The first thing to notice about boundaries is that they are not things, but processes. They are dynamic processes that change not only from season to season of our lives but from situation to situation in our lives. Both intra-psychic and inter-personal definitions and discriminations are implicated in boundary processes. Boundary processes depend on social cues and skills, social definitions of roles, on intra-psychic self and object representations and their differentiation. This list is just a beginning. Like borders, boundaries shape what passes back and forth across them, what kind of exchanges can be carried on and what materials, raw and otherwise. can be provided.

"Doc," said Walt, a burly manic depressive guy in his mid-twenties, "your medicine makes me sick. I’m fine until I see that pill heading for my mouth. I’m just fine. There isn’t anything wrong with me. Then I see your pill and it makes me feel sick. I’m telling you it’s hard to swallow. I’m doing my best, but I don’t know how long I’m going to be able to keep it up. I can’t help thinking I’d be a lot better off without the damn pills."

Why do we find it so hard to take medicine as prescribed even when we have sought out medical help and understand at least the surface rationale for the medicine? Why do we feel so often like the manic depressive patient quoted even if we don’t put it quite so baldly?

I.
One possibly quite useful way to think about shame is as an effort to ward off
imagined loneliness that can produce real loneliness, even lethal isolation. “I can not be or seem this way or I will lose everyone and everything. I will find myself floating on an ice floe. I will send this part of myself, this experience, this feeling into exile lest I be myself exiled.”

In a sense this is not so different than chopping off a leg in order to be free of the trap. Perhaps there is a short run freedom, even a life-saving freedom, but the leg is lost and that has terrible, crippling consequences. Shame is an ordinary and yet dire predicament for the self. It is hard to emphasize enough just how dire the predicament is.

Shame is an inner ostracism that not only sets the shamed one apart from others, but also alienates him from a part of himself. The drama of shame is such that any incursion near the forbidden territory renews the original insult, producing once more a situation in which neither flight nor fight is a viable alternative. The pain of shame can be intense and repeated endlessly without any clear outward indication of what is transpiring.

Shame is an anti-communicative stereotypy, the same pain over and over again without any real gain. It can set up particular experiences of hurt and rejection in the mind as institutions, engendering tenacious expectations of future hurt and rejection. Shame can spread, too, down associative pathways, until there is no psychic domain that is not under its sway. Shame can become a way of living.

I confess defeat at the very outset. I can not tell you what listening is, because listening is not a what, because listening is never the same from instant to instant, from person to person, from pair to pair, from stage of life to stage of life, because, in short, I do not know.

Yet, listening is what I do for a living, what I devote so much of my living to, as do so many of you. Listening is that particular set of mysteries in whose thrall, body and soul, we, psychotherapists, find ourselves. My purpose is to share with you both my fascination and my frustrations with the process of listening, the promise of listening, as well as the perils of listening, which are considerable.

Grief is an essential active internal process of emotional recycling that helps make us available for new living and new ways of living after loss, which is sure to come because it is part of the natural order of things. “Man is born to troubles as the sparks fly up from the fire,” says Job’s wise friend Eliphaz.

Grief is central to how we modify ourselves to meet changed circumstances, often ones that fly in the face of our wishes and that we never imagined. As a man who had lost his wife suddenly in a freak accident put it to me about a year later, “Doc, this sure ain’t the way that I drew it up.” Loss is the dark and difficult side of attachment, which is such a fundamental in human life. We attach because we are built to attach. We attach because evolution has shaped our genius for attachment out of the primary materials of the mother-child mammalian bond.

Striking footage exists of a group of elephants coming on their annual traverse of their territory back to where a female had died the previous year. One of the deceased elephant’s daughters, herself already fully grown, breaks away just a bit from the group and then lingers near the spot where her mother expired. With her trunk she nuzzles at a skull bare of flesh and bleached white, gently turning it over. So she makes contact with the remains of her mother, passes a few moments there with what is left of her mother - inside and out - and then submits to the necessity that life must go on and rejoins her group. Attachment gives birth to loss, whether you are an elephant or a human.

