Meeting the Moment

The Importance of Risk in Therapy

Magazine Issue
July/August 2020
An illustration of two faces opposite one another

When people find out I’m a psychiatrist, they often react in these ways:

One (while leaning back and holding up crossed index fingers): “Don’t analyze me!” To which I smile and say, “Relax. I’m off duty.”

Two (with a shudder): “I couldn’t listen to all that misery, day after day. How can you stand it?” Are you kidding? It’s real and compelling, and I can’t believe my good fortune to do this work.

Three (with furrowed brow): “What is it you actually do? You’re just sitting there.” I’m listening and thinking about what I’m hearing. I’m problem-solving.

What people don’t realize is how unpredictable the work can be. If the patient and I are two circles, where we overlap—the relationship—is a zone of unpredictability. This is where therapy work is done. This is where chance is either my enemy or my friend, depending on my attitude. No amount of practice will ever make perfect. No amount of planning fully protects against the chaos that’s intrinsic to as complex an organism as the treatment relationship.

What kind of person voluntarily takes on the challenge? No one, least of all me, would have predicted I’d go to medical school and become a shrink. As a physician therapist, carrying life-and-death responsibility heightened my fear of making a mistake. What if—I missed something?

What if—I overmedicated? Used the wrong medicine? Didn’t ask the right question? Drew the wrong conclusion?—and the patient died? It took me years to accept the weight.

Increased confidence is the upside of embracing risk. Frequent loss of dignity is the downside. I wish I could be smoother, but it’s not possible. When the unexpected reveals itself, you don’t know what to do because it’s . . . unexpected. New. The only option is to ad lib, a creative activity that requires trust in myself, the patient, and our bond. Sometimes it goes amazingly well. Sometimes not. There’s always something to learn. A sense of humor definitely helps.

Here are two stories that illustrate the razor-thin edge we walk in even our most ordinary sessions, when a single moment has the power to push the session from one direction to another. The only interesting thing in any story is how the protagonist deals with these moments: what she learns, and how she, and others, change as a result. This is what keeps me reading. This is what keeps me engaged in session, not to mention in the rest of my life. These moments are everything.

There’s No Place Like Gnome

“Doc, am I a gnome?” Sheldon asked.

What? It was a cuttingly cold, dreary January afternoon. We sat in my warm office: sage walls, cream trim, potted peace lily, upholstered couch, matching chair stuffed with Sheldon, bookcase, accordion window shades opaque from the lack of sun, tissue boxes as far as the eye could see.

Silly made a nice change. It’d been hours of patients who were desperately sick, chronically suicidal, resistant to treatment, or just plain miserable.

I wanted to laugh. But I didn’t. He was serious. “Uhh . . . no.”

“How do you know?”

“Well . . . gnomes are fictional characters.”

Sheldon nodded. I waited.

“So why does my family say I’m a gnome?”

I looked over his unfortunate jug-handled ears, bald dome, glowing eyes, goofy grin, and 70-year-old, pear-shaped body sagging into the upholstery. It was hard not to giggle. He was a little old gnome. There’s always a kernel of truth in every delusion (and in every nickname).

This was today’s kink in Sheldon’s kookiness. Social reassurance (“Your family wouldn’t say that!”), while logical as well as true, wouldn’t console him. What was the tactful (yet still honest) thing to say? Tact, timing, dosage: that was my challenge. I leaned forward.

“Maybe . . . because you’re bald?”

His hands jumped up to his hairless head. “I shaved it myself! But it’s not too good in the back.” He turned his head so I could see.

Sheldon was the sweetest thing on the planet (when he was stable). An innocent, radiant with wonder, always looking to tell a joke. He’d been a religion teacher at the local Catholic elementary school and a popular performing folk guitarist and raconteur before schizophrenia stole that life. He shifted to face me.

“Doc, do gnomes get erections?” Here we go. All aboard the train of Sheldon’s sexual delusions. I sighed. It was a familiar slog through gray fog, not interesting but still perilous. First stop: erections.

I said, “I wouldn’t know. I deal only with real creatures.” Next stop: celibacy.

“Doc, how do you define celibate?”

“Well, a celibate person is someone who gives up sexual relations for spiritual reasons.” Next stop: homosexuality.

