The causes of most mental illnesses are easily determined. Although patient’s stories vary in intensity, the psychic dynamics they reveal are finite and can be categorized. Unfortunately we can not say, “OK, ‘Stan,’ here’s the deal. You’re a number five and here’s what you must do about it.” Stan must figure it out himself; all we can do is guide him. Even though we have ascertained the root of his problems, from perhaps the first session, it could take years to get him there and we must be very careful that we choose the right roads to that destination. That’s not mysterious or glamorous. That’s tedious. It is a mixture of art, science, empathy, understanding and, of course, caring.

After a therapist is certified and licensed the first thing he needs to do is find an office in which to see patients. He will need a comfortable chair with an ottoman, because he’ll be sitting all day and needs to keep his feet up to prevent circulatory problems over the years. He’ll need a comfortable chair for his patients and a couch. Although the couch has lost favor with many therapists today, I highly recommend it. It must be situated so that patients cannot see the analyst when they are lying on it. This is important and is the main reason for it. We don’t want our patients looking at us. It’s too exhausting.

A psychoanalyst will typically see six to eight patients each day. They’ll be telling him things about themselves which, to them, are extremely important. If the patients are looking at him and note he’s less than enthusiastic about their stories they will tend to embellish them, thus making them less valid, or they’ll take the opposite tack and clam up.

Some therapists take notes during sessions which is distracting to the patients. Before long they’ll get a feel for what the therapist thinks is important ... “He’s writing that down,” and this may cause them to edit what they say, disrupting the all-important free flowing of words. If the patients are on the couch they can’t see notes being taken. (But you can bet they’re listening for a pen scratching on paper.) I never took notes during a session. When patients say something with analytic significance I could not help but remember. It defines them (becomes them) in my mind. Forgetting their names would be possible but not their psychoanalytic dynamics.

The couch is also a wonderful therapeutic tool because it enables the analyst to listen with the “Third ear.” (Theodor Reik coined this marvelous phrase.) Listening this way allows him to hear substance rather than individual words, making it easier to gather patterns of thought and behavior. I closed my eyes and propped my elbow on the arm of the chair resting my cheekbone on my fist. This posture helped me to concentrate on the patient’s unconscious material as it threaded its way through the volume of words.

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A person’s psychic make-up is formed over time by numerous people and events somewhat like tributaries form a river. Let’s say the patient is the Mississippi. The analyst needs to discover Horse Creek, which feeds into the Kankakee River, which feeds into the Des Plaines, which feeds into the Illinois, which feeds into him forming his unconscious mindset. The patient did not begin life as a great river; he was a trickle. His “con-tributaries,” so to speak, need to be discovered (and there will be many of them), those who formed the person he is today. It will be a lot easier for the analyst to recognize these tributaries if his patient is not staring at him.

So why not begin with the couch? Why bother with that other chair? Because, to almost everyone, the couch is scary. It sure was for me. For many patients too much control is lost too soon. A face-to-face rapport should be established first. It may take just a few sessions or dozens of them before the patient trusts enough to give up control, lie down, and reveal what’s really on his mind.

Ideally a psychotherapist’s office will be somewhat secluded from the world’s view. Most people, understandably, are reluctant to let others know they are seeing a shrink. A secluded location is not always feasible, however, as many therapists work together in clinics, hospitals, and institutions where they share common expenses. As a patient seeing Jean Rosenbaum at the Institute, where many therapists practiced, I waited with others in a reception room. One day I was appalled when one patient asked another one, “How come you see a shrink?” The embarrassed patient didn’t look up from her magazine and her face turned red. When I saw Jean I told him about the incident, thinking he’d be disgusted by this insensitivity. Instead he laughed and said, “It’s always dangerous to ask people why they’re seeing a shrink. They might tell you.”

Many therapists work out of their homes, which has advantages. It is private for the patients, the therapist doesn’t have to drive to work and it makes fiscal sense. There must be a separate entrance to the consultation room, however, or it’s not a good idea. Patients should not be traipsing through the therapist’s house observing how “ungodlike” he is.

Yes, “god-like” is what a therapist must be to his patients. They are not bringing their problems and heartaches to an equal human being. They are bringing them, in their minds, to someone very special who can relieve their burdens. And this is a heavy responsibility on the therapist, one he must take seriously. That is contrived but it is also important. Patients have been seriously messed up by “normal” people — normal in their experience. The therapist must be above normal to help them. If he steps off the pedestal they have erected, damage will have been done to their therapy. These are patients, not clients. Clients see lawyers and interior designers. Patients are hurting, and it is imperative to not wreck the doctor/patient relationship they need in their time of desperation.

