About twenty-five years ago, when managed care was threatening to pull psychiatry up by its economic roots and to toss, if not all of it, away, certainly to get rid of relationship in treatment and long term psychotherapy as a cultural practice, I ran into my friend David Lamb, also a psychiatrist, at Eddie’s supermarket in the late afternoon as each of us was picking up just a few items for our families.
“Robert” he asked me in a rushed nearly agitated way at the checkout counter, “do you think that we will still have jobs?”
“I hope so,” I replied, ”of one kind or another.”
We didn’t linger, but the exchange had plenty of intensity.
Three weeks later, under the same circumstances, I ran into David again. This time he was much more sanguine.
“I’ve got it figured out, “ he said, “People will always be willing to pay for gurufication. It is not a luxury. It’s a necessity.”
“Gurufication?” I echoed. a bit bemused, because I could make some headway in construing the term, but not really enough to constitute understanding.
“People need gurus in the midst of the confusion of life,.” David said. “There’s nothing formally religious about it and, yet in the practical sense, there is everything religious about it.”
“So what does that have to do with us,” I asked. “We’re doctors, applied scientists, artfully trying to help our patients feel better and do better. We don’t sit under lotus trees and meditate. We don’t have revelations. We’re really ordinary people.”
“That’s all true, “ David rejoined. “We are doctors and we are ordinary people. We’re not going to give that up. But people need more than that. They need a teacher, a guru, who listens to them, a guru who guides by being more than doing,
a guru who gives advice by how he is more than by what he says. We listen and by listening we help them listen to themselves. They come near and this helps them to separate and to become themselves. It’s because of this part of what we provide
that I am convinced we are going to go on having jobs.”
I was glad that my friend David had found a way to talk himself out of the terror
of unemployment. Outside of that I didn’t think much about our conversation, but I also did not forget it as I mused on what I did for a living, on what I did with my living.
I wondered if I did the same thing or even essentially the same thing with each patient. Even within the same diagnosis it seemed to me that I might proceed very differently. Where did the cues come from? Was I primed in certain ways? Did the patients provide cues? How many of these did I miss? How many did I misinterpret? Was I available to have my misinterpretations corrected by the patients?
Was I a sort of raw material out of which patients could construct what they needed? I remember a patient, now deceased, who told me that she had discovered who I was: I was the closest thing to a mother she had ever had or would ever have.
As I ruminated on my friend David Lamb’s formulations about gurufication over the years, one thing was clear to me, namely that there was no way to develop a manual prescribing a guru’s interventions or non-interventions. All it took was a small scale thought experiment to demonstrate the folly of undertaking the writing of such a manual.
Now it was also clear to me that there was no way to write a manual prescribing what I did or did not do in treating a patient. Pieces might be described by algorithms, perhaps especially pieces describing the use of medications, but even here decisions are much more artful than we might guess, patients much more idiosyncratic than we would like to imagine.
Relationship is an essential force in what invites a patient into treatment, in what helps hold a patient in treatment, in what makes disclosure possible, in what allows a deeper opening up not only to the treating person but of the patient to herself.
Defining “relationship” is no simple task. We know it when it is present and we know when it is missing. It has to do with a psychic commerce back and forth, with responsiveness, with many different forms of receptivity. It has also to do with imagination, with intuition, with trial and error, with mixtures of confidence and of diffidence. Relationship is about partnership in meaning and meeting.
If defining relationship is no simple task, of one thing I am convinced, namely, that relationship can not be effectively manualized. I think computer scientists are out of their depth when they imagine programming devices like a “relationship machine.” Attachment, among other things, is far more elemental, far deeper, for more varied than code can readily capture.
A man in his sixties, reflecting on treatment he had received when he was in his twenties, realized that what had mattered most to him was that his analyst was a cheerful man, that he seemed to enjoy what he was doing. This legitimized pleasure. For this man who came from a family where there were deep and grievous wounds, the idea that you could enjoy yourself, that you could be cheerful
was a revolutionary one. It set in motion profound change.
