The Outcast

“Open the window,” he ordered, getting up from his chair and leaning against the wall.

“Why, Sam? Are you too warm in here?” I asked, confused (it was December).

He didn’t answer. He stood straight, opened his long wool coat, looked at me—and farted. Twice. First, I heard the squeaky, prolonged noise, then—unfortunately, and despite opening the window next to me—I smelled it.

“Why did you do that, Sam?” I asked after a moment.

“What? What’s the problem?”

“What’s the problem with farting in your therapist’s office?”

“Yes, Mr. Therapist, what’s the fucking problem with farting in your office? Would you rather I keep it in? Does that sound ‘empathic’ to you?”

“Well, no, I mean . . . I was just surprised. I didn’t expect that.”

“Do you even listen to yourself? I have gastroenterological problems, for God’s sake! Do you know what that means? Did they teach you that in school, or did they only teach you how to ask stupid, unhelpful questions?”

I met Sam in my internship at a psychiatric clinic in a large hospital in Manhattan. He was a veteran of the clinic—knew all the doctors, the social workers, the administrative staff. “This place sucks,” he warned me early on. “Everyone is up his own ass—we’ll see if that includes you.”

We were assigned to meet for a year for twice-a-week psychotherapy, considered an “intensive” intervention to supplement the numerous medications he took for his symptoms.

Sam was 50 when we met. He was he was single. He identified as bisexual. He was unemployed. He was chronically depressed and suffered from social anxiety.

Very pale, short, and overweight, with a ponytail and an earring in his left ear, he usually appeared in the waiting room sweating and rushing, a few minutes late for his session. He began talking to me immediately, in the hallway, before even entering the room: “I had this dream; I think I have ADHD; is masturbating really that bad?”

Every rule of therapy—spoken or implicit—he tried to break. He pushed for our meetings to be longer than the usual hour. He wanted to meet outside, to take me for coffee. “What’s the big deal?” he protested, when I declined. “I want to feel like I have a boyfriend.”

“A boyfriend?”

“That’s how I felt about Michael, the intern before you. He was so hot—exactly my type. All I thought about was how much I wanted him. But don’t worry, Valery, I don’t want you that way at all.”

Sam would look surprised, sometimes angry, when I suggested in our early sessions that there was something inappropriate, or uncomfortable—for the other person, for me—in his behavior. I didn’t really understand why he was making these gestures. I didn’t even have a good word for them. Apologetically referring to whatever he was doing or saying as “provocative” or “socially inappropriate,” I felt that I was offending him, but couldn’t come up with a more precise, nonjudgmental way to describe his behavior.

As frequently happens in psychotherapy, my confusion and the messy feeling I had—being unsure what it all meant—created awkward, unhelpful dialogues between us. Addressing Sam’s behavior, I didn’t know where I was going, and as a result we repeatedly found ourselves lost.

“What’s wrong with sending you messages on Facebook?” he protested.

“There’s nothing necessarily wrong with that. It’s just that we’d agreed that we’d only communicate by phone.”

“But why do you care?”

“It made me uncomfortable. It felt like . . . you were crossing a line.”

“A line? Maybe you mean ‘boundary?’ A word you psychologists like so much.”

“Maybe, yes. It’s just that sometimes you do things, I think, that make others feel uncomfortable.”

“This is what I don’t like about ‘mental health professionals.’ Everything makes you scared, so you have your little rules and protocols. I just wanted you to understand me better, to save time—the thoughts I put on Facebook are useful to you. But I guess you have a textbook that says, ‘Beware of patients’ attempts to make personal contact outside of the consulting room.’”

“No, no, it’s not the protocols. It’s, well . . . I feel that you’re violating something between us. But, I mean, I don’t know, maybe you were curious about me and wanted to see my profile? See what’s there? Who I am?”

“What?! Are you serious? See who you are? I couldn’t care less about your profile. Seriously, Valery, I’m starting to think that this is your psychological issue and it makes me worried about you.”

Like many other patients I’d met during my training, Sam was considered a chronic mental health patient. For him, it meant that he had difficulty functioning in the world (holding down a job, having a relationship, making friends), and that he’d seen many different therapists and psychiatrists throughout his life, beginning in early adolescence. He couldn’t even remember exactly how many. Maybe 15? Maybe 20? He perceived almost all of them to be incompetent.

