Letter from the Editor

The world pulses though open windows, joining us in the room: cars whooshing by, changes in temperature, snippets of street conversations, birdsong, and sometimes the smell of roasting coffee. When a patient and I pause together as a loud siren passes by — waiting, still looking at each other, mid-sentence, timing when we can pick up again — we are communing in a different way.

The pandemic has been isolating in many respects, but gone is the illusion that the treatment frame is bracketed outside the ongoingness of the world. And this reminds me how clinical work takes place within contexts and systems that I am only intermittently aware of. In the medical field, a literature on paternalism details how physicians can make decisions based on what they consider to be the patient's best interests while disregarding the patient's autonomy. This is clearly an overreaching of authority, but what less obvious effects of an imbalance of power and control are hidden in our work? I assume most people agree that the convention of speaking (and thinking) about patients in the language of deficits and diagnoses markedly biases the treatment relationship. Less obvious is the language of caregiving (feeling “protective” of patients, wanting to help “fix” things) as a more subtle form of paternalism.

While caregiving may not overtly exploit a patient's freedom to live his or her own life, mistakes and all, it can increase interpersonal distance from the patient: e.g., the other needs my help and I am the helper (who doesn't need help). These imbalances of power are not so straightforward because we also feel deeply for our patients — and this very real tension between the authority of the knowing therapist who simultaneously experiences feelings of affinity and compassion for the patient never gets fully resolved. In fact, it seems to me that much of the work gets done in the space where this tension exists.

A man with a strong Northern European accent presents with enough distress to