Change is the most natural occurrence – change means something’s alive. Without change, there’s no adaption, without adaption there’s no survival. It’s one of the most basic principles from the levels of single-cell organisms like the bubble algae that looks like a weird, seedless grape, to the most ‘complex’ as we understand – a case can be made for humans to be considered the most ‘evolved’ species, but we shouldn’t count out others. Dolphins, for example, have a much more sophisticated emotional brains than we do. Or we could take birds – all species have significantly more neurons in their brains ounce for ounce than any mammal does, including humans.
Biologically speaking, we define ‘being alive’ by seven characteristics, environmental responses and growth among them. NASA defines life as a self-sustaining chemical system capable of Darwinian evolution – change, in other words. Yet humans have been hardwired by the same evolution to naturally be wary of change, since new environmental aspects mean the outcomes of our actions are unknown. With change, we no longer have a basis on which we could make quick decisions, the one thing that arguably made humans capable of oppressing other species.
Even in modern societies where most of us don’t have to be on the constant lookout for predators, or at least not in the way we used to need to, we find peace in the familiar. It’s this loss of peace that makes it a lot harder for older generations to adapt to the fast-evolving world around them. I wouldn’t personally consider myself ‘old’, but I do understand the differences I have to my children, for example. Even though I know they are their own person that happen to share a lot of DNA with me, it sometimes amazes me how different they are and always will be. Human brains may prefer predictable scenarios but it’s also very flexible, especially when it’s still forming. Children today are born to be fast to adapt, to take in many-many information and impulses at once rather than focus long and hard on a single task. As a parent, that does present its challenges at times, it’s never been more important to keep checking in with the newest researches about how to raise them best.
It no longer amazes me when my second graders can go bam-bam-bamm and finetune the smart functions on the refrigerator in ten seconds. They could find Fruit Ninja on the iPad when they couldn’t even speak properly and both of them beat my record.
Turns out though, when I see a girl and a boy, seemingly in their early twenties at best, doing this synchronized dance in the middle of the gym facing their phone, all this ‘I understand that’ shit goes out the window and I end up shaking my head in disbelief. I only realize that my staring could be interpreted very badly when the girl gives me a look and I decide I’ve ran enough on the treadmill even though I still had a few miles left.
That’s how I ended up a good half an hour early to my office for the afternoon sessions. I usually do three to nine on these days, since I only deal with adults and virtually none of them can make it earlier than that. I have a few consultations lined up, regular check-ins and two sessions, making it eight patients all in all.
I expected none of them to have arrived already, so my eyebrows shoot up when I see someone sitting in the waiting lounge. I’m sure she’s there for me; the other two colleagues sharing this space are consulting in White Plains today.
“Your three-o-clock,”Lucy chirps in her usual bubbly manner.
“The first consultation?” I keep my voice decently low, so the woman doesn’t feel like she’s being talked about. The TV in the corner gives a constant background noise, luckily.
“Yes. She’s been here for ten minutes. Also, Miss Ling called…” Lucy pushes today’s mails towards me as she catches me up on a few things; a quarterly magazine subscription, a bill notification, some correspondence and a small box. I usually get my orders here, where someone’s bound to sign for them. I leave it with her for now, though, sign off on the bills and turn towards my office.
“Shayana Weaver, if I’m correct…?” I smile at her as I look for the right key on the chain. “I’m Samuel Zimmerman, nice to meet you.” I’ve had a shower at the gym, I can still feel a few wandering drops of water sitting in the hairs at my nape. Showing shirts and slacks into a gym bag without them creasing once you wear them is an underappreciated form of art – and looking unprofessional is something I can’t allow myself easily. “Nice to meet you, how are you…? Has Lucy offered you coffee yet or would you like to have some beforehand?” She usually only shoots up the coffee maker once I’m in. She says I’m particular about having fresh coffee, which I don’t agree with, but based on ‘mug science’ – meaning she says I keep leaving a slurp worth of coffee on the bottom whenever it’s not fresh, she says I’m particular and I’ve learnt not to argue with people who make my coffee.
I open up the office and once I’ve stepped inside, I also step aside, holding the door open. “We can start early if you’d like. First consultations can be lengthy due the evaluation, so it might be better that way.” It’s not uncommon for me to arrive earlier but having a patient already waiting for me has virtually never happened. Usually, I need to read up on my notes before each person but since this is her first time here, there’s nothing to read up on. “You’re welcome to sit anywhere you feel comfortable,” I motion towards the couch and the chairs, closing the door behind her. “What we do here usually for the first time is getting to know you, your medical history, any and all concerns you might have. I… Have a list of topics I’d like to ask about.” I whip out my iPad and take a seat opposite her. “They are here to make sure we don’t miss anything but you’re always free to not answer if you’d prefer. After we’ve gone through them, we’ll see whether we have enough for a treatment plan that may be necessary for your concerns or if we need to go further. Do you have anything you’d like to ask first?”

