Excerpts from Must Read Books & Articles on Mental Health Topics
Books, Part XXIV

Of Two Minds: An Anthropologist Looks at American Psychiatry
T.M. Luhrmann


Chapter Two: What's Wrong With the Patient? (pp. 56-83)

"Beginning to get decent at psychotherapy is like discovering an extra limb and finding it incredibly useful. Once you discover it, it's a little difficult to go back to doing things with two hands. When I'm in a social interaction, I get a little embarrassed with myself. You see people who have boundary problems, and they're seductive and alluring and you can get sucked in. It would be hard, now, to let myself go with the slow with someone like that. Part of me would be noticing what was going on, what was happening. I can't turn it off completely."
     Earle is a tall, slim New Yorker, quite elegant, rather sardonic. He had, as most psychiatrists used to, a background in the humanities. He was thought to he one of the better psychotherapists in his residency program. He was considering analytic training. ''The way I think now," he said, "is very different from the way I thought in medicine. There is so much less that is explained by rules that apply to more than one person. When I first started, I wanted there to be some unifying theory. Rules and so on. Actually, what's Important is knowing the particular person. All people have their own system, their own way of how things work, with particular fears, particular wishes. Getting to know that instance is much more important than the rule it may test or not. One thing I've noticed Is that I'm much less judgmental of my patients than they imagine me to be. I really am. It's not interesting to me anymore to make a judgment: it's interesting to understand. The more I know my patients, the less I diagnose them. The closer you get, the less helpful it is to classify and the more you doubt the classifications. I think my process has been that of coming at the patients with some vague and cherished theories and hoping that they won't disprove them. And they did. They always do."
     Psychodynamic thinking is a curious and highly distinctive manner of thought: between those who think psychodynamically and those who do not, there is a gulf as wide and alienating as between those who think logically and those who do not. It is notoriously difficult to characterize. Psychotherapists produce an array of metaphors to describe the therapeutic encounter--it is a dance, a duel, a drama, an attempt to listen with a different car, to listen for what is under the surface or behind the words: it is peeling the onion, unraveling the psyche, piercing the armor of the character: it is an attempt to see the translation of motive into action in which every action serves the self.
     If achieving basic competence in diagnosis and psychopharmacology is like becoming a master bird-watcher, learning the skill of psychotherapy is more like learning to he a storyteller. One might describe Freud's central contribution to psychotherapy by saying that he "discovered" the unconscious, or at least that more than any of its other discoverers he demonstrated that we are all motivated in ways we do not grasp for reasons we cannot give. But his more fundamental legacy was to suggest that we can decode our behavior and our history to discover the grammar of a particular person's emotions, the implicit rules that explain why a remark offends one person but makes another laugh, why one person enjoys aggression and another finds it terrifying. Analysts listen for the stories that emerge from the way people talk about other people, the way they experience those people, the way they experience the therapist, and the way they experience themselves, although what the analyst hears is not just what the patient says. As diagnosticians listen for clues to a diagnosis, therapists too listen for clues to a model. They listen, however, in a very different way.
     At some point in their first year, young psychiatrists are assigned their first psychotherapy outpatient. In their second year, which is their outpatient year, residents can take on more cases, hut only an ambitious resident--ambitious, that is, as a psychotherapist will take on as many as ten. (That year, their other patients are outpatient psychopharmacology patients. A resident may carry a monthly caseload of more than one hundred psychopharmacology, patients, whom he sees for fifteen or twenty patients, minutes apiece, and three psychotherapy patients.) In the past. residents were encouraged to see their psychotherapy patients twice or even three times weekly, but these days many factors militate against doing so. Usually a resident meets with each patient once a week for forty-five or fifty minutes, although occasionally a patient will arrange to come in less frequently (usually for financial reasons) or more frequently (maybe twice a week). For each patient, or for every two patients, the resident has a supervisor, usually an analyst who volunteers his time in exchange for an affiliation with the medical school. The resident meets in private with the supervisor once a week to discuss the case. During the outpatient year, this resident also runs a therapy group for patients, usually with two residents per group, and as a class, residents participate in a once-a-week session that is described as their own group therapy. At least one hour of lecture time each week (usually out of two to four hours) is devoted to psychotherapy throughout the residency, in all residency programs I have seen. Most residents also enter psychotherapy, some even psychoanalysis, at some point during residency, in part for their own training and in part because they feel they need it. A great deal of time, then, is designated for learning psychotherapy, or at least was when I was doing fieldwork. This training, however, is more optional than the training in diagnosis and psychopharmacology. As a psychiatric resident, you must admit patients and diagnose them. That is your job. Psychotherapy training involves more choice, more willingness to go along with what is offered or seek out what is not.
     The specific kind of therapy taught to psychiatric residents is called "psychodynamic psychotherapy," and its theories and practice derive from psychoanalysis. Psychiatrists use the term to refer to therapy that is guided by psychoanalytic thinking but in which a patient may come anywhere from five times a week to once a month and may use a couch but usually sits in a chair and talks with the therapist face-to-face. The term "psychoanalysis" is reserved for a specific kind of practice: the patient has very frequent sessions, the patient lies on a couch and cannot see the analyst, the therapist is in or has completed training at a psychoanalytic institute. The term "psychodynamic" is used more broadly to include not only psychoanalysis per se but a way of thinking and practicing that is psychoanalytic in feel and style. Psychoanalysts serve as the primary psychotherapy teachers for young psychiatrists, and psychoanalytic writings serve as the primary texts. Residents are supposed to learn the theory and practice of other kinds of psychotherapy as well cognitive-behavioral therapy, couples therapy, family therapy but in general these approaches have low visibility and low prestige in psychiatric training programs. When I refer to psychotherapy, then, my prototype is psychodynamic psychotherapy.
     The learning process itself is more practical than this description suggests. In American culture, psychoanalysis is often associated with intellectuals. People who read Freud are often fairly highbrow. What is taught to young psychiatrists about psychodynamic psychotherapy is not intellectual at all. The expertise they acquire has to do with Freud only obliquely. It develops beneath the surface of texts and lectures.
     In the first place, the lectures on psychotherapy, for the most part, do not present general theories of human experience. They do not discuss the extensive scientific literature on emotion and human development. They do not explore the difficult psychoanalytic writings of W. R. D. Fairbairn, D. W Winnicott, Otto Fenichel, Heinz Kohut, Harry Stack Sullivan, Otto Kernberg, and others. Discussion of Sigmund Freud and human development is extremely cursory. No young psychiatrist is seriously expected to read much; even when reading is assigned, there is no sanction against a resident who does not read, and it is widely understood that the clinical needs of the hospital take precedence over a residents lectures. The primary method of training is apprenticeship. I sat through an eight-week seminar on child development in which Jean Piaget's stages were presented but never fully explained, never critiqued--despite an enormous psychological literature on the topic--and never mentioned by any resident again. I have listened to hundreds of lectures to psychiatric residents. Few of them presented as much material as an average professor's lecture to undergraduates. Very few of them gave evidence of even an hour's preparation for an hour's lecture. Virtually none was attended by all of the residency class.
     Nor, for that matter, does the institution treat the lectures as very important. In the first rear the first psychotherapy patient is often assigned before residents have been told much, formally, about the actual process of psychotherapy, as if to imply that the resident can't do much harm, even though the gist of the teaching is that in fact the resident is a lumbering bear in the patient's porcelain psyche. One first-year resident was incensed by this: "Well, there was a lot of anxiety because you don't know what you're doing, and I was very angry at the department for thrusting us into that situation before sic had had any lectures at all. What is psychotherapy? How does it work? What are some basic principles? I knew a little bit by reading and by three months of therapy I had had, but that wasn't much, and I just really didn't know, my role was very ill defined, and I just felt a lot of anger."
     The point of the lectures is not to teach facts or a science but to teach a practical skill. The lectures talk about what to do in therapy rather than why the therapy works. (This is also true for the lectures on psychopharmacology and diagnosis.) In the summer seminar series I attended, the lectures on psychotherapy were so down-to-earth as to seem brutally naive to the outsider. Where do you put the clock in your office? If you must meet a patient a hundred feet from your office, do you talk on the way there? About what? Do you shake hands? These turn out, as it happens, to be matters of great concern, but they do have a fugitive air of teaching etiquette to someone about to host a dinner party with neither food nor drink.
     When a seminar does focus on a text, as did one that I attended with advanced psychiatric residents, the discussion tends to circle around the ways that the ideas can be borrowed to understand one's current patients. Even in this class, where the text--Melanie Klein's Envy and Gratitude--as treated with greater historical and textual sensitivity than I had ever encountered in a psychiatric setting, the young psychiatrists took the ideas loosely to interpret their patients' behavior. When the class looked at a sentence in which Klein talked about "incorporating the breast," for example, one of the psychiatrists exclaimed that this was exactly what her patient was doing with her now. Klein, of course, was being somewhat metaphorical about infant thought, but whereas a psychology graduate student might have struggled to understand the specific meaning of the metaphor for Klein, the clinically oriented resident ignored that question and instead stretched the metaphor further.
     The primary teaching of psychotherapy takes place in the one-on-one "supervision" for an hour a week, often days after the actual therapy has taken place. Unlike the rest of medicine, the teacher sees the student perform very rarely. In surgery, there may be a see-one, do-one, teach-one approach to cutting, but a senior surgeon hovers by a student's elbow. In most cases, a psychotherapy supervisor never sees a patient in person. In many cases, the supervisor never sees a video of the session or listens to a tape recording of it. Instead, the resident and supervisor meet at a prearranged time, the resident tells the supervisor what went on in the session, and the supervisor advises the resident on what to do next. Periodically the supervisor sends an evaluation of the resident to the director of residency education. The belief that residents learn anything more than the fine art of deception from this process springs directly out of the psychodynamic way of looking at the world.
     In psychodynamic psychotherapy, one person pays a second person a significant sum--$50 to $150, occasionally more--for the privilege of talking to him for less than an hour. He may repeat the exercise once or more each week for many years. The second person, the "expert," comments on what the first person has said. What makes the relationship strange is that the goal of the second person is not to understand and say what is true about the first person's remarks or even what he thinks. The psychotherapist is explicitly taught not to give advice, not to counsel, not to act as a kindly friend. The psychotherapy relationship is deliberately not modeled on teaching, though there is often more coaching in it than is acknowledged.
     Psychodynamic psychotherapy has developed out of the belief that our deepest motivations are occult, for the expert as well as for the seeker of help. Thus, therapy cannot provide a one-way window into the patient's soul. The patient cannot see the real source of his unhappiness--we cannot see our sunglasses when we are wearing them, but everything we see is darkened by them--and the therapist knows that he too is limited by his own personality, though because of his training less so than the patient. Instead, therapy is conceived of as a relationship between two people from which the nature of the patient's hidden psyche must be inferred. Freud's metaphor was that the psychoanalyst and the patient were like passengers on a train. The patient sits by the window, describing the scenery as it passes by, but she does not know what is important. The psychoanalyst knows what is important, but he sits beside her blindfolded. He must infer from the way she talks to him what the landscape really looks like. The therapist's job is also to interpret the relationship between therapist and patient as a means of understanding the patient, despite the full awareness that neither party has full access to the thoughts and feelings of either.
     Psychodynamic supervisors assume that because we are all shrouded from ourselves, young residents cannot but reveal their implicit assumptions about their relationships with a patient. Particularly in residency--that is, at the earliest stage of training in psychotherapy--supervisors tend to treat supervision as being focused on residents' insecurities and blind spots, for our inability to understand other people owes much to the hard shell of our emotional defenses. In other words, supervision is really about the resident. That's why handwritten notes--process notes," scribbled dialogue written on scrap paper at the end of the session--are understood (in this culture) to be as helpful as video recordings.
     A supervisor listens primarily to the way in which a resident thinks and responds. He is trying to understand the way a resident presents herself and what she presumes in a conversation that might he interpreted by someone else in a way the resident might not expect. One supervisor told me that he treated the supervision as couples' counseling with half the couple present. I here is also more than this. A supervisor tries to interpret, through a resident's account, what a patient is actually like. But the focus tends to be upon the resident even when the discussion centers on the patient. In 1992, I sat through a summer's worth of one resident's supervisions with two different supervisors. Paula spent hours writing up the notes from each session (she was very conscientious), and at each supervision she would arrive with the sheaf of paper and read it through, with the supervisor commenting on what was said and whether it should have been said another way.
     The transcript of one such supervision ran in part as follows. In the therapy hour, the patient and therapist (the resident) were discussing the patients anger at seeing the therapist in the supermarket, because the patient claimed that the therapist had seen her and turned away, while the therapist said she had not seen her. The resident read these notes to her supervisor:

PT: You've misunderstood me.
TH: No, you've been saying a lot of hurtful things.
PT: No.
TH: It's hard to see that you can be hurtful. When you hurt, perhaps it helps to put people down.
PT: No, I never put anyone down.

[The supervisor remarks to her, "You are young, and you have everything you want." Paula continues to read without comment:]

TH: In a relationship, you feel that no one should get hurt.
PT: Yes, that's right.
TH: 'That's why you're so isolated. It'll be a long wait for a relationship that doesn't hurt.
PT: I'm isolated?
TH: Yes.
PT: You have something there but the issue here is chemistry.

[Paula says in an aside to the supervisor, "Every time it gets heated, it goes into chemistry."]

PT: Like Sam.
TH: Were there specific things that bothered you about Sam?
PT: Yes [she lists them].
TH: And with me?
PT: No, it's just chemistry.
TH: Baloney. I think you call it chemistry because you're uncomfortable.
PT: It just reminds me, when I come here, that I see someone younger, who has done something with her life. I haven't.

[Supervisor doesn't say anything here, even though it confirms his earlier comment.]

PT: I don't mean to change the subject, but I was thinking about how you think I've tried to hurt you. People always misunderstand me. They used to call me a snob. I'm shy.
SUPERVISOR: The subtext here is that she was shy in the supermarket, that's why she didn't come over. She's not a snob, not aggressive--just avoidant. If you were feeling less embattled and more warmly, you could have interpreted that to her and said, "I wish I had seen you, so that you "wouldn't have had to feel as rejected as you did. I hope that if I had seen you, I would have had the wherewithal to introduce you to my husband."
PAULA: She never says things directly, never owns things. I had to do this for me.
SUPERVISOR: She said pretty directly that you bothered her, and that you've succeeded at things she's failed at. She hints at this, as if you could be two girls chatting together.
PAULA: She asked me if we could do therapy outside.
SUPERVISOR: Talking about it is more important than doing it. PAULA: With her, in therapy, doing is key.
SUPERVISOR: The issue is doing it with you. You embody so much she's not. She's on a slippery slope, got a late start, blew it with the first attempt. You come along, dressed in pink, even, she's seen you smile--think of her fantasy life. You're lucky and you don't deserve it. How can she justify this? She's been unfairly treated, and it will come so easy for you and you don't even make attempts to be nice the way she does.
PAULA: How would you make her feel more comfortable?
SUPERVISOR: Well, you could apologize for what happened in the supermarket.
PAULA: But I've done that. I truly think she needs me to go to lunch with her or walk around the campus. All I was trying to get her to do was to own her own aggressiveness.
SUPERVISOR: Good, but you would have done it differently if you'd realized that this issue was jealousy not the comparison with her previous therapist. You are acting here as if you don't think enough of yourself to believe that someone could be jealous of you.