Chronic patients are often poor, which means that they can afford treatment only in clinics that are predominantly staffed by trainees. And trainees generally don’t stay very long. What Sam needed was someone who could be with him, work with him for a much longer period, who could experience setbacks, abandonments, insults, and recover from them, survive them—together. Again and again and again, like in any intimate relationship.

But that had never happened. Sam had never had a therapist stay with him for more than a year; usually, they turned over after a few months. So what could I—yet another trainee in this endless chain of therapists—do for him in a year of psychotherapy?

Sam lived close to the hospital—three subway stops away—on savings he accumulated from his various temporary, freelance jobs as an accountant. His days started around noon and were spent playing video games, reading (sci-fi and self-help books), smoking weed, and chatting with people online (mostly other sci-fi enthusiasts). He ordered the things he needed online and rarely left his apartment. Frequently, our sessions were the only time he went out.

The simple, mundane stuff of life presented a challenge. In his lowest moments, even the act of changing his body’s position was too much. Based on what he told me, I had an image of him half-sitting, half-lying on a couch in his apartment, by himself, having an internal dialogue about whether to reach for the remote to change the channel on the TV; whether to get up and pull the book he wanted to read from the shelf; whether to call back the person who left him a message weeks ago—or maybe not, because, “Screw it, I’ll do it later.”

His home was a symbol of a lost struggle against the forces of daily living, and he described it as a post-apocalyptic site: piles of dirty dishes, junk everywhere (old magazines, never-used tech gadgets, boxes, books), stains on the walls, and many, many cans of food.

In our early sessions, I tried to energize Sam. I talked fast, I joked, I projected optimism. I told him that the past doesn’t determine our future, that “even to climb Everest, you need to start by getting out of your tent in the morning,” that we needed to establish realistic goals. I was trying, essentially, to instill hope, to make him believe that something else—that had never been there before—lay ahead.

He took it well, initially. Of course, he agreed, he needed to be more active. Of course it was a good idea to exercise more. And to meditate as well. And, clearly (who could argue?) he needed to smoke/watch TV/play video games/lie on the couch/spend time online/procrastinate on his assignments—less. But how?

As a psychotherapist, there’s always a struggle, a conflict within me—between the active, hyper-optimistic part of my personality and the more passive, reflective, “realistic” part. The active part commands: I don’t care what happened in the past, everyone can change. The reflective part is more modest in its expectations: wait, it protests, but what is possible?

This conflict becomes especially acute when I work with passive patients, like Sam. These patients invoke activity in others. Everyone seems to be urging them to do something: to wake up earlier, to exercise, to lose weight, to ask for a raise—to “do something with your life.” You can almost hear the “voices” in their head. Here are their mothers telling them that every other kid in the neighborhood has already begun studying for the SAT; here are their fathers criticizing them for “doing nothing all day”; here are their college roommates laughing at them for not approaching a cute girl in class; here are their bosses asking them for the report that was due yesterday. And here I was: becoming another voice in Sam’s head. Pushing him—in a hyper-optimistic way—to change, to move.

Following behavioral principles, which I was beginning to warm up to when I met him, Sam and I established a “hierarchy of needs,” identifying both the habits in his life that created mental suffering and the strategies to overcome them. He slept too much, for example, so we created a sleeping schedule. We also agreed on 30-minute blocks in which he’d get out of his house, and we counted and monitored them. The general idea was to create positive momentum in his life, to make him do more things—because when we’re active, we’re less depressed than when we’re passive. It’s as simple as that.

Sam’s provocative gestures subsided over the first few weeks. I became more used to him and, I thought, had bigger concerns regarding his treatment anyway. There was a spirit of cautious optimism in our early discussions about what needed to change, and he accepted the goals we established.

Yet there was one problem. When we talked about it, we were not equal. What I imagined was possible, he thought impossible, even if he didn’t articulate it. What I considered realistic, he perceived as “too much.” Perhaps even more important: in front of him, cheering him on, was a man who was 20 years younger, who was not overweight, who was about to finish his PhD, and had—in Sam’s eyes—an incredible, depression-free life.

Sam really wanted a new haircut when I met him. “Great,” I told him, “it involves going out of the house, so it’s a good idea.” But he couldn’t do it for almost a month. He couldn’t call the technician for his broken air conditioner for more than two months; he wasn’t able, despite wanting it very much and designing all sorts of schemes to approach it, to wash the dishes in the kitchen, so he used disposable dishes instead; he was always late with bills; he never took one of the most important professional exams in his field, despite studying for it several times, and had to settle for significantly lower paying temp jobs. Nothing, ever, was easy.

