When I was a resident, training to become a plastic/reconstructive surgeon, friends were often freaked. "Jesus! How can you cut into someone like that. That is crazy messed up!" And while it admittedly tweaked a nerve to cut into a recognizable and sensitive spot like a an eye lid or a child's cleft lip, I always answered them, "It's all about the drapes."

Surgical draping, the squaring off of the minimal exposure necessary for adequate access to the surgical field, defines the difference between cutting or carving into someone and performing surgery, a detached set of technical maneuvers. Once a field is draped out with bright blue paper and green sheets, and the skin painted a deep, faux-tan-bronze with betadine, the act of cutting is transformed into a circumscribed procedure. Rarely, I experienced the shock of actually cutting or sewing up a person's flesh, stitching hand lacerations from a punched out window in the ER, or excising a questionable mole with local anesthetic. But focus on the draped-out field mixed with the single-mindedness and heavily valued efficiency of the surgeon made it easy to bypass the messy humanity.

There's a longer story between, but now I am a psychiatrist in New York, and the messiness of drives, motivations, and fears should be much harder to manage than the surgical field. On my better days in my private practice or working at my affiliated hospital, I visualize myself rolling up my sleeves, even my pants, to get in waist deep. Diagnosis, at least by-the-book diagnosis has become fairly easy and simplistic, checklists of five out of nine symptoms earn you a name for what ails you. But I and most of my colleagues prefer to get into how individuals feel about what ails them, how they deal with it, ways to both manage and sit with their fears, how to listen and be understood.

Though I am still youngish and greenish in the field, I had started to fancy myself as flexible, balanced, even a bit Zen, able to shift sets, metaphors, models of the mind to keep pace with my patients, and, mostly, to empathize and remain fluid, present. But then Tarloff happened.

I realize I just said "Tarloff happened", as if it were 9/11 or Hiroshima, and in a way, for therapists, it was. Unfathomable. Unspeakable. Terrifying. On my way back from a blissful surf escape to Costa Rica, a friend and colleague e-mailed me. "We should talk about Tarloff." At first glance, I mistook this for the classic Tarasov case that premised a psychiatrist's "duty to warn" exception to confidentiality, should he/she suspect a risk of threat or violence. But, when I googled it at JFK, I got the gruesome facts. David Tarloff, a man with a possible diagnosis of bipolar disorder, but, more importantly a complex history of rage, impulsivity, frustration, and resentment, reportedly went to rob his psychiatrist, stalked him from the Dr's office basement, then brutally murdered a bystanding therapist, the elder Dr's colleague, and slashed the psychiatrist as that Dr. attempted to intervene following the murder. As a case, it is a horror story.

I remembered John Hersey's Hiroshima, and his description of a victim's flesh slipping off his hand like a glove as another attempts to rescue him. So horrifying, to a near mythic extent, that it becomes circumscribed, engendered as gore and myth, a little out of reach of the human experience. My first reaction to the Tarloff piece in the Times is similar. In the age of media-commodified tragedy, this is pure horror. "Did you hear the story about the brutally murdered therapist?"

But as I read the details, "East 79th Street", that's near my hospital and my old neighborhood, "psychiatrist in his 70's in private practice", he could have been one of my mentors or a colleague and friend, it works it's way under my skin. I share an office with colleagues. We all have patients with angers, fears, resentments, impulses. We all have off days. And we all impact our patients' thoughts and feelings, sometimes more than we realize.

One of the psychiatrist's best defenses is what I have been describing above as a sense of flexibility, self-knowledge, the impetus for a thorough analysis as requisite for a practicing analyst. The hedged defense at the other tail of the spectrum is "we can only do so much." These are both valid and often true, but they are also our surgical drapes. We try to get in deep, to not simply intellectually understand our patients and their lives, but to feel something of what they feel to understand on a deeper level. But we also have to block out a clean, safe space, maintain a toe-hold, save a little bit of our selves for the long haul. A situation like the Tarloff scenario rips off those sterile drapes, shatters a sense of safety and, leaves us uncertain, vulnerable, and afraid.

What to do with that? I find with most traumas that cut to my most vulnerable core, I hit a three-way cross-roads. React, withdraw, or just slow down. Mostly, if I can do the third, I feel like I am moving forward in understanding and empathizing, and the first two are not so necessary. GD