The exquisite woman on Sandra’s couch did not evince the urgent anxiety that had been in her voice when she made this appointment. Claire Hughes, M.D.: ophthalmologist, mother of twin toddlers, married to a plastic surgeon. Ballerina posture, her crossed ankles displaying the burnished red soles of her boots. Wealth exuded from a creamy draped cashmere dress. Large pearl studs, a wide wedding band of princess-cut diamonds. Rectangular glasses rimmed in rose gold brought out the copper in her luminous skin. She had folded her fluffy sable coat onto the couch beside her and rested what appeared to be a Birkin on top of it. Fragrance wafted in Sandra’s direction. Jasmine, she thought, with a top note of grapefruit. Heads would turn, even in Harrods.

“Dr. Hughes,” Sandra began, “you said that you’ve been suffering from panic attacks. And that you’re certain there’s nothing physically wrong.”

 “That’s right. I had my husband ask around—so my colleagues wouldn’t suspect anything, you understand—and your name was the one most of them suggested. Even though you’re a psychologist and not a psychiatrist.” Sandra was immediately curious. Might this disproportionate skepticism signal something deeper?

“Tell me, Dr. Krasnapol, what’s your treatment plan?” 

“Well, the first step is a bit of detective work. You and I need to try to understand something more about your anxiety.” Sandra noticed that her glasses were slightly smudged. She wiped them with a corner of her dark blue pashmina while the patient appeared to steel herself.

“All right, then. The facts.” Dr. Hughes summarized the history and onset of her symptoms as though she were describing a patient at grand rounds. Succinct. Dates and times of panic attacks. Duration of said attacks. The differential diagnoses, workups, rule-outs. “The panic attacks never occur when I’m with patients. And never in the OR. Can you imagine if . . . well, I’ve made sure that one of the senior residents is always assisting. In case. But the attacks only seem to come when I’m driving, thank God. I haven’t driven alone with the twins since the first time.”

All this spoken as if to a colleague, objectively, no evident perturbation. Sandra’s eyes remained on Dr. Hughes as she scribbled notes across the page, notes that would be virtually illegible even to her—the activity itself, though, integral to concentrated immersion in the emerging narrative.

“The first time—could you tell me about that?”

“I was on the way to the office, in a rush. All of a sudden, my heart started pounding, and I had nausea so strong I had to pull over. It was the first time driving my new car, and I didn’t want to puke all over it. I barely got the door open in time. I just sat there, panting. It was so cold that steam was coming off the vomitus.”

Puke.But then vomitus: the doctor was in conflict about being a patient. Would she permit Sandra to take care of her?

Dr. Hughes shuddered. “I don’t know how I managed, because I was shaking all over, but I got to the garage. It was only another half mile or so. I was too dizzy to walk, so I called up to my office and had them send an attendant with a wheelchair to my parking space. I just sat there, my head on my arm, leaning on the steering wheel. I knew I didn’t have any baby aspirin in my bag. I thought it had to be an MI—a heart attack.”

Curious that she felt the need to translate the abbreviation.

“And then it was nothing. I insisted on looking at the EKG myself. And I told the fellow he had to page the attending to check the results before I let myself feel relieved. I was absolutely humiliated. I mean, I know panic attacks can present this way, but I’m a doctor, for God’s sake. This isn’t supposed to happen to me. And at my own hospital? I was so embarrassed. And then pissed off because they took forever to get me the script for Xanax. Patients were waiting, and I still had charts to do from the day before. I called the nanny from the elevator to warn her that I wasn’t going to be home till late that evening.”

“You’d been in a rush,” Sandra said. “Anything unusual going on that day?”

“No. I just wanted to get to the office early because I hadn’t been able to finish those charts.”

“Your charts. It sounds as if you don’t generally leave them till the morning.”

“No. Almost never. The last time it happened was months earlier when I had to repair a detached retina late in the afternoon. But the night before the panic . . . hmm. That night, it was only that I had a meeting. The committee for professionalism.”

Sandra opened her mouth to ask, but Dr. Hughes continued.