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.

“I don’t know when shame came to live in my house,” observed a woman in her early fifties, “but once it did, it moved from room to room until it had taken over the whole house.”

Although she did not say this in so many words, the implication was that once shame “had taken over her whole house,” there was no place for her to live. If we live in our minds, as surely we do, although not only there, then she was psychicly a homeless person, rendered so by her shame. Notice, too, that her shame is dynamic. It moves from room to room. It takes over. It grows and thrives at her expense. It is a very dangerous parasitic life form. Remember, too, that houses often stand for selves. These are often every bit as ramshackle as old homes, every bit as difficult to maintain.

Where might shame come from? How does it enter our homes, ourselves?

One place to start is with the name, itself, “shame.” The Oxford English Dictionary traces one speculative origin of the word “shame” back through a pre-Teutonic “skem” which in turn connects to “hame”, “A covering, esp. a natural covering, integument; skin, membrane, slough (of a serpent). It also quotes Darwin, in Emotions XII 321, “Under a keen sense of shame, there is a strong desire for concealment.” I am not learned enough to know if there is a word for shame in every language, but I can venture that most have such a word and if some do not, then the underlying cultures would be very interesting for the study of shame just because of their lack. So, at the very outset, we connect shame and the surface of skin, even sloughed snake skin, and concealment, all this without any reference to Eden.

The capacity to develop the sense of shame must be inborn, with the requisite physiological and neuro-physiological apparatus available to support this. Of course, some are constitutionally more prone to shame than others. Shame is often thought of as an affect that becomes prominent in the second year of life and plays an important part in the culturally appropriate molding of a young child’s behavior and internal sense of himself. But shaming and the response to shaming have their roots, too, in interactions of the first year of life. The threat that comes with shaming is a loss of love, a loss of connection, something that can be as drastic as ostracism. This threat can be internalized, too, making shame an important cultural tool in shaping personality. Seneca understood this when he said, “Shame may restrain what law does not prohibit.”

For those in the primate line, the loss of love, the loss of connection can be fatal. So the threat of shaming can be nothing less than a death threat. This can be conveyed absolutely quietly and habitually in the intimate flow of human relationships,
quite without any explicit labeling. without words. It can be conveyed without anyone noticing or knowing that they have noticed. Young children are fabulously plastic and fabulously vulnerable because achieving some sort of at least quasi-satisfactory fit with their primary caretakers is the central existential imperative of their budding lives. Their lives depend on catching hold of the essential and holding on once they have caught hold. This holds both physically and emotionally.

Blushing – shame’s characteristic mark on the skin surface, fainting, particular postures and muscular tones that convey both wishing to get out of the body to find a way to be anywhere else but here and hopelessness about succeeding, all are marks of shame. The experience of shame features a heightened parasympathetic tone. Hence the
vasodilatation of blushing, the tendency to reduced blood supply to the brain and so to fainting of the vaso-vagal type. Shame, if it is extreme enough, can kill immediately and suddenly as well as in the long term, as we see in our suicidal patients. It is fascinating to observe that depression produces shame, but also that severe shame, especially shame based character, may be an independent risk factor for suicide. Of course, shame can produce depression, too. Certainly, alcohol and drugs are used not just to mitigate depression, but also to try to tone shame down. We should remember, too, that shamelessness can be a mask that shame wears. Just as some are too mad to be mad, others may be too shamed to be shamed.

The central neurophysiology of shame is clearly a topic of great importance, about which we are just beginning to get glimpses. But clearly the brain activity involved in varieties of shame goes well beyond, “This brain area lights up and this brain area lights up and so does this one on functional magnetic resonance scans of persons reading shame evoking narratives.” Shame has vital connections with personal history and narrative, personal identity and social and cultural identity, Nor is it clear that shame experiences will be identically orchestrated in different persons, in men as in women, in Inuit as in Italians. There may be central final common pathways for shame in the brain, but they may be complex and not quite so utterly common as neuroscience investigators sometimes posit.

