On being a patient

Tom rang to tell me he had an eleven o’clock meeting with a radio producer in my neighbourhood; we could have lunch afterwards. ‘Why don’t we go to the Italian place around the corner from you?’ he asked.

Five years earlier, when he had felt himself sinking into a depression, Tom had asked me to recommend a psychoanalyst. I’d referred him to Dr A., a woman I’d trained with and whose work I admired. Tom and I had been friends for almost twenty years, and we saw each other often – at least once a week. But during these past five years, he’d never mentioned his analysis, and, out of respect for his privacy, neither had I.

We met for lunch and talked about his upcoming radio series. By the time the waiter cleared our plates and brought coffee, the lunch crowd had gone; the place had emptied out.

Tom turned towards me. ‘You didn’t exactly lie to me,’ he said, ‘but you didn’t tell me what to expect.’

‘I’m not sure I know what you mean,’ I said.

‘Analysis. For the longest time, I just couldn’t understand what was happening in my analysis. Dr A. was so focused on …’ He trailed off.

‘On what you were thinking?’ I asked.

‘Not even on what I was thinking – that seemed to be the whole point. She spent so much time on all this minutiae, on things that seemed to have nothing to do with what I was thinking.’

‘I don’t understand,’ I said.

‘I’m sure you do, but I’ll give you an example.’ Tom studied his cup for a moment. ‘I get to her office. I ring the bell. She’s got a buzzer system. What am I supposed to do if she doesn’t release the door straight away? Should I ring the bell again? If I ring again, will she think I’m annoying? Then she releases the door. Her office is on the fourth floor. I have to take the lift. I’d like to take the stairs, but if I walk up, I’ll be sweaty. So I take the lift.

‘But the lift is a bit of a problem. I wouldn’t want anyone to see that I’m going to a psychoanalyst – I’m antsy about that. So I get to the fourth floor and make it to her door. On the door she has one of those push-button combination locks, so that patients can let themselves into the waiting room. Sometimes I fumble with the lock and I get the combination wrong. Is she listening? Is she thinking, “What a klutz?”

‘I’m in the waiting room five minutes early. Should I start reading something? She once told me that it was interesting that I had started to read something despite the fact that I had only a couple of minutes before the start of my session. Maybe I shouldn’t read. What do I do if someone else comes into the waiting room? Do I smile? What do I do if I see her colleague – do I say hello to him? Is there a rule about this stuff?

‘She’s one minute late coming to the waiting room to get me. Now it’s two minutes. Has she forgotten me? She comes into the waiting room. Do I look at her, or not look at her? As I follow her into her consulting room, do I look around the room, or not look around the room? What do I want to see? Am I trying to avoid seeing something?

‘Now I’m at the couch. Do I really lie down and put my wet, dirty shoes on her nice clean couch, or do I take them off? Do patients normally take off their shoes or not? I don’t know. If I do take my shoes off and most people don’t, I look peculiar. But if I don’t take my shoes off and most people do – then I’m dirty. I decide that I’d rather be peculiar than dirty. So off come the shoes.

‘By the time I finally lie down on the couch, I’ve been through all of that. This entire discussion – my sense of being reproached and my sense of self-reproach, this whole saga of doubt and trouble – all of it has been conducted before either of us says a word.’

Tom downed his espresso.

‘It took a long, long time – probably a couple of years – to really divulge all that toing and froing clearly because, frankly, who wants to let someone else know just how absolutely small your own preoccupations are? But Dr A. kept returning to this sort of stuff, kept encouraging me to talk about it. We spent weeks on that shoe thing, for God’s sake. I wasn’t expecting that.’

‘What were you expecting?’

‘I thought I was going to lie on her couch, and reach into the past, and then we’d discover some buried trauma that she’d elegantly unpack for me … Or we’d discuss my Oedipus complex, or a dream about my dad’s dick. Of course, eventually we did talk about my family and my past – she made those connections – but what surprised me was the amount of time she spent building up this picture of what was going on in my head. Hour by hour, day by day, week by week, she tuned in to the way I think. It wasn’t what I imagined.

‘Slowly, it emerged that at any point in that journey from her front door to the couch, I felt I might be scolded. If I didn’t think that somebody was about to criticise me then this stuff shouldn’t be a problem, right? I just ring the bell another time, so what? I fumble with the door, so what? I put my shoes on her couch, big deal.

‘It turns out that a lot of the stuff I did – like taking my shoes off – I did because I didn’t want to give her any excuse to tell me off. I had in my head the idea that she was someone who would come down really hard on me if I got her couch dirty. Who was this person who was going to be so cross with me? Was it my parents? Was it me? It certainly wasn’t her. She couldn’t care less if I kept my shoes on.