“Okay. If I’m queer in thought, am I queer in deed?” Here be dragons. Not going there.

“You’re celibate. So, no.” Next stop: STD.

“The nurse at the doctor’s office told me I have a rare form of syphilis. What do you think?”

“I think you don’t. Your last blood test was negative.” As were the gazillion before. “You’re celibate. No sex, no STDs.”

Et cetera. More of the same. Can we stop now? The urge to thump my head against a handy wall took me.

Instead, I assessed the data. Psych meds don’t get rid of delusions. They help by softening delusions’ hard unreasonableness. Maybe. Better meds can’t come soon enough. Meanwhile, if Sheldon accepted my reality-based responses and—fingers crossed—suffered less, I’d take it.

Sheldon nodded, “Okay. I believe you, Doc.”

I smiled. Hey, this is going well. I realized I was leaning forward, so lifted his chart off the stack on the ottoman, then scooted back in the chair.

“I was afraid to ask,” he said. “I didn’t want you to think I was crazy.”

A grin escaped me and out popped, “Come on, Shel, we both know you’re crazy. That’s why you’re here.” Oh my God. I tightened my grip on the chart instead of clapping a hand over my mouth. I can’t believe I said that.

Our eyes locked. He shrank into the chair and his head retreated into his rounded shoulders, like a scared turtle. The atmosphere in the room darkened, became charged and still, the calm before the storm. How do I regain his trust?

My body tingled. My mind sizzled, snapped, and popped in lightning-bolt analysis: I had missed the point and with a heavy hand. I had spoken to the surface question, not to what he was really asking, which was: Am I okay as a person? Do you like me, crazy and all?

The clouds parted and the sun came out. I saw the way. I twinkled like mad, maintaining eye contact: I’m sorry! I didn’t mean to hurt you. You are adorable. I love working with you. He stared, frozen. Would he forgive me? I grounded myself in the quality of the session before this awful moment, in the strength of our years-long bond, and in his sense of humor. I beamed warmth, dialing it up.

He gave me a long, searching look and melted. He dropped his shoulders, lifted his head and smiled. “Good one, Doc.”

O! Happy day! I grinned back. Thank you!

I had spoken to the surface question, not to what he was really asking, which was: Am I okay as a person? Do you like me, crazy and all?

Sheldon gave me a goofy smirk, “Wanna hear a joke?”

Wow. He’s reaching out. We’re good. I was totally engaged. Fascinated. I love this.

“Sure. Nothing off-color please.”

“Okay. When Cookie Monster was sick, what did he say to his mother?”

“Um, don’t know.”

“I feel crumb-y!”

He laughed freely, and so did I.

The session in review: His eye contact was good, mood jovial, and affect broad. Delusional content aside, we’d kept the conversational ball in play continuously for 20 minutes. He let me confront him with reality. He let me console him. He accepted my apology. Amazing. A triumph of give and take.

Given he’d required two hospital admissions for terror-loaded paranoia in the last 10 years of treatment, one of them on my watch a couple years ago, he was solidly in the maintenance sweet spot. My cup runneth over.

I wrote the progress note. Did he need scripts? No. I closed the chart and shifted forward in my seat. “Sheldon, I’m not changing any of your meds today. You’re doing great. I’ll see you next month.”

He glowed and heaved out of the chair. He retrieved his winter coat off the couch and struggled into one sleeve while I held the back and other sleeve forward for him. “Thank you.” He wound a striped lime green and white scarf around his neck, then pulled a neon-pink knit cap down over his ears. As he waddled out the door, the bobble wobbled. I had to suppress another giggle. We walked side by side to the checkout window, where we ran into my husband, also a psychiatrist, whom I share the practice with. Sheldon asked him, “Why should everybody buy a good pair of shoes?”

“Why?” Hubby smiled.

“To save their souls!”

It’s so simple, really. What do we all want? To be accepted for our whole selves, from soup to nuts. Especially the nuts.

Sheldon didn’t choose his illness. He was disabled, despite treatment. We both had to live with that. I’m competent and full of goodwill. Still, I screw up. We both had to live with that, too.

One mistake and time stopped. We sized each other up. Sheldon’s psychosis, my insensitive gaffe, those fell away. We connected as human beings and found it good. So good, we laughed.

