From my notes it was clear we’d gone round and round like this for some time. Michael seemed to have some deep anxiety about himself, something he was convinced had to do with his sexuality, but I couldn't get a clear sense of what it was that worried him. He told me that he was a late starter, that Claire was his first and only girlfriend. At one point he told me that he found her passion embarrassing, but he couldn’t explain further. And while everything Michael told me seemed to have some possible significance, I couldn’t understand what he meant when he said that he was worried about his sexuality.

In my notes I recorded the thought that he seemed unable to bear the loss that marriage entails. I meant by this not only the loss of being a child, but also the loss of certain avenues that had been open to him but would now close. I was also struck by his immaturity; he was positively adolescent in his lack of empathy. He didn’t seem to have much sense of the pain that he had caused his fiancée. From his description of events, it was clear she was in a state of shock.

He told me that his parents and friends all thought that Claire was a wonderful girl – intelligent and warm. He agreed. They were convinced he would lose her if he didn’t propose. He found himself telling her that he wanted children and marriage, he had proposed, and they had found a home and were planning their wedding. He’d done these things because he thought this was what he should do, what he should want to do, but here he was, several weeks before his wedding – feeling that he couldn’t go forward.

I wanted to think that it took courage to call off the wedding, but his stopping seemed almost as unthinking as his going forward. And the business about his sexuality wasn’t quite right either – I suspected that it was the only excuse he believed would be accepted by those around him.

It was clear he was desperate to stop the wedding, but he couldn’t say why and I couldn't figure out why. In my notes I concluded that he was breaking down into depression and needed to be helped immediately. He needed an experienced therapist who could help him get a better sense of the cause of his depression, and get a clearer picture of his underlying worries.

There was one further point in my notes, and this may have been the reason why I didn’t recognise his voice on the telephone – I felt that I hadn’t made good contact with him.

During a consultation, I have to gather information – the patient’s life story, the history of his problem – but the most important thing is that the patient should leave our first meeting feeling heard. At the end of this meeting, he should feel that what he came to say, needed to say, has been said, listened to and thought about. In almost all consultations there is a moment when things click, when both people feel there has been an understanding. When that happens, and it can occur at almost any point in the meeting, patient and analyst have a sense that the consultation is over, the thing that was needed has been done – but that hadn’t happened with Michael.

Then, out of the blue, a couple of months ago, I get a call from my mom telling me that she and my dad are getting a divorce. My mom’s discovered that he’s been having an affair with Kathy, his receptionist. She’s worked for my dad for twenty-five years. Apparently, they’ve been having an affair since I graduated from high school. Surprise, surprise – Kathy is Catholic, and blonde.

‘And then I got it,’ Abby says, ‘the bigger the front, the bigger the back.’

Psychoanalysts call this ‘splitting’ – an unconscious strategy that aims to keep us ignorant of feelings in ourselves that we’re unable to tolerate. Typically, we want to see ourselves as good, and put those aspects of ourselves that we find shameful into another person or group.

Splitting is one way we have of getting rid of self-knowledge. When Abby’s father cut her off, he was trying to cut himself off from those hateful aspects of himself that he could not bear. In the short term, this gives us some relief – ‘I’m not bad, you are: But in denying and projecting a part of ourselves into another, we come to regard these negative aspects as outside of our control. At its extreme, splitting renders the world an unsettling, even dangerous place – rather than recognise his devils as his own, Abby’s father meets them, as if for the first time, in his daughter.

Imagine his predicament – it was unbearable for him to think that he’d fallen in love with someone outside of his religion. Able to locate the problem in Abby, he lost awareness of it in himself. He continues his affair with Kathy but because he lacks an internal experience of his own feelings and actions, he’s lost the best means he has of making sense of himself or his daughter.

I like Abby’s phrase the bigger the front, the bigger the back – it’s more telling than the psychoanalytic term. Splitting is thinner, less dynamic; it suggests two separate, disjointed things. Abby’s saying captures the fact that front and back are a part of each other.

Ever since hearing Abby’s story, whenever I hear about a family-values politician who’s caught with his pants down, or some homosexuality-is-a-sin evangelist found in bed with a male prostitute, I think – the bigger the front, the bigger the back.

Anyone can become paranoid – that is, develop an irrational fantasy of being betrayed, mocked, exploited or harmed – but we are more likely to become paranoid if we are insecure, disconnected, alone. Above all, paranoid fantasies are a response to the feeling that we are being treated with indifference.

In other words, paranoid fantasies are disturbing, but they are a defence. They protect us from a more disastrous emotional state – namely, the feeling that no one is concerned about us, that no one cares. The thought ‘so-and-so has betrayed me’ protects us from the more painful thought ‘no one thinks about me’. And this is one reason why soldiers commonly suffer paranoia.