     What the supervisor said quite clearly is that this resident could not hear the patient envy her. To become a better therapist, she would have to learn to listen to all the ways a patient might perceive her. But now she cannot hear the patient clearly because her own personality muffles her ears. For the supervisor to see this, it didn't really matter that the session had been written down from memory. As Freud remarked about dreams, recollection is as useful as exact recall because what was unconscious then will not be consciously removed in the retelling. We reveal ourselves as vividly when we lie as when we are truing to he honest.
     Supervisors tend to be supportive. This supervisor was consistently so. Supervision can nevertheless he exquisitely painful. Paula was just shy of thirty during these sessions, and at the time she was lonely and depressed. (There was something going on at home.) I am struck, looking hack over my notebooks several years later, that I knew she felt bad about herself when we met. I wrote about her bad feeling in my notebooks. Yet somehow, as we spoke over the course of the summer, as I talked to her about psychotherapy and what it was like to do it, as I went from supervision to supervision with her, I could no longer see her as someone who might he stiff and awkward with patients because she was depressed. I think that it was so painful to see her expose herself week after week despite her determination to present herself as a good therapist that I could not hear to see her as clearly as her supervisor did, although I sat there recording the supervision in my notes; I think that nay be a clue to the level of shame residents can experience in the kindest supervision. Certainly Paula experienced the supervisions like a switch on sunburnt skin. Shortly after this exchange, the patient left therapy.
     If a therapist is not helpful, whatever that means to a patient, the patient usually goes away. The force of this experience as a training exercise, that the outpatient is not like some graduate school paper assignment but an independent person who votes on your skills by choosing to see you or not (which the inpatient, of course, cannot) did not become clear to me until my own bout of doing psychotherapy. To get some sense of this skill, I had signed up as a volunteer at a local outpatient clinic. I had eight patients, one once a week and three twice a week for more than a year. I was supervised by the same people who supervised the residents.
     My second patient was a rude, miserable man who didn't think much of women to start with his girlfriend had just thrown him out and when he called up the outpatient clinic for an appointment, he protested at the standard price and asked for someone cheaper. He was passed on to me, the anthropologist in training who because she was not training for a degree could accept reduced fees ($10 per session; it went to the clinic). Although he no doubt felt that he had been offered cut-rate goods, he decided to see me. During our first hour, he remarked aloud that I probably wasn't smart enough to have gone to medical school, suggested that I was too young to be of any use to him, told me that when I grew up I'd have some business cards, and then, after railing about my inability to get his girlfriend hack, left after several sessions and did not return for months. He was not, as they say, an ideal candidate for psychotherapy. Yet I felt terrible when lie dropped out of therapy and tremendously reassured when, eight months later, he decided to reconnect. (I referred him elsewhere because of my teaching schedule.)
     Very few of the patients whom residents see for psychotherapy are ideal candidates for psychotherapy, and so the feeling of being abandoned by a patient is quite common. Student therapists enter the clinic hoping to do long-term therapy with people like themselves and instead find themselves speaking in rounds about the self-esteem issues of drug addicts and felons. (At clinics where trainees are allowed to take patients for very low fees, there are more noncriminal, job-holding, well-put-together patients who are willing to see a student therapist if it costs them virtually nothing.) Even so, what students learn is that keeping patients is more important than understanding theory. In private practice, a psychiatrist has an income only if he keeps his patients. That is why there are two Freuds, the Freud who is read by scholars and intellectuals, who take the abstract portrait of the psyche seriously and who debate the epistemological issues he raises, and the Freud of the clinicians, sometimes unread but inspiring, who helps clinicians think in a way that is helpful to patients.
     One way to characterize the Freud of the clinicians is by saying that training in psychodynamic psychotherapy teaches student therapists to be more conscious of the way they empathize. Empathy is a natural human process. You see someone caving; you feel sad. You see someone smile; your day brightens. It is also true that when you become more self-conscious about empathy, you see how constrained it is by who you are--the way you perceive someone, the way you feel about that person as a certain sort of person, the form of your own past and of your own anxieties, hopes, fears, ambivalences. The psychoanalyst Roy Schafer places a dissection of the therapist's empathy at the center of his book The Analytic Attitude, a taut exegesis of the way analysts do their work. Schafer does not pretend that analysts have an uncluttered, transparent view of patients, nor that analytic theory-the intellectual's Freud-always provides accurate and reliable insight. He sees that a patient tries to describe himself to an analyst and that the analyst experiences empathy for the patient. That is, the analyst genuinely tries to understand what the patient is feeling and thinking, and in that process vicariously experiences some of what the patient thinks and feels. Schafer points out that what the analyst feels empathically is not exactly what the patient feels. For a start, an analyst may build many models in his mind of who the patient is, all of which might be consistent with the "data," with what the patient has said. The analyst has his own sense of who he is in the analytic setting; so too does the patient. Each has a kind of "second self": the patient presents himself as more miserable than most of his colleagues think he is; the analyst presents himself as more competent than most of his colleagues think he is. In fact, Schafer says, the relationship between analyst and analysand--between their second selves--is "fictive." The two create it together. It is their own narrative, and it is a story about who they are to each other. That, Schafer says, is what makes analysis work as therapy. The analyst does not feel exactly what the patient is feeling, because his perceptions of the patient, drawing as they do from his prior analytic experience and his idiosyncratic understandings, are always subtly different from the patient's own, particularly because the patient is slightly different in the consulting room and in his life outside the analytic encounter. When a patient looks into the mirror of his analysis, then, he sees not a direct reflection of who he thinks he is but something different. " This gives him possibility, Schafer argues. It makes him feel free.
     That awareness of the difference between what a patient thinks and feels, what a therapist thinks and feels, and how each thinks and feels about the other, is one of the first major lessons of the resident's psychotherapy training. Suzanne, for instance, started out shocked that psychiatric patients were not always grateful for her help but would actually see her as the enemy. She was the classic "nice girl," always friendly, always helpful, a June Cleaver in a brash late-twentieth-century world. By the end of her first year, she had decided that "sensitivity" was her main problem. She called it "overinvolvement": "Working with these disturbed patients, they can pick up things and they can read things that normal patients cannot, and they zero in on your insecurities. I had one patient whom we committed to the hospital. Every day she would say to me, 'I hate you. I hate you because you keep me here.' For me it was a devastating thing to be told. I care about people a lot, more than they care about themselves sometimes, more than I should."
     By the end of her second year, Suzanne felt far more competent as a therapist. She ridiculed herself for thinking that she had known what she was doing before: "This year has been an incredible year for personal growth. I laugh sometimes because at the end of last year, my first year, we had what we called 'therapy patients.' What a joke! I had no idea of what I ryas doing at all. I remember this one young woman, a young married woman who had a new baby and was having sexual problems. I would sit there week after week not knowing what to say, just feeling totally overwhelmed. [Suzanne, never married, had at that point just broken up with her boyfriend.] She came back week after week: it was just beyond me. Hearing all these intimate things and not knowing what to say or do, what my role was, I felt that I wasn't prepared for this, the lecture course we had just wasn't enough to prepare me to sit in a room with another person who was suffering and feel like I can work with them in some way to help them gain insight and make changes.
     "I started to understand more and more. I could see why the patients were coming back, that if a patient feels understood he's going to come back, he is getting something. I learned to lower my expectations, to meet people where they are and they will feel understood. Sometimes they feel like maybe you're the only person on earth that they can come and sit in a room with."
     "Sometimes I feel like I'm engaged in a dance with the patient--they're doing some steps around me and I'm trying to follow them on the dance floor in a sort of figurative way. Sometimes we're moving in the same direction, and other times we're just falling over each other. One week a patient all of a sudden turned on me. It felt like a bucket of anger just thrown over me. At first I was shocked. Then I said to myself, wait a minute. This has got to be transference ["transferred" from another context] because I know realistically I've done nothing to offend him. Sure enough, it had to do with feelings from his mom that were projected in the anger and the hurt. I didn't confront him at the time because he was too upset to appreciate the interpretation, plus he was mad. Weeks later we did. But I'll tell you, even more critical to me was the fact that during the session, I had stepped back. I had recognized this. It feels like I now have a view of the world that is very special and is kind of neat."
     Recognizing the patient's distortion of the therapist is the psychotherapeutic equivalent of getting a driver's license. The story implies that the young therapist is beginning to do real therapy because she is able to distinguish what the patient is experiencing from what she has experienced. All of us know that sometimes someone is angry at us because he's really furious at the boss, but most of us still get angry in response. Therapists try to live in a double-entry bookkeeping state at all times. They try to he deeply emotionally engaged with the patient and yet not to respond out of their own needs, not to hit back after being hit, not to express pain after being hurt. They try not to respond in kind. That is the "special, neat" way of perceiving the world in psychodynamics: that we each create the world we live in: that we always see through molded glass, and that much of the time, when people are angry at us, we are not the cause of their anger but merely the vehicle for their self-generated, self-inflicted, wounding rage.
     After the end of residency, Suzanne explained that what she had learned in residency was to understand the patient without interrupting with her own needs (getting angry at an insult), yet still to he able to use her own sense of self in the service of understanding someone else: "What psychiatry did for me was to take away my insulation. I found myself face-to-face with a lot of ugliness, and I had to learn to tolerate it, to let it be real. There was no way to close my own pain out, and if you're careful it becomes really useful. For example, I don't think I ever really learned how to deal with anger or process anger myself, and I see that in a lot of my female patients.
     It's real useful for me because I know where they're coming from. I know what the problem is. At first you think, what do I bring to them, I haven't solved this one. But I'm not in the same boat. I don't walk in their shoes. I may have gone through similar things but not the same thing, and I can keep the distance. You can say, 'When he said that to you, I bet you were furious,' and the look of relief on their face! How did you know? I could have stabbed him.' So you use your experiences, and you help the patient."