Being an outpatient psychiatrist is a lot like being married (38 years, thank you). Things go along the same-old for long periods until Hubby and I have a moment. Everything stops and I fall for him again, just like that. Just like the first time. I remember why I love him. Today with Sheldon, I got it, just when I needed to, that I love my work. Gnome is where the heart is.

Stop It!

I walked into the waiting room with my dog Poodle Oodle and knew at a glance that Elaine—hunched on the edge of the wooden chair, hands clenched between knees, head down—was having a bad day. She yanked her head up, eyes wide. She struggled to her feet, lost her balance from the pain of bearing weight, and steadied herself with a hand on the wall. She wailed, “I’m sorry! I’m so stupid and clumsy!” It didn’t take much to set her off into a frenzy of verbal self-whipping.

We walked slowly, Elaine limping, to my clinical office. She not only suffered crippling pain from multiple herniated discs in her neck and lower back, but also had arthritis, degenerative disc disease, and asthma. The awful state of her back was due to a combination of bad genetics and horrifying physical abuse in childhood. She was in her early 40s.

During her elementary school years, her mother locked her in closets, starved her, beat her till bones broke, kept her home from school to do house and farm work, and then beat her some more for “not doing it good enough.” In her middle and high school years, she was abused sexually by various men in the family, including her father and two brothers. Her father also passed her around to his friends, once to pay off a gambling debt.

Had any public authority ever intervened on her behalf? No. Domestic violence and physical and sexual abuse are endemic in our rural community. Social service agencies are understaffed, underfunded, and overwhelmed. Physical injuries are explained away as farming accidents to emergency rooms, pediatricians, and school nurses.

Elaine suffered from severe PTSD: flashbacks, nightmares, panic attacks, and depression. Her Social Security disability check barely enough to live on. She avoided leaving her rental one-bedroom apartment, where she’d lived alone since escaping the family in her early 20s, after the miscarriage that continued to haunt her. She’d hemorrhaged, required admission, and told the hospital social worker enough about her home life to be discharged to a safe house. She’d never gone back.

Although EMDR doesn’t address the betrayal and abandonment issues of severe childhood abuse, Elaine had found a past course somewhat helpful. The medications I prescribed helped some too, and we were working on all the counterproductive ways she coped with the people who triggered symptoms. She’d never married and had no friends, but she tolerated the company of a couple women from her church.

Two years ago, when her 16-year-old dog Boxter passed away, she was inconsolable for months. “Dogs are beautiful. They always love you. They don’t betray you. How am I going to live without him?” she’d wept. With time, she’d come around to the idea that it wouldn’t be disloyal to his memory to let another dog into her life, and she adopted an abandoned puppy from the local ASPCA.

“I call her Toast because without me, that’s what she’d be.” And vice versa. Elaine’s spirits had lightened a bit since. Between the PTSD symptoms and the pain, it was hard for her to make her appointments with me. Yet she rarely missed one.

“My back is killing me,” she said as we entered the office. “Driving kills me, walking kills me. I can’t do anything!” she moaned. “I hate my life! Look how skinny I am! How ugly!” She swept aside her unzipped coat, pulled up her sweater and shoved her protruding ribs at me. “See?!” Poodle Oodle, who ordinarily ran right up to Elaine, stood quietly beside my left foot, head cocked, brown eyes alert.

I closed the door. She dropped her sweater, swiped her eyes with a forearm, and gave me an admit-it-you-find-me-repulsive glare. But I wasn’t accepting any invitations to that party. The anguish in her voice broke my heart. No one should hate themselves that much. Except her vile parents, who wouldn’t, of course.

Elaine was a lovely person, warm and caring, eager to learn and desperate to feel better. She worked hard at it. Fury—at her family for warping her into this dreadful shape—blazed through me. Then despair: evil people are a fact and so is the hell they make for the rest of us. Finally: You can’t do anything about that. Get to work. Focus. I took in a breath and released it slowly.

Elaine lowered herself to sit on the couch with a grimace, but pulled up immediately. “I can’t. Do you mind if I sit on the floor? It hurts less.”

“Of course not. Do what you need to do to take care of yourself,” I said, seating myself while keeping an eye on her. Poodle Oodle sat on the floor beside my chair, also watching.

