I am listening to a psychiatric resident describe her therapy session with a patient in her late fifties, someone whose attachments are unusual and unsatisfactory. Parents, spouse, children, step-children all present difficulties for this patient, who would like to bring people together and have them, if not cherish each other then at least get along without too much hostility and disharmony.   She does a lot of work to bring this about, taking care of diverse people in diverse ways. She does a lot of cooking in addition to her full time job which she enjoys and where she is recognized in a way that she is not in her personal life.

The patient’s tone as the resident mimics it is a pale sort of whining, with some anger, but definitely on the mousy side. This is not a person who puts her foot down.   She is trapped in her relationships and yet they are where she dwells. She is not about to issue ultimatums to her husband or anyone else. She fears psychological homelessness. She is attached to the qualified loneliness of what she knows as opposed to the possible radical loneliness of major change.   She has come to psychotherapy for help which she rejects with each breath even as she seeks it.

The resident who is kind, in her late twenties, interested, wanting to be of use,is completely baffled by the patient.   She says she has no idea what to say, so thatshe finds herself falling back on that ancient friend of the psychotherapist: “Um-hm,um-hm”. She can’t imagine what the patient is getting out of the sessions but the patient does keep coming back.   The resident is very critical of herself. She expects herself to help the patient make things better for herself in tangible and observable ways.   She does not share with the patient how frustrated she is and how inadequate she feels.   The resident is not yet at the point where it might occur to her that her own feelings provide some mapping of the patient’s characteristic. ways of encountering her own self.

The resident is not yet married, although contemplating it, not a mother. She is very optimistic about what life holds in store and, having experienced a run of successes, quite hopeful about her capacity to shape a life that suits her. She does not think much about the plight of Gulliver among the Lilliputians, immobilized by myriad small strings. The kind of situation in life that her patient presents her is quite unknown. She has trouble finding a glint of familiarity in it.   Her coffers of experience of life are just too empty for her to be able to reach in and find anything that matches and might begin to serve as a key.

As I sit with the resident, putting in a word here and there, maybe more than a word sometimes, I find myself utterly baffled, too. I have caught the feeling of bafflement not just from the patient but with the patient.   The point of these weekly supervisory hours is that I am supposed to help the resident become a psychotherapist with resources for being of use to patients.   I have no idea what to say, no idea how to help the resident find a developmental way forward. I know this is important, because at issue for the resident is not simply trying to help the patient, but also the formation of her own identity as a psychiatrist.

What to say? Do I need to say anything? Life, after all, is the great teacher.   Psychotherapy like life is a long and winding road. Somehow in my discomfiture I do find things to say that may be helpful. I point out that the fact that the patient keeps coming back is an important fact as is the fact that the resident listens and does not ridicule, does not cut the patient short. I suggest to the resident that what the patient makes of her may well be therapeutic.   The patient creates her therapist and works with this therapist that she has created. The resident does not need to take such total responsibility for the therapeutic action.   I point out to the resident that sometimes a simple “Say more” may be very supportive and encourage the patient to go a bit farther on, perhaps even enabling her to overhear herself.  I say that I think the topic of anger is huge, not just in the patient but in the surround where she lives. Will the patient ever be able to express a bit of anger at her therapist? I think as I say this, “will the resident ever be able to express a flicker of anger at me?”

I have not parted with my bafflement by the end of the session with the resident. But I have the sense that I have not been utterly paralyzed by it. It is not so much what I say that is decisive for the resident’s growth as a therapist , but rather what she makes of it, what she can make with it.   I end the session feeling much more connected with the resident. My anxiety has diminished and so has hers.   Life will bring her so much and also take away so much.   There is an abiding mystery in this that the patient, the resident and I all share. We are connected, somehow, in living.

I find myself wondering what next week’s supervisory session will be like, that is, looking forward to it.

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