Tuesday, July 23, 1996
1 pm. Initial Session with Cassandra Evans. Ms. Evans, 24, is a secretary/executive assistant who is trying to realize her lifelong desire to become a Hollywood actress. Filled with nostalgia for the Golden Age of Hollywood, Cassie has joined an improvisational theater group called "Winging It" in addition to taking acting classes, etc. from a young age. Cassie was shy and seemed unwilling to discuss her real problems in any depth. This unwillingness was further exacerbated because she arrived 25 minutes late to the session. Apparently she has been having a relationship since college with Brian, who she says is jealous of her acting out love scenes with other men. Cassie also believes that Brian is unwilling to make a commitment to her unless she gives up her unrealistic fantasy of being an actress and becomes a "breadwinner" by devoting herself to her current career. Cassie said one odd thing about how Brian gets his way in everything except "romantically." She immediately became self conscious and refused to go further. Cassie has been keeping a journal for years and I advised her to continue with the journal. She may or may not allow me to read it.

Tuesday, July 30, 1996
1 pm. Session with Cassandra Evans. Ms. Evans made a point of being extremely punctual this session. She describes being treated as a flake by the other employees at SII. She ascribes this to her wish for an acting career and points out that she went to college and has a minor in business technology operations--hardly a flaky major choice. I should order up her personnel file to see what I can learn there. She is trying to prove that she has brains and not just looks. Her family apparently is pressuring her to a "respectable" career path and Brian is joining in the pressure. Apparently Cassie just feels overwhelmed by it all. She has a subserviant attitude towards her superiors at work, and she lets Brian get away with dominating her most of the time, although she clearly resents it. But she is a virgin (and very defensive about it) and won't let Brian sleep with her. She indicated that she might have, if he hadn't come on so strong. This is one area in her life when she is not going to be pushed over. Here she pushes back! I might probe here and find out why this is the point at which she pushes back. It might reveal some formative past events. At the question of whether Brian was faithful, she showed a genuine flash of anger at the idea that he might not be. I suggested that she might do a role playing exercise on demanding respect from her superiors. She was very tuned in to the role that putting on a character's "mask" can have in distancing her from the reality of her situation. She even told me that she could make me blush with her sexual ribaldry, but it would really be a character. To reveal herself, she wants to discourse through her writing. I'm willing to give it a try. She said that she'd drop something off before our next session.

Wednesday, July 31, 1996
I got a letter from Cassandra Evans. I returned to the office late tonight and found a letter had been slipped under the door. The letter is filled with pain. Cassandra felt more comfortable writing the letter than discussing this with me in person. As a young teenager, Cassandra was stricken with some "undiagnosed chronic illness" which was treated with broad spectrum antibiotics. It resulted in a terrible yeast infection, which apparently went untreated for some time because of her embarrassment. Finally she went to a gynecologist and, although uncomfortable, the gynecologist was able to cure the yeast infection. Her gynecologist says that her yeast infection is gone, but that she needs to discuss this with her partner prior to having relations. (I think she misunderstood. Yeast infections are very common among women and are easily brought on by poor hygiene and/or antibiotics. Perhaps her gynecologist said that was prone to yeast infections and that the yeast infection was potentially communicable if active and she took it to mean that the yeast infection was always active. Perhaps I can get her some literature on yeast infections to put this fear to rest.) Her "undiagnosed chronic illness" left her unable to finish high school normally--she had to finish using home instruction. She feels such pain from her experience being ill at that time that she wants desperately to put it behind her, going so far as to not tell anyone of her past troubles. Rallying somewhat, she was able to go to college, although she had to have help from her family to hide her persistent exhaustion. Brian does not know of her medical history. Now she is feeling sick again. She describes it as a terrible flu that won't go away--(Epstein Barr? Lyme? Mono?). Cassandra is also concerned that she might have AIDS and is afraid to test because she feels that she could lose her job if she tested positive. Assuming that Cassandra never had a blood transfusion, and given that she is a virgin and, I suspect, not an IV drug user, Cassandra fits none of the profiles of HIV positive adults. If she is tested, a negative result would reduce her concerns somewhat. Cassandra also says that Brian knows none of this. Now she is afraid that if she tells him, he will leave her. I should refer Cassandra to a good internist and get a proper workup.