The less patients know about the personal lives of their therapist, the better it is for them. They don’t need that distraction and are not in therapy to learn about their therapist. Over time it becomes clear to the shrink that his patients could care less about him as a person anyway, and that’s the way it’s supposed to be. Only the lessons learned from the experience should remain with the patients. Psychotherapy should never be confused with friendship.

The most tempting pitfall a shrink can succumb to is to talk too much. Silence is unnerving to the inexperienced or insecure therapist who may begin filling the air with words. If there is a silence, let it be. It is the patient’s hour and the patient’s silence.

I once saw a young woman, a shoplifter, who was given a choice by the court: Either get psychotherapy or spend time in jail. She wisely chose therapy. She came into my office, sat down, glared at me and said, “I don’t want to be here.”

I asked, “Why not?” Her eyes went to the floor and she stared at it for 50 minutes. Not a word was uttered. I then said, “Your next appointment is Tuesday at 4 p.m.” She left.

Tuesday at 4 she returned to my office and said, “I don’t want to be here because I think it’s a waste of time.”

I smiled and said, “It’s your waste of time, not mine. I’m getting paid for it.”

This made her giggle. “The last time I kept waiting for you to lecture me. Aren’t you going to lecture me?”

“No,” I answered “I’m not the law, I’m a shrink.” I then asked her to tell me anything she wanted to about herself, and that did it. For the next three months I couldn’t shut her up. Silence is a wonderful tool at the therapist’s disposal. It signifies defenses, and removing them is an important part of emotional healing. The silence says, “We’re close to something important.”

And so, too, is candidness a good tool. I had a male patient once whose preoccupation during our sessions was how much money he was paying me and how he was not being helped. His real problems were overshadowed by this concern, and he was driving me nuts. No matter what question I asked him about himself he would segue back to the cost and worthlessness of his therapy. After one of these sessions was over, I said “Time’s up, Bob.”

He responded with, “Well, there’s another hundred bucks wasted.”

As it turned out I had a cancellation for my next hour and said, “Bob, I agree. So far you’ve wasted your money. We’ve gotten nowhere.” I then added that I had the next hour open and told him I would agree to continue the session if he’d agree to waste another $100. He looked at me like I’d gone daft, thought about it for a few seconds, laughed, and agreed to the deal. About half way through the next hour Bob, recently married, told me he thought he was gay.

I learned a lesson from Bob. Some patients, at least at the beginning of analysis, need more than the standard allotment of 50 minutes. (Analysis is called “The Fifty Minute Hour”). It takes more time, for some, to work up the nerve to tell what’s really on their minds. Bob’s bitching about money, and his attempt to belittle me in the process, was simply a defense against what he thought was a terrible truth about himself. He was six months married to Rachel (I knew her — she was a knockout) and unable to have sex with her. Bob figured he had to be a homosexual.

“What types of men are you attracted to, Bob?” I asked.

He gave me an incredulous look and said, “I’m not attracted to men.”

“Then why do you think you’re gay?”

“Because I can’t get it up any more with Rachel and she’s a beautiful woman! I was fine until we got married, but now nothing happens. She’s going to leave me!”

“Let’s talk about getting it up and being married, Bob,” I said. The connect was made and the analysis began.

Being a shrink is hard work. He is not simply listening to patients complain about their lives. He is listening with that “third ear” to their personal history, patterns of thought and behavior and to their pre-occupations. He’ll note their joys (if any), pains, loves, hates, fears, guilts, wants, don’t wants and dreams. He is also noting slips of the tongue, which are most telling. He is forming a picture in his mind of his patients’ unconscious mind. Sometimes I had the feeling I was herding rabbits or loading pigs. Just when I thought the last rabbit was going into the pen or the last pig was on his way up the ramp, a patient would say, “Did I ever tell you about the times my father beat up my mother?” Prior to this the patient had portrayed dad as the gentlest of men, a henpecked Walter Mitty. Back to the drawing board.

Loneliness is a down side to the profession. Although he spends his day with people — one right after another — a therapist cannot be himself. He becomes a creation in his patients’ minds, a figment of their imaginations, a shifting non-entity fulfilling their needs. He cannot confide in them that he, too, has problems, unrealized goals and fears. He cannot go to the movies with them or invite them to stay for dinner. They can never be friends. His day is filled with pseudo relationships. This is necessary for his patients’ well being, but it is an odd, unnatural way to relate to people.

Colleague friends are very important to a shrink. He spends his days observing how logic, reason, intelligence and educational levels are not active ingredients in the emotional area of human minds. This phenomenon demands regular reinforcement from peers. It is too unbelievable.