During the First World War, British soldiers in the trenches became convinced that the French farmers who continued to plough their fields behind British lines were secretly signalling the German artillery. In The Great War and Modern Memory Paul Fussell documents soldiers’ widespread conviction that the farmers were directing the German guns to British emplacements. Fussell writes, ‘In both wars it was widely believed but never, so far as I know, proved that French, Belgians or Alsatians living just behind the line signaled the distant German artillery by fantastically elaborate, shrewd, and accurate means.’ The troops saw terrifying codes in the random movements of a windmill, or in the sight of a man walking two cows into a field, or of a laundress hanging linen on a line. It is less painful, it turns out, to feel betrayed than to feel forgotten.

With old age, the likelihood of developing a serious psychological disorder decreases, and yet the chance of developing paranoia increases. In hospital, I have heard elderly men and women complain: ‘The nurses here are trying to poison me.’ ‘I didn’t misplace my glasses, my daughter has obviously stolen them.’ ‘You don’t believe me but I can assure you: my room is bugged, they are reading my post.’ ‘Please take me home, I’m not safe here.’ To be sure, the old are sometimes abused, tricked by family members and mistreated by caregivers, so it is important to listen carefully to their fears. But all too frequently – like the soldiers in the trenches – the elderly face death feeling forgotten. Women and men who were once attractive and important find themselves increasingly overlooked. My experience is that paranoid fantasies are often a response to the world’s disregard. The paranoid knows that someone is thinking about him.

I asked Amanda P. to tell me more about arriving home from New York. ‘I love my flat,’ she said. ‘But coming home after a trip is one of those moments when I really hate being single. I open the door and there is ten days’ post on the mat, the fridge is empty, the house is cold. No one has been cooking so the place smells abandoned – it’s depressing.’ She paused. ‘It’s the exact opposite of what it was like to come home from school as a child. My mum or nan – or both – were there, making my tea. Someone was always waiting for me.’

As she spoke it became clear that Amanda P.’s momentary paranoid fantasy – of turning her key and being blown up by terrorists – was, to answer her question, not crazy at all. For a minute the fantasy frightened her, but ultimately this fear saved her from feeling alone. The thought ‘someone wants to kill me’ gave her an experience of being hated – but not forgotten. She existed in the mind of the terrorist. Her paranoia shielded her from the catastrophe of indifference.

After twenty-five years as a psychoanalyst, I can’t say that this surprises me. We resist change. Committing ourselves to a small change, even one that is unmistakably in our best interest, is often more frightening than ignoring a dangerous situation.

We are vehemently faithful to our own view of the world, our story. We want to know what new story we’re stepping into before we exit the old one. We don't want an exit if we don’t know exactly where it is going to take us, even – or perhaps especially – in an emergency. This is so, I hasten to add, whether we are patients or psychoanalysts.

I have thought of Marissa Panigrosso countless times since I first heard her story. I find myself imagining her in her office. I see her computer screen, the large windows. I smell the morning smells of perfume and coffee, and then – the first crash. I see her walk to the emergency exit and leave. I see her colleagues standing around. Tamitha Freeman leaves, and then a few minutes later returns for her baby pictures. I see myself there – in the south tower – and I wonder, what would I have done?

I want to believe that I would have left with Marissa Panigrosso, but I’m not so sure. I might have thought ‘the worst is over’. Or worried that it would feel ridiculous to return the next day only to discover that everyone else had continued working. Maybe someone has told me, ‘Hey, don’t go. The plane hit the north tower – the south tower must be the safest place in New York’ – and I stay.

We hesitate, in the face of change, because change is loss. But if we don’t accept some loss – for Tamitha, the loss of her baby photos – we can lose everything.

Consider Mark A., a thirty-four-year-old who has just discovered a lump on his testicle but doesn’t want to see his physician until after his holiday in Greece. Rather than attend the doctor’s appointment his wife has made for him, he runs some errands, picking up suntan lotion and some T-shirts for the kids at Baby Gap. ‘I’m sure it’s nothing,’ he says. ‘I’ll see to it when we get back.’ Or there is Juliet B., a thirty-six-year-old who has been engaged for seven years to a man who regularly has affairs and visits prostitutes, and who behaves like a ‘bully’ with his clients and co-workers. ‘I can’t leave him,’ she says. ‘Where would I go? What would I do?’

For Mark A. and Juliet B. the fire alarm is ringing. Both are anxious about their situations. Both want change. If not, why tell a psychoanalyst? But they are standing around, waiting – for what?

Negativity – this ‘I would prefer not to’ state of mind – is our desire to turn away from the world, repudiating normal hungers. Repeatedly, Bartleby turns away to face the ‘brick wall’, ‘dead wall’, ‘blank wall’, ‘prison wall’ – the subtitle of ‘Bartleby, the Scrivener’ is ‘A Story of Wall Street’. He is surrounded by food – Melville has even named his three co-workers Turkey, Ginger Nut and Nippers (lobster claws) – but he refuses to eat, ultimately dying of self-starvation.

