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Introspections   |    
Steven Ablon, M.D.
Am J Psychiatry 2008;165:563-564. doi:10.1176/appi.ajp.2007.07081241
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Doubt is not a pleasant condition, but certainty is absurd.

Some years ago a woman called me for a consultation. A pleasant, thoughtful woman in her early 30s, she had recently moved to Boston to take a job at an architectural firm. She hoped I would see her while she found a therapist. She had never been in therapy before and since high school had been aware of a sense that there was a part of her that was missing. Despite having many women and men friends, she felt too removed from herself for these relationships to develop beyond a certain point. This arrangement of seeing me while she found a therapist seemed unusual and off-putting. Why would she not choose me to be her therapist? I thought maybe her struggle to choose a therapist had to do with her difficulty in relationships. I found her earnest, likable, and compelling, and I agreed to see her, thinking I would find out more in time.

On her suggestion, we met every week. She had friends in Boston who knew the mental health networks and suggested referrals to her, as they had suggested me. I asked if she wanted me to recommend therapists, but she said she would prefer to ask her friends. When I inquired about her thoughts regarding this arrangement of seeing me while she interviewed therapists, she showed no interest in exploring this and said our meetings were going very well from her point of view. When I wondered about her background and past history and how that might be relevant, she politely let me know that this was not what concerned her, and I felt it best not to insist.

Over several months she saw men and women therapists of differing ages with different theoretical orientations and approaches, ranging from behavioral to cognitive, Freudian, and Jungian. She described the drawbacks of each of them. She interviewed several of my colleagues, and I found myself feeling competitive and wondering why she would not choose me. She interviewed people with whom I thought it would be good for her to work. Her reservations included concerns such as being too formal, giving too much advice, talking about his or her personal life, being too intellectual, being wedded to one theory, and being quick to come to conclusions about her. I wondered to myself if criticisms such as being too intellectual had to do with tendencies of mine or important people in her past, such as her academic father. By and large she did not focus on specific criticisms so much as how it did not feel like the right match. I felt anxious about this unusual arrangement. It did not fit with my usual practice of forming a diagnostic impression and treatment plan. I consulted a colleague, who encouraged me to stick with it and see what developed. After about 8 months she found a therapist she thought she could work with, thanked me very much, and said goodbye. I did not know the person she finally chose. For several years afterward, I found myself thinking about her and puzzling about the meaning of our experience together.

Three years later I received a letter from her. She said she had moved to a large city in the Midwest and during her therapy there had realized what had happened in her therapy with me. When she was 2 years old her mother was sent to a sanatorium for a year for the treatment of tuberculosis. During this time she stayed with a foster family who took very good care of her. She thought that in a way I had served as her foster family until she found the mother she longed for and missed terribly. She said this realization and the return of some memories from this early time had helped her reconnect to an important part of herself, and she felt more alive and related. She had always known about the early separation from her mother but had not felt its emotional impact until she had enacted it with me and explored it in her next treatment. She thanked me for my help and wished me well.

I was quite surprised and delighted with what she told me. I thought of the many child and adult treatments I have had the pleasure to be involved in and how these children and adults have taken me where they needed to go—whether to doll houses, puppets, or board games, while experiencing me as knowledgeable, ignorant, authoritative, or passive—to discover the painful and split-off fantasies and psychic realities that have greatly burdened them. I thought about my anxieties about accompanying my patients to uncharted waters to understand what they were trying to discover, but it is my experience that following the patient’s lead brings us to the most pressing unconscious conflicts and fantasies. I thought about how much I do not know and the delight of the challenge and surprise in our work when we join our patients on their voyages of discovery.

+Address correspondence and reprint requests to Dr. Ablon, Department of Psychiatry, Harvard Medical School and Massachusetts General Hospital, WAC 725, 15 Parkman St., Boston, MA 02114; slablon@comcast.net (e-mail). Accepted for publication August 2007 (doi: 10.1176/appi.ajp.2007.07081241).




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