“It’s the committee in charge of monitoring and improving the professional behavior of the hospital’s medical staff. I’m the youngest ever to have been voted in.”

“Ah. I see.” There had been no tone of pride in the doctor’s voice, Sandra noticed. She already knew what she would ask next, but she glanced down at her notes to offer the patient a respite from her gaze. Ladies always maintain eye contact during conversations, the headmistress of her school had regularly intoned, and Sandra still had to remind herself to allow her eyes to wander. It had taken years, too, to teach herself not to perform a perfunctory curtsy when shaking hands.

“You mentioned that you were driving a new car,” she said.

Dr. Hughes’s Birkin emitted a muffled ringtone. She pulled the bag onto her lap and extricated the phone. She glanced at it, rolled her eyes. “I’m on call,” she said to Sandra, then, “This is Dr. Hughes . . . . Yes . . . no, it’s for FML drops.” Dropping the phone back, she said, “I think ‘fuck my life’ every time I prescribe that, you know.”

They both laughed.

“I’m sorry—I’ve got to leave my phone on. Where were we?”

“Your new car.” Did she really not remember?

“My car?” A small laugh, strained. “What a funny thing to ask.”

Sandra smiled back. “Humor me.”

“We’d picked it up the Saturday before. A Maybach. It’s made by Mercedes.”

Was that condescension or reasonable explanation? In actuality, Sandra had only heard of the make herself a few months earlier.

“I thought it was too much, but Luke—my husband—really wanted me to have it. ‘The best,’ he said. ‘Only the best, from now on.’ We paid off all our med-school loans last year—early!—and there was really no reason not to. The child seats are still in the Volvo, so this car was just for me. Luke got a little Porsche for himself. He’d wanted it forever.” Dr. Hughes’s voice had become quiet. “You’re looking at me in—what do the kids say?—some kind of a way.”

“What kind of way?”

“Oh, I don’t know.” Dr. Hughes shook her left forearm slightly and loosened the metal links of the Patek Twenty-4 sticking to her skin—but for the dial color, the twin of Sandra’s own. The two rows of diamonds sparkled, then disappeared under the cashmere sleeve. “I guess I wonder if you find me braggy.”

Sandra deployed her practiced neutral face. She sensed the tightness of her own stainless band and restrained the urge to shimmy her arm, too, watching as Dr. Hughes frowned.

“You haven’t said a thing,” the doctor continued. “You haven’t given me any indication of disapproval or envy, maybe that’s because you’re obviously quite prosperous yourself.”

A longish pause.

“Okay. I get it. It’s my feeling.”

“Yes, it is, and I think you also preferred to slap yourself down rather than wait to see if I would do it.” The patient was nodding—her first aha moment, Sandra thought. “Can you see, too, that both your car and your committee meeting—the reason you were in a rush—point in the same direction?”

Dr. Hughes appeared mystified.

“It’s pretty clear that you’re in conflict about your enviable success. You have achieved so much. You’ve done all the right things. The rewards are laying themselves before you, and you now find yourself with a symptom that prevents you from enjoying what you’ve earned. It’s as though you feel you don’t deserve what you have.”

“How could that be true? It’s got a certain logic, but I’ve worked my tail off. And I love the life I have. It doesn’t make any sense at all.”

“Anything come to mind when you think of how hard you’ve worked?”

“Not really, no.” Dr. Hughes sounded impatient. “And moreover”—she crossed her arms—“how can you know about such matters? How hard did you have to try? How far did you have to travel to get here? I mean, a non-M.D. recommended by M.Ds. How’d that happen? I know I always refer patients to psychiatrists.”

Sandra felt the incoming hostility in her belly. Offense and provocation were effective distractions and effective defenses against unwelcome self-knowledge, but now was not the time to point that out. “What do you imagine?”

“Well, it wouldn’t be good for me if you were in as bad shape as I am, but you’d be able to understand me better if you’d struggled along the way.” Dr. Hughes seemed taken aback by her own words. “But that’s ridiculous! I mean, I certainly don’t have to suffer all the diseases I treat. So why would I give a damn about you now?”