This notion was not conveyed explicitly, but rather was conveyed atmospherically,
not in what was said. It was not until years after the treatment had ended that it occurred to the former patient to formulate this vital dimension. He did so only for his own benefit and with a fondness and a wry indulgence for who and how the two of them had been all those years gone by.
Where do we find people who can be our teachers? How do we find them? Indeed
how do we go about searching for them? What sort of deep radar do we use and what tells us that who we think we have found actually will fit with us? How do we get close without getting too close and losing ourselves? How do we keep enough distance to retain our sense of self without producing so much barren distance that
we foil our own longings?
Who is my teacher? Who is my guru? These questions point in two directions. Who do I elect as my teacher. my guru? This can be a fateful decision, one that gives
shape and direction to ourselves and to our lives. The second question is, how do I get to know the person I have selected as my teacher in sufficient depth? How do I sort through what I can get to know about this person well enough to notice what is good and what is not so good, what is good for me and what is not, what is fair and what is flawed. Every teacher, every guru, every person for that matter is a mixture, a compound of many different elements.
As the Talmud says, the wise person is the one who learns from everyone. Of course, the universal set, everyone, includes oneself. If one can not learn from oneself, find both inspiration and object lessons in how not to be from oneself, then one’s learning will be radically impoverished.
Some Yogic traditions have it that there is, in each and every one of us, an inner guru, a teacher within. If we accept some idea like this one, then one of the goals of therapy will be to help the patient get connected with this inner guru, to make it possible for the patient to continue on the patient’s path under his or her own guidance.
Many patients come to therapy out of touch with what they know and also out of touch with their own capacities to learn because of one or another major interference. One interesting class of interferences is conflict concerning loyalties. To go forward on an authentic path means to leave someone who has been very important behind without that person’s approval or consent. So the potential gain is laced with loss.
It can be a very complex transformation that is required for a person to move from loyalty as a form of bondage to a more free and discriminating attitude to someone who has been important (or devastating) inside. For a patient to value himself or herself more accurately and robustly, there may have to be a serious value reformation with regard to intimate others. This may make the patient feel like the patient is entering a strange and alien land. It may make the patient wonder whether the journey is worth the pain and confusion.
A guru is a spell that we cast on ourselves. It may contain important elements of transference to provide for some familiarity and continuity. But it is never only transference. It is a spell that is at once exploratory and explanatory. It contains
significant hints of the self we do not recognize as ourselves, the inner other who may be the custodian of much in the way of our possible riches, the wealth of our
personalities that we are never done changing and rearranging.
So a guru is both truth and illusion as is a therapist. Perhaps a guru can not tell us where to go or even how to go but can be with us in our puzzlements, in our wanderings, through our losses and through our being lost.
It may seem odd to say this but one essential function of a guru is simply to keep us company, so that we are not wholly on our own with our loneliness, that predicament that can easily swallow us and destroy us, since we were not designed as mammals to be alone.
So a guru or a therapist is not so far from a teddy bear. I do not mean this disrespectfully, because I have the utmost respect for these animals we animate to the very edge of actual existence. They accompany us in our complicated search for ourselves and flight from ourselves.
As I write this decades after my conversations with my friend Dr. David Lamb I ask myself what I am writing and why. It is peculiar that certain exchanges lodge in our mind and keep making claims on us, keep instigating new observations and also new doubts. Both my friend and I have had careers in private practice, not making as much as lawyers or business people with much less education and responsibilities that do not carry such intimate heft. But we have made enough to support our families and educate our children and enjoy life as relatively privileged Americans.
Not that I know or can say clearly what we do or what we are for our patients. That may be the point of this little essay, that in our work, there are principles of indeterminacy, that clarity and constancy of purpose are elusive. What I do is
approximate and, while this often makes me uncomfortable, I believe it is irreducibly so. This represents both exile and freedom.