Chungwo, China, Middle Kingdom – but my sense is “Middle Kingdom” may not give the full flavor of the name.   Kingdom that is the center of everything may be better. Or simply center of the world.   Bicycles are gone. Urban China belongs to cars in bewildering numbers being driven so assertively that it seems that a twenty four hour game of chicken is being played on the roads.   The pedestrian does not have the right of way and the carnage is considerable. Vehicles collide with vehicles and vehicles collide with people on foot.   You have to be very alert crossing the street.     In the last thirty years China has built a road system that spans the greater part of the nation. This has involved the construction of innumerable bridges, overpasses and tunnels. Much of motor vehicle travel in China feels modern, although there are anomalies.   On a road outside Pingyao a shepherd and his working dog are moving a flock of some hundreds of sheep. This brings to an unhappy halt convoys of heavy trucks headed in both directions.   Cars and trucks produce carbon emissions far beyond what bicycles do.   This is not good for the air.   In fact, the air in cities is often miasmatic, obscuring the sky, threatening the health of the lungs that breathe it.   Of course, the burning of coal, often coal that is dirty, is responsible for much of the degradation of air quality. The energy is needed to power development, but it comes with a bundle of costs.   Could development be smarter and slower?   “Ah,” says one of our local guides... read more


At the very height of the financial crisis as the sub-prime mortgage bubble burst,the federal government was spending some tens of thousands of dollars to send apatient, let us call him Hugo, who had been involved in a piece of financial chicanery to finance his education to jail.   Hugo was guilty as charged although he argued that he had been subtly entrapped. Did Hugo lie about a number of things? Of course he did.   Once the indictment came down, Hugo was deserted by almost all of those he thought were his friends and allies. There were a few exceptions, for which Hugo was deeply grateful. But he was terribly hurt by what amounted to a shunning that deprived him of his social and work milieu.   A man of quite frail self-esteem to start with, this shunning was devastating and dangerous. It made him think ill of himself against his own will.   The prosecution and the subsequent incarceration were costly. They were justified on the grounds of the importance of protecting against “moral hazard.”   Less than thirty thousand was involved in the patient’s financial chicanery, not billions. The little man takes the fall. The big guys smile, apologize, asking for permission to do it again, and move on to do it again. Hugo was fully aware of this.   With a rueful smile of his own, Hugo remarked that he had always been a little guy.   Upon conviction, Hugo was suicidal, overwhelmed by sorrow, shame and dread.   He had grown up in the midst of South America’s most bitter civil war . The dead were a part of everyday... read more

The Unfinished

The unfinished stays with us within us, nagging at us in different ways at different times, sometimes with considerable creativity, sometimes just as a subliminal itch. More than twenty-five years ago a patient came to see me with complaints that were in no way out of the ordinary. You will see as we go along that there is no way that I could violate his privacy rights by writing about him. He complained of being ill used at work, unappreciated at home. He wondered why it was his lot always to have to hold up under such a load. There were tinges of depression, even tinges of suicidality. I remarked that he maintained a peculiar subtle distance from all that he said, as if he were talking not quite about himself, yet not quite about someone else. In the fifth session, I had the sense of him fading out just a bit more, so that it was not exactly a surprise to me when he did not come for he sixth session. He did not come and he did not call. I was concerned about him, puzzled about what had occurred in him, what had taken place between the two of us. I waited a week and then started actively to search for news of him. I called the phone number he had given as his home number. The person who answered the phone said she had never heard of any such person, that it was certain that no such person lived at this address. I called the number he had given as his work number. The person who... read more

My Life: Missing

“I think I’ve missed most of my life…”“Say more.”“I’m not who I meant to be, not that I meant to be anyone. I don’t feel I was meant to be who I am or how I am. I think my mother and father would recognize me, if they saw me now. But when I look in the mirror, that person doesn’t seem like me. There is a certain familiarity, but that familiarity is neither intimacy nor accord. It’s a stand off between myself and the one whom I see in the mirror.”“Go on.”“I wonder how this happened. Did I just take my parents’ word for who I was? If we could exhume them from the yellow midwestern clay where they lie next to each other, my parents would protest that they never had any blueprint for me, that they just wanted me to be happy. The sad thing is that that’s just what I would say to my own kids, if I were pressed. But I don’t go into this sort of thing with my children any more than I went into it with my parents. For a long time I didn’t go into it with myself. I suppose you could say that a certain brand of privacy, maybe even isolation is a tradition in my family.”“Mmmm.”“I’m fifty-eight years old. I have enough money. I have a stable marriage and three grown children. It’s not that I dislike my life. It’s a fine life, but it doesn’t fit. It would be a wonderful life for someone else. Over the last two years, a very strange thing has been happening.... read more


I’m talking with an elderly man who has always been a physical risk taker, so extremely much so that he is convinced that it is genetic and that he has the gene or genes for this kind of behavior. This risk-taking has led to great accomplishments but also to innumerable injuries, both more and less dreadful, some with irreversible and dire consequences. “I’m still a risk-taker,” he says. Together we get to the idea that both thinking and feeling are risk taking activities that many people avoid because they represent threats to their senses of stability and security. If you think, if you feel, you may not turn out to be quite who you took yourself to be. If you think, if you feel, the world around you, including those nearest and dearest, may turn out to be different than you thought. You can sustain thought and feeling injuries that can be as crippling as physical injuries. Of course, if you do not think and feel, as if you do not move, there are opportunity costs. You lose out on opportunities that may heal and help, even inspire, as well as on those that may hurt. Opportunity costs are extremely hard to characterize, becausethis side of realization opportunities are by definition imponderable. To live with an open horizon is not simple, but is a fundamental freedom. Until this conversation, I had not thought to put mental daring next to physical daring.The two are clearly different, but also share basic features. Security and curiosity meldto make daring possible both in the physical realm and in the mental realm. I got... read more