He was tortured by his chronic inability to accomplish the things he needed to do. He often woke up in the middle of the night in a panic, feeling terrible about another task he’d avoided. This only paralyzed him further. Every time he missed a session—because he couldn’t leave the house—he called me, late at night, and left a message. I’d call him back (he never picked up) and leave a return message. He told me once that he listened to my messages many times over to glean from the tone of my voice whether I was angry with him.

His guilt and shame about his passivity (no one understood better than he did that he was constantly screwing up) strangled me: I wanted to do something about it but was afraid of hurting him.

We entered a boring, futile routine: talking over the things he’d wanted to accomplish during the week and the reasons he wasn’t able to do so. Although the active side of me pushed to continue, to find new strategies to move him, I was gradually realizing that all this talk about goals and achievement wasn’t useful. To change our dynamic and the nature of our work, we needed a major conflict, a blowout—the McDonald’s session.

Among the things Sam wanted to change in his life was his diet. His meals were a collection of canned foods and junk food, with an occasional Chinese takeaway for “special occasions.” Sam’s list of reasons for not eating better included a broken refrigerator, not having enough time between tasks to prepare and eat proper food, American eating habits, and being a “depressive.”

It’s not a written rule, but patients usually don’t eat in sessions. They might finish the last bite of something or sip coffee during the session, but they won’t, generally, eat lunch in a therapist’s office. Although we never talked about it, Sam respected this rule. Until he didn’t.

One day, he appeared with a large bag from McDonald’s. He spread out all of its contents, unwrapped the burger, squeezed mayo in the top of the paper box to dip fries in, and began to consume it all with great gusto. Between a bite of a double cheeseburger and a sip of Diet Coke, he told me about his week, in the most casual manner.

I didn’t know how to react. It was the perfect violation: something that I couldn’t forbid (he’d already brought everything in, so it felt cruel to tell him not to eat it), but nonetheless felt inappropriate.

Sam ate quickly and messily—spilling mayo on his shirt, chewing food while talking, inadvertently spitting some out—and I couldn’t help but feel disgusted. He talked about his chronic stomach pain and needing to spend hours on the toilet (“Why are you eating this junk then?” I thought, frustrated), his trouble structuring time (hence, the hurried fast-food meal), his fatigue (“Don’t eat junk!”), the fact that the dishes were still piled in the kitchen, and so on.

I listened to his list of complaints not only impatiently, but also—despite my best efforts to hide it—angrily. I made insensitive remarks about how we talked so much about change, but how he seemed to be stuck. Then I asked him if he could refrain from eating in the office in the future.

“But why?” he protested.

“I feel it doesn’t go well with therapy” was the best answer I could think of.

I felt unsettled after the session, worried that he might’ve sensed my disgust. I felt that my remarks were harsh and judgmental and even my facial expression, I imagined, disclosed my disapproval of him.

But I also couldn’t help thinking that my reaction, my annoyance with him, was something that Sam had brought on himself. “How can he not see the irony of eating this junk and talking about the changes he wants to make?” I continued thinking after the session. “And how can he not even ask, or think, that it might make me uncomfortable when he spits all this shit around and fills the room with these smells?”

Three days passed before I saw him again. Sam was uncharacteristically silent as we walked from the waiting room to the office, ignoring my greeting. He wouldn’t even look at me. He was seething, I could tell. As we walked, I braced myself for an aggressive session, beginning to feel weak, feeling my hands get soft and my stomach turn, dreading the hour ahead.

Sam’s attack began slowly. It felt methodical, planned.

“I looked you up online. I see you went to school in Jerusalem. Good school?”

“Not bad. It has a nice view of the desert.”

“How long have you been practicing? Do you have any specialization in depression?”

“You seem angry.”

“I didn’t ask you to comment on how I look. I asked whether you have any specialization in depression.”

“I see. I’ve worked with depressed patients in the past, yes.”

“Because I’m not sure that you know what you’re doing here. I had a bad feeling about you from the beginning. But I let it be for a little while, gave you a chance—everyone deserves a chance. But let me tell you something: three strikes and you’re out. And you already have two.”