     Young psychiatrists say repeatedly that what they learn to do in psychotherapy is to interpret someone else by factoring out their own participation, by overriding their need to see a good, just world, their need to maintain their honor, or their need to have other people see them as kind. That is, they become increasingly capable of understanding a relationship as the outcome of two complex interacting individuals and to interpret the behaviors of the other person more intricately through the contours of their own selves, as if they were predicting the speed and height of waves by the features of the shore on which they break. They say that they learn to bring their experience to bear on understanding someone else and yet to act on none of their own reactions, which are merely tools for further understanding.
     In order to do this, young psychiatrists (or student therapists) need to construct self-conscious models of patients and themselves: "I know realistically I've done nothing to offend him.... [The anger] had to do with feelings from his mom." The way they develop those models is by talking endlessly about people and what makes them tick: their secret fears, their wants, their dreams, their embarrassments, their confusions. They learn to talk about an event by explaining it from the perspective of all the different actors, and their tales get funnier because they develop a sharper sense of the parallel universes people sometimes seem to inhabit. This is not like the process of learning to diagnose. The person diagnosing learns to distill a diagnosis out of a patient's narrative and to see that many different lives can share a common label. In psychodynamics, the models are rarely taught and memorized abstractly (although some models are, such as the Oedipus complex, in which a male child separates from his mother and identifies with his father). For the most part, the models remain specific, as something some patient did at some time that is kind of like what she did some months later. Mostly, the models are about motivation, and because of the cleaner attention to motivation, the young psychiatrist becomes an increasingly better spinner of tales.
     Tom, for example, entered residency later than most of his peers, first working for years in internal medicine. He is a bluff man, pragmatic and to the point. He spends Saturday playing ball with his kids, rarely reads novels, and thinks he ought to follow the research in his field but doesn't. In the first months of his residency, he felt demoralized about doing psychotherapy: "I'm frankly terrible still at any kind of real psychotherapy. I mean, basically I'm comfortable with trying to make a diagnosis and prescribe the right medicines for these guys. If it's just me sitting there trying to help someone in psychotherapy, I just don't know enough. Actually, I don't know anything." He was reassured to discover that he liked the patients. He had bad dreams, before residency, about being locked up with craze people. But the real surprise here has been that I've really enjoyed the patients. No matter how crazy some of these guys are, I can really empathize with them. It's made me feel real good to feel that kind of a bond with the patients."
     At the end of that year, Tom said that one of his greatest problems was empathizing too well. Understanding his patient's misery made him miserable: "It's terribly difficult, People come to you day after day, just pour out all this misery and open up to you. It's gut-wrenching. When someone's not psychotic but they live with so much pain, you really feel it. Psychiatry just pulls down all these horrors. You feel so drained." At the same time, he was clear that he felt that he had become better at understanding his therapy patients: "It's hard to say how you arrive at some kind of idea of what kind of person you're talking to. It's not any one question or one physical or emotional characteristic of that person. It's the combination of a lot of little things. I think I've become a much more feeling and sensitive person this sear." In his last year, Tom said he didn't believe in classical technique. He thought that a good therapist is more helpful when he does not try to help. He said that psychotherapy worked because he had seen it work for him: but he said that it worked in spite of and not because of grand theory. He said that what was important about the process was that a patient was willing to give up the "big secret" that he had been holding inside, namely that things had not been working right. he said that he didn't think it mattered so much what you did at that point as a therapist as long as you were "there to help guide them in this exploration of themselves."
And as his sense of what he was doing seemed to become more simple and concrete, his account of motivation grew more acute: "I had this one patient, this huge woman who came in last year. She's a really good person, funny, witty, would never miss an appointment. We have a great time. Her whole story is kind of indicative of how loose my psychotherapy can he, Once her depression had cleared [this is a very medical phrase], I was trying to explore her childhood [first the medical necessities, then the psychotherapy]. She picked up that I felt uneasy about what I was doing.
"Well, I moved offices after we'd started meeting, and when she saw how desolate this room is, she brought in a plant. It was pretty much a sick plant. I said, 'You're not supposed to bring gifts, and I can't take care of plants. These things die. I don't even water them. I'm incapable of watering plants.' She said, 'No problem.' She just left it there. Unconsciously, I guess I wanted to torture her by letting this plant die in front of her. Every week we would joke because I never watered it. I honestly completely forgot about it consciously when she wasn't there, and she would accuse me of being sadistic.
     "Now, I have this other patient who is young and attractive. I didn't think she was that seductive, but I had her on videotape, and my supervisor certainly thought she was. He said that there was all this transference. In fact what he said was 'Oh, boy.' Well, she starts to comment on the plant, week after week. I never told her somebody gave it to me, I just said, 'I never water it. I don't take care of it.' She said, 'Well, I'll take it home. I'll bring it to life.' l said, 'No, you can't do that.' At the end of one session she just picked it up and left with it. So one of these weeks she's going to come in with the plant she brought back to life for her psychotherapist, whom she loves, which is okay except that now I have to explain this to the other patient who thinks I'm a sadist. I never should have taken the thing to begin with."
     "We're really storytellers," one resident remarked. One of the more remarkable qualities of psychotherapeutically oriented psychiatrists is how capable they are of remembering the story. This becomes obvious in a case presentation or a seminar with psychodynamic clinicians. Like any academic presentations, a presentation has a great deal of data and some theoretical framing. In an academic setting, however, the audience tends to focus on the theory. The listeners remember the theoretical claim being advanced, and they tend to pursue it with questions, often quite forgetful about the actual data mentioned by the speaker. In the psychodynamic setting, the listening clinicians tend not to pursue the theoretical argument (the speaker disagreed with So-and-so's reformulation of such-and-such an argument). Instead, they talk about patients, and they remember what seems to an outsider to be a stunning amount of detail: where a forty-year-old patient attended school, how her mother behaved at graduation, what her father said about it. A first-year resident said, "I used to find it very difficult to remember what was going on with a patient. Then the guy who ran the psychiatric emergency room said, 'Remember the story. Everyone's got a story.' And then I began to remember."
     What they remember has a certain form. Master chess players can be distinguished from nonplayers because they hold thousands upon thousands of chessboard positions in their memory. When master chess players are shown, in an experimental setting, a chessboard pattern that could be arrived at by play, they can remember it far more accurately than nonchess-playing subjects and probably associate with it moves that would take advantage of the position or even specific games. But they are no better than non-chess players at remembering random images or randomly rearranged chessboards that could not be arrived at by normal play." Academic psychologists have argued that expertise depends in large part on the amount and organization of knowledge around the area of expertise--what they call the "domain": chess, ballet, Aztecs, psychiatry, whatever the expert is an expert in. Many argue that the highest level of expertise is indeed (as therapists argue) reached after ten years in the domain. Experts' memories seem to depend on their capacity for perceiving meaningful patterns (cognitive scientists would call them "schemas"), and the immense storage in their domain of expertise seems to enable them to plan strategically in that domain and anticipate potential sequences of moves in the future.
     What a psychotherapist remembers is a lexicon of narrative patterns that she uses to understand what is going on with a patient, moment to moment, in a particular session and over a long analysis. The complexity of this memory is not unlike the complexity of a chess player's memory. Like the psychodynamic understanding of a life, a chess game consists of a series of patterns each of which has some causal relationship to the past but is not entirely determined by it. Like a life, each chess game is unique, hut, also like a life, the chess game moves from pattern to pattern (board position to board position, event to event) that appear in many other games and many other lives. And like the skilled therapist's, the skilled chess player's expertise lies in part in being able to remember and recognize these patterns far more readily than the untrained person and to anticipate strategy on the basis of those patterns.
     These patterns are best described as "emotion-motivation-behavior bundles." By that I mean an emotion (such as anger) that interacts with a motivation (she is a nice person and does not see herself as hating her patient) that causes some piece of behavior (she was furious at her patient but didn't allow herself to recognize the anger, and during the session for some reason she was unable to hear her patient). Young psychiatrists tell stories by chunking details around such patterns, which can then he combined in many different ways, or which may emerge in new form in new patients. (The word "chunk" is used by cognitive scientists to evoke the way people remember details by pulling them into a central concept, like iron filings to a magnet.) Identifying these bundles is complicated by the inherent oddity of separating out an expert's own emotional responses from the relationship the expert is trying to interpret. That is why it takes so long to become a psychotherapist and why it is easier to be a competent diagnostician (but not a psychopharmacological connoisseur). In psychotherapy, there are many more patterns related to one another in more complicated ways. In some important sense, you are not a competent psychotherapist until you arc a connoisseur-level expert. There is no public and clear-cut threshold of adequacy, no basic competence, as there are in diagnosis and psychopharmacology.
     When psychotherapists tell stories, they are learning to figure out the emotion-motivation-behavior bundles that (as they would see it) explain the way people in the story relate. Telling the story well (convincingly) demonstrates their mastery. For example, for many months I met with a psychotherapeutically oriented resident every Friday and chatted with her While the tape recorder was running. When I met her, she was the chief resident of the outpatient clinic. The strain of this responsibility on someone naturally shy and prone to identify even with people she didn't like made her so nervous that she lost ten pounds in the course of the year and began to smoke. Over that year we talked about psychotherapy, how she had learned to do it, what it was like to go into analysis-she had just started analysis at the time of our conversations-and how she understood what she was doing. These excerpts from our conversations give a flavor of the way she told stories about how people were with people, why they acted, and what they felt.