“Perhaps you’re concerned that I might not be able to empathize with you. And conversely, you’re also indignant—is that the right word?—that I seem to have understood you a bit too well for comfort.”

“I don’t know why that should make me uncomfortable, but it does. I can’t wait to hear the next thing you say. And I want you to keep your stupid smart ideas to yourself.” Punctuated by a sharp bob of the head.

Sandra readied herself. “Shall I say what I think you won’t?”

 The patient’s eyes narrowed. “And that is?”

“That my skin may be the wrong color.”

“What do you mean? What does that have to do with anything?”

“Well,” Sandra said gently, “perhaps your questions about whether I can understand your experience have some basis in reality.”

“I’m not sure I like where this is going.” Her voice had turned cold. “Are you saying that you don’t think you can work with me?”

Sandra realized that she might have chosen her words poorly. Was this to be one of those sessions that she couldn’t wait to escape, one in which her tact and timing had absented themselves? It was a knife-edge moment, not one for an interpretation. “No, not at all. I only want to make clear that you have a choice. I don’t think it occurred to you when you looked for a therapist that your symptoms might have something to do with being Black. And that might affect whether you want to work with me.” She saw comprehension in the patient’s eyes now, a reduction of tension. “Let me ask, though: Is that term all right? Would you prefer African American? Something else?”

Dr. Hughes looked as though she’d been offered a dose of cod liver oil. “Black is fine.” She shifted on the couch but then stood up and walked across the room to the bank of casement windows and their messy ice collages of brown leaf debris, residue of the wet and windy overnight. The warmth of the room had not yet penetrated the panes. Her back to Sandra, she finally spoke. “What do you recommend?”

“I can certainly refer you to a colleague if you’d prefer.” But Sandra liked this woman, would be disappointed to let her go. Then a memory shred, words from a long-ago teacher: Never hesitate to tell patients you want to work with them if they need to hear it. A prompting from her unconscious, a valuable message about what she was not yet aware of knowing.

All right, she thought. But how much to say? There hadn’t been any seminars on proper clinical technique for the no-bullshit zone. “I’ve learned over the years that it’s usually a mistake to assume that people who appear similar in fact are similar. When I think I understand somebody perfectly, I often discover that I’ve been empathizing mainly with myself.” The wind gusted outside, and Sandra reflexively drew her pashmina over her shoulders. “It’s always an honor when a patient trusts me. A gift—precious. But when a Black person allows me inside his or her soul, that is an act of significant faith. So I would very much like to work with you, if that seems to you like a risk worth taking.”

Dr. Hughes drew in her breath sharply, hand jerking reflexively to cover her mouth. Was she grateful? Indignant? Enraged? Trying to prevent unwanted words from escaping? She walked back to the couch, her gait on the edge of unsteady. Was she about to have a panic attack? Sandra’s own anxiety mounted again; she prepared to reach for the package of brown paper lunch bags she stocked for a young man who was prone to hyperventilating. What to do? Help her along? Let her struggle alone? Dr. Hughes’s eyes remained wide, shocked.

Sandra, very softly: “Can you put words to your feelings?”

“I don’t know.” The doctor appeared shaken. Not angry, it seemed, at least for the moment. “I knew—I mean, my parents made it clear as day. We put you on this earth to better your race. They didn’t give a shit what we felt. I mean, they weren’t bad parents. They weren’t unkind most of the time. We had what we needed, and we knew they loved us. But there was a giant poster in the kitchen. ‘Whining’—just the word with a line through it. Red and white, you know, like a stop sign. And they meant it. If I ever asked for anything? You want? You work. That’s what they said. I wasn’t stupid, so I stopped asking.”

“Not much room for the psychological legitimacy of your wants, was there? When your parents were as harsh as the world they were preparing you for.”

“I love my parents. They’re not perfect, but I love them.”

“It’s painful to be disappointed in—much less angry at—people you love.”