Whenever a patient attacks me, I always feel the same. On the one hand, I want to preserve my humanity. I avoid being too apologetic; I want the patient, even in the midst of the attack, to acknowledge that there’s a real person in front of him and that whatever has happened doesn’t justify an annihilation of that person (me). On the other hand, I begin to question myself, to criticize. (“Damn. I messed up again.”)

I also try to understand the reasons for the attack, and to acknowledge those reasons. I imagined that Sam was attacking me because he was feeling humiliated: I, the so-called doctor, had looked down on him, judged him. As he was talking, I decided that I should probably address this first.

“I think that I hurt you in our last session and made you feel ashamed about eating here. I was insensitive, and I apologize for that.”

“You clearly don’t have enough experience with depression. You provide a list of ‘shoulds’ but have no idea how to get it done. You change the rules all the time: one day I can eat here, another day it makes you uncomfortable. Get a grip.”

It didn’t end there. He asked me if I had a girlfriend (I was divorced and single at that time), because based on my Facebook profile picture I looked “like an alien.” He informed me that he didn’t find me physically attractive and wondered if anyone could, and that my ideas were “too big and totally unhelpful.” He concluded that I was really just “a robot . . . a giant head with no body.” He insulted me—pushing all the vulnerable buttons, until the fact that it was a psychotherapy session, not a “real” exchange, became irrelevant: I felt like shit.

I thought about that session for a long time after. Recreating the dialogue between us in my mind, trying to remember Sam’s voice, his words, his body language. It was difficult to endure; he really hurt me. He made me feel bad about myself, not only as a therapist, but as a person—I felt weak, unattractive, too nerdy, unable to stand up for myself.

Yet it was also, probably, the most important session we ever had. Sam’s provocative behavior, all of a sudden, made sense: it was a complex way of asserting himself in the world, of protecting himself, of not being abused—even for a moment. He was shocking, he was creepy, he was inappropriate, he was aggressive—he was the alien. But why? Because the world had spit him out and abandoned him in a side ditch, and then laughed. That’s how he felt; that’s why he never stopped kicking and fighting.

There was no way that I wouldn’t become—at least for a moment—another person from that awful world. He saw me as a skinny, salad-eating, running-in-the-morning guy, who had it together, who was happy. What I realized after the session was that, for someone as sensitive as Sam, talking about his flaws, especially with a seemingly normal person like me, was deeply shaming. The McDonald’s session was like him saying to me: “You want to see me at my worst? You want something disgusting? Crumbs spilling, mayonnaise dripping, talking with my mouth full, bad? Here, have it. Sit with it, feel like I do.” And I couldn’t contain it; I couldn’t hold the disgust inside. I couldn’t digest it for him: instead, I’d spit it out and hurt him. And he’d retaliated.

Tolerating this terribly uncomfortable feeling that he creates, I later understood, is what loving him means—and I had been unable to do that.

One of my favorite concepts in psychotherapy is “rupture and repair.” The ruptures are not seen as unfortunate events that therapists need to escape, but rather as the inevitable result of relating to someone deeply. The process of repairing them is how change happens. Following our McDonald’s session, Sam and I began a long process of repair; a process that he’d never had with his family, or with his friends, or with his colleagues, or with most of his therapists, whom he abandoned or who abandoned him.

In the first few weeks after the McDonald’s session, Sam was belligerent, accusatory; at times, insulting. Like small rocks that continue falling after a landslide, his snide remarks stayed with us for a while. But gradually, they became less frequent, less stinging. I felt that we had survived the conflict, that by holding back, by letting him hit me without hitting back, I was able not to become what he expected me to become: a mean asshole, like everyone else.

In the process of repairing our relationship, new sides of Sam began to emerge; or rather, they became more apparent—I was able to see them. He became sweeter, softer. I saw in front of me a geeky, slightly awkward, ruminative guy, who latched with enthusiasm onto any idea, ready to discuss it, dissect it, argue about it. Social change, the LGBTQ community, sci-fi, self-help, psychology, Judaism—everything was interesting, important. The passivity of his external world, his visible life, did not translate to his inner world, alive and bubbling. In me, I think, he began to see a person who would readily—gladly—share the excitement and, perhaps even more important, see him for who he was beneath the layers of provocation, shame, and disgust.

We didn’t abandon the behavioral interventions completely; I still used them, still examined and monitored his daily routines, and pushed for change. But the emphasis, following our conflict, shifted to his deeply flawed interpersonal relationships.

