I did not begin training as a psychiatrist with an open mind.
As strange as it might seem for someone beginning a career based on insight, I had resolved not to change. I was frightened that my personality might be pasteurized by the process, that forces would make of me a blank slate on which others would feel free to write their life stories.
Worse yet, I feared becoming eccentric -- even driven crazy -- by listening to troubled or mentally ill people. It is testimony to the tenacity of the caricature of the field that this fear survived my close and valued relationships with my mentors in medical school, psychiatrists who were not just personable, but charismatic.
I resolved to keep a vigil of sorts. My interests then ran much closer to pharmacology than to Freud, so I thought it would be easy to skate safely over the contrived meanings that others might coax me to find in everyday speech or events. I would be particularly alert for uninvited analysis of my personal style. I would emerge untouched.
But for all my plans and the energy I expended to keep my distance, I have been swept up by my work. My patients and supervisors have helped me to hear and to feel an undercurrent of meaning in human interactions that is as subtle as it is powerful.
Recently an elderly patient of mine arrived for her appointment, then sat down and insisted it would be her last visit. She said that terminating therapy before we had planned should not matter to me, as ours was a business-like relationship. "You can't care too much about your patients," she asserted, "or you won't have a life."
"You're worried you'll keep me from having my own life?" I asked. "Isn't that what you said last week about your son?"
"You remind me of him," she said.
"And he moved away."
"Well, how long are you planning to stick around?" she asked.
A year ago, I would have heard a simple goodbye in a mother's sadness at not seeing her son. But these connections have occurred with such frequency and emotional force that I can no longer deny them. The harmony or dissonance that plays in the background of a conversation is becoming as loud as the words.
When a valued colleague overslept and missed a recent presentation of mine, I wondered whether we had become too competitive. A friend spent more money than he should on a sculpture, and I warned him that debt could be his way of avoiding change, binding himself to his lucrative, but unfulfilling, job -- just like his father.
The unstated messages and intentions in actions and words sometimes seem so obvious to me that I feel embarrassed for the person communicating them, as though I am eavesdropping on a private struggle between the conscious and unconscious.
I often agonize about whether I should share my interpretations when they arise in social situations with people outside the office. Often, I do not. I don't want to impose my uninvited introspection on others, knowing that it can bring great pain and tremendous anger. That's why people have defenses against their emotions.
I had imagined that, after listening to my patients' problems, I would shrink from wanting to hear about those of my friends or acquaintances. I would have given all my empathy at the office, and would welcome shooting the breeze.
But the opposite has happened. I am uncomfortable on the surface of a discussion, saddened when a conversation is limited to pleasantries. My training and experience have taught me that everyone is in some sort of pain, and that whenever I expend the time and energy to look, I find it. Whether the problem is a strained relationship, an unrealized goal, a denied passion or a fear of death, everything is not all right.
I am less and less able to walk away from the tug of doubt I feel when the answers to my questions, whether put to a patient or a friend, seem convenient or simplistic.
At a restaurant several weeks ago a group of friends and I were joined by a woman we had recently met. I asked how her day had been. "Like the rest of them," she smiled. "I need a beer."
The group chuckled, then quickly went back to arguing about the World Series.
Most of me went along. "Well, how are the rest of them?" I wanted to ask.
I didn't, because I am not willing to pay the price, which I imagine might include social ostracism, the reputation of being the chink in everyone's emotional armor.
Listening to people's pain has connected me to the suffering of others. I understand that what looks like free choice in an adult can have its roots in childhood trauma. A woman who repeatedly engages in abusive relationships, for example, may be replaying a childhood tragedy of abuse at her father's hand, trying to understand it or, perhaps, to finally achieve a measure of control over it.
Recently I went to a bachelor party for an old friend and ended up talking to the topless dancer. "You like this job?" I asked. "I love it," she said. "The first time I stepped onto the runway, I felt so at home." I couldn't resist. "What was home like?" I asked.
I have been told that what is happening to me is just a self-indulgent version of weakness. An older friend of mine, greatly skilled at leveraged buyouts, warned me I am losing my competitive edge. He has a gambler's eye for opportunity. "You have to understand," he explained, "that some people come to the table to lose. That's the reason they are there."
There's an element of truth in what he says. Some people who feel worthless, who have learned in one way or another that the world is cruel or capricious, will go about proving it to themselves, again and again. But I cannot abide it at my table. I have chosen the role of helping people make the most of their cards, even when they seem hellbent on folding.
I have become convinced that most unhealthy patterns are never interrupted, that pain is commonly buried, that terrible guilt routinely lies unacknowledged to fester. What my patients tell me, I imagine my colleagues' patients tell them. I hear hints of some of the same unresolved issues in my friends, and I recognize them in myself. The code of silence around all this frustrates me because the truth is that, although we won't tell each other, we are more alike than different in our needs and fears. We are much more alone than we need to be.
About halfway through my inpatient work at a Boston state psychiatric hospital, I went searching for a passage in Steinbeck's "Grapes of Wrath." The gist of it had stuck with me from years earlier. The words are those of a preacher who has left the cloth:
"The hell with it! There ain't no sin and there ain't no virtue. There's just stuff people do. It's all part of the same thing. And some of the things folks do is nice, and some ain't nice, but that's as far as any man got a right to say."
Touching the pain I work with feels very much like love. The fact that I have had the opportunity to sit with a homeless schizophrenic man or a pregnant intravenous drug user and find their fears -- of failure and loneliness and death and, yes, insanity -- in myself has brought me to tears. As different as our lives are, we know something about one another. In listening to suffering that others had warned would drag me down, I have been lifted to a new optimism, a conviction that human beings are connected by a core goodness that may lie just below the surface.
This goodness, interestingly enough, is not revealed to me in success. I feel there is nothing so honest or beautiful as the connections I have been privileged to make with those who are utterly lost.
Keith Russell Ablow is a writer and a senior resident in psychiatry at New England Medical Center in Boston.