Willie was a patient who fell into the trap of having a stake in staying ill. Before he joined the air force, Willie had lived at home with his parents and had gone to school. In his family, at school, and at his part-time job, he felt hounded by people who were continuously pushing him to do things he really did not want to do. To “show them all,” he ran off and joined the military. Much to his dismay, he once again found himself surrounded by authority figures. Everyone outranked him and everywhere he turned, he was told what to do. Because he had enlisted and could not get out of the situation in less than four years, he felt trapped. What made it worse was that he felt he could not even complain about his fate to sympathetic listeners. During this time, Willie told us later, he fantasized about having a terminal disease, imagining how sorry everyone would be if they found out he was going to die.After Willie developed a lump in his neck, he came in for surgery and was told that a biopsy showed he had a malignant lymphoma (Hodgkin’s disease). When told of the diagnosis, he said he experienced a sense of excitement, almost happiness. Later, he became concerned about his unusual response t what most people would take as devastating news. It was this concern that led him to explore with us the psychological issues of his illness during the weeks he was receiving radiation therapy. During the course of this exploration he came to the realization that his sense of relief at the time of his diagnosis was because his illness “rescued” him from the trap he believed himself to be in and gave him a reason for allowing no further demands to be made on him. The dilemma, though, was that if he recovered he would again have to face the problem of his military obligation. This raised a considerable barrier to his commitment to getting well. Resolving this issue was a central focus of his psychological therapy—to which he responded well. A similar problem was faced by another patient of ours, a young psychiatrist. Approximately six months before his diagnosis, a long-term patient of his tried to commit suicide and another person was killed as a result. To make matters worse, the psychiatrist had been developing new approaches to psychiatry, and several people who disagreed with his ideas used the tragedy as an opportunity to question his “unorthodox” methods, aggravating the guilt he was already feeling. He went into a deep depressive cycle in which he contemplated taking his own life on several occasions. Six months later, he was diagnosed as having advanced lymphosarcoma involving his lungs and liver.The illness served several important psychological functions for the psychiatrist. One by-product was that it silenced his critics. After all, no one needed to or could decently criticize a “dying man.” In addition, the disease appeased his guilt, atoning for the exaggerated sense of responsibility he felt for his patient’s actions. Recovery, of course, would remove the source of his penance.Fortunately, as a psychiatrist, he had developed a high level of insight into his own psychological processes and was able to resolve his feelings substantially. At the time of his original diagnosis, he was given less than a 10 percent chance of surviving five years. Today, after six years and despite two flare-ups of his disease, he has maintained an active psychiatric practice.This patient was able to use the temporary “protection” offered by the disease to regroup his psychological forces so that he could cope more effectively once he got well. But some patients find no way to solve their problems except through illness. Another patient revealed that his disease was preceded by a great deal of stress in his professional life, a lack of time with his wife and children, and a pressure for financial success. His illness provided him with a generous disability allowance, ample time for family, and no pressure to produce. But his problems in going back to work have been insurmountable. Three times he reached the point where he was free of symptoms and could consider working again and each time, within weeks of his seriously contemplating returning to his profession, he had a serious flare-up.In still another case, the patient was part-owner of a business and felt that her partners put an unreasonable amount of the burden of running the business on her. Yet she had great, difficulty refusing their demands. Initially, her illness said no for her. Nobody would dare ask her to do anything while she was sick. But fortunately she realized that if she used the illness as a crutch, she might never get well. Instead, she is learning to say no without using illness as an excuse and has gone back to sharing the operation of the business, feeling’ good that she is able to assert her needs.Several other patients have found that their disease temporarily removed them from an intolerable job. Again, because the disease only suspends the problem for them, it is important that they confront the personal attitudes and behaviors that permitted the situation to become intolerable in the first place—or they are likely to re-create the situation and the disease each time they return to work.Illness gives patients temporary permission to act in more open ways emotionally. But if they cannot learn to give themselves that same permission when they are healthy, then the moment they get well the old rules again apply, and they find themselves in the psychologically and physically destructive situation that first contributed to their illness.This concept also accounts for the depression some patients report when they are told they are in remission—or that their disease is much better. Rather than the elation they expected to experience as a result of their good news, many report being perplexed because they feel depressed. Even though consciously they are pleased that their disease is better, unconsciously they are experiencing a loss of the tool their illness provided. The feeling of depression at the prospect of better health is important feedback that there is still psychologically important work to do.*36\347\2*
