To great personal benefit and at great personal cost, I have worked intensively in both inpatient and outpatient settings and in schools with borderline persons over the past thirty years.. What drove me to do this? What have I gained from it? What did it cost me? I hope you will forgive my framing this essay about borderline patients in such personal terms. I even hope that you will find it useful. I am sure many of you have had encounters, longer and shorter, with borderline patients that have left you wondering not only about the patients but about yourselves.
A resident working with a borderline patient told me in supervision that she, herself, was holding her jaw so fiercely clenched that it hurt. “I’m so angry,” she said, “and this anger just isn’t me. “
I listened and thought, “No, it’s not,” and “Yes, I’m afraid it is.”
This was one of Sheppard’s outstanding residents, a leader in her class, a leader in the environmental movement, who went on to do good work under difficult circumstances for the Indian Health Services in the Southwest. Certainly, that clenched jaw anger was not part of her normal experience of herself. It was not part of her preferred experience of herself. But she had experienced difficult abandonment early in her life, existential hurts from which there was no appeal and to which response in modulated symbolic terms does not come easily. Actually, when we are little, such modulation and response are beyond us. This is why the care of very young children is so important. In caring for them we help them develop the tools for living that will be such important determinants of how they do later on.
Her early experiences played a part in her choice of psychiatry as a career, in her role as a leader among her peers, in her choice of working with populations that have not received a fair deal from those in power, in her concern for the whole environment. How fortunate she was – and many of us who practice as therapists are – to have better tools for channeling and taming our hurts than most borderline patients do, not that our tools do not sometimes fail us. Harry Stack Sullivan, who did an important part of his work at Sheppard, said, “We are all more simply human than otherwise.” This should not be taken to mean that many, if not most of us, are not a good bit “otherwise”, quite idiosyncratic in our approach to the world.
I am regularly amazed at what I learn about other people’s minds and hearts, their basic assumptions about the world, the way they go about relating. When I asked my favorite uncle, who had been a composer before turning child analyst, what went on in his mind, his reply was that there was a searching singing. To speak, he has to find words to match the singing he hears. I am occasionally stunned by a new glimpse of how I work in a corner of myself where the light has shone only lately. For example, I recently saw very clearly how looking down on myself and finding my work wanting were expressions of despairing grandiosity. How did I get to those heights from which I looked down in the first place? Why did I need to get there?
What Sullivan did mean, however, is that what we have in common outweighs our differences, so that the concept of a family of man makes real and, hopefully, realizable sense. Sullivan, of course, was one of the founders of the optimistically, if inaptly, named social sciences. He had the prescience to write at the time of the event itself that the bomb that fell on Hiroshima punctuated history. We struggle to this day to understand how we behave (and misbehave) in groups and the terrifying threat of nuclear force, neither of which issues lacks ties with the issue of borderline personality. Nor should we forget that Radovan Karadzic is an American trained psychiatrist in addition to his chosen vocation as a war criminal. We know that borderline personalities are toxic to social groups, an effect that can be seen in corporations, in locker rooms, and which I have myself seen as early as the lower grades of primary school.
A mother remarked to me, “I don’t know what it is about that girl, but wherever she goes, fights break out around her and kids who used to be friends find they can’t get along.”
It is sad that the core features of borderline personality disorder as a way of being in the world, a way of relating (or not relating) not just to others but to oneself, can be fully established by the age of five or six, if not well before then.
I have argued, only partly facetiously, that borderline personality disorder should be removed from the Diagnostic and Statistical Manual, not because it does not exist, but because borderline traits are so widespread that they are, in at least a statistical sense, normal. Our culture so pervasively discourages subtle feelings, if not all feelings. The interior life, the recognition of limits, including the last limit of mortality, metaphorical satisfactions, kindness, mourning and quiet enjoyment are all downplayed. Excitement, splitting, even the casting out of challenging and nuanced feelings as if they were some kind of devils who threaten internal equilibrium are encouraged. It is important to recognize, however, that splitting operations are a developmental imperative, a crucial organizing step beyond chaos. But to stop there is not just a personal tragedy but a community tragedy, too.
Frantic activity, frantic acquisitiveness, frantic ambition only serve to make us more frantic. As a psychotic patient of mine pointed out some years back, if we think in interior terms, then homelessness may be much more widespread than any of us like to suspect. The most vast frontiers we have to explore lie within us. It seems to me more important to have a heart than to get ahead.
