“Dr. Gary wrote me a prescription I keep on the door of my Frigidaire: You must get dressed every day and leave …” Sharon lost the end of the sentence to her tears. As she cried, I silently offered her a tissue. It was the first lesson I learned about therapy from my first patient: you will need tissues.

During psychiatry residency, I learned to carry tissues the way other doctors carry a stethoscope. Everywhere I went, a hospital-issued supply of tissues stayed in the pocket of my white coat. A cardboard box, sealed for sanitation, with a perforated top. As I ducked into some windowless hospital room to sit down in the chair next to a patient on the couch, I would pat the coat to ensure it was in its place. Never for long. A second, a minute, or a half-hour into a therapy session, I would remove the box and punch my thumb down along its perforation to release a supply of single-ply tissues.

There were always tears, but the people I met as patients came to therapy with varied needs. Some needed a listening ear, others a directive word. Over four years, I learned to accompany patients in a variety of theoretical ways – cognitive, behavioral, experiential, psychodynamic – while learning how to listen therapeutically.

Doing so taught me the second lesson: to work with a patient we must form a working alliance. Sometimes people imagine a therapist as a friend who always has their backs, or an advocate hired to pursue their desires. The faculty told me to think of myself as an ally. When I asked how you know someone is ready for therapy, an older faculty member told me a joke: How many psychiatrists does it take to change a light bulb? One, but the light bulb must want to change.

Therapists are not friends or advocates, but people who form alliances to help patients make changes they cannot make on their own. Together, we identify a goal – whether to lift a depression, quit a habit, or grieve a loss – which can feel insurmountable. We develop a set of tasks to advance toward that goal. The tasks can feel clinical – walk daily, pour a glass of water when you want a beer, share a memory of a lost loved one – so we develop an emotional bond that humanizes the relationship by offering an encouraging welcome, a nonjudgmental instruction, or a settling reflection fitting to the clinical moment.

Goal, task, bond. The goal is the why of the therapy, the desired health outcome. The task is the what of therapy, the health-seeking activities. The bond is the how of therapy, the emotional relationship. Therapy works only when this therapeutic alliance forms between patient and clinician. The therapist to stick with is the one with whom you experience an alliance. There’s a mystery to why it works, but it’s less like making a friend or securing an advocate, and more like working with a teacher or coach. A person who stays in the room, through tears and silences, is one you can trust.

The woman I’m calling Sharon was old enough to be one of my aunts. In her early fifties, she had gray hair styled in a loose bob, which often held her bifocals when she pushed them up so she could dab her eyes. She cried over an unresolved conflict with her sister, over the health of a son addicted to heroin, and over the poor match she had accepted in marriage. She had worked thirty years in a textile mill, moving from the line to the office, but had gone out on disability for breathing problems. When she was hospitalized after a suicide attempt, a faculty member saw her, heard her story, and took out his prescription pad.

Dress every day. Leave the house.

He also wrote a referral to the resident psychiatry clinic. Two weeks later, when I saw Sharon, I confirmed Dr. Gary’s diagnosis of major depression and renewed her antidepressant. I told her I would see her back in two months to check on the medication. She fidgeted, then said, “I’m lonely. I don’t know if it can be fixed or not. I guess I’ll just have to take medications.”

I asked why she wanted more than medications.

“God says he won’t put more on you than you can bear, but I know you can lose your mind worrying yourself to death. I would like to know how to bear my worries. I can’t breathe with all I’ve had to bear.”

We began meeting weekly for psychotherapy in the resident clinic. A couch, a chair, both in neutral colors. An inoffensive landscape on the wall. And, always, tissues.

Some weeks, it was the only place she left the house to visit.

Sharon was experiencing the symptoms of what used to go by the fitting name of melancholia; now we call it a major depressive episode. Medications like the antidepressant Dr. Gary started can reduce or even extinguish those symptoms, but a successful course of therapy can be a way to figure out what the symptoms mean. The kind of meaning depends upon the psychotherapy, but the psychiatrist Jerome Frank discerned that therapies with different explanatory models induce similar outcomes for patients. In his classic Persuasion and Healing, Frank concludes that this is because therapies have more in common than what distinguishes them from each other. All successful forms of therapy, Frank finds, identify a socially sanctioned healer (symbolized by the MD behind my name), a demoralized sufferer (the light bulb who wants to change), and a ritualized relationship (we meet only in bland clinic rooms at set times for a psychoanalytic hour). A therapist, Frank writes, must identify a theory (“you struggle to breathe because you feel smothered by unresolved conflict with your father which you unwittingly repeat with your husband”), have appropriate confidence in the theory (“you can get better if we meet weekly for a two-year course of psychotherapy”), stimulate emotions to transform the meaning of a significant event (“after all those tears, you can forgive yourself”), and foster appropriate hope (“you can leave the house, step out into the world, and make new friends”).

I saw Sharon for psychotherapy because she wanted to talk about her past and how it affected her present response to stress. Like Sharon, most people begin therapy after identifying a problem in the way they respond to stressful events. All of us experience what Sharon called the worries she had to bear, the burdens and stresses of life. Each of us responds in characteristic ways to these stresses. In a traffic jam, some people offer justifications (“there wouldn’t be traffic if other people drove right”) or denial (“this can’t be happening again”), while others display relationship conflicts (“you always pick the wrong route”), remember previous adverse experiences (“this reminds me of the accident I was in”), or return to unhealthy habits (“I need another cigarette to ride this out”).

