On The Couch
Tue, 12/29/2009
Other than “How are you?” which is in reality a greeting, “What do you do for a living?” is the single most common question we ask each other. Not only the perfect icebreaker, it is also a subject that genuinely interests us. Best of all, it is a simple question with a simple answer. Except in my case. Yes, I can give a simple answer: I am a psychiatrist. It is accurate, but it is simultaneously deceptive. The listener invariably makes inaccurate assumptions. So you treat crazy people? Not at all: my wife jokes that my patients are healthier than our friends.   If I am truly honest with myself, I am not at all sure exactly what I do. I know exactly what to do; after all, I’ve been doing it for 40 years. The convenient catchall term is therapy. That begs the question — what is therapy? Helping someone feel better is therapeutic, and we professionals get paid to do that. Truth be told however, friends, lovers and especially parents, who combine both roles, do it for free, and often they do it quite well. As if to prove the point, there is the phenomenon of transference, a concept immanent to therapy. Every patient unconsciously projects onto their therapist their positive and negative feelings about their parents, real and imagined. Just as parents provide therapy, therapists parent. The first gift that I ever received from a patient was a mug inscribed: “It’s never too late to find your happy childhood.” More than one orphaned client has asked me to walk them down the aisle when they wed. Most of the time, of course, we don’t replace parents. On the contrary, by assuming some of their infinite duties, we, over time, succeed in improving, perhaps even resurrecting, our patients’ relationships with them. As I age, my perspective of my therapeutic role has evolved. Psychiatry is a profession in which looking older is an asset. Age implies experience, which suggests wisdom. I grew my beard when I applied to medical school because without it, I appeared to be in high school. As it began to gray, I noticed that it made my job easier. When someone points out that if I shaved it off, I would look a decade younger, it reinforces my need to leave it on. In that respect, I can divide my career into three distinct phases: before I had children, while I helped raise them and now, when they are grown. In retrospect, just as that first phase made me a better parent, my experience as a father immeasurably improved my expertise as a psychiatrist. When Wordsworth wrote: “The child is the father of the man,” in context, he clearly meant that the habits that are inured in our youth invariably accompany us to our grave. I have come to learn, as I’ve aged, that it means much more than that. The first thing that I teach my medical students and residents is to listen to your patient. The first reading that I assign is Sherlock Holmes. It is not because he is the most popular fictional character of all time, or even because he was created by a physician, Sir Arthur Conan Doyle, and based on a physician, Joseph Bell. It is because as physicians in general and as psychiatrists in particular we are in the business of solving mysteries. Our clues don’t come from our textbooks; they come from our patients. If you focus on the right questions, instead of on your patient’s story, you’ll probably arrive at the right diagnosis and, if necessary, prescribe the right medication, if the right one exists. If you listen to your patient’s life narrative however, with all the seemingly irrelevant tangents, you’ll understand how they came to be that way, and in the process, how to change them. As I’ve gotten older, I have realized one more thing. There are only three prescriptions in the Torah for a long life. The first is kibbud av v’eim respecting one’s parents. The second is shiluach hakan, not allowing an animal to see his offspring being taken. The third, enigmatically enough, is evan shalem, fair weights and measures. What I do for a living is, in fact, a combination of the three. The first is the aforementioned parental transference that drives the therapeutic alliance. My patients, to some degree, respect me either because they felt that way about their parents, or because they would have liked to feel that way about their parents. The second is the compassion that must be the sine qua non of every caregiver. If your patients sense it, they will forgive your inexperience, and even your mistakes. Absent it, you can be the finest psychiatrist in the world, but they will still sooner find someone who cares about them, as well as for them. The third goes by many names. When I started practicing, it was called “reality testing.” Today, it is more popularly labeled “cognitive therapy.” In both cases, it means correcting patients’ misperceptions. Repeated studies have shown, for non-psychotic psychiatric illnesses, it is more effective than any medication. I studied in medical school and residency for seven years; I studied in yeshiva for twice as long. I did not realize until recently that in pursuing my life’s work, I learned more from the latter than the former. The “Physicians’ Desk Reference” puts out a new edition every year; the Torah is timeless. Our former medical school dean loved to remind us that half of what we learn in our four-year tenure there turns out to be wrong. No one ever said that in yeshiva. Studying our patients is fundamentally similar to studying Talmud. In both cases, arriving at the correct answer is far less important than understanding it. My favorite description of what I do for a living is metaphorical, rather than literal. I lend my patients my ego, while they grow their own. It is only as I’ve aged that I have come to comprehend that, in the process, my own self-image grows as well. Not coincidentally, the identical development occurs in parenting. We endeavor to become the kind of person that we want our children to imagine we are. More often than not, we succeed. The child is the father of the man. I’m still not sure what I do for a living; I am certain that I love doing it. That never gets old.   Dr. Isaac Steven Herschkopf, a practicing psychiatrist, is president of the NYU–Bellevue Psychiatric Alumni, and the author of “Hello Darkness, My Old Friend: Embracing Anger To Heal Your Life” (Xlibris). This essay is an excerpt from a forthcoming memoir.