She paused in mid-lower—one hand on the sofa and one knee on the ground—to throw me a brilliant, guileless, girlish smile that told me I’d hit it, said the right thing, met a need she didn’t know she had.

“Thank you!” She groaned as she sat on the rug, scooched her back against the couch, and stretched her legs carefully. She’d kept her coat on. I leaned forward and pushed the ottoman toward the bookcase to give her more room. Poodle Oodle padded over to her and snuggled next to her thigh. Elaine leaned down to stroke her head, “Sweet girl.”

A few peaceful moments passed before she looked up. I smiled before speaking, “Bad pain day?”

“Yeah,” she frowned. “This winter cold is murder. The ice. I’m so afraid of falling.” Her eyes filled. “I’m so sick of not being able to do anything, having no life, being so stupid and useless!”

This was too much. “Hold on. Did something happen?”

“Nothing! I’m home all the time. Nothing happens! I don’t see anyone or do anything. I’m a lazy cripple!” Tears spilled.

I knew what this was: someone had been mean to her.

“Did you get any phone calls today?”

She stopped crying abruptly. It was interesting how mercurial she was. One minute she was weeping; the next beaming; then suddenly, pensive. Now she lit up. “Yes!” Just as quickly, she darkened and looked down. “How did you know?” she whispered.

What seems uncanny is just the extrapolation that comes from closely observing how people behave in specific situations. Add years of honing that skill for a living and not just patients get spooked. In an earlier time, I might have been burned for a witch.

I hastened to reassure her. “I didn’t know,” I smiled. “You forget. I’ve seen you like this before, usually after you get a call from family. You say awful things to yourself after. It’s a pattern.” I smiled again, turning up the warmth. She relaxed, slumping back against the couch, stroking Poodle Oodle from head to tail along her back. Poodle licked her hand. “Who was it?”

The tipping point of the session flashed through my body. It could have—so easily and catastrophically—tipped the other way.

Her hand on the pooch stilled. Her face contorted and her eyes flashed. “My mother! I hate her! Whenever I talk to her, I’m a wreck after.” She rubbed the free hand across her eyes and shook her head hard. “I shouldn’t hate anybody! I’m bad. I know I’m going straight to hell when I die!”

Elaine was deeply religious, both a boon and a bane. Her faith had kept her alive; otherwise she might’ve killed herself long ago. But it was a torment, too. She was convinced she should turn the other cheek, and when she couldn’t (being of sound mind), judged herself cruelly. As cruelly as she’d been treated.

If she could accept her hate for what it was—the natural and logical consequence of how she’d been abused—she could begin the work of accepting that her mother would never love her. Not because she was unlovable, but because her mother was incapable. Letting go of her mother would open up space in her heart for someone who could love her.

That’s incredibly hard work to do. We know from monkey research that monkey children mistreated by their mothers cling to those mothers when adult. They won’t let go. They don’t move on to finding a mate and building their own family. The abuse stunts or stops their ability to mature. My therapeutic goal for Elaine was to help her fill in the developmental holes and heal the psychic wounds enough “to have a life.” I knew that’s what she wanted, but that was a many years’ project and it was still early days in the treatment.

I didn’t try to reassure her she wasn’t going to hell. She’d reject that for the platitude that it was. Besides, how could I possibly know? If hell existed, I didn’t have any say about who went there. “Have you considered not taking the call?” I asked.

“I can’t not talk to her! She’s my mother!” she said, scandalized. I ignored the urge to explain why my suggestion was reasonable. Better for her to draw that conclusion herself.

“Why did she call?”

“I don’t know! It’s not like I have any money to give her.”

“What does she want that you can give her? Is she lonely?”

“No!” She paused. “I think . . . she’s bored.” Another pause. “She likes to get me upset!” She jerked with the insight and gasped from the resulting jolt of pain. Poodle Oodle raised her head, ears up, eyes on Elaine.

“She asks me what I’ve been doing, and no matter what it is, I’m stupid and useless!” Her face crumpled. I handed her a few tissues. The pooch cushioned her chin on Elaine’s thigh.

“What do you get when you talk to her?”

“What do I get?” She blew her nose and tilted her head. “What do you mean?”