It makes no sense to talk about shame without talking about pride, because they are inextricably linked, two sides of the affective regulation of self-regard. Shame becomes prominent just in the phase of life where elation, too, comes to the fore. The toddler can go so high and go also so low, as most parents will have observed. In “The Antithetical Sense of Primal Words,” Freud made the point that Egyptian hieroglyphics paired opposites, being unable to express one without reference to the other, so that “strong” would be “strong-weak” and “weak” would be “weak-strong”. Priority, here, is determined simply by order, which of the paired opposite comes first. Humility, a very advanced personality disposition based on a realistic appreciation of our place in the universe, is the best defense against humiliation. We might as well say “Pride goeth before a shame” as the common, “Pride goeth before a fall.”

“What do you regard as most humane?” asks Nietzsche, who responds, “To spare someone shame.” “What makes the pain we feel from shame and jealousy so cutting is that vanity can give us no assistance in bearing them,” remarks the devastating La Rochefoucauld, who had, in the seventeenth century, a preternaturally well formed appreciation of the vicissitudes of narcissism. Shame operates within the defensive perimeter of vanity. It wounds under the armor. The surfaces on which it works are as near to us as our very skin

The major work of psychotherapy is in the “being with,” a task that inevitably calls upon our resources in being with ourselves, a process that is always in development, that is, always involved with struggle, impasses, reevaluation, creative surges, disillusionment and reillusionment. To be useful to our patients in large part depends on our capacity because of her capacity to stay with our own difficult and distressing affective experience, in therapy and outside of therapy. It is the “being with” that brings affects from what we might refer to as a vapor state to condense until they achieve representability, even crystallization. Where we speak so much about affect containment, we might do well, as Erna Furman has pointed out, to speak of affect attainment. Of course, attainment and containment are two aspects of a single process.

Our involvement with others is a mystery, not in the sense that we should remain quiet about it, following some dictum like Wittgenstein’s “Of that whereof we can not speak, thereof we should remain silent,” but in the sense that, whatever we may say about it, there is always more, something about what we have said that falls short, is wrong, does not fit, raises more questions than it answers, deeply unbalances us just when we thought settling the matter (and ourselves) might actually be in our grasp or at least almost in our grasp. Of this mystery of our involvement with others envy is a large and central part, a province teeming with life and hope and despair. Envy means lack, want, desire, insufficiency, incompleteness. Envy is a means, not just an end. Envy is a process for making meanings in an interpersonal and inner personal field.

I am sitting in my office on a bright winter’s morning, listening and musing. A redhaired young woman in her middle thirties sits opposite me. Her hair is a beautiful chestnut color, maroon. I have been seeing her for many years, since she was a very suicidal young woman and now I find myself wondering whether that hair color is natural, which I know it once was, or whether it has been maintained or revised by artificial coloring. I am wondering whether the gray hairs are being kept in exile, held at bay, refused, refuted by chemical means. Of course, my own hair, what there is left of it, is not so much gray as salt and pepper. I have never dyed it, this particular set of initiatives not fitting in with my own style of submission and denial by insisting on not disturbing the natural weathering process. But I do mourn for myself as I once was, dream impossible dreams of being restored to that youthful vitality I did not know how to appreciate at the time, so busy was I with my own sorrows and grudges and ambitions.

I watch her shoulders, the way she holds herself, how her breathing lifts her chest and then lets it lapse, the way she looks at me, checks on me habitually and unobtrusively. I am wondering how it feels to inhabit her body, how it changes the shading of all perceptions, all intentions, all inventions and I am wondering, as I do habitually, what she is wondering about, what the flavor of her wondering and wandering is. She is telling me, in great detail, as she always does, a story of her everyday life, a simple interaction that is anything but simple, charged with color, texture, doubt, confusion, anxiety, hope, a tangle at once impossible and enjoyable. She is entertaining me, holding on to my attention, keeping me right here, now, also keeping herself both busy and beset in the process.

