Patient: “I’d like to be someone else, really, anyone else. I’d like to slip out of my skin and be free to become something I can’t even imagine. As it is, this skin has a stranglehold on me. I’ll die in it like a prisoner in his cell. It’s really quite simple: I want to be free and I want my freedom to have genuine meaning. I want to go somewhere that is not on my map.”

Doctor: “Isn’t this why people take up acting, or become writers, or playwrights or even painters or sculptors or musicians? But perhaps actors go at it most directly?”

Patient: “But actors bend the knee to reality. What they do is pretend and often wildly off the mark. When you think about it, acting is pretty shabby, quite without real convictions or daring. Seeming to take risks while not really risking anything is like eating your cake and having it, too. I acted in high school and in college and was told I was quite good at it, good enough even to warrant trying to make a career out of it. But as an actor I disgusted myself.”

Doctor: “Why was that?”

Patient: “I was a confidence man trying to play a trick that had little if any meaning. I suppose that now I act some in everyday life and certainly when I’m trying a case.
I don’t know how I ended up going to law school. It was a whim, that was then unbelievably boring and then turned into a test of how much unpleasantness I could tolerate, an ordeal that challenged me, so that I stuck it out against my better judgment. My better judgment, if I have any, never had less influence over me than when I was in law school. I was paralyzed as if with curare.”

Doctor: “But you did well in law school?”

Patient: “If you mean that I made law review and was offered ridiculous jobs by absurd firms, then I suppose I did do well. But it was a sick form of doing well. I met my wife in law school. She fascinated me. I didn’t understand the first thing about romance or marriage. I wanted to be her. I couldn’t have put this into words at the time but what I called love was the desire to exchange myself for her and so to exit the terrible trap of myself. I wasn’t convinced that it would necessarily be better to be her, but it would be different and, so, preferable on the grounds of variety. I think I experience it as an affront that I can’t be everyone and everything.”

Doctor: ”How is your marriage?”

Patient: “It’s as good as might be expected. Nora knows that there is something seriously wrong with me, but she doesn’t push at it. If she had been given the box that Pandora was given, she would not have opened it. I think it’s possible that it was her intuition that something was terribly wrong with me that drew her to me.
I was different. That was, in itself, a kind of freedom for her. I’m grateful to her for her discretion. It takes some special personal resources not to ask questions, not to worry at the sore spot, not to ask for more. She loves me and she loves the children. At this point her love for me may be reflected love for the children. “

Doctor: (Raises eyebrows. Says nothing. Waits a few beats.)

Patient: “You’re looking at me that way. I know what you want to know, ‘Do I love my children.’ Yes, of course I do, but I love them the way that I love. I want to be them. I want to slip out of my own skin into another skin. This has advantages because it makes me very attentive. I’m tuned into stray sensual details that other parents might not notice and, honestly, perhaps it would be better not to notice. But my children trust me, sometimes more than they trust their mother. I’m often able to put things right when Nora has trouble. Maybe this is more true with Shira
than it is with Ben.

Doctor: “Sounds pretty good…”

Patient: “That sounds like a question…”

Doctor: “Not really. It does sound pretty good.”

Patient: “But there is a big problem. Since my way of loving is to want to be them,
there is massive disappointment as it becomes clearer and clearer that that’s impossible, even against nature. So that it’s fundamentally perverted. Shira is twelve and Ben is ten, so each day they become more themselves and I’m left in the dust. It’s not their fault at all. I recognize that and I wouldn’t want to impose the pain of it on either one of them or on Nora for that matter. I had hoped it would be different, even though I should have known better. I think I wanted kids in order to be them, another selfish escape from myself. “

Doctor: “So you’re in a lot of pain these days?”

Patient: “I think so. Isn’t that how most people come to be sitting in this chair?”

Doctor: “That’s true.”

Patient: “But I say ‘I think so’ because I never know for sure what I feel. I live at some remove from this sort of thing. I have an enormous capacity for doing things that other people think are very unpleasant, not that I like them, but I do them and without much fuss. I think it’s because I keep a certain distance from myself. It’s peculiar. Much as I wish I could get away from myself, find asylum as someone else,
I also can’t get very near to myself. It’s too bothersome, too chaotic, too unreliable.”

Doctor: “So ‘self’ is a problem in a variety of ways?”