When we speak of trouble in being alone, a trouble so many of us have, to one degree or another, we should remember that the word “alone” derives from “all one.” Among other things, the capacity to be alone is a measure of integration and resourcefulness. Of course, people can be alone too with certain kinds of monomania, a terrible set of restrictions in how they feel, with paranoia keeping them company. We see this in the wilderness of the city as much as in the wild regions of places like Alaska. When we think of something as simple, this may also be a measure of integration, of being well put together
We are, I would say, all borderline in some sense. Borderline is a mode of being. It is a way of being, that can coexist with other ways of being.. We have all been that vulnerable, that helpless, that terrified, that enraged, that baffled, that fragmented, that mistrustful, that all-or-nothing in our responses, that needing of self-stimulation to persuade us we exist. If this were not the case, how could we explain the astonishing sales of Steven King’s novels? Most of us may not have been predominantly in borderline mode very much or for very long or for a very long time since, so that we have the luxury of not remembering. For most of us, the borderline method of operating, the terror, the ruthlessness, the inability not just to consider the other but also to assemble a self to consider anything are contained. We do not regularly experience reality as changing dramatically, even kaleidoscopically, under different affect loads.
As one woman put it, “I was terrified. I had so little I just had to get whatever I could. That’s not lying. That’s something different”
Our borderline pieces are held in check now, even integrated so that they enrich us, by parts of ourselves modeled on parts of our parents and caretakers who helped us develop these containing functions, especially as small children. Winnicott’s wise words that it is the mother’s job to keep the infant as a whole in mind, so that the child can be in pieces are very much to the point. They can be a help to us in our dealings, too, with borderline patients.
Borderline patients live in an Alice in Wonderland type of world where powerful others can be counted on to produce havoc, not even the same way from day to day, but rather on the basis of momentary whims. In fact, borderline patients have taught me a much deeper appreciation of Lewis Carroll and his puzzles, which I now find at least as profound and frightening as I find them amusing. Not to be able to predict what will happen next, not to be able to communicate, not to be able to negotiate are major deprivations. It is a terrible disillusionment to know that your own needs do not count on a regular basis.
Once we take the trouble to get to know a borderline patient, we find the marks not just of intrusions but also of neglect. The two go together as ways of being out of touch with a child. The intrusions are often brutal.
The neglect, which leaves the child alone inside with his own impulses, has its own depleting brutality. In both cases, the child is up against something too big for a child. and the marks not only of intrusion – often terribly abusive – and neglect, which is equally devastating in different ways, because it leaves the child at grips with forces too great for the child to manage that come from within the child. Most borderline patients were not considered as people at all. As one woman put it after many years of therapy, “I’m trying to go from being compliance girl to being communication girl and it’s not easy.” Many borderline patients had the status of parts of their parents, of dolls, or persecuting objects, or inconveniences.
A borderline patient with each one of her ten nails individually and extravagantly painted presented herself at the office of her well-trained psychiatrist, a very competent practitioner. The patient threatened suicide and cut herself in the therapist’s office. She produced a climate of despair and terror that so impressed the therapist she felt it was her duty to call the police. I was at the time the fourth year resident covering the emergency room. The treating therapist called to tell me about the patient. She said she would go to the emergency room to fill out one of the two certificates required by Maryland law for involuntary commitment..
In the emergency room, the patient was calm. She professed no suicidal intent. She said she had just scratched herself because she was upset at the time. She did not understand why her therapist had overreacted so terribly. The patient was amicable, volunteered answers to my questions, seemed to have a subdued, but smug scorn for her therapist, but tried to keep that under control. While I was burdened by trying to decide what to do with her, she seemed to be having a good time, observing the comings and goings in the emergency room and taking in my attention. While I am not sure I would do this today, I decided to certify her, on the grounds that she had made a whole set of threats, terrorized her therapist and could not be counted on to be safe once she no longer had the leading role in this drama of worry that she had set in motion.
I recall another patient like this one whom I sent to hospital on the grounds that certain kinds of threats required response. He killed himself barely a year later after another psychiatrist later decided he was simply involved in attention seeking behavior. As another one of my patients, not so borderline, put it to me once, “I’m afraid we all suffer from attention deficit disorder. It’s just so hard to get enough..”