I am enjoying being entertained, finding myself glad to be with her, yet all the while aware that I have no way to convey this to her except just to go on being entertained and enjoying it. I can not step out of the frame, abstract, interpret. But it always is with me that her mother was, as she once put it, “over it” by the time that she was born, that the psychiatrist she first worked with killed herself in the midst of that treatment, that she has, although she is mostly very discrete, even polite about it, doubts about whether it is worth being involved with other people that are not only grave and deep, but also subtle, shy, elusive. I know she is lonely and that not being lonely is perhaps even more frightening to her than being lonely, because she can imagine it no other way than as merger.

But where and how, you will ask, does envy come into all this? If I were to answer something like, “Everywhere, in myriad ways,” this would be, while possibly truthful, too vague to be either helpful or instructive. So let me try to be a bit more specific, starting with my own envy. To work with envy, we must know ourselves as both envious and enviable, capable of envying as well as of being envied. My envy is present to me, first of all, as an awareness of her youth, her beauty, her vitality, even as an awareness of her lack of awareness of these things, how they are natural parts of her existence, to be taken for granted. I am only too aware of my own different state with its implications of inevitable decline. Perhaps I have lived well, but living well has taken its toll. How many regrets I have and how much I would like to have done differently and to have others have done differently as well. Regret is in my every breath, along with much else.

What of the sensual, the sexual dimensions or tensions? I wonder what it is like in her body for her. I wonder very specifically about her physicality. I watch her and enjoy watching her, even as I suspect she relishes being watched, I imagine something like being her, but am aware of how separate we are, how my imagination must necessarily fall short. There are sparks of desire, perhaps born of a wish to join, a wish to merge, stimulated not just from her side but from my own, too, a mutual longing for consolation, separate desolations, half acknowledged, starting down the pathway of revolt. I wish, at some level, I could be her, so as not to be me, knowing as I do how very inconvenient being me is. Does she long for the same thing, a way to be me as an escape route from being her? I know she has chosen boy friends like this, men she found enviably thin, a bit androgynous, but free from the weight of womanhood, artistic as she insisted for so many years she was not and could never be.

But my envy neither begins nor ends here. Like many of you, I hope, I have been the fortunate recipient of imperfect, irritating, nurturing, even lifesaving and inspiring psychotherapeutic attention. I have been listened to, listened with, spoken to in ways I only dimly imagined as a child struggling with my own limitations and confusions, with my parents and their histories and history, itself, a monstrous hobnailed boot on all our tongues, with a wider world more bent on ignorance than anything much else. I envy my patient, above all else, her subtle, persistent, insistent utterly legitimate and yet also sad and tragic claim on my attention. I know what it costs me when I am tired, when I am worried, when I am grieved, on the days when I have even so silly and banal a reminder of my mortality as a common cold. I envy her the care I give her, which emanates at least in part from the care I have gotten which I needed, which is, inevitably, no more what it once. I envy the good I give (which I always fear may not be good enough) because my greed shows me to myself always poorer than I actually may be. So a bit more self admiration might free me from the toils of this envy, or at least loosen their shackles, but I fear becoming fatuously vain, which I would like to be, if only because I imagine it to be simpler.

From her side, it seems to me that she sees me as more assured than I am, that she both loathes and loves me for this peculiar way of seeing that she has, so that I feel at once compelled to disillusion her and barred from doing so, except gently, at least when my patience holds. Over the years, she has proposed over and over again that some other, usually a figment of her imagination, was more favored than she in my eyes, putting me in a devilishly difficult position. If I disagreed with her she doubted my word., accused me of a familiar sort of insincerity, namely, saying what I imagined she wanted to hear. If I simply let the argument pass and watched what she did with it, she took this as a tacit confession of disfavor on my part and responded with a degree of hurt that was life-threatening. In a sense, she wanted to give me life and death power over her, then envied me desperately for my imagined possession of such power and my calm about possessing it. Only very recently has she made a start on talking on how neglect may be a blessing because it allows a clear field for realistic observation.

