She was one of my first long-term, supervised psychotherapy cases during my second psychiatric residency year. She was young but still a year or two older than her inexperienced, wet behind the ears therapist, and I use that term very loosely. I was to see her once a week, and every other week or so, I would enter the office of my supervisor/mentor to discuss whatever progress I had failed to make with her in the week before. This man advised, admonished, and coached me on how to address the issues that my young patient lay at the sacrificial altar of mental health education four times per month. He had, after all, written several books on the subject of transference, countertransference, and all things Freudian, and he had a formulation and psychoanalytic take on every symptom complex and defense mechanism I could throw at him. He was brilliant, odd, quirky, had a low growling voice, and looked at me askance as he wet his lips and anticipated the next mistake I would tell him about. There were many in those days. As I said, this was my second year in residency, my first clinic year where all I did was see outpatient therapy cases, and the first year where I began to understand just how hard it was to hold on to the psychoanalytic past while rocketing toward the biopsychosocial psychopharmacological future. I was a young man with one foot planted firmly in each therapeutic camp.

She was anxious, no doubt about that. It did not take a rotating internship (my first year) to recognize when someone was hyperventilating and panicking every time they drove across a bridge and headed out of town, leaving home and family behind. We not so patiently explored the myriad things that could cause this response, medical, psychological, developmental, relational, and on and on. She kept saying that she had serious anxiety and panic attacks. I would dutifully respond, following the prescribed script from my supervisory session the previous week, telling her in a brilliant flash of insight and interpretation that her anger towards her mother, coupled with her ambivalence about leaving home and finding her independence, were the root causes of her anxiety, and that if we worked at it, really worked at it for the prescribed two years or so that I needed to follow her to fulfill the requirements of this part of my training, that we would wrestle this beastly anxiety to the ground on that impassable bridge, heave it over into the river and rid her of her heavy breathing, tingling fingers, and cotton-headed worry forever. She was, shall we say, not as impressed with my psychoanalytic prowess as I was.

Back to the supervising psychiatrist’s office for more questions, formulations, and instructions.

“Have you delved into her relationship with her father yet?” he asked me. “How about the time her brother pushed her into a creek? Could the fact that she wears her shoes two sizes too small have anything to do with her psychic pain and suffering?”

Maybe I made those last two up, but you get the idea.

“Sir,” I asked, already knowing the answer before I asked the question. “She has been asking about the use of antidepressants or anxiolytics. Would it be possible to …”

“Of course not!” he bellowed, as much as his low growling voice would allow him to bellow. “We must work through all of her childhood issues, her traumas, her ambivalence, her fear, her anger. Therapy takes time. Have you considered that maybe you are trying to rescue her?” He stared at me, head cocked to the left, then to the right, eyes flashing with the brilliance of the diamond that has been converted from coal and is never going back.

The next week, several months into our foray into ambivalent relationships and inability to drive across bridges, she reached her limit with her young therapist.

“I am so tired of being afraid and scared and panicking every time I try to drive my car to the next town. You must do or give me some kind of medication that will make me less anxious so I can get out and feel better. We have been doing this for months, and I am not a bit better. Not at all!”

Ah, the transference, so this is it, I wisely thought to myself. This is her displaced anger, her frustration at her mother that she is now firing at me across the tiny office. I am the safe target of her verbal abuse, her …

“Are you even listening to me? Did you hear anything I just said? Anything at all? What is wrong with you? I might as well be talking to that doorknob over there as talking to you. I am so done with this. I am anxious, I keep panicking, and you have not helped me one bit. We are done. I am not coming back.”

And with that, she got up, grasped the doorknob that did not say a word to her, slammed the door, and was gone. True to her word, she never came back. Granted, I was a greenhorn. I knew very little. I was being supervised by a man who had spent his life learning and teaching psychoanalytic psychotherapy and seeing the world through Freud-colored glasses. All that being said, and in that very early context of my training, what did I learn? What did this patient teach me?

Sir William Osler supposedly said (though it cannot be found in any of his published works), “Listen to the patient; he is telling you the diagnosis.” This young woman was saying that she was anxious, scared, and panicky. This affected her life dramatically, and she wanted these feelings gone as quickly as possible. She did not want to delve into her past in minute detail. I wanted that, or at least my mentor did. When you are a psychoanalytic hammer, everything looks like an anxious nail. She was coming to me for relief, and I failed her quite spectacularly. In an odd twist, she did her job superbly. She taught me a lesson I have never forgotten and am writing about today.

Pay attention when patients entrust you with their fears, secrets, and pain. Try with all your might to understand what they are feeling, why they are telling you about it, and what they hope and expect you can do to improve them. Use anything at your disposal, anything you have learned, any skill or therapeutic intervention that you have to help the patient, if not to cure, then to alleviate suffering.

I may not have cured or even helped every single patient I have been privileged to treat, but never in the thirty-eight years since I saw that young lady have I ever again been compared to a doorknob. I thank her for that every day.

Greg Smith is a psychiatrist.