But it is true that, if we hospitalize these patients for short periods of time, they come out much as they went in. The hospitalization may further disturb them and they my stress and disturb the ward. So the question is not an easy one at all. Sometimes even a short hospitalization can be a big help, but we do not know when or for which borderline patients. One of our residents said recently that it was hard for him to differentiate the University Hospital psychiatric hospital ward from the nearby alley.
When I went to look at the paper work I discovered that the certificate this patient’s therapist had come in to fill out bore my name, not the patient’s name, attesting that I, Roger Lewin, was suffering from a serious mental disorder and in need of hospitalization against my will because I represented a danger to myself or others. This produced no end of amusement among the ER doctors, as they pointed out that any one of them had the power to have me hospitalized against my will. Eventually, two correctly filled out certificates were produced and the patient went off to the hospital, perhaps necessarily, perhaps unnecessarily.
But what had happened to the referring psychiatrist? How had it happened? Borderline patients do not, for the most part, say how they feel. The late child analyst Erna Furman made the important point that while we spend much time talking about affect containment, it might be much more useful to talk about affect attainment, that is, how inner pushes and pulls, inner states of urge, discomfort and impulse get turned into mental states, affects, that can be characterized and communicated symbolically, so that we can use language, reason and metaphor to mix and modify them.
Many children and many adults, for example, do not even know the names for feelings. They can use words like “mad”, “sad”, “scared,” “shamed”, “embarrassed”, “grateful.” But there is no reliable matching with existential states. They are just words, sometimes put together in dazzling strings, but they are not informative in the sense of bringing form inside and, therefore, providing information to those nearby.
A psychiatric resident in her forties brought me up short in supervision one day by telling me that, given her background, making it to the point where she felt real gratitude rather than something more directly connected with the need to survive was still a long journey, one she was not sure she would ever make. Empathy lived with another person is what makes the names of feelings mean intimately. This is an experience many children simply do not have.
The referring psychiatrist had gotten mixed up about who was who, whose feelings belonged to whom, what was what and become herself part of the emerging emergency. Her mistake in name on the certificate, as well as her going to the emergency room were both signals of her confusions. Borderline patients operate so much by projective identification. That is, they make us feel what they can not bear to know that they could feel if they would make a place for it. A borderline patient who feels out of control, overmatched and deskilled in life has a genius for making us feel out of control, overmatched and deskilled, the latter being a feeling that most therapists who have paid long and hard for their training, before, during and after it, do not like. When I describe therapists as having paid long and hard for their training, I am not referring even principally to money. Existential knowledge of the possibilities of suffering costs us, too.
We have played for years at Sheppard with synonyms for projective identification, where the projector stays in touch with a cast out feeling by putting pressure on someone else to hold it and be in its grip. Among them have been “projectile identification,” “defective identification,” “infective identification,” “derelict identification,” “prehensile identification,” and “collusive collisions.” But my favorite of all, coined offhandedly by Clarence Schulz, my co-author for Losing and Fusing, is “psychiatric ventriloquism,” or “psychotherapeutic ventriloquism.” One of the great virtues of this term is that patients will pick up on it, if we introduce it tactfully and with some measure of timing. I should say that, with borderline patients, tact and timing are both highly relative matters as well as highly relevant matters.
In “psychotherapeutic ventriloquism” there is no doubt who the dummy is. It is we, not the patient, who are being operated on by mysterious means from what seems to us outside, so that our jaws clench tighter than seems like us, our stomachs may be upset, even our vision and hearing may be affected, not to mention our view of who and how we are. In long term work with a borderline patient, we may resist all we like feeling like the depriving, more than half mad mother who so caused the patient difficulty, but sooner or later we will be driven to this and driven to experiential understanding of how it is not just alive in the patient but also alive in us.
Projective identification is that from the outside that turns up inside us, of course, not without making use of what of us was there to work with. Each borderline patient makes a different dummy of us, because each borderline patient needs a different dummy. Each one needs a different way-station on the long and difficult route of learning to communicate with himself or herself about what ails, how it ails and how to live with it and through it. Many of us live with our strengths as our weaknesses and our weaknesses as our strengths. But it is not easy to get to this dual appreciation.
Nor is projective identification or psychiatric ventriloquism a matter of words or other symbolic devices. It is a matter of immersion, an existential dunking in worlds that are often hellish. There is a formless living with, living through, living in, withstanding, interrogating that comes before we even know where a borderline patient has transported us.