Most people who come to these outpatient sessions are high-functioning; they may have heavy emotional turmoils they are trying to work through or they might have certain conditions linked to mental problems but generally, they look like everyone else. I know that some therapists, psychiatrists and psychologist, sleep technicians and counselors alike, like to ask a few questions upfront, partially to make sure it’s ‘worth their time’, partially to know what to expect. I only ever ask Lucy to make sure they know they’re coming to the right place – people wouldn’t believe how hard she has to try to convince certain moms that I can’t deal with children since I do not specialize in neither pediatric or adolescence psychiatry –, and let the first impression work naturally.
She seems very collected up to the point where I’m sure it has to be conscious. She might be trying to cover her nerves this way, most people don’t like going to any doctors, much less psychiatrists. Even with all the work we’ve done in the past decades, there’s a fair amount of people who still shame and belittle the importance of mental health. That’s something crazies do. She also has a slight accent to her voice that makes me feel like English might not be her native language or she grew up around people whose weren’t. My grandfather, for instance, was born in the States, but since his parents were immigrants who came from Germany in the ‘20s and he grew up in a tight-knit German community in Wisconsin where they still often spoke German up to the war, he had a sharp accent until his death. This is further confirmed when she doesn’t say ‘how are you?’ back like it’s usually customary here. Or she might have just spent too much time here in New York City. Not that it matters, not yet, although there are certain difficulties that might arise when you consult with people from different backgrounds. Heavily religious people, for example, are usually better off with a doctor who shares their views. I respect religions – but also think, personally, that all institutionalized religions are scams.
She looks around the office which isn’t unusual, per say, but she seems to be looking for something. Her expression doesn’t tell me whether she finds what she was looking for or not.
“Alright, it’s good to know,” I nod upon her confession. She makes it feel like it’s a confession. “There’s no right or wrong way of doing this so you shouldn’t worry about experience.” Sometimes I find it’s better to not have any; although there are certain guidelines, since it is a medical profession, every therapist differs to others in one way or another. Sometimes it doesn’t matter but other times they can leave certain expectations or practices behind that also take time to change. People who come from other professionals are often more critical since they have had at least some form of bad experience caused by a therapist. Otherwise they wouldn’t be looking for another.  “I happen to have enough for the both of us.”
I’m not wearing a tie nor moccasins, certainly not a white lab coat, and I don’t ask patients to lie on the sofa and tell me about their mother while I humm and take notes. Although there should be a clear boundary in place when dealing with a patient, I prefer to keep the connection not squeaky clean and sterile like an operating room. This might be a medical practice but people are not meant to be clinical. That’s not how trust is built, and when you ask someone else to tell you about their deepest fears or problems, you need as much trust as you can. Different patients need different approaches so the first time is just as new for me as it is for them. I need to catch onto whatever they find comfortable and build on that later on.
When she says ‘statement’, my eyebrows shoot up into an interested arc. I’m listening to her while my eyes jump to her hands. The way she delays forming certain words suggests she’s either unsure whether they embody what she means or she’s trying to hold back. She’s being pretty vague and soft-spoken, her eyes search mine for some type of confirmation, hesitating. She’s not the first person to tell me things like these, and certainly not the last. On one hand, most people think whatever is ‘the problem with them’ is something others won’t really understand; on the other hand, some people simply have the wildest backgrounds.
“Well, as you might know, these sessions are confidential. I can’t and won’t reveal what transpires here, even if someone were to confess a crime they’ve committed. The only exception is if I have reasonable suspicion that somebody poses an active threat to themselves or other people, where I have the legal duty to report it.” A slight, apologetic smile forms on my face as I add, “I hope you understand I couldn’t exactly take ‘the police knows about it already’ as an explanation if I were to ever be in a situation to report something. After all, you weren’t referred to me through official channels. If they already know about it, however, you have nothing to worry about.”
Her collectedness could come from a military or law enforcing background. I had a few of them come to me for seemingly unrelated cases; insomnia, depression, anxiety. It’s not always PTSD, usually it’s simply a stressful, high-paced, hard job, a series of concussions, or even hormonal imbalance where their job has nothing to do with it. I understand why they might think that what they say and how they say it might seem alerting to civilians. A lot of them develop harmful coping mechanisms to avoid getting hurt.
“I’m grateful for you sharing your concerns about this. If it’s alright with you, I’d like to suggest we continue on regardless.”