She is at work this particular morning on telling me a facet of a very complicated story about a woman friend of hers who was enormously, even unforgivably helpful to her last summer while I was on vacation. She had not imagined that this woman could envy her her warmth, her creativity, her effort to articulate a life of her own. She envies the other woman because she has the two things my patient herself most wants, an apparently successful relationship and an apparently successful career. She does not doubt appearance until I ask her whether it is possible that her friend somehow helps her to be so envious because the friend herself may doubt the reliability of relationship or career. It is not lost on me (nor, I am sure, on her) that I have both a relationship and a career, myself. My patient is able to talk about distrusting her friend for trying to get her to feel things the friend can not bear. She talks about the friend’s excessive curiosity about her and her romantic life, as if she wished to participate vicariously in it, or, even beyond that, to steal it. My patient tells me she has been able to thank her friend for being so helpful last summer, even as she debates within herself whether the price is not too high to justify continuing the relationship.

The patient’s relationship with her mother, a woman who was too interested and not interested enough, hard to hold on to and never willing to let her out of her grasp, stymied internally and demanding that her daughter re-supply her with her own warmth and creativity, is scattered throughout this morning’s session. It might even be fair to say it is scattered through this session of mourning, with me taking the role of the mother in a variety of ways, feeling envious of the care I was giving her, feeling over the hill with a sense of my own diminishing vitality, feeling a diffuse discomfort with the patient’s claim on me. Hopefully, awareness of this as well as awareness of my own genuine pleasure and interest in the patient make important differences.

Elsewhere, using material from this same treatment, I have discussed issues involved in learning to come to grips with the complex other, what I called there resolving the Other complex, so that instead of the shadow of the object falling on the ego, the ego can grow in the light of the object. Envy always involves a comparison that finds the self wanting. It can be very helpful if it guides us by telling us what we want, what we lack, without rendering us so desperate that we need to try to steal from others. A certain degree of stability in self and other representations is essential to the fruitful experiencing of envy. Conversely, a certain capacity to buffer the bitterness of envy is required to produce this stability. Working with envy requires our being able to listen and speak, to receive and transmit both from near enough and far enough so that the patient and the therapist are together and apart in the metabolism of envy, without falling into endless shamed and shaming silences that make secrets out of what both feel. What makes the fundamental difference is not so much what we say but how we are with ourselves and with our patients. This, of course, is our fundamental interpretation of life, something so variegated and integrated that our embodiment of it is the only name worthy of it.

I have worked on the telephone with patients from twenty-five to seventy-five, men and women of diverse backgrounds and dispositions. I have always started with them in the office and then good reasons intervened to make it make sense to go on on the telephone.

This work has spanned states, countries, hemispheres, the complexities of time zones. It is a testimony to how remarkably robust communications infrastructure has become that this has been possible. There are limits, too. I have never tried working with a patient who was acutely or chronically suicidal in this way. I have never tried working with a floridly psychotic patient.

One woman who was on the other side of Mississippi from where I am here in Baltimore
used to end each session by saying quite brightly, "See you next time." It was some time before it struck me just how remarkable this sign off was because in the usual sense related to the visual apparatus it was precisely seeing each other that we could not do and would not do. But, of course, I think she meant another kind of seeing, one constituted by emotional presence in relationship mediated by inner attachment processes that guide imagination.

So I found myself slowly wondering how presence is constituted. We often speak of it as if it had primarily to do with shared location in space and time. But perhaps it is much more imaginary than that. Yes, it requires some back and forth as a condition,
but many different kinds of back and forth are possible. I realized that I had patients who came to see me in my office who resisted presence, mine and theirs, any linking, any shared imaginary creative process, while some of those I worked with at great distance allowed me to be quite close and let themselves fully participate in processes of joint open interpersonal imagining.

