Of dreams and duty

Gerald P. Koocher, PhD
Children's Hospital, Boston

Psychotherapists sometimes have work-related nightmares. I remember two in particular.

The first one begins in line for a surrealistic theme park roller-coaster thrill ride. As the line winds slowly toward the start of the ride I notice that I'm standing among friends, relatives, and dozens of bald-headed or bewigged children, several of whom I recognize as patients I treated before they died from cancer. Sudden-ly we are on the loading platform, and I notice a sign with large red letters: "WARNING! Up to 40 percent of riders fall to their deaths. Check your safety bar." I find myself seated in the last seat of the back car. I pull the safety bar toward me and hear a reassuring "click," as it snaps into place. As I look up the car begins to roll down the chute, and I notice that many of the riders in front of me have not secured their safety bars. I feel a desperate urge to reach out and help, but I am locked in my seat and cannot help. We plunge into darkness that is broken every few seconds by the flash of a strobe light. With each flash I see more empty seats in front of me. There is nothing I can do.

The second dream takes place in Joey's hospital room. He's five years old, alone, desperately ill, and very sad. He does not talk about his illness and can hardly pronounce "aplastic anemia" anyway. Still, he knows that he's been getting sicker for the past few months, and has had to live in sterile isolation for several weeks because of a weakened immune system. Everyone who visits him must be gowned, gloved and masked. No human skin has touched his since he entered the sterile environment. He looks me in the eye and asks, "Where are you." I wake from the dream in a sweat; it's 4 a.m. I've been home in bed for four days recovering from a bout with mononucleosis. I feel an urgent need to call the hospital, and despite the early hour dial the nursing station. I ask about Joey, and the charge nurse hesitates for a moment, then says softly, "He died in his sleep two hours ago. We knew you were out sick and were going to call later to let you know."

One need not review Freud's essays on dream interpretation to recognize what is happening. The rational desires to help and to comfort are trumped in sleep by the magical wishes to meet every need, to cure, and even to stave off death. My cognitively oriented colleagues have a solution, "positive self-talk." I remind myself that I'm a good-enough therapist, that no one can (or should try to!) worry about meeting every patient's needs, that my work helps improve quality of life for critically ill children and their families, and that psychotherapy cannot, after all, cure cancer. Sometimes it works. Then I think about Matthew.

Matthew was referred to me for evaluation and then out-patient therapy because of severe behavior problems, including an attempt to hang himself in a school closet, where an angry teacher had locked him. When I first met Matthew he was physically healthy, but his life was in chaos. At eight years old, his family was festering through a bitter divorce and he soon found himself transferred to a therapeutic day-school of emotionally troubled kids with learning problems. I continued to see him twice a week. Then came the persistent back pain and the diagnosis of an invasive tumor near his spine. Surgery "got most of it." The medical prognosis was, "guarded." Radiation and chemotherapy followed, along with more than one fist fight between relatives in his hospital room. Three years, and many therapy sessions, later Matt was able to re-enroll in regular school and try to resume a normal life. There were other bumps in the road; the need for spinal surgery and a steel rod to support weakened bones, continued family crises, and fears of late-effects from chemotherapy, including cardiac toxicity. Our weekly treatment sessions tapered off, but each time a new stressor cropped up another session or two seemed to help. This year Matt will graduate from college with honors and a handful of job offers. He's mentioned more than once that I've helped him get there.

Sometimes colleagues who know me as a researcher, teacher or treasurer of APA are surprised to hear that I regularly treat children and families confronting life-threatening illness. That tends to be a real conversation stopper. I seldom go into detail about the cases, but the usual reply is, "I don't know how you can do that kind of work." I remember Joey, Matthew, the kids in line for the roller coaster, and think to myself, "How can I not?"