     She's a very troubled lady. She was incredibly depressed, chronically suicidal. She would come to my office and-"sob" is not the word for it, the building would empty. Everyone in the annex knew my Friday 3:00 patient was there. Through all this she kept telling me in a semiconvincing way how she loved me, in a maternal way. She suddenly partially got it together, decided to get a job, went from no Prozac to three pills a day, and started doing wonderfully. We went from doing crisis management to talking about how- she felt about things and how she reacted to people and what hurt her. How she felt about being in therapy as opposed to how suicidal she was this week. Then I went on vacation. I came back and tried to talk to her about what she felt like. She says, yes, she missed me, but you know she understands I have to goon vacation. By the way, she says, I flushed my Prozac down the toilet and there's nothing to talk about because I can't help her and life is hopeless. Then she canceled her appointment the next week. I tried to bring it up, but she was absolutely not angry at me. I was important to her, all this positive stuff. What happened to me is that I sat there and I started to get furious at her. At some point I realized how angry I was, I realized it was probably coming across to her, and I felt I had to make some acknowledgment of that. But then she canceled the next appointment. What my anger was telling me was how incredibly angry and hurt she was but she's not able to express that to me. So what she did was not conscious, obviously, but basically she made me feel it and one of us was conscious of it and could do something with it. The initial reaction is, no, I'm not really feeling this because it wouldn't be right to feel that, how, can I get angry at my wonderful poor sick kind patient who obviously needs help and is in such distress, I couldn't be having thoughts of strangling her right now, could I? So first you try to pretend it's going to go away or it's not really there. When denial doesn't work, you hopefully start to become aware of it, and if you're comfortable enough with yourself and your emotions, you can pick it up and look at it.
      I think [a second-year resident] has learned to be out there, to really let his emotions out with the patient, to really react however you react and be able to feed that back. Because he doesn't feel threatened anymore. I think I'm more engaged now than I was a year or two ago because I know I can shut it off. I know that I have control over myself and my life, and I'm not going to lose it in a session with a patient if I let myself get angry, if I let myself feel close to them. I used to have a lot of reluctance to doing that. Supervisors would say, what are you afraid of? The more I let myself be comfortable looking at that, then I could use the information. I could drift into a fantasy about this patient and wonder, what's the character of the fantasy? That tells me where the patient is. But the threat is that your emotions are out. It's safer to say, no matter what this patient says or does it will not affect my life. I'm not going to get upset or angry.
      I got this intake, there was this couple that had come in basically because the wife was having so much trouble with her workaholic husband and she really felt like he was putting in too many hours and working too hard, he wasn't home for her, he wasn't emotionally available, he wasn't this, that, and the other thing, and I sat through the interview going, this is my life, I don't know how to help myself, I don't know how to help them, and I presented in team. I went with the facts, but basically my presentation to the team leader was, I can't take this case, first of all, I relate too much, and second, I haven't figured out how to deal with it and maybe someone older and wiser could figure out how to deal with it. I haven't been able to figure out how to do it in my own life. And the team leader just thought it was charming and wonderful and he said, "Well that's great I think that's exactly why you have to take the case. Because you have so much common experience, you can really use that to help them." I said, "I've been struggling with this at home for a year and a half and all we do is scream at each other." He said, "Trust me." They had five sessions of couples therapy and sent me a postcard six months later saving that their marriage had never been better. I have no idea what 1 did.
      Analysis-I'm now in the second week--truly is regressive. I've gotten hack in touch with feelings that I had as a child, which I never had access to. In face-to-face therapy, I was making some effort to dredge up all this stuff, and it wasn't working. Now, it seems like all this stuff is accessible that wasn't accessible before. The whole experience has been rather like being in the dark and haying the lights turned on. They're not all turned on at once. But you can now start to make out shapes where all you could see before was black. You have a little more access to yourself. But also, as you find the light switch for yourself, you go back to our office and show someone else where it is so they can turn their own on.
     I think as I get more experienced, I have a better cognitive understanding of what I'm doing. I feel more like, you know, when someone asks you how to get to the restaurant and you can't really draw the map. I want to say, I know how to get there, I know that when I see this house I turn, but I can't say, well it's on this street. That's kind of how I feel.