So I have been walking along a peculiar path. I'm not at all sure that the medium is the message. Presence is a puzzle, always with imaginary contributions from both sides. The telephone can serve fundamental mammalian attachment and relationship projects, provided both participants have the capacity for abstraction (and the modulation that it makes possible) to stay in touch without literal touch. Yet actual touch, the kind that involves skin on skin, remains such a vital part of life.

However, it is possible to have skin in the game when the actual skins are separated by hundreds or thousands of miles, not to mention professional boundaries. Psychotherapy is full of mysteries that keep on changing.

Don Quixote, the incomparable, comic, tragic, absurd, possessed by his destiny, dispossessed of his life by his destiny, an explorer who leaves home to find himself but loses himself in trying to find himself, someone perpetually homeless and proud of this homelessness as a quest for the impossible but imaginable.

Sancho Panza, a man like other men, moored in a web of human relationships, not so very grand, but very real, a nobody who is somebody by reason of how he carries being a nobody, being as close to the earth as any other clod, capable of a loyalty that is itself a kind of realization of the imaginary, someone who lives as himself but not so much for his own sake.

A distinguished, tall, thin. extremely learned, very ill elderly man came to see me looking for I didn’t at the time know exactly what and I still don’t know exactly what it was that he was seeking. I find myself thinking he was looking to be made whole. In life as in the law this concept of being made whole is no simple one.

This man yearned to be restored to being who he thought he was. Actually it went far beyond yearning to an insistence that bordered not only on religious faith but on an idiosyncratic religious fanaticism - “I can only be if I am who I take myself to be, even if who I take myself to be is not only complicated but also multiplex, fabulous.”

Ailing had been an integral part of his life, reaching back into childhood. Part of ailing was an unending search for succor and care and healing. He appeared over and over again as a supplicant but as a superior supplicant, one who ought to have been entitled not just to the best of care but to care that was effective.

In fact, the care he received was almost always disappointing, occasionally going well beyond disappointing to disastrous, as serious diagnoses were missed with awful impact on his health. At its very best, the care he received was not quite worthy of him. At its worst the care was contemptuous, injurious, prejudicial, as if something essential about him was a serious threat to doctors and their ilk.

His appearance, how he made himself manifest in my presence, carried at once an appeal that was close to tenderness and an aloofness that expressed a near settled hopelessness about any appeal to another person. “Why bother?” he seemed to be asking himself, “when the results are overwhelmingly likely to be a good bit worse than fair to middling.”

Without being asked, he declared that he was not interested in relationships. They were too much trouble, served only to constrain and limit. Relationships were for those who wanted and needed them, of whom he was not one. Loneliness was not an issue for him. His was the only company he could bear. Anyone else grated on him. He did not miss people and was constitutionally averse to grief.

Strange gambit – to seek out a psychiatrist, going to considerable trouble to do so, in order not have a relationship. He mounted for me formidable displays of his historical and literary erudition. Listening to him I learned a good bit and admired him. He was no fake. His learning was genuine, wide and deep. I became quite fond of him, most of the time enjoying his company. Often I heard the dry rustling of the male peacock’s feathers

I tried to help him with mood, with sleep, even with a host of physical problems. I worked to recruit other doctors in different specialties to help out. I became my patient’s ambassador to the world, even becoming involved in some business difficulties. When I would suggest that he could do some of this, even a majority of it himself, he would retreat into a peevish passive shell, a defiant and unacknowledged insistence on being dependent. He was much too dependent to admit to dependency.

When I found someone who might be of use, he quickly shed them, making short work of their credentials, their capacities, their clinical acumen. Quite regularly he managed to be sufficiently derogatory and dismissive to offend the person in question. In this peculiar way, I became acquainted with a whole circle of clinicians whom I had not previously known and with whom I to this day enjoy cordial and collaborative relations in the care of other patients. My patient helped me reach out and engage, even if he rejected the help proffered. In this regard he was my benefactor.