We can feel at once possessed and dispossessed. I have struggled hard over the years to get hold of these states using a variety of symbolic means, talks with colleagues, supervision, both where I was the supervisor and the supervisee, and writing poems. I even recall one patient who so confused and bothered me that, after each session, I would make a small sketch, because I had no idea how to describe what had befallen me, let alone what might have passed between us. As I look back years later on this series of sketches, they show quite clearly the patient’s formlessness, her sharp edges, her intent to frustrate.
A borderline patient who had previously had twenty three assorted hospitalizations for alcoholism, depression and eating disorders, described the transformation that had taken place in her during her two years at Sheppard in the following way. She had been a championship swimmer in high school. At Sheppard, she went from swimming in order not to think or feel, to thinking and feeling while she swam. She still swam long distances, but these were now conversations with herself, rather than motor discharges unmediated by much in the way of self. After she left the hospital, left outpatient therapy and left the area, she continued with long swims and long runs and long bicycle rides, but much more in the service of being with herself than of being without herself. Not only has she stayed out of the hospital, but she has found her way to a useful and satisfying life involved with others.
When I am in despair about a treatment, as I often am, I think about her and remember how painful I found it for long periods of time even to share the same space with her, to breath the same air, so pervasive were the rage, the scorn, the remarkable refusal to be vulnerable that kept her trapped and isolated in her vulnerability. I am so glad we were able to provide the resources for her to have a life, provision that would not be possible under changed institutional arrangements now. She called to tell me about her current life on the west coast just as I was in the midst of writing this paper. A hard health blow had hit someone she loved. She had resigned her job to take care of him for the past many months. I was very sad for her and very proud of her.
A third year resident, who later, after a good bit of very good treatment, turned into a tender man and psychiatrist, spent most of that year of his residency, when he was working with borderline patients, as well as psychotic ones, walking about muttering, as if trying to inculcate in himself a very difficult lesson, “No good deed goes unpunished.” There is a related Chinese, saying “Why do you hate me? I never tried to help you.” What both these peculiar dicta present is the truth that when we seek to help, when we make ourselves available, we volunteer not just as love objects but also as hate objects. We put ourselves in the way of hurt.
We present ourselves as people on whom patients can take vengeance, people with whom the patient can enact the roles of the ones who hurt them, people whose naive optimism and hopefulness about life patients can not only dent but shatter and grind under foot. We become threats and promises all mixed up together, just the sort of thing that can really mix a person up, if not drive that person crazy. It is not a safe occupation treating borderline patients, because it is hard to know how to defend yourself, the therapist, enough, without defending yourself too much.
So many borderline patients are stuck in worlds where the issues are being hurt and hurting, so that the two roles available are the torturer and the tortured. To introduce kindness into this world is a major emotional and even spiritual upheaval, one which is not often possible, because, in part, kindness requires a tenderness which simply feels too unsafe, even if it is actually the only road to relative security. There is, perhaps, a haunting parallel here to the world of international affairs and so-called security arrangements, which would better be called insecurity arrangements. I am reminded of the borderline patient from a harsh fundamentalist background who said that part of her work in therapy had been to redefine every single term with which she had been raised. “Service,” “loyalty,” “dignity,” “pride”, “modesty” and “integrity” took on shockingly new meanings. This may be a more down to earth version of Nietszche’s transvaluation of all values.
For me, seeing how cruel borderline patients are to themselves, has made me almost able to forgive them their ferocious trespasses against me. I say “almost” because some of the hurt I have sustained, especially the hurt that has most immediately and deeply reminded me of the hurts of my own early childhood which had its share both of abandonment and of intrusion, has stayed with me and gone on hurting. In fact, as I have gotten older, I have found it more difficult to sustain this work, even as my understanding of it has deepened. Perhaps this is so because my sense of the limits has become much more realistic. I have had patients do well and patients do not so well and agree with Michael Stone that prognosis is not easy to predict, so that it is a matter of trying and being tried by patients to see what can be done.
I recall asking Jerome Styrt, an analyst with forty years experience working with these patients, whether there was a way to tell if a patient like these was treatable. I asked him this when he was supervising me during my third year of residency, a time when I had the opportunity to talk with so many experienced persons on a weekly basis. Such richness has mostly now been lost in psychiatric training.