     Here feelings are causes. 'They become entangled with a motivation, with someone's complicated set of hopes, fears, and dreams, and through that entanglement they cause a particular behavior. Mostly, the feelings the therapist talks about are negative. That makes sense because the negative ones are those that trouble people most. ("I didn't realize that I was upset with her, but I put the oatmeal on the burner for breakfast, and you know, I just forgot about it and her pot was destroyed.") What the therapist often does in a story is to follow a feeling through a range of emotion-motivation-behavior bundles. For instance, in the discussion of the "very troubled lady," the resident talks about the good-girl patient who is so miserable (and, one later infers, angry) that she lets the entire building know but also loves the therapist, wants to please the therapist, and so pulls her life together. The therapist goes on to say that the patient is furious at the therapist when she takes a vacation but does not want to acknowledge the anger, and the conflict leads her to flush away the medication that she was taking to please her therapist. Then the therapist segues into an account of how the patient's unacknowledged anger made her, the therapist, angry, and how she sort of recognized it and tried to "catch" it but didn't entirely succeed, and the patient felt hurt and mad and canceled the next session. This then led into a discussion of communicating anger without being able to express it and ultimately into the therapist's anxiety about her difficulty in acknowledging her own anger. A major theme of "powerful feelings that you are afraid to acknowledge" dominates the account, but there are multiple smaller patterns that the therapist infers and patches together into a coherent narrative of a portion of someone's life. In listening to this story, it becomes clear that the therapist has met many people who have difficulty recognizing their own anger. They are all different from this woman-each person is unique-yet, listening to this therapist talk was like watching a chess player recognize hoard positions and know instinctively what is going on and what to do next.
     There are several other features of this therapist's discourse that are not uncommon. First, while good psychodynamic residents use a language marked as a specialist's language, with words such as "regressive," "transference," "internalized," and so forth, the language rarely--at least in my experience--dominates the discourse, which tends to be couched in commonplace words. Second, they use abundant metaphors to indicate the thinking and feeling process. This woman uses spatial metaphors to indicate emotionally powerful events--"shaping" events--and she uses contact metaphors to indicate her capacity to understand her own emotions: she "is in touch with" or "has access to" herself. All people do this, but this discourse is so much more feeling-focused than average that the metaphorical quality seems very marked. The metaphors are particularly striking when this resident talks about what she does as a therapist. Again and again, this therapist resorts to spatial and contact metaphors to point to what she does, and she feels inadequate to put the details of her practice into words. This feeling of inadequacy is quite common among even the most skilled and senior therapists. They have, in general, a remarkably difficult time verbalizing what it is that they do. Third, many therapists tell stories against themselves and use patients' stories to make sense of their own experience. This is what this woman does, for instance, in the supervision anecdote and the couples therapy anecdote: the resident who cannot listen when he is threatened, the workaholic husband who frustrates his wife because he is unavailable. The stories are funny because they suggest that the doctor must remember that the patient is the one with the illness. Finally, this therapist, like many others, thinks that what she has learned to do requires courage and is inherently good.
     For young psychiatrists--particularly psychotherapeutically oriented ones--this language of feeling pervades their lives. "Two visitors? Oh no, that brings up all my childhood anxieties." They are encouraged to talk about their feelings about their patients, their teachers, and one another. They are told that the most important feature of relationships is talking about feelings. They are told--and they experience--that psychotherapy is full of intense feelings. They are told--probably correctly--that emotion is at the center of psychotherapy, that the therapy will "take" only if a patient is emotionally involved in it, that a patient can hear something fifty different times but will understand it only if he hears it when he is emotionally vulnerable. They are told that understanding people is understanding emotions. They use a language that is so feeling-rich that to outsiders it seems a little strange.
     Residents become deeply immersed in one another's lives. Despite the striking and increasing emphasis on biomedicine, young psychiatrists are enculturated by their institution into the expectation of intense involvement with one another. My field notes are full of this intensity, of April's feelings about Bambi, of Bambi's interpretation of Chris's anxiety about April's feelings about Bambi, of David's understanding of the role of Dr. Edwards's supervision of Bambi on April's feelings about Bambi, of a constant over-interpreted interdependence with peers. With psychiatrists, particularly young psychiatrists testing the waters of their psychodynamic knowledge, standard expectations of social distance disappear. If you do not talk about your feelings and their personal sources in one-on-one social interaction, you are substandard. This is heightened by an intensified observational alertness, which means that psychiatrists notice anxiety or distress more quickly than nonpsychiatrists and are much more likely to ask about its meaning (this livens up dinner parties attended by both psychiatrists and nonpsychiatrists).
     A resident breaks up with her boyfriend and says, "But it's really good to go through this with a group of psychiatrists, they really understand." Chances are that she will speak about the breakup in detail with many, if not most, members of her class. Young psychiatrists will talk and talk about their experiences and one another's with them, with others. They are, with respect to private matters, the singularly most talkative people I have ever met. They talk about private matters to the point that they may feel abused. "We were very, very close," Suzanne said when she was talking about another resident. "We started out last year in the same location, even on the same team. He trusted me, I trusted him. We were both going through a bad time, he's having trouble with his girlfriend, I'm having trouble with my boyfriend. We're very supportive of each other. What happened was that I started going to a therapist so I had someone to unload on, but he didn't, he kept coming to me. Boy, did he need to go to a therapist, but he didn't, he kept coming to me. I had to sort of withdraw. I love this person, I care about him a lot. It felt like his problems were starting to overwhelm me, and I started to feel used."
     The rest of the class talked about whether she had a crush on him or he on her; why had he talked to her so much; why had she put up with what had become an asymmetrical exchange; could she tell, once he went into therapy, that he was changing; what about her; hat did that say about their therapists? their capacity for therapy?
     One could argue that these young adults have chosen a career in psychiatry because they enjoy talking about feelings, and for many of them this might be true. But it is not true for all, and whatever an individual's motivations may be, the culture created by psychotherapy training is so powerful that the social demands are hard to avoid. Residents get to know one another extremely well. They work with one another, hang out with one another, are enculturated side by side. They also participate in group therapy together. Most residencies have what is known as a therapy "T group," or training group, which is run by a professional expert in group therapy and meets every week for an hour. In the residencies I visited, participation was explicitly required only for a year, but most groups continued to meet throughout the residency period. I was never allowed to attend these groups, on the grounds that they were too private. But I frequently heard about what had happened in them. During these sessions, people who worked together daily were expected to talk about their private vulnerabilities and fantasies about one another. Sessions not infrequently ended up in tears or rage. They were promptly followed by working interactions with the same people.
     In the T-group, discourse was actively psychodynamic. "There is a lot that goes on in the group," remarked one resident, "and it's weird because we're aware of it. I've had kind of transferential feelings towards Fred because I consider him to he like a father. I project feelings onto him. I've told him so. I caught myself doing it. I described to him that I felt that way, and fifteen seconds later I w as doing it again." "I his discussion must have been particularly memorable in the group-I heard about it from several people because the two men invoked were at that time competing, at the end of their second year, for a chief residency position, an administrative post with a fair amount of prestige. The resident continued, "For me to drop my guard and admit my weaknesses to someone that I'm openly competing with is a concern to me because I'm showing weakness when I'm supposed to be in competition and looking strong. Also, thoughts come to your head, like you realize that you just admitted some degree of psychopathology to everyone you work with. What will people think. Yet to be open is to be competitive, because it is to assert psychodynamic competence, as if to say, "I know myself, while you fear yourself, you refuse to acknowledge your weaknesses." Another resident said irritably about the first meeting of one T-group that Agnes--the resident who was soon labeled the most psychodynamically astute in the group--had asked to be the first person to tell the story of her life (they went around the group in turn, in the beginning), and, by choosing to be very personal, she had upped the ante and taken control of the group.
When young psychiatrists gossip, they are learning how to work. They are at least as nosy and curious as the rest of us. Unlike the rest of us, what they get from their gossip is professional expertise, little narrative packets of behaviors, motivations, and emotions. And the gossip is probably as important to their development as their supervision is. I found the informal focus on how people are emotionally put together particularly remarkable in the discussions about residents who were disliked. Those residents the other residents dissected. They knew that they should not really pass judgment on these people, who they thought might be much like themselves, yet they couldn't stand them. They really tried to figure out what drove them nuts about these people. The following are excerpts from my conversations.