The lawyer makes several attempts to coax Bartleby out of his withdrawal, but helping, it turns out, is not so easy. In fact, the story hints at a dark truth: it is the lawyer’s help that causes Bartleby’s situation to worsen.

I read ‘Bartleby, the Scrivener’ as a portrayal of the continuous struggle at the core of our inner world. In each of us there is a lawyer and a Bartleby. We all have a cheering voice that says ‘let us start now, right away’ and an opposing, negative voice that responds, ‘I would prefer not to.’ When we are in the grip of negativity, we lose our appetite for human connection. We become Bartleby and turn those close to us into lawyers. Unconsciously, we drag others into pleading our case to us.

As an example of this, consider the teenage anorexic and her mother. In the girl’s refusal of food you will hear Bartleby; in her mother’s nervous pleading you will hear the lawyer. Like Bartleby, the anorexic seems to feel no anxiety about her worsening situation. Her anxiety – which is her motivation for change – has found its way into her mother. We may be hearing two people speak, but it is not a dialogue they’re haling – the daughter’s internal conflict is being voiced by two different people. In experience, if this situation persists, if the two continue to act out Bartleby and the lawyer, they will arrive at a similar outcome.

When Sarah told me she had decided not to go away with Alex, I too was tempted to try to persuade her. Like everyone else, psychoanalysts do get caught in the lawyer’s role; our job is to try instead to find a useful question. Our weapon against negativity is not persuasion, it’s understanding. Why this refusal? Why now? Alex had done nothing particularly wrong; in fact, over the time Sarah had spent getting to know him, Alex had proved to be thoughtful and trustworthy. The change was in her.

Consciously, Sarah wanted to meet someone and fall in love, but unconsciously, there was another story. At this deeper level, love meant losing herself, her work, her friends; it meant being emptied out, neglected and possessed. Gradually, by recollecting some of her painful early losses, as well as the deep despair she suffered at the end of her first loving relationship, we began to make sense of Sarah’s demurrals. Sarah was involuntarily negative because emotional surrender and attachment represented a loss, not a gain. Sarah’s negativity was a reaction to her positive, affectionate feelings for Alex – it was a reaction to the prospect of love.

A few months into analysis, Graham remembered a dream. In the dream, he was standing outside the house he grew up in. He wanted to go inside but couldn’t. As a rule I would want to focus on the content of the dream, to spend some time unpacking it with him, trying to understand his associations. And Graham took a very long time recounting it to me. He described the house and its history, and then went into great detail about his feelings for the various rooms and their decor. During a session a few days later, he spent a very long time describing a relatively minor incident from his childhood. And it hit me that Graham was silencing me. He understood that I would consider dreams and memories important, that I would not interrupt him, and so he took his time, staying in those stories as long as possible.

Graham’s being boring was aggressive – it was a way of controlling, and excluding, others: a way of being seen, but not seeing. It also served another purpose. Especially in the context of his psychoanalysis, it protected him from having to live in the present, from to acknowledge what was happening in the room.

When I spoke to him about what was happening in his life, his response was to look back, avoiding how he felt or what he thought now. ‘I was never there,’ says Hamm in Beckett’s Endgame, ‘Absent always. It all happened without me.’ Graham’s long detours into the past were a haven from the present. Over and over, without knowing it, he was refusing to let the present matter.

My experience is that closure is an extraordinarily compelling fantasy of mourning. It is the fiction that we can love, lose, suffer and then do something to permanently end our sorrow. We want to believe we can reach closure because grief can surprise and disorder us – even years after our loss.

On Friday 15 November 2008, a brush fire swept through the hills and canyons above Montecito, California, injuring more than two dozen people and destroying 210 homes. One of those homes belonged to my sister. Though unhurt, she and her husband lost everything but the clothes they were wearing.

A month after the fire, when we were speaking on the phone, my sister told me about the way that the community restaurants were donating free meals had pulled together – to those who’d lost something in the fire. She described the process of getting federal aid, the various loans available, and told me how helpful a government employee had been with her application.

I told my sister that I admired her pragmatism, her ability to pick herself up and get on with things.

Then she told me that she’d been to see a clairvoyant.

I was surprised by this, but still more by my own reaction. When my sister told me that she’d talked to our mother – who has been dead for more than twenty years – I became tearful and heard myself ask her, ‘What did Mom say?’

After we had finished our phone call I had the thought that we turn to clairvoyance when we need our dead and can’t accept death’s finality. We want to believe that the clairvoyant can bring our dead back into the world of the living. Closure is just as delusive – it is the false hope that we can deaden our living grief.