Thursday, August 1, 1996
I received the Hiring Section of Cassandra Evans Personnel File. It confirms what Ms. Evans told me about her educational background. She left her LA position to be close to her parents who moved to the Bay Area. She works for Sylvia Bows in customer service. Sylvia writes a glowing evaluation of Cassandra at the end of her probationary period.

Tuesday, August 6, 1996
1 pm. Session with Cassandra Evans. Cassandra was more upset during our session than she had been during the previous sessions. I believe it was a release occassioned by bringing me into her confidence respecting her medical condition. It is clear that Cassie has a lot of medical problems and it is extremely important to try to straighten them out. Unfortunately, the kind of undifferentiated symptoms that she is presenting can tend to lead to inconclusive diagnosis. And she has lost faith in doctors in general. She tested negative on Lyme and Epstein Barr, but has never been tested for mononucleosis. HIV can be pretty well ruled out. I looked up the internists in the CalaCare HMO plan and found Doug Halsey at UCSF. He's a young guy without a lot of experience, but I got the sense that he is a caring practictioner. I will make a referral to him, but Cassandra might be reticient about going through yet another round of tests. Cassie's illness is making her break dates with Brian, who is becoming increasingly jealous. He can't understand what is going on, and Cassie won't tell him. She doesn't think she can explain it to him until she understands it herself. Her family and a high school friend know about her condition and help her cover it as best they can from outsiders. Cassie is feeling sicker now than she has in a long time. She is spending all her energy trying to keep up at work.

Tuesday, August 13, 1996
9:30 am. Telephone Call from Cassandra Evans. Cassie called and cancelled her appointment this afternoon. She is too sick, and has missed a couple of days of work. She is extremely afraid of losing her job and said she was worn out from physical pain, crying, and emotional distress. I referred Cassie to Doug Halsey at UCSF and, after some hesitation, she agreed to call him and make an appointment. She spoke to her previous general practictioner who was reluctant to release medical records. I told Cassie that I'd give him a call.

Tuesday, August 20, 1996
1 pm. Fourth Session with Cassandra Evans. Cassie has been going to work again, although she has had to resign from her improvisational theater group. She still feels unappreciated at work. Cassie has an appointment next week with Dr. Halsey. She is concerned that SII will find out about her medical condition, which I told her was partly unavoidable, given the health plan. She seems to be opening up somewhat to Brian, taking her part way into her confidence regarding her health. Brian has been supportive so far, but Cassie is concerned that he will dump her when he realizes the extent of her problems. Cassie thinks that Brian is not very tolerant of illness based on his comments about an uncle who was ill. Cassie wants to bring Brian to her session with Dr. Halsey or to one of our therapy sessions to explain it all to Brian. Cassie seemed most concerned about the long cured yeast infection, which I assured her was the least of her problems. Her friend Michelle, who is very close--like a sister, doesn't like Brian because he is impatient.

6 pm. Got a look at Cassandra Evans doodle she brought me today. Clouds with a lightening bolt are above, sun peeks through the clouds below and Cassandra is in the middle left of the frame, a tear in the eye but a half smile on her face. She looks brave. A pierced arrow and two flowers surround Cassie. It has a happy, optimistic feel.

Tuesday, August 27, 1996
1 pm. Fifth Session with Cassandra Evans. Cassandra seems extremely tired. She says that she requires 12 hours of sleep a night, and rarely gets it. She had a fainting spell at work, which concerns me. She has seen Dr. Halsey, who's called me and left a message. I'm waiting on his report. She liked him, which is extremely important given her strong aversion to doctors. She had a fight with Brian over her ability to go out with him. She's proud of asserting herself with him even if it leads to discord in their relationship. A girlfriend is coming to town on an expense account, and Cassandra is looking forward to staying up all night, talking and having a girl's night out. She hasn't internalized her medical condition, because she is still able to think of herself as able to stay up all night. She vaguely requested sleeping pills which I deferred until I had a chance to talk with Dr. Halsey.