Sam grew up in a small, predominantly Jewish suburb outside Chicago. The stories he told about his childhood were fragmented and consisted, mostly, of instances in which he was hurt and bullied—by family members, friends, neighborhood kids, everyone. I was never able, based on his stories, to create a solid image of his parents. I knew they were middle class, their marriage was deeply unhappy, they treated Sam with a mixture of indifference, neglect, and scolding. When I met him, he’d lost contact with his family, and had only one person whom he considered a friend, although he rarely saw him.

“The world,” he told me once, “is 50 percent predators and 50 percent prey.”

“No wonder you’re walking around with your sword drawn, ready to attack,” I replied.

Our conflict helped me realize just how aggressive the world seemed to him. His attention, his mental energy were devoted—at all times—to assessing danger and assuring safety. To protect himself from the “predators,” Sam developed hypersensitive antennas: he registered every social signal around him and, most often, interpreted it as an attack. He rebuffed human contact so he wouldn’t get hurt. As a result, he felt safer; but he was also completely alone.

He was passive, unmovable, resistant to any stimulation from the outside world. But, notably, there was one area in which Sam’s passivity did not manifest at all: sex.

Very shortly after I’d met him, it became apparent that sex was constantly on his mind. “I’m very shallow,” he once told me. “I’m a lookist.” New York, to him, was the most pleasurable and the most frustrating of places. Here were the attractive people on the subway, the handsome doctors in the hospital, the hot tourists in shorts in the summer. Sam was searching, hunting. Every gathering, every free meditation class, every rally for social change, was seen as a sexual opportunity. He was afraid of the social jungle but lusted over all the creatures in it.

His moves were vulgar, direct, frequently shocking. “I don’t understand what I did wrong,” he’d protest. “I just sent an air kiss to this guy [stranger on the street] and told him, ‘You’re cute, and you’re too cute to be alone.’” Often people would, quite literally, jump away. Sometimes they’d scream at him. His sexual pursuits were aggressive, relentless, but he didn’t really expect to have any success. His main goal in life, he told me, was to “get laid.” It happened rarely (once every few years), but the pursuit never stopped.

In almost every session we had during that year, there was at least one story of an (unsuccessful) attempt to seduce someone. “I’m here to get babes” was how Sam introduced himself to the meditation group that he irregularly attended; “I want to give a straight guy a blow job” was another attempt, in another group.

“What’s the problem with saying that?” he’d protest when I asked him to think of the possible effects of these statements.

“We’re learning a new language, Sam: ‘how to be with others without constantly pushing them away’ language.”

Then, one Tuesday morning, several months into the treatment, he announced: “I’m in love.”

“Oh wow. What happened?” I asked in surprise. Only four days had passed since I last saw him.

Leila happened. He’d met a 22-year-old transgender woman at a local LGBT center on Sunday evening. He seemed so happy. “We had an immediate connection, but we’re also realistic—it’s an open, polyamorous relationship,” he told me. The night they met she came to his apartment, they had sex, and Sam told her that he loved her. The next day, he related, “She took me shopping. I spent $700 on cosmetics for her.”

Leila was homeless and had been clean for eight days when Sam met her. She was a former prostitute who’d attempted suicide several times in the past. He’d known her for two days.

I had a dilemma. I didn’t want to dampen his enthusiasm, to be the “adult” who asks him if he realizes that he spent half his monthly rent on someone he just met. But I was also very concerned for him. I decided that there wasn’t a lot I could do in that session, that he was too high on love to listen to my concerns anyway. “Let’s wait a session or two,” I thought to myself. “He deserves to enjoy this, even if it’s dangerous for him.” So I told him that I was happy that he was happy, but that it also sounded a little fast. I asked him to—please—protect himself and be safe.

He was not concerned at all. His emotions at the time were all that mattered. The boring cognitive process of examining their encounter and Leila’s possible motivations could not have happened then, and I let it be. I didn’t want to become an enemy of his emotions, despite realizing the train-wreck potential of the situation.

Everything unraveled rather quickly.

Sam missed the following session and came a week later. Leila had been hospitalized in a psychiatric hospital during that week, after attempting suicide by overdosing on drugs. He visited her there, but gradually felt more distant. “She doesn’t appreciate anything, doesn’t care about me,” he lamented. They’d had several fights, on the phone and when he’d visited her. She’d hit him, screamed at him, accused him of not loving her.