I don't really know, all I know is that he apparently has a much harder time. When he was growing up, he didn't have any parents, or maybe a stepmother or something like that, and Florida was kind of a drug capital in that period, and I think he probably had a lot of problems. 1 know he had a lot of therapy, but trying to give him the benefit of the doubt, I just hope this is an improvement over the way it used to be. I hope he's going in the right direction. I think there are a lot of times when he shows that he has a conscience and he's genuinely sorry for what he does. It doesn't seem like it prevents him from doing a similar thing again. I will say this, though, he has definitely added a lot of life, a lot of' spark to our otherwise kind of boring social life that we had last year. There's a certain neediness about it.
      I've had conflicts with Anne, for example. I've definitely used my understanding of her dynamics. I've understood that the only way to resolve problems is to be very frank and honest rather than harbor resentments. I haven't told her why I feel that she's done what she's done. Very often, my understanding of her is that she's rather narcissistic and that she really tends to walk over people sometimes, and so when she goes to walk over me, I've called her on it and I've told her that this is where I stand and these are my concerns and this I why I would appreciate it if she wouldn't do what she's doing, and she's responded to that. I haven't told her, well, you're narcissistic and just don't think about other people. Obviously that wouldn't go over too well.
      Diane is what I would call a group deviant. She's flamboyant, she's hysterical, by that I mean very dramatic, everything's extreme in her descriptions of things. People looked at that as peculiar and odd. So she got set on the outside fringe of the group, not yet labeled the group deviant. Then she engaged in some behaviors that irritated and angered, alienated her from certain charismatic members of the group, and these charismatic members spread the word. So everyone became sympathetic to the charismatic members and further alienated from the outlier, and that was when she became the group deviant. To fit in now, she would have to dump the odd behavior, I mean that's like telling someone to grow two right arms. It's just not possible for her to change her behavior like that. She would have to go through five years of analysis to be able to change her defense patterns and behaviors. When people get together and talk about the difficulties of residency, it's Diane. All their concerns were legitimate, but they weren't talking about anything more important, like how hard it is to take care of people who don't want to become better. How hard it is to take care of people who will never be functional. That's hard. So we use Diane as a way of expressing anxieties and frustrations and ventilating.