“What’s in it for you? Besides hating yourself, of course.” She lifted one side of her mouth ruefully at that, and dropped the used wad of tissues into the small wastebasket beside the couch.

There was a long silence as she went deep inside, hands folded in her lap. In the street, a car whooshed by. Faintly, from far away, a police siren wailed. Outside the office door, the white noise machine droned. When she resurfaced, she looked . . . Puzzled? Astonished? Hopeful?

“I . . . I don’t know,” she said. “What is in it for me?” She looked at me for The Answer.

I shook my head. “Only you know. Take a wild guess. Be bold.”

Another long silence. She took a deep breath. “Nothing?”

Wow. Most people, even if they can, refuse to see what isn’t there. Elaine was smart. And open.

“I can’t stand her! Do you know what she said? She said I should be dead! She said she should have aborted me!” She broke down sobbing. Poodle Oodle ran from her side and vaulted into my seat. “And then . . . .” She clenched her fists, punched down on her thighs and yelped. “And, and, the miscarriage!” She covered her face, wretched. “But, but . . . God hates me too! He punished me when he took the baby.” Her body shook. “I must be really worthless!”

The words poured out in a flood, one memory triggering the next, wave after wave of misery, harsh judgments rushing after, in a rapidly escalating cascade. Her neck muscles stood taut like ropes, her torso heaved, a deep red flush suffused her neck, ears, and face. She gasped, increasingly short of breath. She was heading for an asthma attack or a panic attack or both—

“STOP IT!” I barked, and shifted forward in the chair, my weight over my feet, ready to rise. I’d spoken without thinking, with utter conviction, without doubt. Yet if I’d misread the situation, this was one of those moments that could topple a session. Jeopardize the relationship even. Which way would it go?

Abruptly she stopped, panting heavily, the sudden quiet pounding with all the words dammed back. Her tears dried up. The flush receded, leaving her neck and face blotchy pale. She stared at me.

“Good,” I said carefully. “Well done.” I leaned forward and handed her the wrinkled tissue I’d been clutching.

“Thank you,” she said and blew her nose. I handed her another. She wiped her eyes and took a moment to breathe, then gave me a tentative smile.

“You were working yourself up.” I said.

She thought about it and nodded.

“You might want to try not doing that.”

She thought some more. “How?”

My turn to think. “You know how bad it made you feel to hear your mother say you shouldn’t have been born?”

She nodded, her red-rimmed eyes glistening. I hurried before the floodgates opened again. “Then it triggered a memory of your miscarriage, and more bad feeling and so on. It kept building. It was turning into a tidal wave.” I paused. Was she with me?

She nodded: Go on.

“If you’d kept going, you might’ve had a panic attack or an asthma attack—” I stopped. “Do you have your inhaler on you?”

She shook her head no. Images flashed by my inner eye: Elaine passed out, blue-lipped from lack of oxygen. Punching 911 on the phone. The ambulance rushing to the hospital, red lights flashing.

“When I shouted at you to stop, you did. Instantly. Good job.” I steepled my hands to my chest, bent forward from the waist, bowed my head—Namaste—and straightened. Beside me, head on crossed front paws, Poodle Oodle watched Elaine, too.

The silence was deafening. She stared at me, unmoving, for so long it became uncomfortable. Then her face split into a radiant, charming grin. “Really?” Poodle lifted her head and ears.

“Yes. You can work yourself up. But you can stop, too. That’s what we both learned today.” Her grin broadened. “The key is to notice when you’re sliding—“ I interrupted myself. “What shall we call it? That wave of bad memories and bad feelings?”

Silence. “A tantrum?” Elaine giggled. Her sense of humor was back! Sunshine, after heavy rain. I grinned, delighted. Poodle jumped down, ambled over to Elaine and sat down beside her.

Tantrum is such a judging word. How about we call it a surge?

She nodded.

“As soon as you notice that surge of self-hate—”

“But I always hate myself!”

“Well, not always at the same level, right? Sometimes it lightens up and you can feel your loving self, yes?” I paused to give her a chance to explore that.

She nodded, a bit hesitantly. Poodle Oodle pawed her thigh. Elaine smiled and stroked her head.

“Your loving self comes here to work with me.” I raised my eyebrows and smiled: Right?

