Reflections on Loss...of Facial Hair

I sheepishly peered into the waiting room, scanning for my next patient, Ms. J. I felt naked as a first-year resident, unsure of myself, and frightened about what was about to happen. For the first time in 15 years, I was reporting to work clean-shaven.

A beard has long been part of my identity as both a person and a psychiatrist. I wore it for many reasons: to appear older, to save time in the morning, and to be more like Freud (whose bearded image looks back at me from my office wall). My psychiatry mentors all had beards. My patients joked about it. I thought everyone liked it.

When I turned 40, however, looking older was no longer such a good thing. My family suggested I shave it off. My midlife crisis hit me hard, and I was ready to get rid of the graying facial hair.

Yet I delayed, for weeks. Mainly, I came to realize, I feared impending encounters with patients like Ms. J. I'd been seeing her for over a decade. She knew me as the "guy with the beard and the glasses." Neither she nor any of my patients had ever seen me clean-shaven. How would they react? I wondered.

I was familiar with some of the psychodynamic literature on how the psychiatrist's life and appearance can intrude into the therapeutic process. A psychiatrist's pregnancy, for instance, can cause profound disruptions in a doctor-patient relationship.

True, I was not doing analysis with Ms. J. She's someone I work with in my community mental health clinic, a woman with long-standing depression and multiple psychosocial problems: tenuous housing, conflictual family relationships, unemployment, and poverty. We'd been through a lot together, and I like to believe I'd been helpful to her over the years: visiting her in the hospital, changing medications, working with her in an intensive outpatient group, linking her to services, and rooting for her when she had life successes. Even though we were from very different backgrounds, we were about the same age, and I felt a strong affinity toward her.

In fact, as I nervously looked for her in the waiting room, I remembered other times when my personal life had intruded on our relationship. We had to prematurely terminate a session after I developed a viral gastroenteritis and spent 5 minutes throwing up into a garbage can. She once saw me on the street walking with my wife, and we had the typical awkward acknowledgments. But she also cheered for me when I took paternity time off for my two children, knitting small gifts for the new arrivals.

As my head swirled with questions and doubts, I also began to realize how unexpectedly naked I felt. For me, the beard served not only as a psychiatrist's "mark," but also as a kind of shield, protecting me from the unknown and the frightening. In therapy sessions, I would stroke my beard as I imagined that Breuer and Freud did when they treated Anna O. Without it, I had nothing to do but devote myself fully to what the other person was saying, no easy options for displacing anxiety.

Fortunately, Ms. J recognized me as I wandered around the waiting room. She came back to the office without comment, then launched into a discussion of recent stressors and symptoms. Depressed again, she could barely bathe and cook, struggled to concentrate, could not sleep. She felt ugly, hiding her dirty hair under a hat. While we got her back on her meds and set her up in intensive outpatient therapy again, I felt a little silly about all my anxiety. Had she even noticed?

Indeed she had. As she thanked me for the session and headed back out to reception, she smiled slyly and said simply, "I can't decide if I like you better with the beard or without it. See you next week."

Although this statement certainly assuaged my narcissistic need to be noticed, I quickly realized how ridiculous my thoughts were. How could I even compare this small change in my appearance to Ms. J's efforts to prevent her electricity from getting shut off? Ms. J valued me, our relationship, the process, not because I "looked" like a psychiatrist or because I looked the same as always, but because I tried to help her. And that realization made me feel a lot less naked as I went out to the waiting room to get my next patient.