Thursday, August 29, 1996
7 pm. I received a letter from Dr. Doug Halsey on his examination of Cassandra Evans. Dr. Halsey believes that she may be suffering from an immunological disorder, although he is not ruling out infectious disease or other possibilities. He is concerned about ordering a multitude of tests because of Cassie's extreme distaste for medical procedures.

Friday, August 30, 1996
1:30 pm. I received a call from Cassie. She says that she has felt quite sick the last few days, and she is hoping that Dr. Halsey can get to the bottom of her ailments. She complained about irregular sleeping patterns. I told her that I wanted to wait until I got the lab report from Dr. Halsey before considering anti-depressants.

Tuesday, September 3, 1996
1 pm. Sixth Session with Cassandra Evans. Cassie was sick again during the session, and very sad and depressed. Physically, she is having joint, muscle, and skin pain in addition to exhaustion, sleeping problems, chills and hot flashes. Emotionally, she reports crying hysterically. She is panicked about possible reprisals at work because of her illness and absences, together with the fact that she is seeing a psychiatrist. When I questioned her about it, she said that she could deal with the fact that she has a chronic ailment if only it was properly diagnosed. A school friend once told her that maybe she was suffering from Munchausen's Syndrome and, after looking it up, Cassie was outraged. I told her about factitious disorder and how I was convinced she was not looking for attention in this manner. Dr. Halsey hasn't given her a report yet, but she has an appointment tomorrow. With regard to Brian, she had a fight with him which he cured by bringing over roses, pizza, and a video. Cassie thinks she may be in love with Brian, and yet she is considering ending the relationship because it might not be worth the trouble. Cassie described a romance dream with a stranger with smoldering blue-gray eyes, and she is wondering if Brian is the right man for her. I believe that Cassie is suffering from serious depression brought on by general medical conditions. From my experience with pain management centers, I believe that Cassie should be taking anti-depressants. She may find a substantial improvement both in depression and outlook but also a reduction in the severity of her pain. Discuss with Dr. Halsey about appropriate anti-depressant therapy and suggest it to Cassie at our next session.

Monday, September 9, 1996
9:30 am. Telephone Call with Dr. Halsey regarding Cassandra Evans. Doug Halsey over at UCSF gave me a call to report his findings on Cassie. He found her quite challenging. Physically, he found lowered magnesium and calcium levels with elevated titers for Human Herpes Virus 6 and a lower than average white blood cell count. She had various physical symptoms including low blood pressure, swollen lymph glands, abnormal heart rhythms and she reported a previous EEG finding of non-functional dysrethmia. Halsey's preliminary diagnosis is that Cassie is suffering from the "Yuppie Flu"--Chronic Fatigue Syndrome. There is no definitive test, rather it is the elimination of a number of other items which leads to a positive diagnosis. One of the factors is psychological and so Halsey asked me to opine on Cassie's mental state. I stated that while she was clearly suffering from depression, it was exogenous and not endogenous. I ruled out a diagnosis of primary depression and thus told Dr. Halsey that I did not believe Cassie's depression was a causative agent of her physiological disorders. Dr. Halsey was in agreement about putting Cassie on a serotonin reuptake inhibitor. Unfortunately, there is no generally accepted treatment for CFS. Halsey is going to talk to the international community which has had more success fighting this problem than we have in the U.S. But Halsey confirmed that CFS is definitely of physiological origin and is decidedly not psychosomatic. I believe that alone will be a great relief to Cassandra. Since it appears that there might not be a lot we can do for the underlying physical complaint, Dr. Halsey's job is to try to reduce the severity of the symptoms, while my job will be to help Cassie first understand and eventually accept her physical condition, to help her reduce her depression, and to cope with her life given her disability.