Patient: “I was seven when it first occurred to me that I wanted to be anyone but myself. I found my skin imprisoning. There was a physical sensation that went with this idea. Of course, I didn’t tell anyone. Certainly not my parents. Maybe
this was a choice on my part or maybe I just didn’t have the words for it. I haven’t told anyone. I haven’t told my wife or my sisters or my friends from college. Actually, you are the first person that I’ve ever told about this. “

Doctor: “That shows a lot of trust in me.”

Patient: “Maybe. Maybe it does. I don’t mean to imply that it doesn’t. That would be insulting. I don’t want to reject that out of hand.”

Doctor: “But there is more to it than that?”

Patient: “Yes. Maybe. I mean yes. For sure there is. I’m not sure that I know how to put it into words. I have a lot of trouble putting anything about myself into words.”

Doctor: “Maybe it’s worth a try?”

Patient: “This isn’t exactly about myself. No, that’s the wrong way to put it. It isn’t only about myself…”

Doctor: “And…”

Patient: “I hate it. I sound like a goddamn lawyer, which is what I seem to be.”

Doctor: “Go ahead.”

Patient: “Well, it’s not only about me. I think it might be about you, too. I know what you do. You sit and listen to people all day long, just like you are sitting here and listening to me. You do this all day long every day or at least every working day. You do it year after year. You do it a whole lifetime. You sit by this river and listen to it”

Doctor: “Something like that…”

Patient: “And what you hear…

Doctor: “That’s true. However long you have listened there are still surprises…

Patient: “And the details, the depth to which you get to know people. Maybe sometimes you get to know them better than they know themselves. In your mind you run simulations of each one, but such rich simulations. Really it’s a fabulous undertaking, but I asked myself, ‘Why would anyone undertake this fabulous journey? Why would anyone submerge himself so deeply in anyone else?’”
Doctor: “That’s a good question. Why would anyone?”

Patient: “I know the conventional responses about seeking to heal, about altruism and so forth. But there has to be more. In fact, I believe there is much more. Why take on and in so much about someone else? Why acquire that much data, seek
that level of intimacy? Why, except that there must be a tipping point, one where you have taken so much in and on that you are near becoming the other person. My guess is that you are in quest of that tipping point.”

Doctor: “So you came here in search of a kindred soul. If I want to become you and you want to become me, then we have grounds for mutual understanding. You believe I must want to be someone else and you want to be me. The ideal outcome would be for me to leave this office as you and you to leave this office as me, all traces of you expunged.”

Patient: “Exactly.”

Doctor: “There is a lot to think about.”

Patient: “No, no, no, this is not about thinking at all. Thinking is what the timid do.
I hoped I wouldn’t have to tell you this, but I’ve been considering killing myself. I would do it without any hesitation if I knew that reincarnation actually happened. I wouldn’t care if I didn’t come back as a Maharajah but only a dung beetle. At least, I would not be me.

Doctor: “What about your children?”

Patient: “They’ll be better off without me, just as I will.”

“I’d kill myself if I could attend my own funeral.”

The speaker is a seventy-five year old man, a lawyer who specializes in wills and estates, always peculiar, now semi-retired with a sterling professional reputation as someone who can craft a complex trust so that it can not be broken. He is from an old family, himself the beneficiary of rich trusts, but has made a fair amount of money by his own labors in the arcane province of wills and estates.

“The reason that I would like to attend my own funeral is that I would be the center of attention while yet remaining exempt from the obligation to exert any effort. I would be glad even to pretend that I wasn’t there. In life, if you want to be the center of attention it requires such a lot of work. It saps your energy to arrange your self-presentation just so after having compiled extensive intelligence concerning the tastes and distastes of those you wish to arrange in circles around you. It has always been beyond me. I have tried but I never lasted more than a few weeks. I can’t imagine running for office. I’m simply not robust. I’m not even sure I could serve as a hereditary monarch unless I were permitted to remain out of sight for decades at a time.”