     These accounts display many features of a young therapist's discourse: the technical language, the spatial metaphor (although in the absence of personal reflections, there are no contact metaphors), the identification of feelings, and sequences of emotion-motivation-behavior patterns. What they add is the sense of relentless determination in trying to figure out why, despite all their training and all their rationality, some of their peers behaved so badly (on the one hand) and the other residents weren't mature enough to cope (on the other).
     Psychologically minded people create such models (large and specific) all the time. Psychiatric residents (and others in training) have two additional sources of help in building these models. The first is psychodynamic theory, which provides a great abundance of partially abstract models to interpret human behavior. The residents learn this theory from teachers, from peers, and occasionally from books. The theoretical model suggests that if someone exhibits a certain set of behaviors, the behavioral pattern is this and the motivating emotions are that. For example, in a well-known book entitled The Drama of the Gifted Child, the analyst Alice Miller describes highly successful people who do not have the secure self-assurance you would imagine. Their success seems hollow to them, their failures monumental; although they are envied and admired by many, they feel empty, abandoned, and depressed. They strive for more success to quench these feelings, but to no avail. Miller calls these patients "narcissistic." She describes a narcissistic person as someone who learned to be and to do in order to please someone else and to be loved by them in return. That is why they arc so successful and why their success is so meaningless to them. Such a model explains what motivates these patients and, ultimately, how therapy should be focused so as to help them understand and reshape their motivations. Young psychiatrists read such a book and make sense of it by using the model to explain people they know or indeed to explain themselves. Miller remarks that many insightful, intuitive children who grow up taking care of their parents by being good, responsible children become psychotherapists as adults. That is how they make use of their earlier intense interest in what their parents felt and needed.) The models offered in various texts do not all complement one another. Sometimes they flatly contradict one another. (A famous example is penis envy. Some psychoanalytic writers believe that women are motivated by penis envy; others do not.) In general, psychiatric residents (or psychiatric clinicians) are not worried by the contradictions, and in general they do not see their task as one of arbitrating them. These models are tools they can use to help them understand their patients. They are like spades and garden shears, useful or not useful, rather than like equations, true or false.
     The second source of models is a privileged access not only to a greater-than-average range of human experience (including serious depression and psychosis, which laypeople rarely see and recognize) but also to feelings and stories usually kept private. By the time they graduate, psychiatric residents not only have seen hundreds of severely disturbed patients, they have heard hundreds of detailed accounts of fantasies, actions, desires, frustrations, and so forth, the likes of which most people encounter only in novels and in a handful of living people. These are not abstract models. They are stories of how one patient spoke about commonplaces for three months in therapy and suddenly began to cry or another abruptly quit therapy and called back four months later, or how the son of an entrepreneur was crippled by his fathers great success, yet had to take care of him as he sank into senility. These are like chess games a young psychiatrist plays again and again, seeing lives unfold, looking for the ways different strategies play out in different settings. They help a psychiatrist say to herself, "Ah, that is the way you reacted to your brother's death, but it is not the way all people would react. It is a unique reaction, and it tells me something about you, because I have seen similar reactions to different problems and I have seen people react differently to similar problems."
     This learning process probably helps most young psychiatrists to sense other people's emotions more accurately. At least the process helps residents to make fine distinctions between emotions and their roles in different settings. I think it also enables residents to sense emotions more keenly. My evidence is simple and observational. I believe, having spent years in this world, that good, psychodynamically oriented residents become more intuitive over time. They seem to be able to meet a person for a short time and to summarize that person's experience in a manner that rings true. Some residents become identified as "wizards" who are able to interview a patient and dazzle a crowd with their skill in understanding, who give people in their office a sense that they have understood them deeply. Even so, the understanding is undoubtedly shaped in an idiosyncratic fashion: out of the many possible valid interpretations of one person's behavior, a therapist settles on one, and, because no person has a single interpretation of his own life, a patient's sense of being understood arises in what is essentially a negotiation between his perspective and that of his therapist. It must also be said that some psychiatrists never learn. Some residents are clumsy in the psychodynamic china shop at the beginning of their residency and remain so at the end.
     "It's an anxious profession," another resident remarked at the end of his first year. It seemed to me, in sorting through my transcripts and notes, that there were different modes of and stages in coming to terms with psychotherapy. First and most common was rejection and a sense of inadequacy, coupled with an appreciation that psychopharmacology is easier to master. All psychiatry residents feel this inadequacy to some degree throughout most of their residency. How could they not? A second-year resident, skeptical of psychotherapy but caught by his own expectation that to be a good psychiatrist was to be a good therapist, reported, "I felt like an imposter. Someone was actually coming to me weekly for psychotherapy, and I didn't know what I was doing. My supervisors would reassure me by explaining that it takes ten years before you become comfortable doing psychotherapy. And I thought, ten years? ten tears? I didn't expect to he an analyst after my residency, but I expected to be confident. I thought, don't give me that crap. But everyone said ten years. So I felt better, but I am still much more secure with the psychopharmacology and much less secure with psychotherapy I feel very put off by it. It's easier to be a competent psychopharmacologist than it is to he a competent psychotherapist. The patients don't seem like they're getting better, or a patient leaves and I feel terrible. And I feel anxious, because even though I know it takes ten years and all that, still I feel sheepish and stupid with a new supervisor."
     Then one must become engaged with the ideas of psychotherapy before being able to feel much ease in the practice. This leads to mild paranoia, because a resident who recognizes that there is a new way of' seeing but feels he hasn't got it thinks that everyone is pointing at him. Of course, he is right. Senior psychiatrists have meetings to talk about the residents and how they are doing, and these discussions are in large part about the residents' personalities and whether they can make it as psychiatrists. "They have these meetings," Phil complained in his second year, "and they talk about us. I'm sure they think I'm too extroverted and outgoing. It's so unfair. I can't stand it."
     Phil turned out to be a reasonably gifted therapist, but he was not an intellectual, and he was not comfortable in the training experience. By the beginning of his second year, he had the guarded look of the hunted. "Before I was a psychiatrist," he said, "I was innocent on the unconscious level. Now I'm guilty on the unconscious level. The year has been really hard. I'm sure psychiatric training is harder than other fields. For myself, I've had a lot of self-doubt about professional identity, about my ability to do this work, the ability to be a psychiatrist, whether I've got it inside of me. In cardiology, if someone had a specific arrhythmia, there is just one specific treatment, and if that treatment doesn't work there's a specific alternative. In psychiatry, first of all, you don't have anything to diagnose that's as concrete as an arrhythmia. But then, you can make a good clinical assessment on one level, but if you neglected something you would he called on and criticized, and you'd have to ask yourself, why did I do that' The chances are that the reason I didn't go into a certain detail was so deeply seated in myself that I'd have to do some serious self-analysis to understand why 1 missed it.
     "There are no excuses in psychiatry. Everything you do is for a reason. Circumstance just doesn't exist in the minds of psychiatrists. Senior psychiatrists are always looking at you and judging you. I was on call the other day, and I slept from about ii p.m. to 3:30 a.m. I went to sleep again at 6:00 a.m., and for some reason my watch alarm didn't wake me up. I was late for sign-up, and my excuse that my watch didn't wake me up was meaningless. I missed the time for some reason: some unconscious motivation meant that my watch didn't wake me up. That's understood. Any psychiatrist would say that it's understood. My unconscious is guilty of not wanting to go to morning sign-up rounds."
     The final step in the learning process is developing some sense of mastery. That people feel as if they know who the good therapists are says something very interesting about this profession, where you never see the professional's work. Residents and more senior psychiatrists certainly had clear views about who was as likely to be a good therapist and who was not. Often the judgments were quite consistent. The capacity to use oneself to understand another self is not, after all, a mystical quality. It is a part of human intuition that some people have naturally and that psychotherapists, who often fall into this category, learn to hone. What becomes surprising is how the process of honing can make a person feel as if he is becoming unnatural. It transforms the way he looks at people, thinks about people, reacts to people. Good psychotherapists sometimes say that they have always had the skills they have now learned to use, but that using them skillfully has changed them utterly. Or so at least they perceive.
     In both of these approaches, the biomedical and the psychodynamic, what one learns to do affects the way one sees. A psychiatrist in a hospital (or a more biomedically minded psychiatrist) learns to memorize patterns and starts to use them in a rough-and-ready way. He learns to think in terms of disease and to see those diseases as quickly and as convincingly as a birdwatcher identifies different birds. For him, what is wrong with a patient is that the patient has a disease, and being a good psychiatrist involves seeing the patient in terms of the disease. For him there is a clear-cut difference between illness and health. A psychiatrist in an outpatient clinic (or a psychiatrist thinking psychodynamically) learns to construct complex accounts of his patients' lives. He thinks in terms of the way his patients are with other people and in terms of the emotions and unconscious motivations that lead his patients to hurt themselves. Here there is no clear-cut line between health and illness. What is wrong with a patient is that his interactions with other people go or have gone awry, and being a good psychiatrist involves understanding how and why. Both take the complex mess that is human misery and simplify it in order to do something about it. In the process, each approach constructs a different person out of one unhappy patient.