Whenever I talk about my belief in the link between etiquette and successful psychotherapy, people exclaim "Manners?! You mean how to set the table?" In fact, manners are a vastly underutilized resource in helping people manage the deep currents of stress and anxiety that bring them to therapists' offices. Rather than an archaic, artificial code of conduct, manners are the means generations of people have used to establish their social relationships, long before the invention of psychotherapy. The following case demonstrates how my attention to my own therapeutic manners and my patient's concern about a serious breach of etiquette in her family led to a surprisingly efficient and satisfactory treatment outcome.
When the case manager at the managed care company told me about Rose, I knew I was getting a difficult referral. Despite all the pleasantries, the subtext was, "This woman is driving her internist crazy, and you'd better fix her up, calm her down and get her off his back as soon as you can!" Rose was a divorced, Italian American woman in her fifties who was complaining of severe and persistent headaches, for which her primary care physician and two specialists could find no organic basis. Medications had not been helpful, and Rose was beginning to complain of fatigue and dizziness and demanding to be considered for permanent disability. Having been steamrollered by somatically preoccupied patients before, I thought, "Oh, great, what am I supposed to do? Stand in the way of her mad dash for disability?"
Rose was a strong-willed, independent-minded assembly-line worker who could have stepped off the screen of Prizzi's Honor . She smoked like a chimney, cracked gum sassily and swore like a sailor in a low, husky voice. Prior to the onset of her symptoms, she had been a stellar employee who had never complained of any psychological problems. She had always relied on her close-knit family, especially her mother, the extended family's matriarch, for support. Now, however, her mother thought Rose was "acting like a baby," and that Rose should just endure her pain the way she herself always had--silently and stoically. But the real problem, Rose explained, was that her mother, as well as others in their extended family, were angry at Rose's son, who had just gotten married, and they were, according to Rose, "taking it out on me." Rose's symptoms had developed shortly after her son's wedding.
Rose was devoted to her only child, Richie. Despite recurring familial struggles and shifting allegiances, which were actually part of her family's connections ("We're not arguing, we're discussing !"), Rose and Richie held privileged positions in the family--Rose as the eldest child of the matriarch and Richie as not only Rose's only child, but the oldest male in his generation.
Rose explained that Richie's wife, Jane, had not yet sent out wedding thank-you cards, four months after the wedding. Intensely aggrieved by this etiquette breach, Rose "picked a fight with Richie" about some money she had lent him, and now she thought they "would never speak to each other again!" Referring to the thank-you cards, Rose said, "After all I've done for him, and this is how he disrespects me! It makes me look bad."
Prior to his marriage, Richie had lived at home, and his marriage was a difficult separation for Rose. Further, he married a non-Italian "girl" whose family was far more involved in planning the wedding than Rose had been. Rose said that these small slights had made her feel "tense and disrespected" prior to the wedding, and the late thank-you notes were "the straw that broke the camel's back."
I saw the obvious links between Rose's headaches and the wedding, but I resisted the urge to interpret. …