He has shown me pictures of himself from decades gone by. Tall and thin with an air of elegance, he is a handsome man in these photographs, perhaps with just a hint of fragility. Long nose, long thin fingers, pale blue eyes – in each of these photographs he seems to be impersonating himself slightly differently, as if he can not quite make up his mind. The pictures have both an eloquence and something that can easily be called beauty . He is in the pictures simultaneously a beautiful object and a beautiful subject

Well past seventy, he looks a bit gaunt and stooped, with his cheek bones more prominent. Or should I say “unwell” past seventy? If the law has been his primary career, then being ill has been a second career that has given his first career a serious run for supremacy.

“I don’t like doctors. I’m afraid of them,” he says. “You go to them because you are suffering. You go with the expectation that they will deploy actual intellectual energy and practical discernment in pursuit of diagnosis and treatment of your specific ailment. You expect them to wrestle with your ailment and to stay with the match even if it causes them great discomfort. After all, you, the patient can not quit the ring. You have no choice but to stay the course. But doctors rarely, if ever, engage in this way. They are more flighty than analytic, more vain than engaged.”

I do not observe to him and have not observed to him in the long time of our work together either that I am a doctor or that his relationship with doctors seems at the very least to be a love/hate relationship. I often wonder whether he includes me in the tribe of doctors which he so excoriates or grants me some anomalous status just outside the borders.

“I hurt. I especially hurt in my feet and legs, but I also have abdominal pains, sometimes so severe as to make me wonder whether I have pieces of necrotic bowel. The doctors run tests, find nothing and then seem content as if they have pronounced some priestly blessing for which I should be grateful. I go on hurting just as I did before the useless exercise. I’m dizzy, not all the time but enough so that I’m always worried about being dizzy. I can hardly walk. I’m becoming weaker all the time. I hardly go out any more. I find it harder and harder to work and, if the truth be told, my work doesn’t have the distinction it once had. People retain me now not so much for my actual performance, but for my reputation, which has always seemed to me exaggerated. Perhaps I still deal with complexity just a little bit better than other people, but this is nothing to get excited about, given what a pathetic species we are.

“The doctors tell me that all my tests are within normal limits and then seem offended when I tell them that all that means is that they haven’t run the right tests.
How I feel is not within normal limits. How I struggle through the day and how I suffer through the nights, barely sleeping three or four hours and plagued by nightmares that color the entire next day, is not normal. I am not within normal
limits. I can not get it through the blockheads’ thick skulls that they have not been retained to care for my laboratory tests or scans or tissue biopsies, but rather to care for me. Actually, over the years of my involvement with medicine I have known two or three doctors who have been frank with me that they had no idea what was going on with me and that they were very bothered about this fact, but had no clear idea how to proceed. These are the princes of the profession, the ones who admit failure and are tormented by it.”

This man is not married, has never been married or had any interest in being married, let alone in having children. For him other people represent an unnecessary burden. He says that other people might feel differently but then they did not have the pleasure of being raised by his parents. He feels there should be a licensing system for having children and that, were there such a system properly operated, then the problem of overpopulation would be well on the way to a solution. He is very fond of dogs and horses, the preferred companions of his youth

“The job of a doctor is to figure out what is wrong with the patient and to fix it.
Now I have had my appendix taken out, my gall bladder removed, four melanomas excised, coronary artery bypass surgery, although I am not so sure that was indicated. I have also had treatment for a host (I almost slipped and said ‘hoax’) of medical conditions: hypothyroidism, hyperthyroidism, Addison’s disease, hypertension, diabetes, even an exotic tropical fungus which normally appears
only in those who are severely immunologically compromised. I can’t tell you how many times I’ve been worked up for auto-immune diseases, as if I were turning against myself. But I have never been relieved of my sufferings. Nor, unlike so many, do I believe that there is any aesthetic, ethical or moral privilege that derives from suffering.”

This gentleman, with a lawyer’s diligence and respect for documentation, has made an exhaustive collection of his medical records over a bit more than half a century as if each EKG, each lab report, each reading of an X-ray, ultrasound, CAT scan, ERCP, MRI, EEG and so forth were a tribute to him or, even beyond that, a part of himself, much too valuable to allow to be dispersed and destroyed. He says that he has two full filing cabinets devoted only to the medical records of which he is both the original cause and the curator. I have in my possession more than nine hundred forty pages selected from these materials. It is important to him that I am willing to read what he brings me. It is at once tedious and fascinating, illustrating the best and worst of medicine in a maelstrom of confusion. A medical anthropologist
or medical sociologist could produce an instructive and useful volume based on nothing but these records.

