Conversing With Uncertainty: Practicing Psychotherapy in a Hospital Setting

"When I first saw Kay, she looked larger than life, and she scared me. She was dressed all in black and outraged. Her hair was black and spiked up on her head, she had rimmed her blue eyes with black, her tight jeans and tee shirt were black, and her mood was black. I felt pale, if not invisible, by comparison and scurried past her room without stopping to introduce myself."
Thus Rita McCleary begins a remarkable account of the hospitalized adolescent, Kay, whose treatment forms the basis of McCleary's "conversing with uncertainty." Following a frank recounting of the confusion and disillusionment that attended her initial effort to treat Kay, she explores her successive engagement of three sets of ideas that helped her find her bearings: James Masterson's treatment recommendations for working with borderline adolescents, contemporary concepts of projective identification, and the impact of the treatment setting as expounded in the milieu literature. Out of her "conversation" with these ideas emerges a brilliant meditation on how McCleary, then a therapist in training, used theory both to structure the therapeutic encounter and to monitor her performance within it.
For McCleary, each theoretical perspective provided a sense of professional and personal anchorage, enabling her to cope with a difficult patient in a disorienting context. Yet, each set of ideas, in turn, became a stumbling block on her path to clinical understanding. Drawing on the work of Donald Schon and a number of relational and interpersonal theorists, McCleary recounts how the "back talk" of both patient and milieu led to progressively mature forms of "reflection in action" that enabled her to work through, and eventually see beyond, her reliance on a given theoretical perspective.
Conversing With Uncertainty is a unique chronicle of why therapists must use theory while resisting the allure of theory, maintaining a double vision that allows them to appropriate theory only to break it open to enlarge the interactive and interpretive possibilities of therapy. But McCleary offers far more than a vivid experiential rendering of this insight. She argues persuasively, here in conversation with the writings of Irwin Hoffman and Lawrence Friedman, that a narrative case study - such as her case study of Kay - offers a unique window to comprehending the type of reflection that culminates in psychotherapeutic knowing. It follows, for McCleary, that case narratives are especially relevant to psychotherapeutic training, and by implication, to the way in which therapists acquire expertise.
Framed by a foreword by Stephen Mitchell and an afterword by Glen Gabbard, Conversing With Uncertainty is the premier volume of the Relational Perspectives Book Series. It also introduces a gifted writer of rare therapeutic sensibility. For it is McCleary's achievement, finally, not merely to convey with arresting candor the stress and uncertainty of clinical training, but to use her encounter with Kay to probe with fresh insight perennial questions about the narrative structure of therapeutic knowledge, the experiential foundations of theory choice, and the use and abuse of theory in clinical practice.

Rita Wiley McCleary, Psy.D., holds Master's Degrees in Philosophy (York University) and Ideas and Methods (University of Chicago), and a Doctorate in Clinical Psychology (Chicago School of Professional Psychology). She is currently Assistant Clinical Professor of Psychiatry, Yale University School of Medicine, and is in private practice in New Haven.