“You try,” he said, “and then you watch to see if the patient uses what you offer.”
“How long do you try,” I asked.
“I don’t know,” he answered, shaking his head. “You try long enough but not too long.”
“How do you tell if they’re using what you offer, “ I asked.
“You watch,” he said, “but it’s not easy, because you have to decide what signs to look for and these can be small signs that are different for each patient.”
We both lapsed into a silence that I still remember and carry about with me. Nor have I been able to be more specific on this topic in my own mind in the years since that conversation. So the treatment of borderline patients, for all that has been written and said about it, for all the theoretical formulations, including those advanced by Clarence Schulz and myself in “Losing and Fusing” which tries to stay close to difficult clinical reality and tell useful stories while also presenting clarifying concepts, remains solidly in the domain of clinical wisdom, which is acquired slowly and at great price, requiring sustained proximity to patients and puzzlement about what they are presenting. Probably what is most destructive about managed care is that it attacks so directly the proximity between patient and doctor, the relationship that is medicine. I hope that in the long run our species’ innate drive to attach will triumph over managed caring.
The “Damned if you do, damned if you don’t” experience is at the core of treating borderline patients. A number of patients have insisted on suggestions from me, then taken such pleasure in refuting them, showing my complete ignorance and lack of attunement in making them, that I felt as helpless and foolish at the end as, I inferred, they felt at the beginning of these interactions. One patient made me feel so bad about the offerings she insisted on that, when she would start to demand them, I would say I was not up to providing clay pigeons for her skeet shooting exercises, even though I admired her marksmanship.
Maria Klement used to counsel residents who were in a dither about choosing between alternatives regarding a decision about a borderline patient to do what appealed to them, so that they could then learn in detail what was wrong with that way. The lesson here was that, given how un-integrated borderline patients are, how much is excluded in any given self-state, so that it lives to haunt and sabotage, there are, in the short term, in the medium term and often in the long run, simply no such things as right answers. It is “this mess” versus “that mess.” This does not mean that anything goes, but that work must be sustained in compromised and difficult circumstances for long periods. Borderline patients need help with all kinds of thinking and feeling, with every imaginable form of practical matter including that most elusive and difficult practical matter, the use of metaphor as an ongoing moment-to-moment inner connecting and transforming device, a teddy being that lives in our neural networks.
A borderline lady in her fifties came to see me on an array of medicines for a mixture of physical and psychological symptoms that, frankly, made no sense. So many symptoms made for the possibility of so many exotic diagnoses, each perhaps plausible at very low probability, none likely. These patients are internists’ nightmares because they gain such leverage over these doctors with the specter of the doctor’s being responsible for missing something dire. The patient is, in fact, virtually always sorely missing a partner in relating in ways that are beyond the patient’s capacity to recognize and so to state explicitly. These patients are rarely diagnosed by internists or family practitioners as character disorders. Yet some primary care physicians do an excellent and kind job of taking care of them.
Whatever anyone had done with this patient with the best of intentions, nothing had worked. All efforts to assuage complaints had only increased them. I worked with her for three years, reducing the burden of medications and symptoms in tandem by paying attention to her losses and listening without understanding quite what I was hearing. Listening without understanding is a large part of what I do. It was not comfortable. I was afraid of her, which probably was my internal read out of how afraid she was of me. The telling of this following story shames me, but I think its usefulness outweighs my embarrassment.
One day this patient presented me with a gift of the pastry for which she was known in her family. Gift, incidentally, as Freud pointed out in his little essay, “The Antithetical Meaning of Primal Words”, has also in German the sense of “poison.” At dinner time, my wife and I unwrapped this pastry, which looked quite good, from its foil. I waited for my wife to taste it before I tried any. I confessed my hesitation to her, but it was not a good moment for my self-esteem. I do not like, even now, noticing that I once used my wife as a taster. Nor can I say precisely why I felt so menaced by this patient.,
After a while, this patient found herself with much revived religious interests and began attending a church which was close to her husband’s church, but not to his taste. In fact, for reasons I listened to without understanding them, he detested it. She would remark to me that Jesus had much more to offer than psychiatry and I would assent very quietly. She eventually left me for the church, presenting me with a picture of myself as a teddy bear in an armchair sitting opposite a woman who is so indistinct that she almost seems a vapor. The sorrow in this picture is how well defined the teddy bear image of me is as opposed to how ill defined her image is. It is barely there as an outline. It looks more like an unbounded emptiness.
