I've heard this speech more times than I can count, and yet every version sounds fresh. How do you do it?"

"Nothing complicated. I stay current. And I try to make each person feel I'm talking to him," Jonas grinned deviously. "That's what Samuel Clemens did when he lectured. Now, there's a man with a phenomenal grasp on human nature."

"d.a.m.n, you're good," Pete said. "Even though she keeps kosher, you could sell my mother pork-belly futures. Have you considered a sales career with Amway?"

"I don't know about that," Jonas laughed. "What I do know is I can't wait until the meetings are over. Tomorrow, I'm strictly a tourist. Then, I'm heading to the c.r.a.ps tables to set my inner child free. I hope you both come, too."

"Sounds great. Let's see what the girls are up to," Eddie said.

"I know exactly what they're doing," Jonas said. "They're getting the full spa treatment, probably just finis.h.i.+ng up. Let's go out to dinner tonight to celebrate."

Eddie borrowed Pete's Blackberry. "I hear you three are at the spa," he said when Margo answered. "Jonas. .h.i.t another grand slam today. I swear, every time he lectures, we get three more cases. The guy's a walking ATM. Tell Jennie her husband was terrific. He had everyone mesmerized, including me."

"I heard that," Jennie chimed in. "Put me on speaker."

"After reflexology, they treated us to avocado, eggplant, and oysters for lunch; they claim it rejuvenates a woman's s.e.x drive. I hope they're right, but even if they're not, we'll be ravenous by dinnertime. We'll be here until five. What time is it now?"

"Four-thirty," Eddie said.

"Let me talk to Jonas in private."

Jennie asked her husband, "So, how was it?"

"Great. Everyone liked it," Jonas said, his mind and body consumed by a very different appet.i.te. "How's this? I'll meet you back in the room as soon as I can and finish your treatment the proper way. After a nap, the six of us will go out to eat. What do you say? Eddie and Pete agreed to amuse themselves until dinner."

"How soon can you be here?" Jennie asked.

"If I get going now, I'll be waiting when you get back to the room."

"Mmm. Can't wait to see you, love. I'll be ready. I'm so proud of you, Jonas. So proud. And even though he's not here, so is Dad. Especially Dad."

12.

Wednesday, November 4, 1981

Jonas stared ahead as he pa.s.sed Dr. Fowler's open door on the way to Dr. Amernick's office. Dr. Stan Amernick, Jonas's supervisor, had been in Switzerland for six weeks teaching psychotherapy. Jonas could hardly wait to tell him about Dr. Fowler and about Victoria.

"I have something to tell you," Jonas said as soon as he sat down in Amernick's office. "I had a blowout with Dr. Fowler. I'm done with him." Dr. Amernick, his pearly hair combed front to back over a ruddy pate, smiled faintly. "To tell you the truth, I'm relieved. I stopped telling him my free a.s.sociations a long time ago." Amernick broke into a wide grin.

"Why are you smiling?" Jonas said.

"Thank G.o.d you got it! You and Fowler were a terrible match."

"Why didn't you say anything?"

"Why? Because criticizing someone's a.n.a.lyst is like bad-mouthing their girlfriend. And Philadelphia's a small town. Everybody knows everybody's business. It's a big deal when a candidate dumps his training a.n.a.lyst."

"And everyone a.s.sumes the candidate is una.n.a.lyzable."

"Don't a.s.sume, Jonas. Don't a.s.sume. It was Henry Plummer, director of your clinic, who backed Fowler's promotion to training a.n.a.lyst. It was political. Plummer steers residents like you to Fowler in return for favors."

Dr. Amernick removed his feet from the ottoman and inched forward in his Eames chair. "Just between you and me," he confided, "after college, Fowler's daughter Morgan went wild. She even had a romp with one of her father's patients, an older female college professor. When Fowler heard about it in the woman's a.n.a.lysis, he sent Morgan to Plummer for therapy, hoping Plummer would keep a lid on it. I found out because Morgan was friends with the daughter of someone we knew. That's what I mean about Philadelphia being a small world."

