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
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
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 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
Each patient resonates differently. Resonance is a matter both of the inner strings of the therapist and of the inner strings of the patient. When a note is truck near a piano, it often sets strings singing, waking sound from them by elective affinities. It is a matter of a string’s recognizing something of itself in the waves of sound that reach it. So it is between patient and therapist. Resonance explores links and kinships that may not be obvious. One was a young guy, big, burly, voluble when his mood was not so low that it interfered with his getting out of bed. He was unmarried, without a girl friend. He had no children. He had hallucinations, delusions. Sometimes he did things hat made perfect sense to him, but only to him because he had his own distinctive take on what was going on around him. Or you could call it his own idiosyncratic rake on things. He was sometimes too much for himself, often too much for others. His size scared people, as did his intensity, suggesting that he was out of control. Most often, when others saw him as out of control, he was not quite out of control, near there but not having reached it. He had suicidal impulses, not just when he was down, but also when he was flying high. Yet he had never gone too far and injured himself or anyone else. He could not tolerate sitting still in an office and talking. So we walked and walked and walked and talked as we walked, noticing what was... read more
“I’m whining. I should just stop it. It’s an ugly sound. No one wants to hear it. It would be better if I were just gagged.” “All I do is complain. I don’t know why that is, but it gets tedious. I can tell by the look on your face that you hate it. You listen because I pay you. I know there are better things to do than complain.” It is possible, of course, to whine about whining and to complain about complaining. I have puzzled over the years about how to respond to these regressive sallies. I call them “regressive sallies” because they aim to close down psychic space, to preempt any investigation that aims to reach psychological depth. Instead of proposing to listen to themselves, the patients who propose these solutions through will power are trying to shut themselves up, to shut themselves down, to shut themselves in.. The Free Online Dictionary defines “whining” as “to utter a plaintive, high pitched protracted sound as in pain, fear, supplication or complaint.This is a reasonable place to start, although whining can be applied to sounds that are not so high-pitched, not so protracted. It can be applied to what would be described as normal speech were it not tinged with overtones of reproach and accusation. Whining has to do with frustration and rage. Whining has in common with itching that it has a direct route to the limbic system. When a person whines, we feel a distinctive kind of discomfort that reflects and propagates in the interpersonal field the acute discomfort of the whiner. Two important ingredients... read more
There is no “talk” therapy without “listen” therapy. Patients are as likely to say that they want a therapist who talks as they are to say that they want a therapist who listens. Of course, there are patients who can talk but not listen and also patients who can listen but not talk. Or at least there are patients whose predilections are heavily skewed in favor either of talking or of listening. Ideally both therapist and patient are competent in both modes, both able to speak and to listen. This makes a reliable and rich back and forth possible. It supports the ecology of exploratory conversation. For the first ten years of my career as a psychotherapist I was tormented by a voice in my head that kept ranting at me during sessions that I talked too much. The voice was humiliating without having any particular corrective impact. It simply served to make me miserable as I continued to say what I had to say. The position advocated by this voice was one, I believe, that my mother would have endorsed when I was growing up. I had many questions, many more in my head than I expressed or could have expressed. But I had ways of expressing that I had doubts, that I was intrigued, that I needed to know more, that explanations presented to me did not seem to hang together, that I had seen moments that had become mysteries. I was in many ways a nuisance and a burden to my mother. She surely thought I asked too much in both senses of the word. But... read more
T was a very disturbed, attractive, bright young woman, chronically suicidal, sometimes intensely suicidal. She was almost always in despair, perhaps always there. In the days when this was possible for someone whose family was not enormously wealthy, she spent long periods of time in the hospital. She was a management problem, cutting, burning, eloping from the hospital. In general she terrorized the nursing staff charged with taking care of her. Their terror followed her terror as her behavior transmitted terror very effectively. The nursing staff took its job seriously. In addition, many of them genuinely liked T, who could be charming and interesting as well as dangerously out of control. The nursing staff may have hated T because she regularly threatened to expose their powerlessness and incompetence. But they also loved her, so the conflict was heightened in them. Certainly there was a sadistic element in T’s behavior, a way in which she was so out of control that she needed to tyrannize over those who tried totake care of her. T had a horrendous history that was definitely operative in her predicaments of the moment. There really is no point in reciting it in any detail. She was actually a very sensitive person who had experienced both neglect and abuse. She actively resisted looking at her history and how it worked on the present and in the present. She was too beset “right now” for this other enterprise of internal self-observation. She could do a little, but recoiled even as she did so. A few of her most disturbing memories were externally corroborated during her time in... read more
1.A woman in her mid-eighties brought me flowers from her garden for one of her early appointments. The flowers were lovely but I was a bit taken aback, so I asked her why she had brought them. “I brought them so you won’t forget me,” she answered unhesitatingly. On the one hand, this was poignant. She was deeply worried about being forgotten by others, this being tantamount to being wiped out of existence. On the other hand, this implied that I was one who was prone to forget. It was a criticism in floral form, reminding me of Freud’s noting that “gift” in German meant poison. “You don’t need to bring flowers for me not to forget you. I won’t forget you even if you don’t bring flowers,” I responded. This exchange had no effect on her behavior at all. Each week she came with a gift of another small vase with flowers from her garden in it. The flowers were lovely but I continued to be a bit taken aback. She gave me watering instructions. She brought a cactus on the verge of blooming. She brought a huge red hibiscus flower,cautioning me that I couldn’t expect it to last for more than a day, but it was so beautiful that it was worth bringing even if it would last just one day. She brought me many other kinds of flowers which had a special spot on the sill of a window in my office. Over the months that followed the initial gift, I learned more about the parade of flowers that came to my office. I accepted the... read more