This may provide us with a window into the function of all those symptoms, all those treatments, all those predicaments with all those frustrated doctors that brought her to me in the first place. We know that drinking and drugging, eating disorders, fanatical exercising, peculiar pains, cutting, burning and being chronically suicidal, not to mention aggressiveness and being homicidal are all part of the borderline picture. One patient treated at Sheppard, both of whose parents had been alcoholic, did her own drinking each day, taking a nip of chlordane, so that she became the first case of chronic chlordane poisoning known to the manufacturer. Another used to go to sleep by cutting off her air supply with the tie of her bathrobe, so that she fainted away each night.
“Cogito ergo sum,” said Descartes, who worried about how he could know the world would go on existing in the next instant. However, acquiring a sense of being in the world, of existing however fleetingly, of having something like a self is a question so vexed for so many borderline patients that it goes well beyond any formulas, however clever. Concrete self-stimulation is so often an effort both at self-soothing and at self-animation, at being and at bearing the problem of being.
Whenever I have immersed myself in the world of a borderline patient deeply enough to begin to understand what ailed him or her, I have been struck by how many meanings a behavior like cutting or burning or binging or not eating carried, how it was freighted with connections to important, often awful others, who nonetheless were central in the patient’s life. In “Creative Collaboration In Psychotherapy,” I have described the whole host of connections that went into one very disturbed patient’s cutting. So dense were they that the cutting seemed a first draft for a project for getting a life. As one patient who died probably of a bleeding esophageal varix caused in part by her deep identification with her hated and loved alcoholic father put it, “My father was a monster and my mother was a martyr and they were always at war, so that left no room for me.” This patient could be both a monster and a martyr and, despite many hard years of work, never found her way out of the inner trap represented in the drinking, the cutting, the multiple suicide attempts and the deep rage, sorrow and despair. A rare genetic disorder did not help, either.
“Hug me, but don’t touch me,” say so many borderline patients, issuing another one of those paradoxical instructions that call for responses and ways of formulating responses that are very different than what we are used to in medicine and science and technology. “Be with me and leave me room, so that I can have company and the illusion of being alone, too.” “Work your hardest with me, but let me have the feeling that what I accomplish is all mine, because my needs to depend and fear of engulfment are so great that collaboration is not a word that has a living meaning for me.” “Don’t you understand that I have to do what’s more than terrifying to me right now because I just can’t stand by and let it happen to me.” “I’m so helpless and you’re so powerful that, no matter what I do to you, it has no effect. “
I can not say how many therapists, including myself, I have heard bleakly and bemusedly wondering out loud over the years what kept them working with a borderline patient and why they had started in the first place. They get under our skin, so that it can feel like we do not have any.
The word vulnerable, means “able to be wounded.” We are dreamers made so that we can be traumatized. This is one of our core abilities, a feature of our marvelous openness to the world around us. It is out of this core vulnerability, if empathy is added, that compassion, the intelligent pursuit of kindness, comes. Compassion is a greater pleasure than it is a sorrow, because it can redeem our view of our own natures. Compassion can also produce a redemptive agenda in our lives, a set of priorities that make life with people very worth living.
Years ago, an art therapy intern said that she saw Sheppard as a big barn where Moses Sheppard, one of those odd bachelor Quaker merchant philanthropists, had rounded up all the black sheep, not just patients, but also staff, so that she generously included not just me but herself in that flock. I think she had it just right. For me, work with borderline patients has been about work with myself and my family, both nuclear and wider than that, about helplessness and rage and dread and difficulty and hopelessness and whether we can find practical ways to restore ourselves, others and our communities from the depredations of cruelty and war and other natural calamities.
It is a sobering thought that even as we discuss what we can do to help borderline patients, how we can maintain our capacity to see them as very human even when they put such painful pressures on us, circumstances in the intimate world and the wider world are conspiring to produce new generations for whom these personalities are the possibilities most readily realized under conditions that go from bad to worse. Borderline patients, to paraphrase a patient of mine, were not born meaning to be borderline. As I have urged in Compassion: The Intelligent Pursuit of Kindness, we are ethically obliged to remember that the consulting room is only a very small part of a much larger and troubled world which is also a beautiful world, the only one we have.