Tuesday, September 10, 1996
1 pm. Seventh Session with Cassandra Evans. Cassie and I spoke about her diagnosis by Dr. Halsey of chronic fatigue syndrome. Cassie is just beginning to understand what it is and how it is going to affect her life. She is very happy, though, just to have a diagnosis. Dr. Halsey suggested that Cassie find a CFS support group, a suggestion with which I concur. Cassie got some letter about her absenteeism from Ms. Bows which went into her personnel file. She is quite unhappy about that. Cassie also heard that Ms. Bows was in the hospital and she went to bring her flowers. She was quite surprised to learn that Ms. Bows was in the maternity ward. Cassie hasn't told anyone about her diagnosis yet--her parents are out of town and she doesn't know what to tell Brian. I told her that we would work together to find a way that she could explain the disease to others. She is to get a packet of information from Dr. Halsey on CFS probably forwarded on from the Center for Disease Control. But Cassie is very pleased to find out that there is a physiological causation to her illness and that it wasn't psychosomatic. Cassie is still crying a lot and feeling helpless. I prescribed Prozac, 20 mg. once each morning.

Friday, September 13, 1996
10:30 am. Telephone Call from Cassandra Evans. Cassie called and reported that she is having a poor reaction to the Prozac. She reports that she is feeling dizzy and lightheaded, nauseaus, and some slurred speech although I didn't hear it in our conversation. She says that she feels intoxicated. She started taking the pills on Wednesday, so she has only had three 20 mg. doses. I asked her to take one more dose on Saturday and to see how she feels on Saturday. From what Dr. Halsey said, CFS patients often have hypersensititivity to drugs and she could merely be experiencing a longer acclimation stage than normal. But if she is still experiencing problems after four days, I will switch to another antidepressant.

Tuesday, September 17, 1996
4 pm. Tenth Session with Sylvia Bows relating to Cassandra Evans. No one at SII knows about Sylvia's pregnancy except Cassie, apparently.

5:30 pm. Telephone Conversation with Cassandra Evans. We had scheduled a session by telephone during our last session. I can't say that it was completely satisfactory. It's amazing how much difference it makes to be in the room with a patient during a session. In any case, Cassandra is still having vestibular difficulties with movement, balance, and nausea, potentially as a result of the Prozac. So I discontinued the Prozac and will start Cassie on Zoloft during our next session. Cassie is unhappy with Brian because he doesn't make her happy. She has a recurrent character in her dream--a man with smoldering eyes who sees through her soul--that makes her wake happy. Brian suffers in comparison. But Cassie sees herself as "damaged merchandise," given her medical condition. Cassie has yet to tell anyone about her diagnosis except for an aunt who questioned her sharply about her slurred speech on the phone. But I listened closely and couldn't detect any slurring of Cassie's speech.

Wednesday, September 18, 1996
I got a call from Cassie. What we talked about was inconsequential--about her health insurance's bill--but I did notice that she was slurring her words slightly. I thought it odd that she would still have some adverse effects from the Prozac after we had discontinued it 24 hours earlier, but perhaps the effect will go away after she has stopped the Prozac for a longer period.

Thursday, September 19, 1996
Letter to Bill Bennett respecting Cassie. I spoke in part about Cassie in my letter to Bill Bennett.

Thursday, September 26, 1996

5:30 pm. Eighth Session with Cassandra Evans. Cassie reports that the side effects from the Prozac have diminished and I couldn't hear any evidence of the slurring speech problem that she suffered from previously. I was horrified by the insensitivity shown by the members of her acting troupe who equated Chronic Fatigue Syndrome with voluntary laziness. Cassandra was very hurt at her first attempt to "come out of the closet" as she put it. Her parents were more sympathetic but not being acquainted with the disease were of little help in trying to assist Cassie in coping with her diagnosis. They will become a better resource as they come to grips with Cassie's condition. Cassie's relationship with Brian is getting stranger and stranger. She reports that he is much more attentive to her now that she is increasingly hostile towards him. Cassie seems to be deliberately seeing how much he will take. She is irritable towards him even when he is making an effort to be nice. Cassie continues to have her dream about a mysterious stranger against whom Brian suffers in comparison. I think that the dream is having an effect on Cassie's relationship with Brian. The mysterious stranger with all the positive attributes sought in a lover (or at least missing from the current love interest) is a fairly common fantasy. I was startled when Cassie described almost smashing a vase over Brian's head because he was irritating her, but she successfully checked her violent reaction. It seems completely out of character for her, but a long exposure to pain can change one's personality rather drastically. I think that Cassie should receive some pain medication and I will speak with Dr. Halsey about some appropriate analgesics. I'm concerned about giving Cassie narcotics-based medications because of their addictive potential in a chronic pain situation. Perhaps Dr. Halsey can recommend a better pain management program, perhaps involving Naprosyn or Datril. In general, I'm concerned about Cassie's ability to cope with her newly diagnosed condition. While before her base emotion was fear and being out of control, now she is getting more aggressive, and not channeling her aggression against her condition. She seems fatalistic about her disease and hasn't yet learned how to direct her aggression against her disease rather than those that surround her.

