Session Note
Confidential. For training purposes only. Do not circulate.
Date: Friday, 7.6.2002 11a.m.
Psychologist: Dr Carola Rivas, PhD
Patient: S.H., 25yo White male, cocaine and heroin user, mood disorder NOS. Session No. 6.
CR: Good morning.
SH: ...
CR: I haven't thanked you for the list that you left me.
SH: Oh, that.
CR: Yes, that. The list of possible hazards for patients here. It was very-thorough.
SH: Did anything come of it?
CR: I passed it along to the director.
SH: Dr Franklin?
CR: Yes, Dr Franklin.
SH: My psychiatrist. I am meeting with her later today.
CR: Yes? Anything I should know about?
SH: I'm sure it hasn't escaped your notice that I've been in a wretched mood.
CR: After Wednesday-
SH: It was better on Wednesday. But over the weekend, when Lestrade-the detective-came.
CR: What were you feeling?
SH: My symptoms? The usual: fatigue, listlessness. I don't feel anything. The most overwhelming sense of tediousness. Ennui. Can't be bothered to do anything. If there were anything to do around here.
CR: Textbook case of cocaine withdrawal. You know that, don't you?
SH: What?
CR: That you're describing what all the literature says about cocaine withdrawal. Some people find it helpful to know that there's a typical course, that it says more about the drug and what it's doing to their bodies than about who they are. Exhaustion - have you been sleeping more than usual?
SH: Yes.
CR: Increase in appetite?
SH: Unfortunately. The food here is less than appetising, I can tell you that much.
CR: Anhedonia? Meaning-
SH: 'Lack of ability to feel pleasure.' I know the term. Yes-. No.
CR: No? No to pleasure? No to anhedonia?
SH: We were-talking. Wednesday. About Manolo. And Mycroft.
CR: Yes.
SH: I felt desire then. Not sexual desire-I'm afraid I have to disappoint Dr Freud-but the wanting of something.
CR: Yes. You started off by saying that you felt that there was no end to your wanting.
SH: Immense. Irretractable. I wouldn't say infinite, that's hyperbolic. But yes. The wanting of more.
CR: What is the 'more'? What do you want?
SH: What don't I want? Quiero. Quiero. Quiero. In Spanish, the same word means 'to want' and 'to love.' Loving and wanting are merged. To want is to love, to love is to want something, someone. I want another green Sevillian night, without everything that followed. That much you could have guessed. I want-I want to play Bach again. Hang Sibelius-I don't care for Sibelius nearly as much as Bach, Schubert, Beethoven. Give me the baroques and the romantics. I want to play again.
CR: And your violin-isn't it here now?
SH: The violin is not the problem. I am the problem. My hands, to be precise, are the problem. Peripheral sensory neuropathy, as it says on my treatment plan. Translation: tingling, numbness in my fingers. It hasn't gone away, even without the cocaine these last few weeks.
CR: So you can't play.
SH: Precisely. Why else do you think I'd be here?
CR: I'm sorry?
SH: Why else do you think I'd be in therapy? Did you imagine that I like to talk about traumatic childhood events? That I like being locked up in here with the loonies? And I'm not talking about the patients, either. Then there are the ridiculous rules. The paucity of reading material. The absurdly transparent goals of the therapy groups.
CR: When you put it like that, I'm surprised anyone consents to being here.
SH: You said it, not I.
CR: So what are we going to do now?
SH: I've told you about my childhood-well, about the most singular event of my childhood. And now: can we get to work at cleaning out the abscess? Draining the wound? Because I don't like leaving things open like this. They will start to fester.
CR: You speak as if you had a physical wound. And in metaphor.
SH: Don't I? Have a physical wound, I mean. I thought we had already established that I know how to use metaphors. In any case, Anatomy is destiny, as Freud was wont to say. I've been reading about him. You planted his books in the library. I saw that.
CR: …
SH: As I was saying. So. My dopaminergic system is shot, to that I can attest. I know what coke does. And my serotonergic pathways? Forget it. I've downregulated those synapses, too. Not to mention the heroin. Stripped dry my opioid receptors; what to do about the pain, then? The lack of pleasure? I'm like a man who can't get it up, neurologically speaking. Now the trouble is I can't fire those damn action potentials without a large shock to the system. A shock that, if I'm not careful, will overload my synapses, set into action an undesirable cardiovascular event. Vasoconstriction. Infarct. Death by suffocation. I know what I risk if I use again. Especially after - after remission. So I'll risk the boredom. The ennui. Wait until homeostasis is restored.
CR: You sound pretty determined.
SH: But I'm an addict. So I wouldn't wonder if you doubt what I'm saying.
CR: You are an addict who knows the biochemistry of addiction.
SH: Of course I do. I have a doctorate in organic chemistry. That's not grandiosity, either; you can ask Mycroft.
CR: I already have.
SH: …
CR: Not recently. I'd tell you beforehand if I had reason to speak to him.
SH: Is there any addict who doesn't know the biochemistry of addiction? Who doesn't know exactly how much drug to take to get the desired effect? Who can't measure the seconds, minutes, hours to the next high in the level of his distress? You don't need a doctorate to know that.
CR: No, you don't.
SH: So why point out that I have one? What does that matter? What does it matter that I'm a genius? When I'm just the same as any other addict, in the end.
CR: Are you?
SH: I thought I wasn't. I hated all of that Narcos Anonymous drivel. Yes, I'll admit that I'm an addict. Not hard to admit to. I know I'm experiencing chemical dependency. I've become sensitized to my drug of choice-cocaine, I mean, heroin was always a complement to it, but cocaine is what I crave-and I need increasingly higher doses to get the same high. My functioning is disrupted; can't play the bloody violin. Otherwise I wouldn't be here.