My notes from that session read: “Going the whole trajectory of a relationship in a week. Wow.”

Leila eventually disappeared. And a deep, terrible depression followed.

Sam didn’t leave the house for three weeks. He called me every few days and left long messages—usually at night. He ate whatever he had at home and ordered the rest online. He watched TV and smoked weed. He slept most of the day, at times for 20 hours straight. He stopped shaving. He never picked up when I called, but eventually he called back and caught me in the office.

“You have to come here, Sam, please,” I told him. “We’ll figure this out, I’ll help you. I promise.”

“What’s the point? I’m done. My life is shit.”

Almost a month after disappearing, he came back. He claimed to not be in the mood to talk, but was certainly in the mood for expressing a hopeless outlook on our work together. “I tend to reach this point with all mental health professionals,” he said. “They really can’t do that much for you, and they know it. I guess it makes them—and you—uncomfortable.”

He was silent for an unusually long time during that session, pensive. As if returning from a retreat, or a long trip abroad, he looked like someone who had reached a certain conclusion about himself. Close to the end of the session, after not saying much, he spoke up.

“One of my earliest memories as a kid is going with my parents to the beach. I had a toy. Another kid took it. I’ve been always picked on. . . . At some point I decided, maybe I can’t fight back, but at least I’ll hold a grudge. It’s self-respect, you understand? It’s either that or I’m a complete victim. Anything I try, I’m the stripped-down thing that always gets abused. I’m so sick of the whole thing. I just want it to stop.”

My eyes burned with tears. I looked at him for a really long time and said nothing.

For weeks we fought his depression. Unshaved and gloomy, Sam would come to sessions to protest again and again, “I have nothing to look forward to. I have no friends, I have no money, I don’t have a family, I’m not having sex, I’m overweight, I don’t have a partner. What do I have? Why should I come here?”

I threw everything I could at him in response. I cursed, I joked, I talked about the future, I was quiet, I was loud, I told “inspirational” stories. Nothing seemed to help.

Sam gradually became worse and expressed suicidal thoughts. I consulted with my supervisors and his psychiatrist at the clinic, and thought about the possibility of hospitalizing him. But he didn’t want to go, and since he didn’t have a “clear plan or intent” to kill himself, we decided against it.

In sessions, his depression removed any traces of his early provocation. It was easier to connect with him, to empathize with him.

“I get on the subway,” he told me one day about his experience coming to the clinic, “and there’s always someone staring at me. I look weird, I know. I always see someone good-looking on the train, but I know I can’t get them. It’s painful to look at attractive people. I get off the train and see stores selling things that I can’t buy. I don’t have a job. I have nothing! Do you understand? Nothing!”

“But you have this. You’re telling me this, right now—we have that. Isn’t it something?”

Despite his intense depression, Sam kept coming. The atmosphere in our sessions became, perhaps paradoxically, lighter—he was depressed and dark, but our relationship became better; I felt suddenly freer.

Initially, when I’d first met Sam, I was afraid of making mistakes. I was constantly on my toes—anticipating an attack, a retaliation. But his depression exhausted him. Like a tired boxer at the end of a fight, he leaned on me, accepting that it was over. Or maybe: instead of his opponent, I became the person in his corner, rooting for him, as he mustered whatever he had left for another round with his nasty depression.

He wasn’t “creepy” anymore; he wasn’t “provocative.” He frequently made me laugh, and I think I made him laugh, too. Our sessions became what good psychotherapy sessions should be: something to look forward to. Sitting with him one day I recall thinking, “Forget about the big stuff, like love or career—he never even had the average, regular stuff, like a vacation with a girlfriend, or a birthday party as an adult.” I’d experienced those things; most people have. Sam had not.

In the midst of his depressive episode, we clung to one hopeful prospect. Sam came up with an idea: to rent out one of his bedrooms through Airbnb to earn some money. For months, he went back and forth about this idea, unable to pursue it, mostly because he couldn’t clean his apartment and get it ready. He struggled that winter. He was, quite literally, running out of reasons to wake up. But he kept showing up, and after a few months, a shift occurred.