“For a second—this is crazy.” Dr. Hughes hesitated. “I can’t explain it, but when I gasped? For a split second, I looked at you and saw my grandfather. He was light-skinned, the lightest in the family. My father’s father. I was his only girl child—child or grandchild. He’d take me to the zoo, just me, and we’d stay in the bird house for hours; that was my favorite. And we’d go to the movies in the winter. Whatever I wanted to see. Then back to his house, where he’d make hot chocolate. He’d put a peppermint Life Saver in, too, so there was an extra-sweet crunch at the bottom of the mug. We’d talk and talk.”

Sandra found herself salivating, practically tasting that last mouthful on her tongue. She could not remember a patient ever having moved this quickly, but she relaxed into the empathic attunement, feeling linked to Dr. Hughes by their finely wrought loops of alternating self-disclosure and anonymity. It was touching to have served as the displacement of the cherished Black grandfather. And oddly disorienting, despite years of playing the role of implausible transference object to so many others. Dr. Hughes was ready for the interpretation, though. It would require only the tiniest nudge.

“Tell me, what brings your grandfather to mind just now?”

“He made me feel special.”

 “A light-skinned person who treasured you, listened to you, made you feel special.”

Dr. Hughes looked miserable. She must be terribly conflicted about accepting Sandra’s empathy. The office itself suddenly felt insubstantial to Sandra, as though it might depressurize, ceasing to hold the two women together in the same space, flinging them toward distant singularities, a black hole and a white one. A muscle in her left hand twitched: she had clutched the chair arm so tightly that her knuckles had whitened.

“Do you know that I have new patients who, when I enter my own exam rooms—they complain that the doctor is running late? They refuse to see the m.d. on my coat, even when they’re not blind. No white person, not even a woman, would have to take that crap. But why do I get to complain? I’ve made it. What gives me the right to want to have things come easy for a change?” The patient’s embarrassment was palpable. “It’s a simple matter of loyalty. To my race. I mean, how can I say anything that might lend an iota of credibility to —for all I know, you think there are entitled welfare queens out there.”

To carry this accretion of injustices and indignities, the weight of this history, Sandra thought. All this—plus twins, a demanding career, and leadership positions. Oh, my young friend, your eyes are bigger than your stomach. You can’t take so much on your plate, not without a big helping of stress on the side. No woman can, even with help. No wonder you question whether you deserve your success. You’re treating yourself like that watch on your wrist—a beautiful bracelet that houses the most basic quartz movement—when you’re actually full of complications. Alas, there’s no tourbillon for life, no ingenious mechanism to eliminate the tiniest imprecisions and imperfections. I like things tidy, too, my fellow obsessional, as close to perfection as possible. And I’ve got my own complications. At least you knew your real parents loved you. Everybody bears some burden from the past, some trauma—the gift that keeps on giving. But I’m a woman, and I’ve survived those trying years; maybe I can help you beyond the threshold.

A memory flitted­. The seventh-and-eighth-grade dance. Boys provided by Collegiate, on the West Side. The glamorous mirrored ball rotating in the darkened auditorium. The big question—the only question: Will I be asked to dance? Toward the end of the evening, Sandra was, so she joined the triumphant few. Her adoptive parents picked her up at ten o’clock, and she bubbled with excitement during the taxi ride home. A boy asked me to dance—and he was taller than me! And he likes math, and he wants to be an astronomer, and he has three sisters, and—only when they were nearing their building—Derek is a negro. That was the word they used then. For years, her parents told the story to their friends, proud that Sandra had buried the lede. Over time, though, she had come to think it strange, probably defensive, that she had been so manifestly indifferent to difference. After all, she was old enough to have formed a memory of April 4, 1968.

Sandra ached with guilt. Had she just repeated this retreat into a fantasy of sameness? Forgotten that her whiteness was inescapable? She’d never had to worry about belonging in any way that mattered. She had the luxury of being blind to the special dangers this woman faced whenever she left home. How could Sandra possibly comprehend what it is to live with so high a baseline of fear? The idea of attempting to heal wounds this pervasive made her feel overwhelmed, puny. Was it arrogant, selfish to want to try? Maybe she should have recommended a referral.