Not How I Drew It Up

“This is not how I drew it up. This is not what the blueprints said. I really don’t know what it is. If it’s my life, I really don’t want it, but I have kids to think about, so that’s why I’m still here. I’m going to go on being here, too. I wonder if I’ll ever get used to myself. I hardly can remember what used to be but I can’t forget it either.” “I feel like I got lost and wandered in to someone else’s life. If they want it back, they sure can have it. I feel like an immigrant. I haven’t learned the language and I don’t really want to learn it.” “I don’t know how I got here. I suppose one thing led to another, but I never had any idea of the destination. I was kind of just along for the ride. I’ve turned in to someone I hardly recognize. The particulars of my life shock me when I stop to consider them, which is why I try not to, which is why I don’t understand what I’m doing here talking with you.” “I don’t like Kafka, but the reason I don’t like him is that he knows too much. He’s too close to truth that is beyond inconvenient. You really can wake up in the morning to discover you have been turned into a huge bug. Some mischief in the night. An accident. Nobody meant you any harm. But how do you learn to live like a bug? And even Kafka is still being polite, because you can be turned into something... read more

She Is Telling A Story

She is telling a story as she has been telling a story for years — this imaginary person, this imaginary patient. This story is not one story but many stories nesting in each other, sometimes bursting into flight to land somewhere else and make a new beginning. She is a reliably unreliable narrator. It is not even clear when she plots beforehand, when she does not, when she is speaking for calculated effect, when she is speaking because she can not help herself, can not any more impede the rush of words from her mouth, She is present at once so carefully and also so self-indulgently. There are so many of her and and this crowd is not even one. I am listening to her story as I have been for years — this imaginary person, this imaginary doctor. I am listening to her and I am making it up as she goes along. I am breaking it into pieces as she goes along. I am elaborating these pieces as they wake me up and develop fingers of dream that reach from her into me and touch me not in one way but in many ways. Listening to her is a kind of ecstasy that almost lets me stand outside myself except that I keep tripping on the threshold. As she is a reliably unreliable narrator, I am a multiply and extravagantly unreliable curator of her story, not from malice, but out of that most peculiar hope of helping. This hope is imbued with pride and shame, the two sides of an exquisite fabric. Look at this side and... read more

End of Life

When we discuss end of life medical care, we have to be careful to recognize that the word “end” has multiple senses. We regularly mean it in the sense of “terminus”, where life reaches its stop, its limit and is no more. but we need to remember that “end” also has the sense of purpose. Is life an end in itself? Is life good in itself, no matter how painful and restricted it is, no matter if a person is utterly demented or comatose? If life is good in itself, an end in itself, then whose good is it? Is it a personal good, a social good, a theological good, a combination of all these? Of course the question of what life is for, what its end is comes up for us everyday in our living, if we let ourselves arrive in the vicinity of the question “How shall I live?” and dwell there. What gives lives its worth is not the same for all persons. In fact the diversity is staggering. What life is for, what its end is is not the same for one person in different phases of his life. Different people identify themselves differently with different faculties. When persons can not communicate with recognizable lucidity or at all, then we are in the realm of inference about their dispositions. Inference calls for what can be excruciating... read more

Freud’s Lasting Achievements

Freud’s two great contributions were taking child mind seriously in a new way and taking the possibilities of intimate communication seriously in a new way. For Freud, the mind of a child was a marvel in development, that is, a moving marvel with its own predilections. He believed we encountered the history of the child mind in the predilections of the adult mind. The vast field of inquiry into child development received enormous impetus from Freud’s theories. For Freud, a special kind of emotional intimacy, a special kind of conversation, one he called “analysis”, made possible changes in how we experience not just the world around us, but ourselves. Psychotherapy, in all its variety and peculiarity, was born out of this new emphasis, which, of course, hearkened back to rabbinical practice and confession, perhaps also to shamanism. Both of these fundamental notions of Freud, taking child mind seriously and taking the possibilities of emotional intimacy seriously, have borne rich and varied... read more


Shame is a raw psychological surface, a prototypical border, a first draft of skin. When early attachment is difficult, shame acquires the status of an active drive to avoid what is intrinsic to us because acknowledging it might not be compatible with our survival. Shame is arousal we disavow, perjuring ourselves in a realm before conscience, which may later prosecute us on this basis for crimes of which we have only the dimmest, most diffuse and vestigial awareness. Shame is the origin of much of the disposition of conscience to be bad. Shame is all at once agonizing, voluptuous and addictive. The luxury of shame’s certainty, which depends on the inner fictive presence of a cherished intolerant and absolute other, deprives us of a chance to see ourselves with our own eyes. To the extent that our prior states and situations in life shame us, we will find ourselves lying even to ourselves about our current state and situation. The resolution of our shame requires that we be able to look at it through a maximum security prism. No one of us can do this alone. Our best qualities embarrass us as much as our worst ones. We may be shamed by what is deep, tender, powerful and true about us. Shame and embarrassment are the consternation of the current regime. Consternation may be for the good , as well for ill, but it is always uncomfortable. So many people can let themselves be known only when they know they are leaving, as if they need an escape route from their shame. Shame is a most intimate part of... read more
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