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Introspections   |    
Tip of the Iceberg
Samuel G. Siris, M.D.
Am J Psychiatry 2010;167:1031-1032. doi:10.1176/appi.ajp.2010.10030322
View Author and Article Information

Introspection accepted April 2010

Address correspondence and reprint requests to Dr. Siris, Department of Psychiatry, Zucker Hillside Hospital, 75—59 263rd St., Glen Oaks, NY 11004; ssiris@lij.edu (e-mail).

Accepted April , 2010.

Copyright © American Psychiatric Association

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In therapy and in life, seemingly random or capricious influences can impact crucial "tipping point" choices, as the following narrative illustrates.

When he initially telephoned, "Brian" explained that he did not really need psychiatric help. He reported that his life was very successful and gratifying, but he had been struck by the enthusiastic way his mother, who suffered depressions, had spoken about conversations with her psychiatrist. Since Brian desired every possible positive life experience, he wanted to talk to a psychiatrist too, just to be sure he was not "missing something." I agreed to meet him for the single session he requested.

When Brian arrived, he confidently elaborated on his successful life. In the 8 years since college graduation, he had climbed the corporate ladder to the point where he controlled national distribution for a top-tier fashion apparel manufacturer. In this role, he limited his "work week" to 2 hours on Tuesday afternoons, during which he accepted calls from rival stores desperate to receive early product shipment. Those offering the best bribes won. The rest of his time was largely spent naked in bed, cavorting with exotic women, watching cartoons, and smoking cocaine. He enjoyed an exorbitant income, dined at chic restaurants, and whipped around town in an extravagant sports car. By his own account, he embraced the "perfect" existence. At the end of our session, Brian thanked me for an experience that, he noted wryly, had reassured him that he was not missing anything. He paid my fee in cash, placing a 20% tip on my desk for being so accommodating (the only time in my career that anyone has offered me a tip)! After I refused the tip, thanking him but explaining that my fee is my full payment, he replied, "Then let me give you a fashion tip" and, grinning knowingly, gave my outfit a detailed critique.

Six months later, Brian called for another appointment. At that visit, he explained that what had caught his attention was my not being devastated by his comments concerning my wardrobe. He recognized that he himself would have been sorely humbled by such a knowledgeable negative evaluation. But I apparently had not been—a suspicion confirmed by my (not consciously being aware of it) wearing the "same dumb sports jacket" as I had worn 6 months before. To Brian that meant I had some sort of internal resource, protecting my self-esteem, which he did not possess. He wanted that and asked if I could give it to him. I said I honestly did not know if I could, but I would be willing to talk with him about it—however, this would not be amenable to a superficial quick fix. We agreed to meet weekly.

Brian spoke about his drive for ostentatious material success being linked to his parents' behavior during the divorce that had ruined his adolescence. Studying life themes as a literature major in college had refined his impression that relationships were prone to be corrupted by greedy motives, and this had helped fuel his acquisitive assault on the world after graduation. With much to talk about, once-a-week therapy became twice a week. Brian spoke about his mother's depression making her inaccessible and how his father vacillated between being overwhelmed and being rejecting. Brian questioned whether any good alternatives existed, other than simply protecting himself by "not getting deeply involved with anyone."

Twice a week became three times a week. Brian found himself assuming that I would ultimately either reject him or become overwhelmed. I did neither. But did I love him? And if not, why not? Was he fundamentally unlovable, as he had suspected while growing up? Three times a week sitting up became four times a week on the couch. Was the real issue whether or not he was lovable, or was it whether or not he himself could ever truly love someone else? With the lifestyle he had been leading, this was impossible to know. Having already abandoned cocaine, he decided that he wanted to know the truth about himself and "went all the way," giving up his job, the "golden cage of self-indulgence" in which he had become entrapped. He took a "real" job in the garment district, for much less money, recognizing that the truth required "reality, not a cartoon version of life." He gave up the sports car, his dynamite apartment, and the meaningless sex. He did not become depressed or lose interest, as he had feared. Neither did I (as he had also feared). He met a girl who seemed quite different from anyone else he had ever known. She was witty, caring, and sincere. He discovered that making her happy gave him a previously unknown pleasure. He knew he really, really liked her but was not sure if he loved her—still not knowing if, indeed, he was capable of love. Yet this was as close as he ever had been to love, she clearly loved him, and they brought out the best in each other. So he married her.

Brian rediscovered his delight in literature—a joy he grew to share with his wife. A year later, they had a baby. Brian knew he loved that baby, and he also had come to the realization that it was better to "feel deserving on the inside rather than just look good on the outside." At that point we both knew that Brian was ready to continue his development on his own—with the help of his two new partners in authoring his life story. And he no longer questioned if he was somehow "missing something."

Delicate tipping points can select between vastly different paths, as occurred with Brian when he was apparently spurred into entering treatment by a subtle element of my behavior. I am left pondering whether such pivotal opportunities for change will occur (and reoccur) inevitably or whether, alternatively, in the vicissitudes of random chance, some mutative moments are truly unique, when "missing something" will mean losing something forever.

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