Monday, September 9, 1996
2 pm. Therapy Session with Sarah Wright. Sarah came into my office, took off her shoes and tucked her feet under her on the sofa. She is a white woman, quite short, 33 years of age. She has three children, ages unknown, and a husband named Jeff. Sarah suffered a heart attack three months ago, and is having related post-cardiac mental difficulties. Repeatedly, she has gone to the emergency room with chest pains, believing she was suffering a recurrence. And repeatedly, she has been examined, sedated and sent home. She is also suffering symptoms of panic attack and depression, long periods of crying, a feeling she describes as like she is going to explode or jump out of her skin, sleep disorder (can't stay asleep), recurrent nightmares (falling down a flight of stairs). She also describes an intermittent problem of confused speech where she says one thing but means something quite different. I didn't notice any evidence of disorganized speech (positive formal thought disorder) during this visit and certainly alogia is not indicated. The example that she gave did not sound like the disorganized speech manifests only in times of high stress or at times of other physical or mental extremes. She is hiding her speech problem from Jeff. Sarah was apparently under quite a bit of stress at the time of her heart attack, working two jobs part time in addition to her family responsibilities. She tries to justify her heart attack as happening for some cosmic reason, but she is clearly terrified of a recurrence. Sarah doesn't get along well with her mother-in-law. Until recently, she felt like other people were controlling her life, especially her husband and her boss. She wouldn't talk about her problems with her previous (?) employer. Sarah carries nitroglycerin pills and reports that the Ativan (lorazepam) she has been taking aren't working for her. I've switched her to alprazolam 1 mg. tablets t.i.d., and cautioned her against drinking and pregnancy. Xanax has withdrawal problems, so I must be careful especially if she goes over 4 mg. daily.

Monday, September 16, 1996
9:30 am. Telephone Conversation with Sarah Wright. Sarah has a sinus infection and so cancelled our session. She said that she hasn't had any side effects attributable to the alprazolam, nor any effects at all for that matter. We rescheduled the appointment for next week.

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

Monday, September 23, 1996
2 pm. Second Session with Sarah Wright. I started to talk to Sarah about her heart attack and the stress in her life leading up to that event, but she deftly changed the subject to tell me a story about her ex-boyfriend Robby Treynor, who also became her employer until a month before the heart attack. The upshot is that when she was 18 and just finishing college she discovered that he was gay after she had become pregnant. Without telling Robby, she ended up marrying Robby's best friend Jeff who knew that she was pregnant with Robby's child. This was in 1981. In 1982, Melissa was born, followed by Jeff, Jr. (JJ) (approx. 1985) and Nicolas (approx. 1987). The two boys were fathered by Jeff. At one point during their marriage, Sarah tried to initiate a relationship with Robby again, but Robby informed her of his sexual preferences which Sarah eventually accepted. Robby now knows that he is Melissa's biological father, although Melissa has not been so informed. Sarah was surprisingly dispassionate as she told me this tale of lost love. She seemed to be relating a story that happened to someone else, chuckling sometimes at some of the parts that must have been particularly wrenching when they occurred. She seems to have come to terms with this part of her history.

Monday, September 30, 1996
2 pm. Third Session with Sarah Wright. Sarah complained of a series of symptoms--crying spells without warning, mental anguish, a sense of losing her mind--classical anxiety symptoms. She explained how she has been living a lie with her husband Jeff--a loveless marriage where she feels under an obligation to play the role of the loving wife because Jeff saved her from a tough predicament when she found herself pregnant by Robby. Sarah believes that Jeff is unaware that the role she has assumed for his benefit is anything other than completely genuine, and Sarah wants to keep it that way. At the same time, Sarah believes that her destiny lies with Robby. She believes strongly in reincarnation and believes that her soul and that of Robby are destined to be together--that they were kept separated from each other in past lifetimes. It is certainly true that they are being kept apart in this lifetime--Sarah by the bondage of her obligations and Robby by his sexual preference. I believe that the stress of sublimating her own personality (she describes the real Sarah, which she says comes out with Robby, as crass, opinionated, and sassy while Jeff's Sarah is the soft-spoken, non-opinionated wife and nurturing mother) to satisfy her obligations to a man whom she respects but does not love, is now surfacing in the form of these anxiety attacks. She even mentioned that she has thought about suicide, although she believes she lacks the "courage" to take that step. She gave me the business card of her cardiologist. I'd like to talk to him about my prescribing alprazolam tablets (Xanax?) to treat her anxiety attacks. This is a patient who might need medication in the short term, but whose continual stress caused by acting a role is bound to cause further physical difficulties.