But no, Sandra reminded herself. The dangers this patient faced were not all from the outside. Survivor’s guilt—thriver’s guilt—can get under skin of any color; every symptom is particular. The mind could attack itself, too, even if it had learned those skills from external sources. And the mind was Sandra’s wheelhouse. She could help this woman live with herself. And it was also possible, Sandra knew, that a Black person of such high achievement wouldn’t feel so free to express this sort of unease and doubt to a Black therapist.

Dr. Hughes had not taken her eyes off Sandra’s face. “You’ve got guts, don’t you? To have humbled yourself before me. Made yourself out to be the one who’s lacking something. To get me to tell you things I could never, ever say to a sister or a brother. So what are you going do with everything you know about me? And, yeah, I was just being deferential before. I haven’t forgotten my psychiatry rotation. I know how this works; I know you’re not supposed to tell me what you really think.”

“No, I’m not. At least not if I go by the books.” Sandra gestured toward her shelves. “But there is no book on my shelf with your name on it—you and I have to write it together. And I’m sure you remember why it’s better for me not to burden you by revealing too much about my thoughts, yes? So that you are free to fill the room with your observations and perceptions.” Sandra hoped that her instincts and reflexes would be adequate to keep pace with the patient’s increasing velocity.

“You want me to fill the room? I trained side by side with people like you. People who had no idea—none!—what I had on the line. If I missed an answer on rounds? I studied my ass off so that would never happen. Studied harder than anyone I knew. No surprise to me when I matched with the best residency: I was the best.”

Dr. Hughes looked around the office at the artwork, the furnishings, the framed degrees, then scrutinized Sandra herself. “I’ve worked for every fucking thing I’ve done, everything I have,” she said. “Did you work for that sapphire on your hand? That’s Ceylon. I can tell the color from here. Did your husband work for that, like mine had to? Did your husband take you into any store he wanted so you could pick out whatever you liked? Or was it a family heirloom, paid for with money that ought to have been my grandparents’ living wage? My grandparents —some winters, they had to choose between food and heat, and I have more than everything.”

Sandra felt pinned to the back of her seat as though by the G-force of that powerfully accelerating Maybach.

Another memory flashed by: blue-tunicked six-year-olds. Pencil-scarred desks in a circle, windows open to the autumn breeze. Mrs. Weekes, English and ancient, led the lesson. A jar of cream was passed from one set of just-washed hands to the next, the class counting ten shakes aloud at each stop. Finally, there was enough liquidy butter for each little girl to have a smidge on a saltine cracker. Butter can’t revert to cream, Sandra thought, and this patient, too, is undergoing a phase change.

Dr. Hughes leaned forward, her body coiled. “Do you know, the Mercedes salesman at the dealership where we picked up my car—obsequious and condescending all together. The first thing he asked us was why we were interested in a Maybach. Emphasis on ‘we.’ ‘Uppity’ was floating in a word bubble above that bald head of his.” She sat back, took a deep breath, crossed her now-trembling arms. “Look at me now: not a poor colored girl who doesn’t really want to succeed. No. An angry black woman. What are you gonna to do with that, Dr. White?” The single hissed word pierced the few feet between the two women. “You gonna tell everyone you know about Dr. Hughes’s shaky hands? You gonna write one of your articles about me? You—someone who never worried if people wanted to share the air in the room with you!”

White. It echoed in the room. Dr. Hughes’s defiance was tinged with disbelief. “Oh, God. Did I really let myself say all that? And I just accused you of—I just questioned your ethics.”

“You did,” Sandra kept her tone even, matter-of-fact. “And what am I going to do? I’m going to listen as carefully as I can. And do my best to understand how you feel.”

Dr. Hughes looked back, curious. “If a patient ever spoke to me that way, I’d throw her out of my office.”

“Well, my guess is that you’d know how to handle such a patient quite professionally. But if I threw you out, I’d have no chance of helping you with the agony behind your anger, would I? And this isn’t hospital rounds, either. I’m not the judge of the rightness of your opinions.”

