First, accept that you will be at the mercy of the clock. Your patients may feel that the meter is running, but you don’t run the meter. You’re as much in debt to chronos as they are. You will start the sessions on time. And you will end them on time, even when you have more to say, or something that just now occurs to you to say, or when you feel guilty about having had nothing useful to say and are afraid that your patient will never come back because you’re too dense and you want to at least apologize by going five minutes over. The discipline takes no prisoners.

Second, accept that there will be long stretches in which you will have no truly useful ideas. Try not to fill those stretches with busyness. Try not to feel too stupid and inadequate. Bear the thought that you may never get to a clarifying insight about this person. Try not to think about a rival who would have been smarter. Well, you can’t not think about her, but at least try not to let it get to you.

Third. Remember that however your patient is negotiating his life, however abysmally self-destructive his choices may be, for him every alternative to this life is more horrific. Being alone is worse than being hated, for him. Try to get your mind around that, it’s the single most important thing about doing therapy. So it’s not going to be helpful to chasten him, in the encouraging and supportive and clarifying and interpretive ways that we do that. The first thing to understand, to really understand, is just this, that from his point of view he is doing the very best he can. Unless he knows that you get that, he may listen to what you have to say, and make apparently appreciative, even brilliant, contributions, but he’ll privately think you’re clueless, and that his plight is hopeless.

Fourth. Be grateful for small moments. One extraordinarily difficult young woman, who I was temporarily seeing for free after she was fired from her job, surprised me by saying that the smallest changes are priceless. I thought she wasn’t deliberately being ironic. Doing therapy is like fishing, waiting patiently, sleepy and alert, not too eager to jump but ready for the unexpected tug, while accepting that it may never come. Jesus said to the two mariners he took as apostles: Come with me and be fishers of men. Take delight in being caught off-guard. And when the moment comes, don’t commandeer it. Less is more.

Fifth. Never assume that you know what your patient means. The one thing you can never say too often is: Tell me more about that. You know less than you think.

Sixth. Harold Boris said that being your patient’s therapist is not an invitation to tromp around untrammeled in your patient’s mind. Knock before entering. Don’t try to be clever.

Seventh. Our therapies are strewn with compliance. We all figured out how to rescue our mothers. If we need to have our patients need us, they will do just that, in the guise of helplessness. Never take anything for granted.

Eighth. Don’t hold on. Our patients usually know when it’s time to leave, by their lights. Only hams are cured. Bear the fact that their departures are usually tougher on us than they are on them. Don’t be like the mother who yelled after her kindergartener heading off for his first day of school, “Some day you’ll miss me when I’m gone!” Let them exit graciously.

Ninth. Love your patients.

August 1, 2008
Stowe, Vermont