Tales from the Valley of Death. Rachel E. Menzies

he would not permit any light to be switched on, day or night. His insisted that the refrigerator was permanently turned off, along with the washing machine and dryer. No cooking of any sort was allowed. He didn’t sleep in a bed, preferring a thin mat on the floor. He lived in primitive conditions and almost complete darkness, like a caveman.

      Ten years ago, Berat’s desperate mother appeared in my rooms. Through tears, Elif described her son’s worsening condition. Berat had been losing weight and was becoming weaker by the day. Elif would bring him takeaway meals so that he could have hot food, but he rarely kept anything down. Typically, fears of poisoning would overcome him and he would regurgitate the meals. Elif was shaken by his decline and ruminated about where it would all end. ‘You’ve got to help my son’ she pleaded. ‘He’s going to die’. I moved him to the top of my wait-list and managed to see him for an assessment within the week.

      Berat was a wild, wiry figure with long hair and a pale complexion resulting, no doubt, from an appalling lack of sunlight. He resembled Rasputin — and seemed similarly indestructible. Despite vomiting up his food on a daily basis, and living in prehistoric conditions, he was sprightly and somewhat animated in our first session. I wondered whether his mother had exaggerated the way he was living, but Berat told the same story. No lights, stove, washing, or refrigerated food. ‘I can’t have any of that, doctor — I get too agitated,’ he said.

      By Berat’s account, his mental health had declined over a long period following a near-drowning at the age of eight, an event that continued to affect him. ‘Being near water is very difficult, doctor, and I try not to drink it if I can’ he told me. To avoid anxiety and the sensations of impending suffocation that he associated with that early trauma, Berat slowly developed a complex set of magical routines. And, as in so many other individuals that I’ve seen, the rituals had become increasingly complex over time and had to be perfectly performed to prevent harm. Every object in his apartment had its place and had to be returned correctly, or Berat would become unstable. He would only leave his home for appointments with his specialists, and then as infrequently as possible.

      Elif faced tremendous difficulty getting her son to my office and successfully home again. Everything had to be done in patterns and reversed and done over if there was an error. On one occasion, near the beginning of our work together, it took Berat more than an hour just to walk down the five sandstone steps between my front door and the gate of my clinic. I watched in shock from the window of my consulting room. It was like looking at an acrobat performing a deft routine at the circus. He would leap down two or three stairs at a time only to spring back up in reverse and repeat the action. This happened at the end of many of our early sessions. If I came to the front door and insisted that it was time for him to leave Berat would do so. But, left to his own devices, he would be there for many hours, bouncing back and forth with the stamina of an elite gymnast.

      Berat’s most dangerous behaviours related to this habit of retracing his steps and repeating behaviours to get them right. On the face of it, such compulsions are not unusual. In fact, the need to walk back through doorways, or repeatedly open and close locks and light switches, are quite common in Obsessive Compulsive Disorder. But Berat took reversing rituals to a whole new level. Firstly, he would literally walk backwards down the street, rather than turn around to retrace his steps. He would do the same on stairs and, most dangerously, even in cars. ‘In the past — not now, doctor — I’ve done it on the road’ he said sheepishly. ‘I’ve put the car in reverse and gone backwards down a street, doctor. I just had to start the street again’, he said searching for understanding, if not approval.

      Berat had other odd beliefs and behaviours on the road. He strongly maintained that one should only drive to a place if you could return by the same route. This superstitious belief is much harder to implement than one might first imagine. Though it’s possible to do it at times, what happens with one-ways streets, no right turn intersections and single direction tunnels and bridges? You simply can’t go back the way you came in those circumstances, or so I thought. ‘I even did it in the Sydney Harbour Tunnel’ he declared. I sat speechless as Berat described riding on a bike in the wrong direction, dodging the oncoming traffic, just to ensure that he could travel to the north side of the city on the same road that he had travelled south. ‘I could have died that night, doctor, on my little bike with its lawn mower motor’ he said with a grin, reminiscing on an event that was clearly a triumph for him.

      When I first met Berat, he had no belief in himself. His confidence in his ability to recover was almost non-existent. He had suffered from extreme levels of anxiety for more than 20 years and he couldn’t see the way out. Maybe others could recover, but not him — more than anything he needed to believe. I knew he could face his fear, but he didn’t. This concerned me greatly because, in my experience, no-one achieves more in therapy than they think they can.

      Berat and I quickly established excellent rapport, something that is generally easy to achieve with patients who are engaged and transparent in sessions. Honesty is a powerful bonding agent, melting away the masks that humans so often hide behind. Berat had a delightful simplicity in his manner, and I always enjoyed seeing his name in my appointment book. As our therapeutic relationship grew, so did his confidence. ‘Little by little’ he would say with a grin. ‘I’ll get there little by little’ he would tell me as we set his homework at the end of each session.

      Over our 49 meetings during the 10 years that I have known him, I have watched a transformation in this man. His diet began to improve as he allowed his mother to cook again. He stopped regurgitating food, and he started to gain weight. He reconnected with old friends, had his teeth mended and capped, cut his hair, and started dating. I watched a lonely, isolated young man re-enter the world. It was my great privilege and joy to witness Berat’s rebirth over this decade.

      Sometimes in therapy the things that impact people the most are not what we’d expect. Was it the complex formulation that I’d provided? The specifics of the homework tasks? My feedback for the thought challenging exercises? ‘No, doctor,’ he said, smiling at me recently. ‘Doctor, it was when you told me that I looked like George Harrison. And you told me that together we would sculpt me out of hard rock — bit by bit we’d chip away to reveal all my potential. Do you know how many times I’ve told that story, doctor?’ he announced, beaming with joy.

      I don’t remember saying this at all. But Berat does, and that’s what matters.

       Our interview with Berat