“I’ve been thinking about my situation although my ability to think is significantly diminished from what it once was when I was younger and captivated by, for example, the history of the Ottoman Empire, of which I remember only a small amount. I was at Massachusetts General Hospital with weakness, variable abdominal pain, nausea and migratory joint pains. This would have been in the middle seventies. My attending was a man named Frank Duffy. He was honest with me and told me that he had no idea what was wrong with me, except that it was a real bother. He said hat he hoped and even expected it would go away without ever being diagnosed, like a man who comes to town, commits a crime and then fades away, leaving no trace.

“He kept coming back in he evenings with no clear purpose except to converse with me, as if he were genuinely interested in knowing what sort of a creature I was. Maybe, if he couldn’t diagnose my ailment, he was at least trying to arrive at some diagnosis of who I was. One evening, he told me that his favorite hour of the week was the “Morbidity And Mortality Conference” where, in particular, the cases of patients who had died and undergone autopsies were presented. Duffy reveled in this conference because he felt it set a standard that could help medicine to improve.
More than half the cases died of something that had not even been considered during their clinical course. So, Duffy remarked, we doctors have colonized only a small piece of the vast continent of man’s illness. Doctors should be humble and aspire, not make proud and excessive claims.”

What my patient does at this juncture in his narrative is idiosyncratic and telling.
He almost smiles, half closes his eyes and seems to absent himself not only from me
and my office, but also from himself. He very quietly goes away and then comes back without any major use of his musculature.

‘I think Duffy was apologizing to me, not directly, but in a roundabout way that was as realistic as it was severe. I imagine Duffy, like most of the best people I have known, is dead now. He must have been at least fifty at the time of that admission to MGH. But I suppose he has a certain life as a peripatetic shade in my mind. In any case, it is he who has inspired my recent ruminations. What I need is an autopsy, only I want to be there to see it. I’m convinced that I’m one of Duffy’s cases, not that there is any particular distinction. What is wrong with me is something that no one has considered, not even myself. An autopsy – a living autopsy – would overcome the opacity and mute obstinacy of the flesh. I did a PubMed search and it returned no citations. I’m surprised no one has thought of this before me. It makes complete sense.”

He says this without the least trace of irony and looks at me, as if I were in a position to say or do anything. I am thinking that it all has to do with an insatiable appetite for attention, a tragic flaw but very human

I sometimes urge that I should be titled the Vicar of Towson, since I specialize in vicarious experience, sitting and listening and living with what people tell me. I do this on the grounds of Sheppard Pratt, one of America’s great old and very beautiful mental hospitals. Just outside my office is a beautiful old ornamental cherry tree. I have lived in Towson immediately north of Baltimore for more than twenty-five years now.

I am acquainted in depth and detail with many parts of town where I have never been or through which I have passed only occasionally – Dundalk, Glen Burnie, Pikesville, Pig Town, Randallstown and so forth. There are houses and and dinning rooms and basements and kitchens and bedrooms and yards and woods and school rooms that live vividly in my mind although I have never seen them and they existed in other times and other places. I have lived vicariously, too, in foreign countries – Israel, Iran, Zimbabwe,
France, England, Trinidad, Argentina and more

Proust wrote that “the only real voyage of discovery consists not in seeing new landscapes, but in having new eyes, in seeing the universe with the eyes of another, of hundreds of others, in seeing the hundreds of universes that each of them sees.” Psychotherapy is an art of such listening that the other can world forth a world, this world being his world - and have it shared, not statically, but so that it can live and breath, declare itself and grow. Psychotherapy is a partnership in presence. A good psychotherapist is a gifted story listener.

In his great ballad about war and loneliness, destruction and despair, “Talkin’ World War Three Blues” Bob Dylan evokes contagious dreams of a landscape of devastation in which “everybody sees himself walking around with no one else” and then proposes the antidote, simple, practical direct – “’I’ll let you be in my dream if I can be in yours,’ I said that.” This goes right to the heart of the matter and to essential matter of the heart. When we deaden ourselves to others we go dead and this kind of deadness has everything to do with how war comes about.