I’m not sure whether what she has to say would truly be concerning, but it doesn’t matter right now.
“If you’d like to talk on your own or if you have a certain topic in mind you’d like to start with, you’re certainly welcome,” I nod along, opening up my notes on the side. “One of the most important aspects of a first appointment is assessing, on both of our ends. It’s important to know that we share a goal, which is making sure that in the long run, we’re able to manage whatever concerns might have led you here. When it comes to psychotherapy, or talk therapy, it’s also important for you to know that you have a right to choose. Sometimes one professional’s method is not fit for you, while another’s is. So you should also be evaluating me too, in that regard. Whether or not you think you can work with me.” Just like she did before, I leave time for some kind of confirmation from her part. I need to make absolutely sure she’s aware of her choices. “I also need to make sure I’m able to give you the best care possible. That’s why we have the questions. First thing would be getting to the starting point. Could you tell me why you feel the need for treatment?”

One of the hardest challenges of dealing with people as a medical professional I’ve found, is that sooner or later you need to accept: some of them lie. Some lie to ‘save face’, some to make them seem more whatever they think they should be, some lie so ‘they won’t make me angry’, all explanations I’ve hard throughout my practice both in outpatient and inpatient settings. Most importantly though, some lie because they don’t know they are lying; because they truly believe that whatever they are saying is reality. And that’s the hard point. I’m not here to play detective, it doesn’t matter to me if someone lies about something such as their marital status, their job, their background, as long as it doesn’t stand in the way of progress. Even when it does, it shouldn’t matter. Being lied to feels bad at first, but then you learn to not take it personally, like you shouldn’t, ever. Being lied to becomes part of the job, just one of the ways the client interacts with the world. It doesn’t really matter what they lie about as long a we can get to why, when relevant.
I don’t even really like calling it a ‘lie’, that carries an unwritten connotation of judgement. Understanding their lookout on life is important in evaluation and psychotherapy as well. I’m not saying she lied about the law enforcement’s involvement in anything; she definitely seemed a bit wary when I didn’t outright say: sure, I won’t tell anyone. She must have anticipated as much, though. Straightforwardness is one way to put it;I’d call it honest. I’m down for a lot of new wave psychological practices but I’ve always abhorred the overcaution of some. I understand the importance and effect of feeling statements, and reinforcement works better than punishment; other areas of ‘positive psychology’, however, lead to this grotesque, forced happiness-narrative a lot of Americans seem to practice. At the end of the day, I’m a doctor, and rely on empirical evidence – which seems to show that honesty is better than sugarcoating.
Her short answer doesn’t give away much; I’m still not sure whether her concept of her being a ‘dangerous individual’ (at least that’s what she seems to allude to) is grounded in reality or not, so I just nod, as a sign of understanding.
“We have time,” I offer her a small smile that slowly melts away. I always try to seem attentive but neutral. One time, I had a patient who’d tell the funniest stories with a punchline at the end, guy was a walking dadjoke book; I always laughed. One time, he blew up at me about how he’s ‘glad he’s entertaining me’. Turned out, he used stories like this to placate his father who was otherwise cold and uncaring towards him. We worked through it, but it was sobering.
So I was right about her being born somewhere else. I do know about the military service, though, as one of my cousins married a Jewish guy with family there. Her collected yet on-edge stature is easily explained by that part, then. She mentions the death of her parents which I make a quick note of in my head, I’ll jot it down later as I don’t want to make her feel like I’m not listening. She doesn’t seem too concerned about it, maybe because it happened so long ago. Liking the military life for the feeling of belonging is also highly usual for servicemen. There’s a reason military and other armed forces all around the world have an easy time recruiting from certain social groups.
The other half is the less usual and less easily digested part. She’s telling about being secret service in a monotone tone, without hesitation. It might mean that it’s mostly made up, a scene she’s rehearsed to come off easy. It might also mean she spent a lot of time thinking about it. Or that I’m not the first person she’s had to sum it all up to. She stops here and there, but her speech seems coherent and pointed. Most of the time even when people lie, the basics are true – she talks about vengeance, which is more likely than not a feeling she’s had. She also talked about it in past tense.
“Is that why you’re unsure whether or not you might become someone others might deem as “threat to themselves or others’?” I’m trying not to throw out the stereotypical curveball of ‘what do YOU think about it?’, but I obviously can’t answer, either. “I can’t answer that rhetorical question, since it’s not up to me to decide who you are. We can certainly seek out ways to strengthen your sense of self if you feel it’s something you struggle with.”