Monday, October 7, 1996
2 pm. Fourth Session with Sarah Wright. Sarah had a dream that has a lot of significance for her. She keeps replaying the dream in her head over and over. And I believe that she has given the dream an appropriate interpretation. She dreamt that she was handcuffed to a wheelchair and Jeff push the chair around, but when he wasn't there, she could slip out of the handcuffs and walk on her own. Jeff treats her like an invalid and she lets it happen, when she knows that she is a strong individual. She describes a series of complaints against Jeff, all of them objectively petty. But to her they are serious issues of lying and disrespect. My guess is that she can read the actual motivation behind Jeff's actions and thus is reacting to the motivation (the disrespect) rather than to what he actually says or does. For example, she was furious when Jeff questioned whether or not she should volunteer to buy a camping coffee pot. She's also caught him in petty lies that don't really amount to anything but which annoy her nonetheless. However, she describes Jeff as a good husband who doesn't drink, cheat, or abuse her. She is trying to stand up for herself more and Jeff is concerned about how this will impact on his life. Sarah thought once of leaving Jeff to marry Robby and construct a front behind which Robby could hide his homosexuality, but Robby refused the offer. I'm surprised that being homosexual could hurt a dental practice in San Francisco, but perhaps the fear of AIDs communicability would cause patients to seek another dentist. I also presume that Robby purchased a rather conservative dental practice. Sarah's upbringing was loving but unstructured. Jeff, who idolizes his mother, insists on emulating the conservative upbringing of his youth. Sarah is feeling stronger in her position and is starting to challenge Jeff's dominance over their lives. Sarah believes that standing up to Jeff makes her a better person--someone she respects. I told her that making such a transformation was not going to be easy to accomplish as she and Jeff have long established patterns that must be broken. But Sarah sees making these changes as the key to her survival.

Monday, October 14, 1996
2 pm. Fifth Session with Sarah Wright. First Sarah recounted a dream where she and Robby were having sex and everything was idyllic until after the act was consummated. Then Robby turned vicious, dragging her by the hair and demanding to know if she was happy now. When she next turned around she saw Robby back on the bed having sex with six other men. The dream, which Sarah took as an allegory representing their sexual relationship as a whole, led to a discussion of Sarah and Robby's sexual history. Although they dated for a couple of years in high school, they only actually attempted intercourse twice. Once was when Robby was at least partly inebriated and had difficulty maintaining an erection except when acting almost savagely and the other after he became aroused viewing an X-rated videotape featuring, at least in part, homosexual fellatio. The second occasion, which presumably led to Melissa's conception, ended with Robby vomiting in the bathroom subsequent to emission. He blamed it on food poisoning. It was after that last sexual encounter that Robby left unexpectedly to college and Sarah discovered that she was pregnant. Looking back on it, Sarah believes that she was some kind of test for Robby to ascertain his true sexual preference. Sarah described how years later Robby actually told her that he was homosexual in response to her desire to initiate a relationship. Sarah didn't believe him at first, but Robby convinced her through a narrative of the pain of discovering a homosexual sexual preference. I was struck by the assumption that Sarah expressed in a prior session that she and Robby would get married after high school. I can only assume that Sarah was blind to what must have been obvious to Robby--their sexual relationship was such that without dramatic improvement, they were not going to have a successful marriage.

Monday, October 21, 1996
2 pm. Sixth Session with Sarah Wright. Sarah discovered that her husband and Robby have been conducting a long-time homosexual affair. She heard a message from Jeff to Robby setting up a meeting when he was supposed to be playing golf and went over to Robby's place with a friend and watched as Robby kissed Jeff goodbye at the end of their rendezvous. When confronted, Jeff walked out the door without a word and hasn't been seen since Saturday afternoon. Sarah believes that her marriage to Jeff and the last fifteen years of her life has been a set-up orchestrated by Robby and Jeff. She is enraged and said that she is plotting violent revenge, although she assured me at the end of the session that the violence is just a fantasy of what she'd like to inflict upon Robby and Jeff. I suggested St. Helena or at least a tranquilizer, but Sarah was having none of it. I don't think that Sarah is really a danger to Robby or to Jeff, but I begged her to contact me this week and let me know how she is doing.

