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 George Eliot’s Dorothea have a certain kind of life in my mind.   I think of them. They comment from their inner perches on one or another feature of my experience.   I am very grateful for their company.   But the linear rush of type and words, the lack of immediacy of the senses, the very form that defines them and gives them life, also cramps them.


The stories of the patients we see live in the consulting room go on and on, veer this way and that, take on different casts as circumstances change.   They improvise their lives as life improvises them. We share a space and look at their faces, their dress, their bodies even as they look at us.   Their voices sing a special music or a set of special musics. Doing therapy is a sensual experience, even as it carries with it a whole series of restraints. Even the most boring patient can be fascinating, if we become intrigued with how this person goes about being boring and how this person came about being quite this boring.   Would being interesting have been unbearably risky? Exactly how?


We have no impact on Baron Charlus or Hamlet or Dorothea. But we can have impact on our patients. It is a thrill when a patient gets better. It is a thrill when we can help a patient find what they have wanted in life. It is a thrill when we can help a patient find that life holds something unsuspected.   Doing therapy is about helping create something living, something that will find its way and grow and develop.   Psychotherapy is about living encounters and encountering living, not just in old and familiar ways, but also in new and startling ways.   A chronically suicidal patient develops some insight into her suicidal states which then moderate a bit.Little victories are big. Sometimes even a person who hates himself develops a glimmer of appreciation for himself, possibly even a hint of love.


This is not to say that patients are not aggravating, obstinate, worrisome, sometimes malicious, passive aggressive, belittling, even contemptuous. All this goes with the territory. It is chaotic and messy, not aesthetically pleasing. If it goes with the territory, it makes us want to withdraw from the territory, to go somewhere else that is radically different. Great art is more harmonious and makes no such irksome claims on us. Art is rooted in life but lends itself to a certain brand of idolatry.   It can claim to show us a reality that is better than living reality because its form is clear and it lacks the frustrations of everyday ordinary life. We can wish to emigrate to the domain of art without being aware how much of ourselves we have left behind. It takes modesty to stay behind in the consulting room with all its limits and unanswerable questions, its dynamic dilemmas.


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