“Oh, I see. Yeah,” she said, her hand stroking Poodle’s back.

“When your loving self notices a surge of self-hate, let her ask: What happened? Was someone just mean to me?”

I paused. Did she get that?

She nodded.

“You want to find the pattern of cause and effect. The cause is what triggers you. The effect is the surge. You see?”

Her hand went still: Yes! She raised her eyebrows: Then what?

“As soon as you notice, you stop. You say to yourself: I’m not going there. I’m putting my mind on something else. I’m distracting myself. Like say, your laundry hamper is full of dirty clothes. You say to yourself, I’m putting a load in.”

I studied her closely. She looked back, alert.

“Your mind can only do one thing at a time.” I paused. She nodded. “You either sink into a horrible memory or you take the puppy for a walk.” I paused again.

“A walk? Toast runs!” She grinned, and looked down at Poodle Oodle. “Toast is so good!” She looked up at me. “If I didn’t have to take her out, I’d just stay on the couch. It hurts to walk her, but it’s a good hurt.”

“See? You’re smiling! Walking Toast puts your attention on her and gets it off you. Whenever you get upset, walk Toast.”

“I can do that?” she asked with wonder. Was she asking for permission or if it could be done? Either way: yes.

“You can do it. Distracting yourself from your upset is a technique. You use it to calm down. To soothe yourself.” I smiled.

“Wow,” she said.

“Elaine, you’ve just never asked yourself to, is all. It’s a skill. It gets easier with practice.”

She gave me a beatific, loopy grin.

“I’ll try it! I’ll try anything!” We both watched Poodle Oodle stretch in downward facing dog, then the other way, and finish with a total body wiggle.

I smiled at Elaine and stood up. She was a joy to work with.

It didn’t matter that she wouldn’t hang on to it. She’d forget. But each time I reminded her, she’d be thrilled, grateful, and redouble her efforts. As Kurt Vonnegut said, “If that isn’t nice, I don’t know what is.”

Using the couch for support, Elaine levered herself up off the floor. “Whew,” she said, giving herself a little shake to balance herself. She smiled at me.

I smiled back, amazed at how good she looked. The tipping point of the session flashed briefly through my body, an electric charge that raised all the little hairs and made my heart race. It could have—so easily and catastrophically—tipped the other way. I saw her fighting for air, face red and neck veins bulging. I saw her face after, paper white. I’d intervened with unknowing certainty, and upon rational review, I knew with certainty I’d done the right thing. Another electrical surge, this time of satisfaction, hummed through me.

“Elaine, one more thing,” I heard myself say, the words emerging from that wordless knowing that made forethought redundant. “Carry your inhaler in your purse, so you always have it with you.”

When I spoke without thinking in these sessions with Sheldon and Elaine, we entered the therapy hazard zone, where anything is possible. With Sheldon, I overshot and created a crisis. With Elaine, I nailed it and prevented one. With Sheldon, a swift nonverbal acknowledgment that I’d gone too far and was very sorry not only repaired the breach, but strengthened our therapeutic bond. With Elaine, processing what happened after the event deepened her commitment to her healing.

If the risks inherent to these flashes of intuitive response are managed well, they contain an energy that moves the treatment forward, in a way that textbook interventions often don’t, or can’t. Decades of experience have taught me the discernment required to trust my instincts, as well as the skills to address any resulting fallout. Although there are no guarantees in this work, I’ve come to believe that the risks are worth it because, more often than not, it’s these moments that matter most to both my clients and to me.


Adapted from Practice, Practice, Practice: This Psychiatrist’s Life by Daniela V. Gitlin, MD © 2020 by Daniela V. Gitlin. Published and reprinted by permission of Corner Office Books. All rights reserved. “There’s No Place Like Gnome” was first published in a different form in the Psychiatric Times (, November 2016.



Daniela Gitlin

Daniela Gitlin, MD, is rural psychiatrist in private practice in upstate New York. Her clinical memoir Practice, Practice, Practice: This Psychiatrist’s Life was selected a Finalist by the 2021 International Book Awards. Her second book, Doorknob Moments: Why Clients Drop Shockers on Their Way Out the Door and Why You Want Them To will be published by WW Norton in 2024. Learn more at