Monday, October 28, 1996
5:40 pm. Telephone Call from Jeff Wright. Jeff called looking for Sarah. He hasn't talked to her since that day when he walked out after she confronted him with what she knew about his relationship with Robby. He didn't deny a sexual relationship with Robby but did say that Sarah was mistaken in her belief that their entire relationship had been a set-up from the beginning. Jeff wanted me to tell Sarah that he wants to talk to her. I told him that I would, although Sarah missed her session today.

8 pm. Letter from Sarah Wright. I went out for dinner and came back to the office to catch up on some paperwork. A letter from Sarah had been slipped under my door. She apologizes for missing the session this afternoon. It's apparent that her homicidal impulse has subsided somewhat but that her anger has not. She hasn't yet told her parents about Jeff and Robby, which indicates that she is still considering a possibility of some sort of reconciliation, although I wouldn't be surprised if she used this incident as her chance for freedom from a loveless marriage. The stationary, from Robby's dental office, has his logo, which is shaped like a smiling face, marred by vampire teeth and a crude representation of a penis aimed at its mouth. Robby's name has been scratched out.

Tuesday, November 5, 1996
I received another letter from Sarah Wright. This one was slipped under the door. She apologizes for missing the session yesterday and says that she is not ready to mentally confront the issues with Jeff and Robby, although paradoxically she says that she needs the time to sort things out. I don't think that Sarah quite understands the value that a therapist can have in dealing with emotional crisis--she is avoiding talking with me as a way of avoiding having to come to terms with her husband's homosexuality. She is talking about divorce and trying to figure out how to explain the situation to her kids. She promises to call in the next few days and set up an appointment.

Monday, November 11, 1996
9 am. Telephone Call from Sarah Wright. Sarah called to cancel our appointment this afternoon. However, she actually sounds desperate to talk to me--I noticed something akin to panic in her voice. Jeff told her that Robby has AIDS. Jeff had himself tested and he is negative. Sarah has an appointment with her doctor to get tested herself. Furthermore, Jeff has asked Sarah not to divorce him. In fact, he has requested that Sarah consent to allowing Robby to move in with them now while Robby suffers through the later stages of AIDS. So if Sarah consents, she will find herself living with her own and her husband's lover.

Wednesday, November 20, 1996
2:30 pm. Seventh Session with Sarah Wright. Sarah called and asked for half an hour today as that was all that she could spare. Obviously I agreed to see her on short notice. Sarah was almost buoyant during our session--I had expected to see someone who had been crushed by recent events, but Sarah is bustling with energy, intent on starting this new phase of her life with a certain gusto. Perhaps after recovering from the surprise of discovering years of deceit coupled with suddenly losing a husband to homosexuality, Sarah found herself in a position which she sort of likes: she can guiltlessly abandon a marriage which was for convenience and not love, and she can minister to Robby during his decline, just as she had forecast in her fantasies about the future. Robby is apparently going to be under her dominion for some time to come. Sarah has decided to honor Jeff's request and allow Robby to move in to an in-law unit above their garage. She's telling the kids that Robby is giving up his dental practice and that he is quite sick, but she is not mentioning that he has AIDS. She plans to work until the end of the year and then to quit to be able to care for Robby full time. Sarah admitted that she doesn't know very much about AIDS, but I am afraid that she is probably in for a shock about AIDS in its later stages. The popular image in the media of the tragic patient who, quietly and stoically, becomes progressively more frail has little to do with the patients suffering from AIDS-related dementia that I've seen in my practice. And Sarah loves Robby. Her emotions are going to be ravaged as she tries to sooth his emotions in tumult as he comes to terms with his mortality.