Dr. Hughes contemplated Sandra for another moment. She shook her left arm, again freeing the watch from her skin, then stood up and walked once more to the window. The ice was slowly releasing its grip, and the leaf fragments at the very top of the windows were slowly sliding down the glass. It had warmed outside, but early morning gloom had not lifted.

Sandra took a deep unsteady breath while the patient’s back was to her. Did Dr. Hughes also need a moment of privacy? Was she afraid that Sandra could see her thoughts? It could have represented an attempt to regain control of herself—or to return control of the room to Sandra. She let Dr. Hughes work it out on her own, not wanting to assume the position of the one who deserves an answer. But the session was almost over. The skin of Sandra’s fingers was dry again, and the paper of her pad felt as unpleasant as cheap polyester chenille.

Almost five minutes elapsed before Dr. Hughes returned to the couch. She settled herself before speaking. “The anger I couldn’t voice—that’s why I had panic attacks, isn’t it?”

Sandra nodded. “I think so, yes. You were probably overwhelmed by guilt as well as rage, and those feelings made you terribly anxious. Because you were not aware of this anxiety, your mind used your bodily pathways to create a symptom. A flashing neon sign: ‘Pay attention to me.’ And so you have.”

Sandra hated to end in the middle of a state of flow, but they had gone over by a couple of minutes. “I said I wouldn’t throw you out of my office”—wistfully­—“but I’m afraid our time is up. I don’t think I need to tell you that you’ve made an excellent start.” She reached for her appointment book.

“Do you know, Dr. Krasnapol”—tentatively—“I’m not sure I want to make another appointment with you right now. I’m not sure I need to. Maybe I can handle this myself.”

Sandra was unable to hide her surprise, her arm freezing halfway between her lap and the table. Disappointment, sadness passed through her, and she took a moment to collect herself. How to allow this patient to depart, leaving the door open for a return—and do it with grace?

“Dr. Hughes, as you can see, I wasn’t expecting you to say that. But I can understand. You’ve given voice to things that have roiled in you for as long as you could form thoughts. These words needed to be spoken and heard. You’re a woman of enormous strength and inner resources, no matter how freaked out you’ve been by these panic attacks, and I believe you’re going to be able to go about your days just fine.”

She saw the patient release her breath.

“It would be good, though, for you to reflect further, especially on the difficulty you’ve had accepting the legitimacy of your subjective experiences. If you decide you’d like to do that in discussion with me—in five days or five years—well, you know where I am. And sometimes life does deal us blows we can’t manage on our own.”

Dr. Hughes stood, put on her luscious coat, and offered her hand. “Sandra. I’d like it if you called me Claire.”

Sandra rose as well, but into the glow of unexpected redemption, and the two women held rather than shook hands. “Claire. Best of luck to you.” Sandra’s eyes almost teared up, and she guessed this had not escaped the ophthalmologist’s notice.

The soft sable kiss lingered on Sandra’s wrist, and she remained standing, hand on the doorknob, inhaling the last of the jasmine. By the time she turned toward her desk, she heard the faint sound of her next patient expostulating into his cell phone as he entered the suite precisely on time, as always. She would have to write the note in Claire’s chart later.

About the Author:

A practicing psychoanalyst, Susan S. Levine has published three books in her field: Useful Servants (Jason Aronson, 1996), Loving Psychoanalysis (Jason Aronson, 2009), and Dignity Matters (Routledge, 2018). Her contribution to the latter volume, for which she served as editor, originally appeared in the International Journal of Psychoanalysis as “Means and ends in Hitchcock’s Vertigo, or Kant you see?” She taught classes in clinical case writing for many years and served on editorial boards of professional journals. Her first Sandra Krasnapol story, “Seeing Red,” was published in Constellations: a Journal of Poetry and Fiction (2020), the second, “Certifiable,” by International Psychotherapy Institute EBooks (2022), and the third, “Taking Leave,” by the White Wall Review. A fourth, “Break,” will appear later this year in The MacGuffin.

*feature image by Gerd Altmann from Pixabay