The case described here has been a very fascinating and interesting one for me. It has also aroused considerably more than the usual amount of doubt and uncertainty for two reasons that comprise the themes in the title of this paper. One is that the treatment has been going on for more than nineteen years, the first nine being conducted four times a week in analysis on the couch, the last ten in twice a week face-to-face therapy. Interestingly enough, although many believe that such long treatments become dependent, supportive relationships, my more recent work with this patient has proved to be the most insightful and productive of these many years.

The second reason for doubt is that despite considerable clinical improvement, the patient's recurrent obsessional thoughts and compulsive night-time checking rituals finally forced me to consider that, in addition to his widespread neurotic and narcissistic pathology, he might also be suffering from the clinical syndrome of obsessive-compulsive disorder (OCD). This led me to prescribe a trial of medication