Monday, November 25, 1996
2 pm. Eighth Session with Sarah Wright. Robby moved in with Sarah and Jeff this weekend. Apparently there has been a shift in the balance of power in the Wright household and Sarah now believes that she holds all the cards. In the past, Jeff was quite tightfisted with money, apparently. Besides for certain bills, most of the household extras came out of the money that Sarah earned. Now Sarah has demanded that Jeff deposit $300 a week into her private bank account to compensate her for ministering to Robby. Jeff laughed in her face and Sarah apparently hit him in response. But my guess is that Jeff will bow to her demand. Sarah has made it clear that she is only staying with Jeff for the children's sake, although I suspect she is also staying with him because he will make it easier for Robby. Everything revolves around Robby in the Wright household, for both Sarah and for Jeff. Robby apparently sold his dental practice, although the way that Sarah talked about it, she apparently doesn't know that it was an economic transaction between Robby and the referred dentist. When Robby gave Sarah a chance to talk privately with him about all the issues that are swirling around her, she froze and was overwhelmed--finally leaving without saying anything at all. These issues are certainly going to come to the fore over the next few months. Sarah made a set of rules for Jeff and delighted in the arbitrary nature of some of them. She's enjoying flexing her muscles--quite literally. I told her that physical abuse was not appropriate given that she didn't fear that Jeff would harm her, but she equates her actions with Jeff's psychological abuse in lying to her over the years. Sarah has split her current situation into two--one is that the man she's married to is in love with another man and the second is that the man she loves is dying of AIDS. With respect to the former, she is just considering herself not married to Jeff anymore, even though they have the current arrangement for the sake of the children.

Monday, December 2, 1996
2 pm. Ninth Session with Sarah Wright. Sarah had a stressful Thanksgiving at Jeff's family's house, with relatives whom she doesn't like. Robby went to his sister's house. Robby's family doesn't know either about his sexual preference or about his contracting HIV. Jeff's family also doesn't know about Jeff's sexual preference and Sarah has no interest in telling them. She said that they would find a way to blame it on her anyway. Sarah is still willing to continue the charade of her marriage for the benefit of the children, but she says that she is starting to feel like one person again--not like the dual people that she initially described to me--one real and the other a false front for Jeff's benefit. Now things are more on her terms, although she has found out that the man she loves is dying and that her husband is gay. Others might not be able to turn that situation into one of personal growth and fulfillment, but that is exactly what Sarah is doing. Sarah welcomes Robby's interest in Melissa--now that Robby knows that Melissa is his daughter, he is interested in developing some form of relationship with her. Sarah is clear, however, that she doesn't want Melissa to know the true circumstances of her birth until Melissa is much older. She is having some sleep problems, although she reports improvement. Sarah ended the session early because she was tired. Sarah is also finding herself increasingly lonely and sexually frustrated. She gave a hint that something happened along that line, but declined to discuss it, putting it off until next week. She also directed my questions away from her sex life and from Robby at one point--she has definite ideas about what she wants to talk about and what she would rather leave alone.

Monday, December 9, 1996
2 pm. Tenth Session with Sarah Wright. Sarah had an encounter with her best friend's husband, Glen. It could have been innocent, and then again it could have been the initial tentative feelers of a developing extramarital relationship. Sarah finds herself thinking and dreaming about Glen frequently. As we explored her feelings, she realized that Glen is really a substitute for Robby--both physically and in his personality differences from Jeff. Sarah has suffered through multiple rejections, including several from Robby and from her husband whom, as much as she detests, was her intimate for a number of years. Now she finds herself completely alone, even while surrounded by both Jeff and Robby. Sarah plans to deal with her feelings towards Glen through complete repression. I told her that it might not be as easy as she thinks. Her contempt for Jeff grows with each week. Now she's threatening to expose his sexual preference to his parents unless he toes her line. As a strategy, it seems to be working too. Sarah has the whip hand and is feeling increasingly free to wield it. Sarah is jealous of Jeff's relationship with Robby, probably intensified by her own loneliness.