But how do we open ourselves up and make it possible for others to lead us to imagine them so that they may be helped in how they imagine themselves, that is, in a crucial department of the reality of how they experience themselves? There is no fixed methodology. Getting the imaginative knack of someone else is compound of curiosity, mischief, the waking and stirring of pieces of the listener that may previously have been almost in a stuporous condition.

Each patient is a dream. Every way of living is a way of dreaming. Part of what language makes possible is that this waking dreaming should be able to be made sociable. I listen to my patient talk about how hard his conscience makes life for him, finding fault with him wherever he goes. I see a lonely little boy, one who does not know what he can count on. I see myself as a lonely little boy.

I think about expecting the worst and there being security in having something clear to expect. I think about how much safer it is to rage at yourself than at someone you need when you are little. I think about how tangled it all is and how there is no sword that can cut through the knot at a single masterful stroke. I say something about all this and notice the faintest hint of a smile on my patient’s face, as if I have somehow wormed my way into the dream and opened it up and let it begin to breathe.

I have seen him waiting and wounded by his waiting, a drawn expression on his little face as if somehow, unaccountably, he must be at root responsible for the punishment of deprivation with which he is living. I have seen this and felt it in the muscles of my face as they are drawn into a mirroring mask. He has found a way to let me keep him company, to let me in and himself out.

Vicarious living may be deeply real, if subtly so

I am listening to the psychiatric resident describe her session with her patient. She is well along in her training, reasonably poised and reasonably convinced in her approach. She is telling a story and, in this story, she comes off as both kind and competent,

The patient comes off as a bit confused, clumsy, dependent, not very good either at thinking or feeling. The patient seems pale and out of focus. I keep wanting to sharpen the focus to make the patent clearer. Of course I can’t do this. I am mildly annoyed that I can’t – mildly annoyed at the patient, at the resident and at myself.

I ask myself, “Why do you ask for the impossible? Why can’t you just be patient and let things be what they are and find their own natural pace of development?

I am sitting in my rocking chair. I am, as more than one patient has pointed out, “on my rocker.” My rocker is a beautiful hand made cherry rocker with flexible back slats so constructed as to provide considerable unobtrusive lumbar support. The chair is the vanquisher of the back troubles that were incipient when I got it. For this, I am very grateful to it and to my wife at whose instigation I got it.

It is the single most expensive piece of furniture I have ever bought. I remember how acutely uncomfortable I was waiting for it to arrive from northern California nine months after I had ordered it, how worried I was that after all the expenditure of money and effort I would hate it. I do not.

I enjoy my intimacy with it. I try to imagine when the wood was a tree and the tree was in blossom, pink like the ornamental cherry just outside my window that is one of the highlights of spring here. I don’t rock much in my rocker, mostly just sit, shifting weight from time to time following the ebb and flow of the story that the resident is telling me.

I am struck that this resident’s skill in storytelling is limited. She is inhibited. She is trying to get it right, so she is conscientious to a point that borders on vanity. She does not seem to be enjoying herself very much either with me or with the patient. In fact, she seems to be a bit frightened of me.

What am I going to say next? What am I thinking? What kind of power do I have over her? Can I be part of denying her something that she wants?

A detail does it. The resident mentions that her patient was cooking dinner for an elderly aunt who was becoming demented.

This detail is jarringly familiar. I fumble about in my mind trying to grasp why it is so familiar and so jarring. I am disoriented for a minute or two, lost inside myself, barely able to stay in touch with what the resident is saying.

Then I find it. Two years earlier I supervised another resident who was at that time treating the same patient. Or is this one the same patient?

I am amazed that I can have taken so long to figure this out. I am staggered that I have been listening for months without solving the puzzle. It explains why I have felt so awkward, why the resident’s narrative has always seemed to me just a bit out of focus. It clashed with the picture that I had stored in my mind from my first vicarious encounter with this particular patient in supervising the previous resident.

I have the urge to correct the resident I am now supervising, to use my database on the patient to point out to her that there are a number of important areas in which she is mistaken about the patient and how he works. A psychotherapy supervisor is always tempted to assert superior knowledge, a temptation that is regularly dangerous, but especially so in this case.

I stop myself, recognizing inside myself that what I am wanting to do is to make a situation simpler for myself when it is not simple at all. Does previous knowledge of the patient uniquely qualify me or disqualify me as a supervisor of this resident’s treatment efforts? Does it make any difference that I have the illusion of prior knowledge of the dementing aunt?