All the doctors whom my patient shed suffered from a simple invidious comparison. He clung to the notion that, if a doctor simply possessed the requisite clinical and scientific knowledge, that doctor would be able to make a clear and profound diagnosis, placing all his difficulties in an orderly array and so rendering them vulnerable to a virtually surgical strike – neat, unambiguous, effective. My efforts to suggest to him that medicine was almost never like that fell on deaf ears. The ideal of the omniscient omnipotent healer was simply too precious to him. It was the dam that protected him from being drowned in despair.

Measured against the ideal I, too, fell far short. From time to time, my patient would develop intense disgust with me and attack me in the most personal and cutting terms. His tone did as much damage as the content of what he said. It was a long while before I gathered myself to defend myself and repulse his attacks. A number of times he fired me as worse than useless, an insult to him, someone who was complicit in harming him, virtually a criminal. Then there would be rapprochement, more or less gradual, without apology or reflection.

I grasped that, as the messenger bearing news of manifold unacceptable realities, I often seemed terribly toxic to him, as if I were bent on sapping his strength, painting him into one corner or another. I was the attack on the fundamental premise of his existence – his capacity to rise out of and above the ordinary facts of life, but strangely also a nutritive link, someone who listened and responded and tried, even when it seemed quite hopeless. I would have put it that we were in relationship to each other, a characterization he would have rejected.

We were together for years that were often harrowing. He was very skilled at eliciting worry, at making rather extreme demands. I felt helpless a good bit of the time and knew that the situation was fundamentally hopeless, that he was not likely to change in any fundamental way. I could do my very best but my very best would make little difference. My very best was not even close to good enough.

So what held me to it? This is when I began to think of myself as Sancho Panza to my patient’s Don Quixote. He could not help himself and, as a result very much needed my help, not that there was anything much to be achieved or any real reward.. Or perhaps there was a great deal in the way of real reward utterly devoid of glamour. A Sancho is short enough to hug the earth and to feel the earth hugging back. In the long run the earth’s tug takes hold of all of us and we return to it.

I am listening to the psychiatric resident describe her session with her patient. She is well along in her training, reasonably poised and reasonably convinced in her approach. She is telling a story and, in this story, she comes off as both kind and competent,

The patient comes off as a bit confused, clumsy, dependent, not very good either at thinking or feeling. The patient seems pale and out of focus. I keep wanting to sharpen the focus to make the patent clearer. Of course I can’t do this. I am mildly annoyed that I can’t – mildly annoyed at the patient, at the resident and at myself.

I ask myself, “Why do you ask for the impossible? Why can’t you just be patient and let things be what they are and find their own natural pace of development?

I am sitting in my rocking chair. I am, as more than one patient has pointed out, “on my rocker.” My rocker is a beautiful hand made cherry rocker with flexible back slats so constructed as to provide considerable unobtrusive lumbar support. The chair is the vanquisher of the back troubles that were incipient when I got it. For this, I am very grateful to it and to my wife at whose instigation I got it.

It is the single most expensive piece of furniture I have ever bought. I remember how acutely uncomfortable I was waiting for it to arrive from northern California nine months after I had ordered it, how worried I was that after all the expenditure of money and effort I would hate it. I do not.

I enjoy my intimacy with it. I try to imagine when the wood was a tree and the tree was in blossom, pink like the ornamental cherry just outside my window that is one of the highlights of spring here. I don’t rock much in my rocker, mostly just sit, shifting weight from time to time following the ebb and flow of the story that the resident is telling me.

I am struck that this resident’s skill in storytelling is limited. She is inhibited. She is trying to get it right, so she is conscientious to a point that borders on vanity. She does not seem to be enjoying herself very much either with me or with the patient. In fact, she seems to be a bit frightened of me.

What am I going to say next? What am I thinking? What kind of power do I have over her? Can I be part of denying her something that she wants?

A detail does it. The resident mentions that her patient was cooking dinner for an elderly aunt who was becoming demented.

This detail is jarringly familiar. I fumble about in my mind trying to grasp why it is so familiar and so jarring. I am disoriented for a minute or two, lost inside myself, barely able to stay in touch with what the resident is saying.