While any therapy that meets Frank’s criteria can be helpful, a cognitive psychotherapist targeting justifications can help identify and correct negative thoughts. When a patient is ready to think about how she repeats the same patterns in relationships, a psychoanalyst can address unconscious conflicts. When a patient wants to overcome past adverse experiences, an experiential therapist can offer exposure therapy or psychodrama. When a patient wants to change habits, a behavioral therapist can change observable behaviors through teaching relaxation training, progressive muscle relaxation, rebreathing, and other behavior modification techniques.

Sharon had suffered many harms in her husband’s home and, before that, in her father’s home. She told me, “In all my relationships, there was never anything for me. Now when I get something, I hide it.” She mentioned the few nice things that came her way: dresses that flattered, foods that delighted, and our therapy sessions that unburdened her. “I need this time for myself, but if my family knew, they would think I was crazy.”

Far from crazy, Sharon needed someone to say what many people in her small town knew but never said to her face. In high school, she met her future husband. She was a student, he was a teacher. When she was pregnant with their second child, he mocked her before the other students only to drive her to their shared home afterward. She never really stepped outside her husband’s shadow until she attempted suicide with a handful of medications three decades later.

Sharon taught me the third lesson I learned in therapy: there will be secrets. People carry secrets like rocks in their shoes, walking on them until they can no longer endure the feeling. They stop carrying their secrets alone only when they find a place where they can empty the rocks out in front of someone else.

Sharon told me many secrets before finally describing her father. Christmas Eve: a bottle, then another. “He tore down the tree, wrecked the house, and tore up the hardwood floors Mother had waxed for the holidays. Daddy allowed alcohol to mess up Christmas. Mother called her own father. They walked into the woods together. They found a tree. We decorated it and had Christmas Eve in the woods. On Christmas Day, Mother talked to Daddy about the night before. He told her, ‘The one who accuses is the guilty one.’” Sharon became the one who carried the guilt forward for decades and into her own family, until she emptied those rocks out at my office.

Week after week, she taught me. The fourth lesson I learned from her is that if you can listen to someone well, she will generally do her part. Over the next two years, Sharon committed to walking daily and leaving the house, first to the mailbox, then to the end of the block, and then to the park. Soon after that, she declared herself ready to leave therapy, telling me, “I’m not putting anything off anymore, not sitting around and waiting to die anymore. I’m gonna live.”

Recently, I was thinking about Sharon. I learned more from her therapy than she ever did from me. Deep within a locked cabinet in my office, I still have the lined notebooks from our therapy sessions. I wrote her words down inside quotation marks and fenced my observations behind brackets. Reading them now, I can see how little I knew at the time, how hard it was to understand another person, and how I defended myself intellectually from the mystery of what was happening for Sharon in that room. The only thing I did right was approaching understanding through Sharon’s trust.

As I read the notes years later, Sharon now teaches me a fifth lesson of therapy: there will be limits. I was taught to keep boundaries. Never abandon a patient. Never abandon ethical principles. I am grateful for those limits and how they bracketed our relationship to focus on her health. Other limits seem too strict to me today, especially those that caused me to miss the chance Sharon offered to reflect on what God says about what you can bear. Throughout our therapy notes, I recorded Sharon talking about her husband’s atheism, her children’s wandering faith, and her mother’s steadfast belief. Sharon was raised a Baptist but was registered in a local Methodist church. She attended only occasionally, often staying home to watch a televangelist instead. I wish I had helped her experience God’s ability to bear our burdens as an active member of her faith community.

Two decades later, after a pandemic of loneliness was declared in 2024 by the US surgeon general, church attendance has declined, and society has become ever more polarized and individualistic, I regret that limit. If a therapist is an ally, coach, or teacher who helps you walk somewhere you cannot imagine having the strength to go, I should have encouraged Sharon to leave her house and head to church, just as Dr. Gary encouraged her to go to therapy. A therapist can offer new ways to think, to behave, to remember, but it’s immanent work. At its worst, therapy can make a patient believe she is the protagonist of her life, and the therapist its author. A life is so expansive, no person can be its protagonist. A life is so surprising, no therapist can be its author. Neither patient nor therapist can even be the true narrator of a life. To experience grace and mercy, she needed something more than I could offer. If I saw her today, I would tell her about the limits of therapy.

In The Theological Imagination, Judith Wolfe suggests that poetry

is as important as therapy: it brings to consciousness the work of inhabiting our interpreted world and exercises the skills to perform it. Unlike some forms of therapy, poetry does not do so by trying to eliminate the risk of deception, delusion, and error, because this would be a false security. We are human; there’s no cure for that. Rather, poets … tell us that such risk is intrinsic to our lives on earth, where we are never fully or merely at home; and they give us the courage to bear and engage it creatively.

In her way, Wolfe names the limit I wish I had shared with Sharon. There is no cure for being human, not even therapy. Part of why you need to leave the house every day is because we are never fully at home on this earth. Sharon, like me, needed something beyond therapy to fully shift her perception. We all need a mercy beyond the ability of an ally, coach, or teacher, something beyond the limits of our imaginations.

Today I train future psychiatrists. I tell the lightbulb joke as my own when I help a resident identify who should and should not begin therapy. I teach the differences between varieties of psychotherapy, and how to identify treatment goals, set tasks, and build therapeutic bonds. Nowadays, deep down, I realize that the intellectualizations of psychoanalytic theories are there to help me and my trainees remain present in the mystery and ambiguity of how other people experience life. I tell my students that patients come to therapy when the pain is too much to bear, when things are irreconcilable, when they can’t leave the house, when they feel trapped by the losses of their lives. I tell them about Sharon. I tell them to ask one good question, then stay silent and listen. I remind them to bring tissues.