Thirty-nine at the time of our first meeting, Dr. Payne approached the history phase of therapy with mixed emotions. While on the one hand he understood my need to know how he got to be the man who sat in my office, he was quite uncomfortable with the past. Born and raised at the periphery of a South Philadelphia enclave of Russian Jews ("Payne" is an Ellis Island alteration of "Panofsky"), Harold's earliest memory was "a scene of my being in bed, sick with measles." His parents owned and operated a hardware store in the "we lived above the shop" tradition. No part of their living space was sacred to home life, for everywhere around the living room and hallways might be barrels of nails, cartons of electric fuses and toilet paper, or boxes of switches, drill bits, and sandpaper. "To this day," he said, "I refuse to do a single bit of work around the house. I will not allow a hammer, a wrench, a box of nails in the house, or anything like that. Even Martie wants to do the work herself, I insist that she hire someone to do it."
He remembered that his mother walked him to the first day of school, that he had been a bit apprehensive, but that the day on the whole had been "really okay." It was awkward being the only Jew in his class, but since everybody in the neighborhood shopped at the family store, he felt reasonably well accepted. Quick-witted and facile, Harold felt at ease both socially and academically until High School, when he was faced with serious homework for the first time and awakened to the necessity for intense study by a terrible first report card.
While he was in High School, the family relocated across the river to New Jersey and a far less demanding curriculum, from which he graduated to attend Temple University. "I goofed off for the first 2 1/2 years," he said, "although I loved math. I flunked out, took off a half year, switched to a psychology major, and went to night school where I began to do really well. During the day I worked at my dad's store and on the weekends as a technician at Haverford State Mental Hospital." He continued to help his father through most of his graduate training in psychology, leaving the business only when a clinical placement drew him to another city. Doctorate in hand, Harold accepted a job with a senior colleague with whom he worked for 3 years until deciding to go out on his own. By training and orientation, he is an eclectic therapist equally at home with suggestive, uncovering, and behavioral modalities. Most of the individuals who have worked in therapy with Dr. Payne have remained friends and feel free to call on him to discuss important events in their lives. He is never too busy to see someone who needs him, and puts in countless hours answering calls at night and writing letters for clients.
Harold is the youngest of 5 brothers, ranging in age from 22 to 11 years older than he, working as pharmacist, physician, salesman, and businessman, respectively. "I was like an only child," he said, noting that his brothers were "out of the house when I was little." His father was now 87 and growing increasingly senile: "He did everything for his family---I mean his children---my mother was there to take care of him and his children, and that was the way he treated her. They were never close. I liked him, especially the fact that he had so much wisdom even though he never went to school. The only thing I really disliked about him was the way he was so inconsiderate of my mother. I think it was terrible to her that he insisted on using the house as a storeroom. She could never decorate anything, unless you think of a barrel of nails as a chair." When angry, his father would raise his voice briefly and calm quickly. His mother had died a year-and-a-half earlier at 81, and was described as "a very unselfish person. Someone you could talk to---intelligent, sensitive, sacrificed herself to the family." When angry, she would hit ("when I was small and couldn't run away"), even though she was immediately guilty. She seemed to feel hurt easily.
As noted above in the initial interaction, his 37-year-old wife is described as beautiful, intelligent, and austere. "She is compulsive, neat, orderly, exact. The perfect obsessional personality. I can't stand it. Lists for everything. I was the opposite of that when we got married. Her extremes drive me crazy. When she's angry, she doesn't care who's right, who's wrong. She gets just like a toddler---pulls her hair, makes cheap shots at me, takes a long time to cool down." All three of their sons (13, 11, and 6) are well and successful in school.
Asked to interpret the proverb "A rolling stone gathers no moss," he responded that "if you stand still you get crusty, or barnacled, whereas if you keep moving you keep freedom of movement, well oiled." To "People who live in glass houses shouldn't throw stones," he responded that "people who do something wrong, or the wrong way, don't have the right to criticize others who do the same thing." "Don't cry over spilt milk" was interpreted as "Something is done, move on," and "Every cloud has a silver lining" as "There is, in every situation, some good that will come out of it, some good hidden that we may not perceive." Asked how he acts when he is angry, Harold said "I explode. Recently, I feel my heart pumps to a point where I feel out of control. I get extremely effective verbally. When I cool off, I think whether I was justified, and get out of it as soon as possible. I explode, then I cool off." He'd been through a number of medical examinations not long before beginning psychotherapy, and reported that there had been some question about his thyroid, which seems to be okay, that his cardiac stress test was normal, but that "when I am under stress, everything gets me excited." He sleeps between 7 and 8 hours under normal circumstances, perhaps 5 hours when under severe pressure, and takes one or two 5mg Valium tablets in the course of a normal week "when I think I'm going to lose control. I take a Librax occasionally when my stomach goes bonkers."
At the end of every history I ask whether there is anything I missed, any information my patient thinks I should know. Harold completed our second session by saying that the problem was "the marriage. We're just different. Early on, maybe it was fun for a while. She was pregnant when we got married, and we never really had a chance to get to know each other."
My working diagnosis (not part of DSM-III) was Marital Discord, and a Characterologic Problem Expressing Emotion. For the purposes of an insurance form, I would have used the diagnosis "Adjustment Reaction with Mixed Emotional Features" and what we now call "Undifferentiated Somatoform Disorder." Although he seemed relieved that he was now committed to personal psychotherapy, Harold said frankly that he felt more at ease taking care of other people than being taken care of. "I guess it is a good thing that you are so well known," he said, because otherwise I would be pretty embarrassed at having to go to someone. At least everybody knows you, and I can let them sort of think I am coming to you for some sort of training."