Doodles of Cassandra Evans. Cassandra gave me a little pink sheet with some doodles on them and said that they related somehow to her romantic mysterious stranger dream. Although they are less revealing than they might be, the thing that strikes me immediately is that they are all crowded into the upper left hand corner of the paper. They are little doodles, cramped, tight, and disconnected one from another. There is a small face with big, closed eyes and a straight line for a mouth. There is a little group of wildflowers, lots of stems and not a lot of flowers. There is something that looks like a broken toy jack-in-the-box and one shape that looks like a cross between a teddy bear and the state of Louisiana. A little box with a shadow and a tiny arrow pointing at it completes the quintet of drawings. The drawings all give the impression of being broken somehow, perhaps slightly damaged. Perhaps Cassie really does view herself as "damaged merchandise" as she said during our last session. I can't see any connection between these drawings and her attempts at sketching the face of her mysterious dream lover.

Thursday, October 3, 1996
5:30 pm. Ninth Session with Cassandra Evans. Cassie is worried about losing her job because of missed days of work. She missed work today and came to her appointment by cab. Her friend Michelle is planning a visit to San Francisco and called Cassie brimming with exciting plans for the two of them. Cassie was at a low point and wept over the phone to her friend. Michelle was very sympathetic and said that she is going to do some research into CFIDS (Chronic Fatigue and Immune Dysfunction Syndrome) for Cassie. The reaction of the nasty girl from the improv group to Cassie's confession about her illness still haunts Cassie. Brian is becoming a non-entity in Cassie's life. She told him about her illness over the telephone and he apparently related it only to himself--"Is this why you won't sleep with me? Is it contagious? How could you put me in harm's way?"--until Cassie hung up on him. He has called and left messages apologizing, but Cassie won't return his calls. Cassie says that she doesn't know if she loves him or even if she could love him, but she is concerned that she won't be able to do better because of her illness. Oh, Cassie came up with another name for CFIDS that I liked better--myalgic encephalomyelitis, or muscular pain resulting from a viral infection of the central nervous system. Cassie confessed to not liking the name Chronic Fatigue Syndrome as well--it seems to trivialize the disease. Cassie is thinking about a roommate to help her out in return for cheap rent, which makes some sense. And Cassie likes Dr. Halsey, who is boning up on CFIDS for her benefit. She railed against some overpriced predatory specialist in CFIDS and feels that Dr. Halsey is much more human and probably just as good. I was actually pleased with Cassie during this session. Although she was very weak and sat in the chair without much animation, I could tell that she has a new determination about her condition and coping with it. I think she's slowly learning to channel her aggression constructively. Perhaps eliminating Brian as a distraction was a good move on her part.

Thursday, October 10, 1996
11:30 am. Telephone Conversation with Michelle Markson relating to Cassandra Evans. Cassie's friend Michelle called me to tell me that Cassie was going to miss her session. Michelle is visiting from out of town and they are in Michelle's hotel room at the Clift. Cassie had too much excitment the night before and is paying for it this morning. She is having trouble getting out of bed. She asked Michelle to call in sick for her at work in addition to calling me. Michelle also said that she was in pain. Unfortunately there isn't much I can do for her physically. In CFS patients, there is no substitute for rest.

Thursday, October 17, 1996
5:30 pm. Cassandra didn't show up for her session. She has always been very responsible about her sessions--even when quite ill she either dragged herself to the session or at least called. But last week she had her friend Michelle call for her and this week I have had no word at all. She must be ill and I'm worried about her, so I'll try and get in contact with her tomorrow.