Monday, December 16, 1996
2 pm. Eleventh Session with Sarah Wright. Although Christmas is her favorite time of year, Sarah said that she is having trouble getting into the spirit this year. Sarah started reminiscing about Christmas. As a young girl, she would spend Christmas with her grandparents in a beautifully decorated house. She still remembers the tree and the presents and how it felt to be safe and loved. Both grandparents died when she was seventeen. But Sarah and her mother believe that Melissa is her grandmother reincarnated. Sarah's reincarnation beliefs are apparently shared and fostered by her mother and the rest of her family. Sarah wanted to switch the subject because she said there was no way that I was going to understand, which is probably true. While previously she was unsure about the decision to leave work, as her last day approaches, she is feeling better about the decision. It's only a couple of weeks away and they haven't hired someone else for the job, so she has a limited amount of time to train a replacement. As a financial matter, Sarah is now more comfortable. Jeff has acceded to her demands and now transfers a sum of money each month to her private account to compensate her for giving up her job to care for his lover. Sarah is talking about using the money to travel with her mother. Sarah did get a call from Glen, her best friend's husband. She has decided to meet him clandestinely in the week after Christmas and refused to discuss this decision with me further. Sarah wants to skip her next session so we scheduled for December 30th.

Monday, December 30, 1996
2 pm. Twelfth Session with Sarah Wright. With an uncharacteristic freedom in discussing sexual matters, Sarah told me about a series of sexual liaisons she had with Glen, her best friend Lisa's husband. She's not guilty about having sex with Glen, because it seems that she had explicit permission from Lisa to help herself. It seems that Lisa enjoys her husband sleeping with other women and then describing the encounters in detail to her. So Sarah went at it with a certain amount of gusto--and describes with awe and admiration Glen's penis, which she characterises as having the girth of a soup can. Sarah rejects the term "affair" because she feels an affair means that you are going behind someone's back--but she holds her husband Jeff in such contempt that she doesn't even consider him in deciding whether to apply her definition. It's beyond feeling no guilt. Sarah doesn't even conceive that she might feel guilty for having extra-marital sexual contact. Sarah recognizes that there is little emotional fulfillment in empty sex with Glen, but she certainly likes the sex itself. Sarah believes that she can replace emotional fulfillment with the satisfaction of physical needs, for at least some time. I need to make sure that she doesn't confuse the physical and the emotional as this relationship progresses.

Monday, January 13, 1997
2 pm. Thirteenth Session with Sarah Wright. Sarah described herself as falling into a recurring depression, so after a consult with her cardiologist, I switched her medication from the Ativan to Zoloft, 50 mg. once each morning. This will be the beginning of a six week trial. Sarah quite succinctly described her emotional symptoms as being afraid in crowds, being distressed by ordinary noise levels, unmotivated crying spells, and an inability to concentrate. At work, Sarah decided to stay on an extra month because they are having difficulty finding a replacement. Robby's AIDs is progressing fairly rapidly and Sarah is trying to have an opportunity to resolve a number of emotional issues with him. Sarah believes that Jeff's interest in Robby is waning somewhat, now that Robby is being cared for by Sarah. She believes that Jeff is inventing reasons not to spend time with Robby. I suspect that Jeff is repressing his feelings regarding Robby's illness and is avoiding Robby somewhat to help avoid the issues that it raises for him. Sarah hasn't repeated The Game with Glen recently, but just because she hasn't found the time. Sarah is convinced that she can skate the emotional issues involved in her sexual relationship with Glen and come out unscarred at the end.

Monday, January 20, 1997
2 pm. Fourteenth Session with Sarah Wright. Sarah seemed more depressed during this session than I have ever seen her before. She has completed the first week of her Zoloft trial, with no improvement. She reports being tired all the time, with some days worse than others. She reports a profound lethargy which she describes as trying to move through wet cement. It was Jeff's birthday, and after a family dinner, Robby and Jeff went out together. Robby later told Sarah that he suspects that Jeff is seeing someone else. Sarah doesn't care at all. Her contempt for Jeff is so strong, it's palpable. She even voiced her wish that it was Jeff who had AIDS rather than Robby. And while she is able to talk to Robby about his relationship problems with her husband, she is currently unable to broach to Robby the emotional issues which are so important to her. Sarah cut off our session early and didn't make an appointment for next week. She said she'd call and set something up. I would hate to lose Sarah as a patient, especially now where she is apparently in crisis.


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