"You know, when you cross him, Fowler's tongue turns into a chain saw."

"I'm not surprised," Dr. Amernick said. "Whenever I challenged his ideas at Inst.i.tute functions, he twisted my words so much, I wasn't sure what I believed. Anyway, the good news is that you're free of him. Good for you."

"Won't Plummer hold it against me?" Jonas asked.

"Maybe, but let's look at the big picture. Do you mind if I smoke? I a.n.a.lyze better with a Macanudo." Dr. Amernick cranked opened the window for ventilation, guillotined the end of an impressive cigar, then lit up. "Where do you want to be in five, ten years?" he asked after a few minutes.

"In New York City, near my brother. Married, family; I can see our kids growing up near each other."

"Career-wise?"

"I get along great with all the residents. Psychology interns, too. We've evolved into what amounts to peer supervision. Sometimes, so many people show up in my office, it feels like an overcrowded Volkswagen. They're a riot, those sessions. You should hear the things they say about their patients and how they gripe about the faculty."

"That's great and all, but how are you going to pay the bills?"

"Teaching, supervising, private practice of psychoa.n.a.lysis."

"Sorry, Jonas, but the days of psychoa.n.a.lysis are numbered. The federal government dropped insurance allowances for it from unlimited sessions to fifty a year. It'll go even lower. You'll see. No one can show that a.n.a.lysis is cost-effective. Don't get me wrong; I still think it's the best way to learn how the mind works, but twenty sessions of cognitive therapy treats depression and anxiety better and faster. a.n.a.lysts will be swimming against the tide, so don't pin your hopes on having full-fee patients, especially when you're just starting out. And New York has tons of compet.i.tion. Mark my words. In twenty-five years, the only people coming for therapy four or five days a week will be psychoa.n.a.lysts-in-training, and the training-and-supervising a.n.a.lysts will be in a feeding frenzy to get their jaws into those cases. You really want to get mixed up in that?

"Look what's happening in biological psychiatry. Not to mention combining medication and psychotherapy. It's very exciting. Who knows where we'll be in twenty years? You could be leading the way if you keep an open mind."

"Most every a.n.a.lyst maintains that medication interferes with a.n.a.lysis by covering over the underlying causes," Jonas a.s.serted.

"Hogwas.h.!.+ Rationalization: pure and simple. If anything it's the other way around. When symptoms are under control, therapy works better. a.n.a.lysts are scared because combining medication with psychotherapy gets people better quicker. Less business for them."

"Well, I still want to finish a.n.a.lytic training first," Jonas said. "And I can't do control cases without having a training a.n.a.lyst."

"Of course, you should finish training. It'll make you a better therapist and a better person. You're so musical; I can't believe no one told you about Scott Frantz, head of the Inst.i.tute's education committee."

"When I started a.n.a.lysis I didn't feel I had a choice."

"Well you do now! Scott's the man I would have recommended for your training a.n.a.lyst. His wife, Johanna, plays cello for the Philadelphia Orchestra, and he's a decent pianist. They play duets, which says a lot about how the man relates. He'd be perfect for you. I'll call him and tell him about you, okay?"

"What a relief. And here I was worrying the Inst.i.tute would throw me out."

"I see potential in you, Jonas. Strength, courage, and imagination. But I know how the psychoa.n.a.lytic gristmill works. If you're not careful, it can grind away your creativity and churn your interpretations into aphorisms. Look at Fowler, a brilliant mind trying to cram his point of view into other people's mindsets. His daughter's a mess, while he plays word games. Plummer, Fowler, they're hanging on by a thread. Once word gets around about you leaving Fowler, you'll be more of a threat to them than they are to you."

"Really? I never looked at it that way."

"Define life for yourself, Jonas. Don't live someone else's. When I was your age, I lived in Switzerland for a time. What an eye-opener. My patients stopped being obsessives or hysterics; they became people. I stopped a.n.a.lyzing solely in terms of 'intrapsychic conflict' and began helping them find their way. There were two men there who changed my life. Maybe I'll tell you about it someday. It's quite a story."