CR: ...
SH: But I'm here, and I'm clearly an addict. Fit the definition to a tee. But so what? I'm also a violinist. A chemist. An Englishman. A homosexual. A member of the aristocracy. Any number of ways to identify myself. Why focus on the 'addict'? At least, that's what I thought, until the 'addict' started getting in the way of all the other things.
CR: …
SH: Why won't you say anything?
CR: What would you like me to say?
SH: Say something. Anything. Just don't cock your head like that and imagine that I don't know that you're bored.
CR: I assure you, I am not bored.
SH: No? You've yawned twice in the last minute.
CR: I'm thinking. Something you said before; how you wanted to get on with the business of draining the abscess?
SH: Yes. Physical pain as a metaphor for psychic pain. Though, with what we know about biochemistry, we can't entirely separate the two, now can we? Physical pain is psychic pain. Emotions are carried in our neurotransmitters; our sentiments shape our brains, our bodies. Isn't that it? So - I used metaphor, yes. But more importantly: I want to get on with this.
CR: You want to be cured.
SH: Obviously.
CR: Psychotherapy is not surgery, Sherlock.
SH: …
CR: But it's admirable - your desire to change.
SH: Oh, shut it! I don't want your pity.
CR: Is this pity, then? My admiration?
SH: Superfluous flattery. I don't want that. I want you to see me for what I am. I don't shrink from it, so why should you?
CR: And what are you? What part of me do you want me to see?
SH: The miserable addict.
CR: What else?
SH: …
CR: I've been thinking about something. The way you say that you're 'a homosexual.' Not 'homosexual.' Not 'gay'. Not like it just happens to be a trait of yours, like saying 'I'm English' or 'I'm gay.' I've been wondering-
SH: -At the quaint anachronism?
CR: Is that what makes it sound unusual? I can't quite put my finger on it. But-by saying that you're a homosexual, it sounds as if you belong to a particular class of people. An undesirable class, at that.
SH: Are you telling me that homosexuality should be desirable, now?
CR: You look as if you expect me to recoil from you, every time you call yourself 'a homo' -
SH: Not recoil.
CR: What, then?
SH: ...
CR: Did you want to shock me with it, then? Show me the worst - what you believe is the worst of yourself - from the get-go?
SH: There's no point in sugar-coating the facts.
CR: The facts being...?
SH: Who I am. What I am.
CR: And why would that shock me?
SH: Maybe it wouldn't shock you. You work with addicts. You know what we're like. God knows why you want to work with people like us. Maybe the same reason I'm curious about dead bodies: you can tell something about a person by the damage that has been done to him.
CR: As if every addict were the same. As if every body were the same. They're not, you know. And we need people to be interested in both: in the damaged brains and the dead bodies.
SH: Damn it! You want me to be good, is that it?
CR: …
SH: You want me to be admirable? I'm not admirable. I'm selfish, and I'm moody, and I don't get along well with others. You don't want to know what I do for kicks, whom I'll sleep with. You don't want to know.
CR: I do want to know. But-
SH: Time's up?
CR: Not quite.
SH: ...
CR: I want to know - what is so terrible about my showing admiration for you?
SH: It's not terrible. It's just - it's not right. It's a lie. I'm not like that. I'm not good.
CR: All right. I'll grant you that. You're not good. But-can't I admire just one thing about you? The fact that you want to quit. Starting there. That's admirable.
SH: What would have been more admirable would have been not starting in the first place.
CR: ...
SH: ...
CR: Now that we're talking about perfection...
SH: What's that supposed to mean?
CR: There's a phrase that comes to mind: 'The perfect is the enemy of the good.' Which do you want to be, Sherlock? Perfect? Or good?
SH: Perfection is impossible. An ideal. Unattainable. And neither of us can honestly believe that I'm good.
CR: But that's what you have been looking for. Perfection. Am I wrong?
SH: ...
SH: You're not wrong. But I was-if not perfect-I don't have those illusions of grandeur, really I don't-then something close. Not perfect. Certainly not good. But-a prodigy. A genius.
CR: Must a genius be perfect?
SH: I DON'T KNOW! Why must you ask me these questions? I already told you about my childhood, about the trauma. Now why can't we get on with it! Or go back to that, if you prefer. Let's talk about Mycroft, or my father. I'll tell you more about my mother's death. Ask me anything. Open book.
CR: It's easier for you, to talk about the past, than-
SH: Than what? Say what you mean for once!
CR: I'm trying to understand. To understand you.
SH: There's nothing to understand that I don't know already.
CR: ...
SH: I am a genius. Certifiably so. I've done intelligence tests before. But we both know about the biases in that kind of thing, don't we? So. Genius by the book, genius by popular opinion.
CR: Is that another thing that makes you undesirable? Your brain?
SH: Ha! I've never thought about it that way. Does my brain make me undesirable? I don't usually think about the brain and desire in the same context. Depends on whom you ask. To date, I'd say, 'yes.' My brain makes me undesirable to others. No one wants to be entirely seen, not really.
CR: Entirely seen?
SH: I can see through people. You know that. I can see through you. I've shown you that.
CR: And - did you think it would put me off?
SH: You're a professional. You hide it well. But yes, it generally puts people off.
CR: And so you do it first. Before they can get to know you, you get to know them. You reveal their flaws. Hold up the mirror to them.
SH: Are you surprised that I don't have many friends?
CR: I'm surprised that you keep doing it. And that's something I want to understand better.
SH: I take it time's up.
CR: We've run over, so-yes. Time is up.
SH: Thank you, Carola.
CR: You are welcome, Sherlock.