I’m not caught up on the part where she says she’s killed people since she’s not the first to tell me that. She’s also not the first to confess to being apathetic towards that fact. “Most of the time hardening yourself to traumatic experiences, such as hurting others, is a simple conscious strategy, a way coping; the same way you have a fever when you have an infection, your body and mind is trying to fight for your well-being, to reduce the harmful impact of unpleasant emotions. Vengeance, similarly, is a way of dealing with being wronged, something evolved from what the scientifical word calls ‘retaliatory aggression’. It’s found in many species, but we took it up a few notch. What any of that makes you by themselves is human.” I shuffle around a bit, as my position is getting too static. “I’d also like to note that there should be a clear difference between the past and the present. Who one was does not conclude who they are now; capability doesn’t mean intent. You talked about these feelings in the past tense. Do you still feel like they are present now?”

She seems slightly taken aback by my words, missing components of guilt or anger – I suppose most people she tells these things don’t quite react this way, or at least she thinks they wouldn’t. My educated guess is, as military personnel, even if you’ve ‘retired’, when you’re about to get into an unfamiliar situation, you make up scenarios to best prepare for each of them. Maybe her eyeing up the details of my office weren’t of curious nature but of caution, anxiousness even.
I lean my head slightly to the side; it’s definitely a conscious, professional decision, and not the sign of me being too old to just ‘fall asleep’ on ‘couches’ whenever I feel too lazy to get up. She really does seem like an interesting case – not really a ‘case’, rather a person, without the subjective undertone of the word. I haven’t noticed the wedding ring before, but her anxious tinkering draws my attention to it. Why some parts of her private life aren’t mine to know about, it’s important to know how much of a support system she has. A significant other is usually a good start; it seems relatively new, too, which would be logical, considering how she said she was part of this… organization until a few years ago.
She speaks and I take mental notes, not wanting to interrupt her. Talking freely and on her own accord is important, if not the most important. You can be aware of something, but saying it out loud or even writing it down helps you solidify them. They aren’t a mystical concept anymore, they are out there, crystal clear. It also helps in processing your feelings – and no one can process for another person. While some people feel like therapy isn’t worth it because they are talking on their own for a shitton of money and they could be doing that at home for free, it’s crucial to the healing process. A therapist isn’t actually there to talk with you, not like in a normal conversation. With psychotherapy, it’s more like… Guidance.  
I nod when she says she knows what’s it like to feel like someone’s more important than yourself. I can’t say I ever really had that with my wife – and it sounds like she’s referring to her significant other – but it’s a feeling you can never shake once you have kids. I’m not saying it happens for everyone, some just can’t be bothered, but supposing it’s a healthy relationship, there’s no two ways about it.  
“I understand where you’re coming from. The fear of losing or seeing loved ones hurt is in a way threatening our own existence, so the desire to protect them is just as important as self-preservation.” I’m not about to tell her I have children, if she wants, she can look around and find a few indications scattered around the office. This isn’t about me or my situation; validating her feelings, however, is part of the session. “Aggressive feelings aren’t unhealthy – there are no inherently unhealthy feelings, despite what most of us have grown up learning. They can become unhealthy if we learn to attend to the needs they suggest in a harmful way. Aggressing, being hostile or malicious are examples of unsafe ways of responding to our own internal aggression, often stemming from suppression. Your desire to protect the one you love can manifest in ways that would be benefitting for you and by proxy your relationship as well. You seemed to have answered a question you’ve probably asked yourself: how far would you go for that person? In order to make sure your next decisions are as beneficial as they can be – and I’m sensing that’s your goal – understanding where such response comes from, why you feel the need for that reaction, is more important.”
Like I said: I’m not a hundred percent sure if what she says about her background is a hundred percent sure, and I don’t need to be. Assessing her boundaries, needs and state is more significant.
“You also said ‘remorse’. That you don’t feel it, and I’d like to differ. ‘Remorse’ means you’re admitting your mistake, take responsibility for your action, and moves you to avoid taking part of the hurtful action. I’m sensing all three,” I open my palms up for a moment, in lieu of shrugging which would be too disinterested of a move. “What you might mean is regret – wishing you hadn’t done something, because it hurt someone else or it hurt you, cost you, lead to something you find undesirable. It also puts blame on yourself for the bad outcome and wishing you could undo it. If you take out the sense of free will, meaning you had no other choice – that can easily take the edge of regret off to the point of non-existence.”
Sometimes it’s simply a matter of culture. Here, most of our teachings lead to the individualist culture. Everything’s up to you. In more collectivist cultures, such as in the Middle East where your family, your country, even your workplace has a bearing on your life choices, sharing the blame is easier, too.
“Do you think that your desire to protect this person manifests in a way you’d like to change? In your daily life or specific situations.”