‘And then it became clear – painfully clear – that I’m not just like this when I go to see my psychoanalyst. My everyday rules of engagement are so frustrating and weird. If someone doesn’t immediately respond to an email I’ve sent, I feel criticised. If their response is a little cool, I’m at fault. Most closings – “kind regards”, “best wishes” – feel like a rejection.

‘I take almost everything personally. I get on the Tube: I get a seat – victory; I don’t get a seat – defeat. I get a parking place – victory. I don’t get the parking place – defeat. The repair man can come over straightaway – victory. I’ve left a fleck of shit in the toilet – defeat. These tiny, tiny moments are the way I measure my progress in the struggle that is daily life. Moment to moment, my thinking is utterly, unremittingly banal.’

‘But it’s not banal,’ I said.

‘No, you’re right. It’s not, because, of course, there’s a pattern to these petty thoughts. I was operating on the assumption that people were basically reproachful. And because that was built into the way I did almost everything, I felt caged. All these moments weren’t just the way I thought about my life – they were my life.’

Tom looked at his cup. ‘Do you want another coffee?’

I nodded.

We called the waiter over, and ordered two more. Then Tom went on. ‘Bit by bit, it became clear that this wasn’t just about reproach, it was about something bigger. I thought my life was structured around a desire to live well. But I found that what I really wanted was to be clean. It’s all there in that business about putting my shoes on the couch. Obviously, to anyone else, this will seem crazy, but I was beginning to see something that made sense to me.

‘It turned out that there was no grand trauma behind my feelings of depression and isolation. What there was, was my incessant scrutinising, my calibrating myself to fit in with others. In analysis, my first impulse was the question: what does Dr A. want? That shoe nonsense was my attempt to fit in with what she wanted. But who knows what other people want? All of our thinking about other people’s desires is assumption – assumption, assumption, assumption.

‘I’d like to think I’m pretty astute,’ Tom said. ‘The truth is, sometimes I’m right, sometimes I’m wrong. The real question is whether or not we’re trapped by our assumptions. I wasn’t aware that I felt people were fundamentally fault-finding. I didn’t know that my idea of a person is of someone who wants to scold me. I just thought people were that way, but it turns out I was wrong.’

Tom leaned back in his chair and said: ‘Dr A. had another insight which I didn’t see coming. It isn’t always true, but it was in my case, that if you’re frightened of being criticised, you’re probably pretty critical. And what a surprise – it turns out that I’m a critical person. It turns out that when I’m not finding fault with myself, I keep busy reproaching others. I won’t bore you with the one thousand and one things that are wrong with the decor in Dr A.’s office – or with Dr A. herself. You can imagine.’

Tom leaned forward and put his hands on the table. ‘Do you know the word captious?’

I shook my head.

‘I didn’t either. Fabulous word – it means apt to notice and make much of trivial faults. Fault-finding. Difficult to please. Sound like anyone you know?’ He set down his cup. ‘I must have been an analyst’s nightmare.’

I stopped him. ‘Hardly,’ I said. ‘It sounds to me like you did exactly what you were supposed to do. You went in and told her what you felt. I don’t think it was too difficult for her to spend an hour a day with you.’

‘Thanks,’ he said, ‘but that’s bullshit.’

‘No, it’s not.’ I said. ‘A nightmare is the patient who doesn’t tell you what’s on his mind. He drinks, secretly. He slaps his child, but he can’t – or doesn’t – tell you about it.’

‘Not telling isn’t my problem,’ Tom said.

‘No, you’re an honest guy.’

‘I didn’t want my analysis to fail.’

‘But some people do. Think of the teenage boy who is about to be thrown out of school. Week after week, session after session, he sits silently for the whole hour. The analyst does the right things, makes thoughtful and true interpretations to the boy about why he won’t speak to her. But, still, he won’t engage. It may be that the boy needs the therapist to fail in order to feel that someone else is more useless than he is.’

Tom nodded. ‘That’s not me. But I really could be very negative,’ he said.

‘She’s trained to think about your negativity, and she did. But OK, imagine your problem pushed a little bit further – an intensely negative patient. Imagine a patient who is so thin-skinned that he experiences almost every one of his psychoanalyst’s comments, no matter how true, no matter how gently phrased, as if it were an attack. Even the analyst’s silence feels like a reproach. Or maybe he continually scans the room to find the things that the analyst cares about – cut flowers, pictures on the wall, books – and day after day he mocks them. That’s a difficult patient.’

‘What do you do when you have a patient like that?’

‘I might see them first thing in the morning.’

‘No, seriously.’

