Devotion And Common Sense

I took on the inpatient care of an African-American woman in her later thirties after her previous psychiatrist was banished for misconduct and terrible judgement. I was a resident just about her age and the small extra amount of money I got paid for adding her to my case load made a difference to me.   She was intensely suicidal, but without vegetative signs of a deep depression. She had more children than fingers on one hand. It was her avowed purpose to treat each one as if that child were an only child. She felt that it was her job to give each child everything that child might need or want. These requirements were absolute, as she saw them. It was all too easy to see the shortcomings of such a model for practical child rearing policy.   From the point of view of psychological economy and personal energy it was obviously not viable.   A real effort to implement it could not help but leave a mother in a seriously depleted state. This was a grandiose project that demanded a regime of self-oppression that was virtually unthinkable.   It had no limits. Here she was wanting to end her life, refusing to make concessions to reality, as if any concession would be a source of boundless shame. The degree of harshness against herself, the all-or-nothing features of her thinking were striking. She was beautiful and quite used to being envied because of it, not that she ever avowed either of these. Her beauty was striking. It was something it was literally impossible not to notice.   She was intelligent.   She was quiet,... read more

Unaccountable Fatigue

Why am I so tired at the end of the day?   What do I do all day long? I sit in a handcrafted cherry wood rocker whose flexible staves provide exquisite lumbar support and talk with people.   I listen and I talk. More than one patient has remarked that it is good to have a shrink who is on his rocker.   Probably most of what I do is inside myself. I ponder. I simulate. I take in and I take on. I call on my own experiences to help me which means they come to life again. In this second (or third or fourth, but always from a slightly different angle) coming there is both joy and pain.   Most of the maneuvering I do is inside myself. Some of it has shape that I can describe, but most of it is well below the surface of declarative awareness.   It has to do with who I am and the road (or roads) I have travelled to get to myself. It is implicit in each breath that I take. Why am I so tired at the end of a day of being with patients? In one way seeing patients is absolutely ordinary.   I open the door to my office. The patient and I greet each other. We sit down. There is nothing so special about the furniture, the windows, the light, the rug on the floor. Yes, my office is in an old brick building at the top of a hill. Yes, just outside the window is an old cherry tree which bursts into glorious bloom each spring.   Its... read more


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... read more

Pushing Seventy

I am pushing seventy, so that I find myself in what may be prime time for a psychiatrist who takes psychotherapy seriously and works with people in blocks of three quarters of an hour or an hour, instead of fifteen minute snaps, and across years and sometimes decades, not weeks or months.   So possibly I am not just old but old fashioned.   However, to describe something as old fashioned is not necessarily to deny it value. After all, the Pythagorean theorem was born long before any one now alive was conceived. However, as one gets older, it is hard not to reflect on getting older.   Many years ago the New York Times ran a piece by a retired psychiatrist who said that he had stopped practicing because he wanted to have time to read the great novels whose pages he had not yet turned.   The point of the essay was his remorseful discovery that the characters and situations in these novels, their plots and perplexities, were nowhere nearly as interesting to him as his patients had been.   He meant his reflections as a cautionary tale, a navigational aid to help others from going astray as he had. His words were generous.   Why are patients so interesting? In large part this is because we are interested in them.   It is not only the devil that is in the details, but also life itself.   Whether it is characters in a book or actual embodied persons in the consulting room, it is the organ of imagination that we use to take them up and in. Proust’s Baron Charlus and Hamlet and... read more

Dead Patients

Dead patients live on in my mind.   My relationships with them continue in quite different ways than when they were alive, much more one-sided, but still with considerable similarity.   They are with me even as I am without them in the outside world.   In some cases, I get to know them better or at least differently after they have entered the past tense .   While I was on vacation one summer a number of years ago, a patient of mine, a young man in his twenties, hung himself.   Suicide had been a preoccupation of his for many years as a way out, as a total solution to vexing problems. His death was a shock and also not a surprise because he had been on the verge of it many times.     After I heard I swam all the way around quite a large pond on Shelter Island. It was hard to assimilate what had happened, horrible to think of his resolve, of his last moments. I was very grateful to the fresh water for how it held me and still let me move.   I could not believe that it had happened and also did not have the luxury of not believing that it had happened.  I thought of all the things I might have done differently. I thought of the futility of this thinking.   Shortly after I got back from vacation, I met with the patient’s parents.   We had already spoken on the telephone, but this did not make the meeting any less difficult, any less heartbreaking. They had other children but the loss of this one... read more
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