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.