Surely, if it were a question of choosing a jury, I would be disqualified because my previous acquaintance with the matters at hand could not help put prejudice my hearing of the narratives embedded in trial testimony. If, however, I was a candidate for a diplomatic posting in Amman, the fact that I had gone to prep school with the King of Jordan would surely count in my favor.

Is this patient the same one whose treatment I supervised or is he a different patient?

The first resident, male, older than many residents, a dissenter from a family of businesspeople and lawyers, had quite a sponsoring, approving optimistic view of the patient, who was a rather rambunctious businessman who had known real success and then real failure, boom and bust. The resident was wholeheartedly interested in the patient.

The patient was in his forties, not successful in relationships, trying to recoup his losses and rebuild. Also, he had suffered profound losses and neglect in his childhood, been involved in cycles of boom and bust all his life. Nor had the cycles of boom and bust spared the holding environment on which he depended for care and comfort.

The first resident liked the patient and the patient had no trouble taking this in. There were some minor boundary questions with the resident doing perhaps a bit too much for the patient and even being a little bit conned by the patient.

We discussed these in supervision and how they had their good points and their bad points. Doing for a patient can sponsor a patient’s efforts to do for himself as well as subvert them. Psychotherapy is a balancing act. A seal balancing a striped colored ball on his nose comes to mind.

So I say nothing to this current resident about my previous life with this patient. I go on listening, noticing that as I do so, I am making many different comparisons in my mind between how she portrays the patient and how I knew the patient before I knew her as the patient’s psychiatrist.

I feel mildly guilty because I feel that I am holding out on her, keeping something to myself that might be germane to her work. I wonder what she may be withholding from me, what the patient may be withholding from her, because withholding is always part of the communicative process, often motivated by shame.

I am very interested in how her manifestation of the patient is richly at odds with the first psychiatric resident’s. I get the idea that she is frightened of him, that she is aggravated by what she feels as a hyper-masculine vanity, treading near the border of aggression. At least it is overbearing, demeaning of her and her authority and competence.

She does not grasp that she is feeling what he feels in the face of her therapeutic presence– at least one down, not sure how to change the position, ashamed to be where he is and unwilling to talk about it.

I try to discuss this with the resident. The discussion does not go all that well. I feel clumsy, as if I were treading on her toes at each step. She feels in relationship to me something akin to what is active between her and her patient. Our discussion is eerily competitive. What makes it eerie is that the competition is not acknowledged in any way. We are wrestlers who refuse to acknowledge we are wrestling.

The image is close to sexual, so that I become aware of the dimensions of sexual intimacy between her and her patient as well as between the two of us. Wrestling involves an enormous amount of contact. I am stunned how different this treatment is from the previous one.

But it is also true that in my wanderings and wonderings I manage to free myself from comparing the two treatments in a way that privileges one over the other. The patient is the same patient and not the same patient. A person is a territory vast as a continent, so there is plenty of room for the most diverse explorations. Cooking for the demented aunt is a bivouac common to both treatments, indicative of the patient’s capacity to take care not just to seek care.

Don Quixote, the incomparable, comic, tragic, absurd, possessed by his destiny, dispossessed of his life by his destiny, an explorer who leaves home to find himself but loses himself in trying to find himself, someone perpetually homeless and proud of this homelessness as a quest for the impossible but imaginable.

Sancho Panza, a man like other men, moored in a web of human relationships, not so very grand, but very real, a nobody who is somebody by reason of how he carries being a nobody, being as close to the earth as any other clod, capable of a loyalty that is itself a kind of realization of the imaginary, someone who lives as himself but not so much for his own sake.

A distinguished, tall, thin. extremely learned, very ill elderly man came to see me looking for I didn’t at the time know exactly what and I still don’t know exactly what it was that he was seeking. I find myself thinking he was looking to be made whole. In life as in the law this concept of being made whole is no simple one.

This man yearned to be restored to being who he thought he was. Actually it went far beyond yearning to an insistence that bordered not only on religious faith but on an idiosyncratic religious fanaticism - “I can only be if I am who I take myself to be, even if who I take myself to be is not only complicated but also multiplex, fabulous.”