I don’t know why. We could posit words like cognitive restructuring or internalization. We could cite someone, or present a theory. But maybe it was just time that passed and the winter finally ended. Maybe it was the inevitable ups and downs, the yo-yo nature of our moods. Or maybe (I so hope it’s true) our work had something to do with it. Maybe some of the interventions were helpful. Maybe I understood something about him, and he felt it, and it helped a little. Maybe he felt that I was concerned for him, or that I really liked him, as a person, and that helped.

Whatever the cause, Sam became a little better. One of the main signs of his improvement was his renewed dedication to the Airbnb project. Little by little—he moved a box, he took a photo of the room—he returned to it. Eventually, he put up an ad.

Celebrating together, in one of my favorite sessions with him, we looked at the ad that he published online. He wanted my advice on it.

“Oh, the room looks sunny! Nice view,” I exclaimed enthusiastically. I’d imagined a much gloomier place.

“Yeah, it’s not that bad, I guess.”

He talked about his excitement, thinking of his potential guests. Thinking, of course, about sex. Alarmed, I cautioned him against that.

“Is telling her [the guest] that I find her attractive too much?”

“Yes! You will creep her out. Don’t do it.”

“Okay. I won’t.”

To our surprise and delight, people began booking the room. Guests began to arrive. I constantly worried, “Will he do something inappropriate? Scare them?” But week after week, guest after guest—the Midwestern couple, the guy who rented the room to bring a date (not as bad as it sounds), the French exchange student—Sam was fine. They stayed, they paid, and he survived. It became a significant source of income, but maybe even more important, a project that he was able to complete successfully and a source of regular social interaction.

“This is huge, Sam, really. You did it and it’s amazing,” I kept telling him, encouraging him, cheering him on. Even—feeling proud of him.

“Okay, chill with your sweetness, grandma. It’s no big deal.”

But it was. It was a sign of progress and a small victory for the forces of life battling his depressive hopelessness.

Sam and I became close. He wanted me to come with him to meet the leaders of a psychotherapy group that I’d suggested he join. And to other routine meetings: with his psychiatrist, the social worker in the clinic. I accompanied him a few times, observing him acting awkward and not knowing what to say about the forms he was supposed to fill out or his insurance details. In these meetings, we’d look at each other with what seemed like an implicit understanding; it felt like we were coconspirators against the bureaucracy and unfairness of the world—and, I think, he stopped seeing me as part of it.

We were approaching the end of my year at the clinic. Anticipating my upcoming departure, and to the satisfaction of his psychiatrist and his social worker, he agreed to begin attending that psychotherapy group I’d suggested. It was the first time in his career in our clinic that he’d agreed to do so. (As I write this, he’s still there.)

Over the course of our year together, I could observe a change in our relationship. It was easier to be with each other; we learned how to like each other. Other changes in his life, outside the therapy room, were more difficult to observe: he joined a group, rented his room on Airbnb, and eventually got a haircut.

But was that enough for a year? Was that enough to count as change in psychotherapy with a chronic patient?

Sam began our last session with a jokey comment: “Okay, I see that you’re pregnant with the fact that it is our last session. Come on, get it out.”

We talked about the year together, and about how he’d become less provocative. “Please, Sam,” I said, “try to maintain that. You’re so wonderful when you’re not hurting others.”

Several months after we’d finished, his next therapist, an intern from the clinic, called me. “How’s he doing?” I asked. “Is he giving you a hard time?”

“Based on what I read in your discharge summary,” he told me, “he seems to have mellowed out. He’s pretty cool now; he’s nice.”

Before we ended our last session, I told Sam that I was going home in a few days, to Israel. And when I go home, I share a ritual with my father. We drive to the desert, early in the morning, and climb a mountain that overlooks the Dead Sea. My father brings bread and onions and salami. When we arrive at the top of the mountain, we have lunch and look at the sea below and talk. “Whatever happens in my life, wherever I am, the desert is there,” I told Sam. “And that is a lot.”

I think that he liked the story. He responded with his own.

When Sam was in college he used to drive by himself to a beach on Long Island. He liked that beach because it was deserted: “No sign of humanity.” And, he told me, you could reach a point where all you were able to see was the ocean and the sand; no houses, not even trees.

“One day I got there, I think it was October or November, and it was really cold. I got out of the car and there was no one around. I don’t know why, but I began running and screaming—‘No one can hear me! I’m here alone! It’s just me!’ As I ran, I felt something falling on me. ‘Damn,’ I realized, ‘snowflakes!’ Snowflakes in November—can you imagine? How great is that?”