Friday, October 18, 1996
I tried to get in touch with Cassandra Evans today, calling her home and her work with no success. At work they told me that she had been absent for quite a period of time. They weren't specific, but I gathered it was at least a week. At home, all I got was Cassandra's answering machine--I left a message of course. I even talked briefly with Dr. Halsey, but he said that he hadn't heard from her, although they had no appointment scheduled during the last couple of weeks. I should make sure to get an emergency number for Cassie. I am starting to get really worried.

Tuesday, October 22, 1996
11:30 am. Telephone Call with Cassandra Evans. I got a call from Cassandra. She's been at her grandmother's house at 555-9801. I was getting frantic with worry over her since she wasn't at her last session, Dr. Halsey hadn't heard from her and they hadn't heard from her at work. Apparently, she has suffered a fairly serious relapse, including several seizures. Her speech is slurred and she sounded almost drugged and very lethargic. She has trouble putting together her thoughts. And she sounds like she is in a lot of pain. I contacted Dr. Halsey and he said that he would call her right away. Cassie says that she hasn't been able to sleep for days, which would account for the disorientation and some dementia. I suggested to Dr. Halsey that he might consider a sleeping pill, but he seemed doubtful. He told me that CFIDS patients often have bizarre atypical reaction to drugs, especially to sleeping pills and that he was afraid of over-medicating Cassandra. He did think that it might be appropriate to bring her into a hospital setting especially with seizures. He said that he would very much like to run some EEG studies on Cassandra to see if she might be suffering from another undiagnosed disorder on top of the CFIDS. I wish there was more I could do for her, but her problems are primarily physiological rather than psychological. I can help her deal with the consequences of her illness, but I can't do much to treat her illness itself. It makes me feel inadequate, like I've failed her somehow like so many other doctors before me.

Thursday, November 14, 1996
10 am. Telephone Conversation with Cassandra Evans. I finally heard from Cassie this morning. She is still very sick and is staying with her grandmother. She took a leave of absence from work and is even sub-letting her apartment, so it sounds like she feels that her convalescence is not going to be brief. She sounded confused and dispirited. I asked her if she had talked to Dr. Halsey and she had not--she said that she had left him a message but might not have included a return telephone number. Instead, she has been investigating alternative therapies recommended by another CFIDS sufferer. She went to one doctor who suggested aggressive treatment including some combination of blood removal and sterilization, radiation and chemotherapy. Cassie believes that the doctor was just a predator who saw her as a profit center. She may be right, actually. I'm really worried about her and feel impotent in the face of her physical medical condition. I wish that there was a way to keep in closer touch with her, but for now I must take whatever time Cassie is willing to give me.

Friday, April 18, 1997
9:15 am. Telephone Conversation with Cassandra Evans. Cassie called back! Taking me completely by surprise, she called out of the blue, interested in renewing her therapy sessions. I hadn't heard from Cassie since November of last year when she suffered a serious decline in her health and moved in with her grandmother. Apparently, she has recovered somewhat. She is even trying to get back to work part time. She has ended her relationship with Brian and has taken up with a new man named David, who is a psychology student presumably doing research at a CFIDS support group where they met. Cassie is still very unwilling to be dependent upon others, and when she is forced to be, she reacts emotionally. That was her reaction when she was telling me about David's willingness to take her to therapy sessions. But I was unwilling to set our sessions at 8:30 at night to accommodate David's schedule. I asked Cassie to try to work something else out, and I'm willing to resume our sessions by telephone, if need be.