Money is another down side of the psychotherapy profession. One must make a living, but sometimes the patients will have financial setbacks. What if they lose their jobs? Does a therapist dump them until they can pay again? With that rejection they need therapy more than ever. Also, in difficult economic times therapeutic practices are some of the first ones hit. Practical problems become more pressing than neurotic ones, and seeing the shrink is put on hold. The problem of finances is a constant in the psychotherapy business. A colleague once theorized that the reason Freud worked into his 80s was that he needed the money.

Another negative of being a therapist is the day-to-day grind of dealing with human misery. The analyst should remain emotionally detached from his patients and their problems to maintain objectivity. At the same time, if he does not genuinely care for them they will know it and they won’t get better. It is a difficult balancing act — objectivity tempered by caring. I never had a patient that I did not eventually like as a person. They all had sweet spots, although some took awhile to find.

I mentioned in the Preface that psychoanalysis was a dangerous profession. This does not mean patients sometimes attack their therapists with guns, knives, or fists. I was never threatened by a patient in any physical way, but they do attack in ways so subtle that neither you, nor they, know it is happening. Their neuroses sometimes plug into your neuroses and you begin to have their symptoms. It is bizarre.

When Bob, who thought he was gay, and I finally got into his analysis we spent a great deal of time on his anger toward women, which was the underlying cause of his inability to have sex with his wife. Bob had deep, unresolved issues with important females in his life, particularly his older sisters who teased him relentlessly.

One night I was unable to “perform,” just like Bob. This had never happened to me and I freaked out. Fortunately I was seeing Bob under supervision and quickly called the supervising analyst and made an appointment. She heard my story and asked me to relate the details of Bob’s last session. In doing so I remembered that I, too, had a similar experience with women in my past and, obviously, had not completely worked through it. An insight accompanied the memory and my problem was gone as rapidly as it occurred.

The insight and memory had to do with seeing, at the impressionable age of 10, a soiled Kotex at a neighbor’s house. I was told by an older boy who lived there what it was and where the blood came from. In a hushed tone he said, “I got four sisters and they bleed down there all the time” pointing to his crotch. “And that’s the place you’re supposed to put your pecker so they’ll stop bleeding.” This was a most frightening concept to a 10-year-old, and I recalled thinking that where the blood came from was certainly not a place I wanted to put my pecker. I had forgotten this episode in my life until Bob jarred it loose with a similar experience in his childhood. He’d grown up in a household of women and remembered that, “Them rags were all over the place.”

My neurotic reaction to Bob’s story was more dramatic than most, but it illustrates one danger of being a therapist. No one is completely, thoroughly analyzed. He couldn’t live that long. So we are vulnerable to our patients’ problems. Usually they show up as mild malaise, boredom — or fantasizing about becoming a forest ranger. We empathize both consciously and unconsciously with their stories. We can’t help it, we are human. To lessen this danger to ourselves it is important for a therapist to have a therapist, to take regular vacations, and to have shrinks as friends. Being a psychoanalyst can be harmful to your mental health if you are not prepared when your unconscious mind gets zinged by your patients.

When I went into private practice, a psychoanalyst buddy and I took turns seeing each other on a twice-a-month basis. We passed the same $50 bill back and forth, taking turns being doctor and patient. This strategy worked great and kept us grounded.

Being a psychotherapist has many positive aspects, too. He is doing a lot of good and the world will be a little better place because of it. He is also his own boss choosing how, when and where he works. The study of the mind is a relatively new and interesting field and the literature is rich. There are numerous seminars, workshops, and lectures to attend to enhance knowledge and tweak skills. From time to time characters like Albert Ellis emerge with a different take on the subject of mental illness. This famous psychoanalyst, who recently turned 92, once stated: “All human beings are out of their fucking minds — every single one of them.” Some day I’d like to meet that guy. He may have a point. There’s lots of laughs to be had as a psychotherapist.

Another nice aspect to the profession is that colleagues will not take themselves too seriously. They wouldn’t dare because they understand the multiple entanglements and layers of neurotic thought in every mind, including their own. They are, by and large, a neat group to associate with. Most I know are bright, interesting, interested and have self-effacing senses of humor.

I once had a particularly difficult case and shared the dynamics with a colleague while we attended a seminar together. When I saw her some months later she asked how that patient was doing. I was having a bad day and blurted out, “The bastard’s doing better than I am.”

Without hesitation she said, “I hate it when that happens.”

Waynesville resident Jim Joyce’s memoir, Use Eagles if Necessary, is being published in weekly installments in The Smoky Mountain News. Each week we begin a chapter in our print edition and then put the entire chapter on our Web site. All previous chapters are available online. The book can be purchased at rockpublishing.com/eagles.htm, and may be ordered through bookstores after May 31.