‘Seriously. I advise my students not to see too many patients like this, and to see them first thing in the morning, when they’re less likely to get irritated.’

‘But isn’t it impossible not to take things personally?’ Tom asked.

‘Sure. I get irritated, but hopefully I’ll find the reason the patient needs me to be irritated. My job is to listen, then check what I’m hearing against my emotional reactions – like with the teenage boy. He made his analyst feel angry and like a failure; she understood that he needed her to fail.’

Tom nodded.

I said: ‘You brought in your criticisms of Dr A., and she thought about them with you. What can really be worrying is when a patient needs to think too highly of his analyst and the analyst goes along with it. Analysts have anxieties too – usually about their capacity to handle what the patient brings to them. Almost every analyst has, at one time or another, colluded with a patient to keep that patient’s most disturbed feelings – anger or madness – from entering the room. It doesn’t sound like that happened very often with Dr A.’

We were quiet for a minute.

Then I said: ‘I can’t figure out from what you’re telling me – did your analysis help?’

‘Dr A. and I are discussing this very question in my sessions right now, because I think it’s time to stop. If you’re asking me if I’m fundamentally different – I don’t know. I can’t tell. I think I’m fundamentally less critical of myself. I do know that I’m more aware.’

‘That the way you were thinking trapped you?’ I asked.

‘I’m more aware of what’s going on behind the scenes,’ Tom told me. ‘And that gives me a degree of choice. When I find myself feeling hurt or depressed, I can try to decode the feeling – I can decide if it’s something I’m doing to myself or something that’s being done to me. This gives me a way out.

‘When you have no choice, you’re doomed, you’re stuck in a web of reproach and self-reproach. You have this way of thinking – a way of being – so deep in you that you can’t question it, you can’t even know it. You just live it. Having a choice is a very, very big liberation.’

Tom watched the waiter crossing to the front of the restaurant. ‘I’ve got to tell you this,’ he said. ‘A couple of weeks ago, I was lying in bed. Jane was downstairs making us a pot of tea. I could hear the boys in their bedroom, laughing, playing with their light sabres – a perfect Saturday morning. I reach over and switch on Radio 3. Some piece of music ends and then the announcer says, “In place of our scheduled programme we’re going to broadcast a programme by the historian and presenter” – and at this point I’m thinking “Oh fuck, for fuck’s sake,” – and the announcer continues with his big, fat introduction for this marvellous, world-conquering genius. And I’m thinking “Oh for fuck’s sake, who is your fucking expert?” And, just as I’m about to switch off the radio, he says my name. They were rebroadcasting a programme I did a few years ago. I burst out laughing. It was such a surreal moment.

‘Who knows why they were repeating an old programme of mine? I presume the CD they were going to play was scratched. Who cares? The thing is – I’m still pricked by all the real and surreal stuff life throws at me. I still want to be the only expert in my field, and there’s still part of me that wants to believe that if I stay nice and clean, and work really hard, and I’m a big success, I’ll be protected from depression and anxiety.

‘What’s different now is that I have in my memory this repertoire of exchanges with my analyst to call on, that I can use to understand my way out of a painful moment. I feel less lonely now.’

The waiter put the bill down between us. ‘Let me get it – you paid last time,’ Tom said.

I still wondered why we hadn’t talked about his analysis before, and I asked him.

‘I couldn’t talk about my analysis because I didn’t know how to talk about it. How could I tell anyone – including you – about that shoe malarkey without them thinking I was wasting my time and money? I wasn’t sure anyone would see the bigger thing.’

Buttoning our coats, we stepped outside. Tom put his arm around me and gave me a hug. I hugged him back.

We stood for a moment on the pavement. Tom motioned up the hill towards the post office and shops. ‘You going up or down?’ he asked.

‘Down, back to the office.’

I watched Tom walk up the hill, to take the Tube home. As I stood there, I found myself filled with a recognisable feeling, a disquiet that sometimes comes over me after a patient has left my consulting room, and I’m left with the sense that we’ve only talked around what’s truly at the heart of the session. I feel that I’ve failed both my patient and myself, and I want to redo the previous hour, start again the session just ended. Of course, Tom wasn’t my patient, and this wasn’t a session. We were two old friends having lunch. But it bothered me that neither Tom nor I had talked directly about what he’d called ‘the bigger thing’ – neither of us had used the word love.

As I lost sight of him, I was still thinking about our conversation. Tom’s minutiae – the smell of his sweat, the mud on his shoes; how opposite this view of himself from my own picture of this big, gentle, civilised man. I thought about his fear that if he was known, if he was seen as he believes he truly is, he would be found dirty, broken. And being dirty and broken – how could he love, or be loved?