Friday, May 2, 1997
11 am. Tenth Session with Cassandra Evans. Cassie started the session by telling me just how miserable she felt. This was the first session we've had in nearly half a year, and while there have been many changes in the external circumstances of her life, many things have remained the same. Her feelings of frustration and anger over her affliction--Chronic Fatigue and Immune Dysfunction Syndrome--are as deep as ever. Cassie hates being sick and having so little control over her life. She doesn't know day to day if she will feel well enough to get out of bed in the morning. Cassie is also frustrated by the lack of treatments available to her. The medical community has little to offer her and the self-help options found in popular magazines and books are questionable, to say the least. Cassie described one with derision that recommended a concoction made of bananas, carrots, and linseed oil. Cassie wanted to spend the session analyzing a disturbing dream that she thought might hold some key to her psyche. The dream had her inflicting great violence on a white rat, which she associated with the prying busybodies who ask her ceaseless medical questions. Cassie constantly has to deal with people who feel that her condition is a sham. I was at a dinner party recently and a man told me, with a knowing wink, that his shiftless brother-in-law had told him that he was suffering from chronic fatigue syndrome. I thought of poor Cassie as I told the guy about the very real medical problems faced by those inflicted with CFIDS. At the end of our session, Cassie grew pale and was clearly too tired to continue. So I let her rest on my couch with the lights dimmed low while waiting for her ride home.

Monday, July 7, 1997
12 pm. Eleventh Session with Cassandra Evans. Cassandra came in after about two months of no contact. Other than being a sounding board for Cassandra's frustrations, I'm afraid that I am unable to offer her much in the way of treatment. But I'm glad to be of help, even in a minimal way--perhaps I can help allay her distrust of the medical profession in general. She is still suffering acutely from CFIDS, but has developed a series of coping strategies. Her relationship with David is still strong--he seems to have the ability to make her laugh at her own irritability, which removes a lot of stress from their relationship. Cassandra is still seeing Dr. Halsey, and thinks highly of him. But she has decided to also seek treatment from a chiropractor. I've met very conscientious chiropractors in the past, but the field also seems to attract a number of quacks. From her description, the guy sounded like he might fall into the latter category. She said that, aside from having a general distrust of modern medicine, he doesn't believe in germs, thinking instead that all maladies come from back alignment problems. But Cassie is having back pains, and his treatments seem to help that a little, so I didn't dish the guy. Cassandra is also having problems in getting Social Security to recognize her malady as a disability. Cassandra brought in an article about a 40 year old woman suffering from CFIDS who sought Kevorkian's help to commit suicide. Cassandra clearly identified with the woman, although she evidently has no plans to commit suicide herself. Cassandra is still troubled by recurring dreams, and has taken to keeping a dream journal. After hearing Cassandra's dreams about the black and white rats that she told me about during her last session, David purchased a porcelain figurines representing those rats, and the dreams disappeared. Cassandra notes that the dreams seem to go away when she has learned whatever it is that she thinks she was supposed to learn from them. So that dream has been replaced by a new one, where she is mountain-climbing with some friends, but has inadequate equipment and falls a long distance, finally landing hard. She is blinded by the fall and regains consciousness with unseen things pecking at her. Her screams are muted. She has difficulty dragging herself awake. Cassandra felt that the inadequate equipment was the CFIDS, the falling was despair, the blindness was a feeling of having lost her way, and the pecking was the doctors trying to analyze her medical problem. By the end of the session, Cassandra was clearly getting exhausted, so I ended it a few minutes early.

Tuesday, July 15, 1997
5 pm. Twelfth Session with Cassandra Evans. Cassandra called this morning and asked me to squeeze her in for a session today. She and David had an argument over money--David was angry that Cassandra was spending some money that she really couldn't afford to take a friend to lunch to celebrate her friend's promotion. I've never met David, but it sounded a lot like the argument was over something very different than what was expressed. Cassandra said that David seemed to be spoiling for a fight. Cassandra reacts poorly to arguments. She said that she's afraid that she'll appear stupid, she's afraid of the argument escalating, and she's afraid of feeling even more pathetic. She feels like she's being punished for not being a good person. I tried to teach Cassandra some fairly straightforward communication skills--refusing to be drawn into an argument, but instead framing a conversation as an explanation of how she is feeling without interruption. But I know that all that is much easier said than done. Cassandra also is feeling helpless in negotiating the normal details of ordinary life and it makes her feel like a sick pet. She finds it difficult to accept other people's help. I asked Cassandra about her day, and I got the distinct impression that she is waiting to get better before giving herself permission to live at all. So I told her to find something that interested her--a hobby perhaps or a field--and try to spend some time working towards that goal. I told her not to spend her life waiting to get better--to engage her life in whatever degree she was capable in now.


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