Hands

         "I don't want to do this anymore." I remember that. I remember her saying it.

         I didn't listen, not really. "It's common to have nightmares," I said.

         My son of 11 said close to the same thing after entering middle-school, "I don't want to do this anymore." I didn't listen to him either. As his mother and as a therapist, this remark is easy to dismiss as a side effect of his ADD. But this event has made me reconsider to some degree the nature of mental illness as a whole, and the issues that face the therapist in ethical psychiatric diagnoses.

         My patient's recurring nightmare seemed just a symptom at the time, but now it refuses to leave my mind. She described it to me during our first session, dozens of moist hands ascending from the depths of the sea, grasping desperately at her thighs, caressing her palms, their salty fingers inserting themselves into her mouth. She said they pulled her far out to sea, to a place deeper than we have technology to explore. It was only a dream, but she was haunted by the thought. She was afraid of her nightmare coming true.

In my naive opinion, this constituted a phobia. Her fear of the ocean was 'excessive and irrational'. A professional swimmer shouldn't need to fear the sea, I thought. This belief of mine is what convinced her to confront the ocean. What happened was, therefore, my fault, and her nightmare is now mine to bear.

         During the first month of treatment, I exposed her to pictures of waves, pictures of people swimming, and various undersea images. She quickly became comfortable with pictures, so I brought her to the beach, behind the dunes, where she could hear and smell the ocean but not see it. She adjusted well to that.

         During the second month, we moved within sight of the shoreline. It was a gray summer's end, when students were at school and clouds often threatened rain, so there were never many beachgoers to observe. I asked the lifeguard if she would be willing to talk to the patient about other swimmers. The lifeguard, however, seemed fearful of the sea herself. She spoke of incidents of swimmers being taken by rip currents during unexpected times of the year. On this beach, rip currents sweep people away faster than the lifeguards of the beach are able to react, resulting in more average casualties than other beaches. She assured me that there hasn't been any incidents since last year. I decided to avoid telling the patient. I thought that the increase in average casualties was a coincidence. I failed to take into account that the average count for casualty by rip current is zero. Rip currents are rarely fatal.

         The third month, we moved closer to the water. The first week of this month was the first time her feet touched the ocean. I told her before going in that it was common to feel fish or seaweed on your feet. She seemed to accept this, but shortly after going into the water there was an incident. She panicked. She almost fell further into the ocean than she was willing to go, claiming that something pulled her. I convinced her that she had imagined the pulling; waves can be quite strong, and there was seaweed covering her feet. She was able to relax, and after some time she again became comfortable with her ankles under the waves.

         The fourth month is when it happened. Finally she was ready to swim in the ocean. We had talked it over many times. On the third week of the fourth month, she finally agreed to swimming, full body, in the water. I had no doubt she was skilled enough; she was a highly respected sports swimmer, on track for swimming on the olympic team. It was not the water she was afraid of; it was not even the waves - it was the hands. The nightmare of the hands still haunted her, and the night before our final session it haunted her again, but this time she said it was more vivid and intense than it had ever been.

         "I don't want to do this anymore." I still remember her saying it.

         I desperately wish I listened, but I didn't. Instead, I convinced her to push through her fear. She was a brave woman, and she did push through her fear. She waded out into the waves, trembling at first, but within the hour she became extremely comfortable, and she even yelled out with joy. She swam beautifully for a while; certainly she swam farther than I was able to, screaming with laughter and accomplishment. It is hard to describe how proud I was at this moment.

         Before I realized, she was far out to sea, and I realized that her screams had been muffled. And I hesitate to write this; at first I thought I was mistaken due to my taking off my glasses in the water. But I have since thought it over. My guilt forces me to. I am certain now that I saw what muffled her screams - hands. I am certain I saw them covering her mouth. I am absolutely certain. Her body was never found. Many, including myself, claimed she was taken by a rip current. But despite all logic, I know what I saw; I am certain.

         I apologize. I don't wish to dwell on this.

         Regardless, guilt drives me to reflect on my diagnosis of her and psychiatric diagnoses as a whole. A behavior is a disorder if it impairs the life of the patient; this is the criteria that therapists use for diagnosis. But it is of great ethical importance to make absolutely certain that it is truly the patient's behavior that is at fault, and not - as in this case and perhaps others - the waters in which the patient swims.