T was a very disturbed, attractive, bright young woman, chronically suicidal, sometimes intensely suicidal. She was almost always in despair, perhaps always there. In the days when this was possible for someone whose family was not enormously wealthy, she spent long periods of time in the hospital. She was a management problem, cutting, burning, eloping from the hospital. In general she terrorized the nursing staff charged with taking care of her. Their terror followed her terror as her behavior transmitted terror very effectively.
The nursing staff took its job seriously. In addition, many of them genuinely liked T, who could be charming and interesting as well as dangerously out of control. The nursing staff may have hated T because she regularly threatened to expose their powerlessness and incompetence. But they also loved her, so the conflict was heightened in them. Certainly there was a sadistic element in T’s behavior, a way in which she was so out of control that she needed to tyrannize over those who tried to
take care of her.
T had a horrendous history that was definitely operative in her predicaments of the moment. There really is no point in reciting it in any detail. She was actually a very sensitive person who had experienced both neglect and abuse. She actively resisted looking at her history and how it worked on the present and in the present. She was too beset “right now” for this other enterprise of internal self-observation. She could do a little, but recoiled even as she did so.
A few of her most disturbing memories were externally corroborated during her time in the hospital. She felt worse as a result of this, not better. The corroboration was even harder to metabolize than the memories themselves. She was not happy to have been right, but rather had new losses to deal with. She would have preferred to be proven wrong, as being shown to be correct threatened her primary relationships. This common heartbreaking conflict is one that she had with special intensity, probably because of her temperament which had been with her at least since birth and perhaps before.
When T was out of control in one way or another, all ways that held the promise of real danger, the nurses and mental health workers negotiated with her, offering her more freedom, less supervision, more opportunities to do what she wanted, provided that she would abstain from the behaviors that were so frightening and so
dangerous. These were tough negotiations. Although she was hesitant about admitting it, T enjoyed the attention. She liked to bargain, to match wits, to be oppositional. She was good at it, too. She managed to consume a disproportionate share of the ward’s nursing resources. Although the means were negativistic, she made sure that she did not experience anything like the neglect she had known as a child.
The negotiations were difficult and lengthy, sometimes even absurdly convoluted, as a spontaneous legalism took hold. However, an accord that seemed promising was always reached. With it came some good feeling on both sides. The agreements hammered out always had the same form. If T complied there would be positive consequences. If she failed to comply, there would be negative consequences, substantial but not unduly harsh. After all, what was being asked of T was in no way extraordinary. It all always seemed very reasonable and very rational.
But it never worked. After some period of time, not necessarily a long period, T
would do something that broke the agreement. Usually what she did was not subtle. This would be disillusioning for the nursing staff, producing spasms not only of disappointment in them but of anger. More than one nurse, more than one mental health worker expressed the feeling that their work was being deliberately sabotaged by T. They worked very hard to be considerate of her and she responded by being as inconsiderate of them as she could possibly be. What, after all was the point? Sometimes she seemed to them to be an unregenerate terrorist.
The nursing staff did not distinguish between T and myself, her therapist. If T was causing so much trouble, if she was upsetting them so much, if she was making a mockery of the treatment they worked very hard to provide , then it was my job as the head of the treatment team, to take measures to fix things. If I did not find and take such measures, then I was as much a part of the problem as T was. If I remained puzzled by what was happening and wanting to try to understand it, if possible, then I was as much a part of the problem as T was. The nursing staff came to detest me, even though a good many of them had had good relationships with me.
They worked with me because they had to, not because they wanted to.
I was not indifferent to the pressures and problems involved in T’s treatment. In fact, some of the time I was as despairing as the nursing staff was. I told myself that I had a case of the despair that T felt. But I was exasperated as she made one agreement after another and then proceeded to wreck the agreements that she had just made. T was not someone who spoke easily. She could have long periods of silence in therapy. These could be hard for me to endure because I found her inner states very hard to imagine. I needed her guidance.
In one session, I told T that I was really perplexed by what went on in her relationship with the nursing staff. I could not understand, I said, why she made agreements and then proceeded to destroy them. I felt that, when she made these agreements she intended to keep them. But what she was doing was spoiling her relationship with the nursing staff and spoiling things for herself. To my great surprise, she took my perplexity seriously and responded quite directly.
“Whenever I get frightened enough of something, then I have to make it happen immediately. That way I have some control. I have a say in what happens to me.”
She looked over at me and seemed to imply that it was very simple and that I should have figured it out long ago. But to me it was a new idea, counterintuitive and even frightening in itself. It certainly did not give a person the chance of outcomes that were very favorable. But I understood it. I called it the theorem of T. If you got scared enough, then your sense of being helpless and having no control could be so daunting as to possess you. If you called down on yourself what you feared, at least
you could feel for a moment that you had some measure of control. Being frightened enough can threaten a person’s integration. The fear can be worse than the fact.
Since T explained the logic of this theorem, I have seen it in operate in other patients who were terribly frightened. For example, a gifted young man who is terrified that he will never amount to anything, behaves in a wild and delinquent manner, which virtually guarantees his failure by his own inner standards. It is a rationally irrational strategy. It may operate, too, in what leads nations to go to war.