Then I find it. Two years earlier I supervised another resident who was at that time treating the same patient. Or is this one the same patient?

I am amazed that I can have taken so long to figure this out. I am staggered that I have been listening for months without solving the puzzle. It explains why I have felt so awkward, why the resident’s narrative has always seemed to me just a bit out of focus. It clashed with the picture that I had stored in my mind from my first vicarious encounter with this particular patient in supervising the previous resident.

I have the urge to correct the resident I am now supervising, to use my database on the patient to point out to her that there are a number of important areas in which she is mistaken about the patient and how he works. A psychotherapy supervisor is always tempted to assert superior knowledge, a temptation that is regularly dangerous, but especially so in this case.

I stop myself, recognizing inside myself that what I am wanting to do is to make a situation simpler for myself when it is not simple at all. Does previous knowledge of the patient uniquely qualify me or disqualify me as a supervisor of this resident’s treatment efforts? Does it make any difference that I have the illusion of prior knowledge of the dementing aunt?

Surely, if it were a question of choosing a jury, I would be disqualified because my previous acquaintance with the matters at hand could not help put prejudice my hearing of the narratives embedded in trial testimony. If, however, I was a candidate for a diplomatic posting in Amman, the fact that I had gone to prep school with the King of Jordan would surely count in my favor.

Is this patient the same one whose treatment I supervised or is he a different patient?

The first resident, male, older than many residents, a dissenter from a family of businesspeople and lawyers, had quite a sponsoring, approving optimistic view of the patient, who was a rather rambunctious businessman who had known real success and then real failure, boom and bust. The resident was wholeheartedly interested in the patient.

The patient was in his forties, not successful in relationships, trying to recoup his losses and rebuild. Also, he had suffered profound losses and neglect in his childhood, been involved in cycles of boom and bust all his life. Nor had the cycles of boom and bust spared the holding environment on which he depended for care and comfort.

The first resident liked the patient and the patient had no trouble taking this in. There were some minor boundary questions with the resident doing perhaps a bit too much for the patient and even being a little bit conned by the patient.

We discussed these in supervision and how they had their good points and their bad points. Doing for a patient can sponsor a patient’s efforts to do for himself as well as subvert them. Psychotherapy is a balancing act. A seal balancing a striped colored ball on his nose comes to mind.

So I say nothing to this current resident about my previous life with this patient. I go on listening, noticing that as I do so, I am making many different comparisons in my mind between how she portrays the patient and how I knew the patient before I knew her as the patient’s psychiatrist.

I feel mildly guilty because I feel that I am holding out on her, keeping something to myself that might be germane to her work. I wonder what she may be withholding from me, what the patient may be withholding from her, because withholding is always part of the communicative process, often motivated by shame.

I am very interested in how her manifestation of the patient is richly at odds with the first psychiatric resident’s. I get the idea that she is frightened of him, that she is aggravated by what she feels as a hyper-masculine vanity, treading near the border of aggression. At least it is overbearing, demeaning of her and her authority and competence.

She does not grasp that she is feeling what he feels in the face of her therapeutic presence– at least one down, not sure how to change the position, ashamed to be where he is and unwilling to talk about it.

I try to discuss this with the resident. The discussion does not go all that well. I feel clumsy, as if I were treading on her toes at each step. She feels in relationship to me something akin to what is active between her and her patient. Our discussion is eerily competitive. What makes it eerie is that the competition is not acknowledged in any way. We are wrestlers who refuse to acknowledge we are wrestling.

The image is close to sexual, so that I become aware of the dimensions of sexual intimacy between her and her patient as well as between the two of us. Wrestling involves an enormous amount of contact. I am stunned how different this treatment is from the previous one.

But it is also true that in my wanderings and wonderings I manage to free myself from comparing the two treatments in a way that privileges one over the other. The patient is the same patient and not the same patient. A person is a territory vast as a continent, so there is plenty of room for the most diverse explorations. Cooking for the demented aunt is a bivouac common to both treatments, indicative of the patient’s capacity to take care not just to seek care.