Ailing had been an integral part of his life, reaching back into childhood. Part of ailing was an unending search for succor and care and healing. He appeared over and over again as a supplicant but as a superior supplicant, one who ought to have been entitled not just to the best of care but to care that was effective.

In fact, the care he received was almost always disappointing, occasionally going well beyond disappointing to disastrous, as serious diagnoses were missed with awful impact on his health. At its very best, the care he received was not quite worthy of him. At its worst the care was contemptuous, injurious, prejudicial, as if something essential about him was a serious threat to doctors and their ilk.

His appearance, how he made himself manifest in my presence, carried at once an appeal that was close to tenderness and an aloofness that expressed a near settled hopelessness about any appeal to another person. “Why bother?” he seemed to be asking himself, “when the results are overwhelmingly likely to be a good bit worse than fair to middling.”

Without being asked, he declared that he was not interested in relationships. They were too much trouble, served only to constrain and limit. Relationships were for those who wanted and needed them, of whom he was not one. Loneliness was not an issue for him. His was the only company he could bear. Anyone else grated on him. He did not miss people and was constitutionally averse to grief.

Strange gambit – to seek out a psychiatrist, going to considerable trouble to do so, in order not have a relationship. He mounted for me formidable displays of his historical and literary erudition. Listening to him I learned a good bit and admired him. He was no fake. His learning was genuine, wide and deep. I became quite fond of him, most of the time enjoying his company. Often I heard the dry rustling of the male peacock’s feathers

I tried to help him with mood, with sleep, even with a host of physical problems. I worked to recruit other doctors in different specialties to help out. I became my patient’s ambassador to the world, even becoming involved in some business difficulties. When I would suggest that he could do some of this, even a majority of it himself, he would retreat into a peevish passive shell, a defiant and unacknowledged insistence on being dependent. He was much too dependent to admit to dependency.

When I found someone who might be of use, he quickly shed them, making short work of their credentials, their capacities, their clinical acumen. Quite regularly he managed to be sufficiently derogatory and dismissive to offend the person in question. In this peculiar way, I became acquainted with a whole circle of clinicians whom I had not previously known and with whom I to this day enjoy cordial and collaborative relations in the care of other patients. My patient helped me reach out and engage, even if he rejected the help proffered. In this regard he was my benefactor.

All the doctors whom my patient shed suffered from a simple invidious comparison. He clung to the notion that, if a doctor simply possessed the requisite clinical and scientific knowledge, that doctor would be able to make a clear and profound diagnosis, placing all his difficulties in an orderly array and so rendering them vulnerable to a virtually surgical strike – neat, unambiguous, effective. My efforts to suggest to him that medicine was almost never like that fell on deaf ears. The ideal of the omniscient omnipotent healer was simply too precious to him. It was the dam that protected him from being drowned in despair.

Measured against the ideal I, too, fell far short. From time to time, my patient would develop intense disgust with me and attack me in the most personal and cutting terms. His tone did as much damage as the content of what he said. It was a long while before I gathered myself to defend myself and repulse his attacks. A number of times he fired me as worse than useless, an insult to him, someone who was complicit in harming him, virtually a criminal. Then there would be rapprochement, more or less gradual, without apology or reflection.

I grasped that, as the messenger bearing news of manifold unacceptable realities, I often seemed terribly toxic to him, as if I were bent on sapping his strength, painting him into one corner or another. I was the attack on the fundamental premise of his existence – his capacity to rise out of and above the ordinary facts of life, but strangely also a nutritive link, someone who listened and responded and tried, even when it seemed quite hopeless. I would have put it that we were in relationship to each other, a characterization he would have rejected.

We were together for years that were often harrowing. He was very skilled at eliciting worry, at making rather extreme demands. I felt helpless a good bit of the time and knew that the situation was fundamentally hopeless, that he was not likely to change in any fundamental way. I could do my very best but my very best would make little difference. My very best was not even close to good enough.

So what held me to it? This is when I began to think of myself as Sancho Panza to my patient’s Don Quixote. He could not help himself and, as a result very much needed my help, not that there was anything much to be achieved or any real reward.. Or perhaps there was a great deal in the way of real reward utterly devoid of glamour. A Sancho is short enough to hug the earth and to feel the earth hugging back. In the long run the earth’s tug takes hold of all of us and we return to it.