An excerpt from Behind the Couch.

If you were to ask me how many patients I have seen over the years, I could only give a very rough estimate. Unless, of course, I were to dig deeply into my records. But from that great mass of people, a number of patients will always remain in my memory. Some were simply more remarkable than others, more unusual, or they came with a story that could not easily be dismissed.

Such was my encounter with the next man.

Our first appointment was scheduled on a perfectly ordinary working day and had been arranged by telephone. The conversation had been brief and strictly businesslike. No drama. No emotional display. He arrived exactly on time, and I managed to hide my surprise when I went to collect him from the waiting room.

Standing before me was a true gentleman in an expensive tailored suit. His tie neatly knotted, his posture rigid, nose and chest slightly forward. At first glance you might have taken him for a bailiff, a judge, a banker, a lawyer, or perhaps a tax inspector. But when I shook his hand, his entire appearance seemed far too intellectual and worldly to fit comfortably into any of those professions.

I invited him to walk ahead toward the consulting room, and he seemed to find that perfectly natural. It was clear that he expected nothing less than to lead the way. This was not a man accustomed to following.

That same attitude continued once we entered the office. He remained standing firmly in front of my desk. Even after I sat down and invited him to do the same, he did not move an inch. Like a rock he stood there, looking down at me with a certain hauteur, as if he were the superior preparing to put me in my place. There was an energy in the air suggesting that he intended to punish me for something I had done wrong.

Even after a second invitation to sit down, he took his time before finally, and clearly against his will, lowering himself into the chair I indicated. A comfortable chair, by the way. And yet he shifted uneasily in it. It was obvious that he was not accustomed to situations like this.

For a while we sat in silence. I found myself thinking of a former patient, a twenty-two-year-old man so extraordinarily full of himself that I had once taken the very unusual step of politely but firmly showing him the door. The silent man now sitting before me was not quite of that caliber, but it was clear that he sought at least equality in our encounter and preferably superiority. That subtly contemptuous stance created an immediate tension between us.

At that moment, a fortunate coincidence brought some relief. Quite literally, in fact. The late afternoon sun suddenly illuminated the consulting room with a warm glow, and we both seemed to settle slightly. The quiet play of light softened the atmosphere.

It was the ideal moment to begin with an opening question. A very standard one.

“This is the first time we’ve met. Perhaps you could tell me what brings you here.”

I asked the question calmly and in a friendly tone. His answer was short, direct, and once again unmistakably haughty. With raised eyebrows he looked toward the ceiling as he offered his explanation.

“My wife wants to divorce me. I think the problem lies with me. That’s why I want therapy. Because I don’t want a divorce.”

Every word seemed to cost him visible effort. He spoke them as if he had just placed something unpleasant in his mouth. But he had now laid his problem before me together with the unspoken message that it was now up to me to do something about it. Having said why he was there, I sensed a certain satisfaction on his part. It was out in the open. For me, at least, it was a positive sign for the possibility of treatment.

Unfortunately, he offered little further explanation, and it took some effort to draw more from him. After a few cautious and discreet questions, I could already conclude that he was neither depressed, nor psychotic, nor particularly anxious. What I did know was that I was dealing with a man suffering from pathological narcissism. A diagnosis that, in this case, did not require a very long session to establish. Had he abandoned the therapy, he would have disappeared from sight forever, and all the time and effort invested would have been wasted.

At the second appointment he arrived punctually, just as before. Once again his rigid posture and meticulous behavior were striking. It suggested obsessive-compulsive traits. This could mean that he was not only suffering from pathological narcissism, but also from an obsessive-compulsive disorder. Quite a mouthful. For him, everything had to be perfectly aligned, carefully measured, everything flawless and carried out according to his own rules. Including the relationship with his wife, his work, and even himself.

During that first full session of forty-five minutes I managed to obtain some insight into his biological background. He had two brothers and two sisters. Both sisters had received privileged treatment, and his brothers had also been favored by their parents. As a result, he had been the least accepted child in the family and had grown up with a chronic lack of affirmation and appreciation. Placed in the context of a family environment without close emotional bonds and combined with the fact that he was a highly intelligent boy with considerable abilities, my hypothesis of a narcissistic personality disorder was further confirmed.

For the time being I left the obsessive-compulsive element aside. He was here because his relationship was collapsing, and those obsessive traits could always be addressed later if necessary.

At that moment I chose an analytically oriented therapy with three sessions per week, each lasting forty-five minutes, with the patient lying on the couch. I do not call it psychoanalysis, because strictly speaking it is not. Nevertheless, therapy on the couch incorporates elements of the psychoanalytic method. There are strict agreements about time and schedule. The patient provides the material, and the therapist listens. While listening, the therapist maintains what is known as an abstinent and evenly suspended attention toward what is being said, intervening only occasionally with clarifications, observations, or interpretations.

Just as before, the man arrived perfectly on time for his first session on the couch. You could practically set a Swiss watch by him. I took the time to explain all the rules to him. And there were quite a few. I spoke about my fee, the handling of administrative matters and payment at the beginning of the session, and how we would deal with absences or vacations.

Paul J. de Keyzer is a neuropsychiatrist in the Netherlands.