A nascent pearl inside my shell: from Existing to becoming Alive.

This is a presentation I have given a while ago about a patient I have seen in Therapy during one year. Some elements have been modified in order to preserve the patient's confidentiality. It illustrates the process of Psychodynamic psychotherapy and how listening to the unconscious takes place, bringing along with it a transformative experience.

Description

Mr. M. is a 22 year-old single man of Italian background who lives with his parents. He works as a supervisor in a school (part-time job). The patient was referred to psychotherapy by his psychiatrist. His chief complaints were “social anxiety, mood instability and not belonging anywhere”.

His request for psychotherapy was the following: “I want to figure out who I am, whether or not I can manage my mood disorder by being committed to a proper routine”. “I would also like to get some tools to manage my social anxiety”.

Mr. M. is a slender and tall young man who looks his age, with short black hair. He has black eyes rimmed by large, round eyeglasses and delicate features. His clothes are neat and well-coordinated with a casual student flair, and almost always a black pant and a dark coloured shirt which give him a melancholic and mysterious look. Arriving up to one hour early for his sessions, he carries a black coat, a black book bag and reads while waiting for his session to start. As I greet him in the hallway, he often has the look of a little boy who is lost and anxious, awaiting the arrival of his parent. He walks with large measured steps and speaks with a clear and sometimes anxious voice, almost always apologizing for taking his seat in the room.  During the two first months of therapy, he began each new topic or association with an anxious smile, shaking constantly his right leg and drinking water throughout the sessions. His thoughts were always logical and well-structured and his speech was often intellectualized.

History of Present illness

 Mr. M.’s first feelings of depressed mood and anxiety began during his childhood. He stated that he was a lonely child and that he used to invent a fictional character with whom he would talk with a language he had invented. At school, he was diagnosed with ADHD and when his parents were told about it, they didn’t give much consideration to it and no follow-up was pursued. Instead, at home, he was severely punished (physically and verbally) by his father for his behavior. For example, when Mr. M. wouldn’t be able to stand still at dinner time, his father would hit him and deprive him of food for the rest of the evening. His mother wouldn’t try to protect her son, and the physical/verbal abuse would go on over the years, until the patient was 19 years old.

At the age of 11, a significant person in his life, his uncle (from his mother’s side) died and the patient recalled being extremely depressed after that event. He mentioned that the way his father told him about his uncle’s death was traumatic because he sounded dry and no one ever talked about that event afterwards. As a kid, he was bullied and beaten by his peers because he “was chubby and short” which led him to believe that relationships with others were insincere and threatening.

At 13 years old, Mr. M. started drinking socially (daily one bottle of wine) two to four times a week. He would use alcohol especially before meeting people and he is now abstinent for two years. Mr. M. mentioned that he used to drink in order to self-medicate. From 14 to 17 years old, Mr. M. used to cut himself (he would self-mutilate on his stomach).

Since his teenage years, Mr. M. presented with mood swings that would occur during the same day or every three to four days.  His low mood is characterized by the following symptoms: anhedonia, decreased energy and attention, hopelessness, increased sleep, low self-esteem, social isolation and boredom.  He stated that “Most of [his] life, he was playing the role of a clown” hiding his pain. He mentioned that although he doesn’t have suicidal ideations at the present moment, he has a fascination with the idea of death. He also has had periods where he felt euphoric (hypomanic), with an increased desire to socialize, decreased sleep (he would sleep at 6 in the morning), increased energy (he would write or create music). Usually that state can occur during the same day, mixed with a depressed mood.

Two years ago, the patient tried to commit suicide twice (with alcohol and medication) which led to his hospitalization. He was treated with different medications and was referred to an outpatient unit for his addiction, where he was attending individual therapy. The patient is not taking any medication since the beginning of the psychotherapy with me and he shows resistance to the idea of restarting a pharmacological treatment that would make him feel “not like [himself]”.

Mr. M. mentioned that he is extremely anxious and “paranoid” socially and that he tends to avoid social situations, which leaves him painfully lonely. A year ago he used to have a full-time job in the warehouse of a tee-shirt company for 8 months and he describes that he constantly felt extremely anxious to the point where he had many panic attacks before going to work.

Personal History

Mr. M. was born in Italy. He is the youngest of three children. He has an older brother who is 26 years old; his sister is 23 years old. His father works in a company and owns a soccer store in which the patient’s brother and sister work. His mother used to work in a school many years ago.

Mr. M. mentions that during his childhood, there were major conflicts between his parents as well as with his father who was physically and verbally abusive to him. He describes an absent mother, busy with helping her own family out. He considers his father as being a “fascist”. Therefore, the patient never felt close to his parents. Mr. M. also stated that as a child, he always believed that he was adopted.  In school, although his grades were poor, he was able to finish his high school in due time and got a certificate in film production. He currently has one close friend besides his sister. He has been single for the last 9 years and has had one romantic relationship when he was 14 years old that lasted one year. He mentioned that he felt betrayed and used by his ex-girlfriend. This would appear to repeat itself in his current object relations as people are routinely described as taking advantage of him.

During his free time, the patient enjoys writing poetry, novels, as well as lyrics for his songs.

Key Psychodynamics

The patient was followed by me on a weekly basis for a total of 22 sessions. After the first two assessment interviews, I came up with the following psychodynamic formulation: Mr. M. was born into a home where considerable tension existed between his parents. The mother’s lack of nurturing feelings impaired the early infant-mother bond with the result that the patient has felt a lifelong sense of disconnection from others, depression, anxiety, feelings of worthlessness. Unfortunately, these feelings were aggravated by his father’s abusive attitude towards him. The rage he felt towards his father was repressed. He unconsciously turned his rage against himself by harming himself, self-mutilating, etc. It seems that lacking a positive identification with his father, Mr. M. has instead introjected a sadistic and bad father image that is critical, angry, and rejecting. By constantly criticizing and attacking himself, he maintains the masochistic connection to his father. It seems that Mr. M. considered his maternal uncle as a good father image and that losing him was extremely devastating to him. It also seemed to me that he lacked a “good-enough” environment that could have led him to construct a solid sense of self as well as a feeling of existing.

I admired his incredible capacity to create a world of his own in order to protect a part of his self against the chaotic environment in which he grew up, to maintain a sense of sanity. He questioned whether he was adopted as a child: he probably thought that it wouldn’t be possible for parents to treat their child the way he was treated. Very early in his life, that split between the reality of life and his own fantasy world, helped him somehow survive in a cold and unloving environment. Unable to turn to his parents or to anyone else who could have contained his painful feelings, the patient’s anxiety increased considerably to the point where he was diagnosed with ADHD when he was in school. He turned to alcohol as a way to numb his internal pain. It seems that underlying his incapacity to concentrate and his hyperactivity, was a deeply rooted depressive state associated with his anxiety that came from his early traumatic childhood years.

I tried as much as I can, while working with Mr. M. to avoid diagnosing him which would have had the effect of impoverishing my capacity to think, to listen fully to him and to be open to what Jacques Andre called “the unexpected” in session. However, I would only like to highlight that it seems to me that Mr. M’s core conflicts are pre-Oedipal resulting from fixation at an oral level (which might explain his use of drugs and alcohol). The patient seems to be oscillating between a schizo-paranoid position and a depressive position as described by Melanie Klein. The paranoid-schizoid position is considered the state of mind of children from birth to six months of age. This position develops into the next position, the depressive one. Mr. M. seems to be moving back and forth between the two positions. Paranoid refers to the central paranoid anxiety, the fear of invasive malevolence. In this position, the ego deals with its anxiety by splitting off bad feelings and projecting them out. Schizoid refers to the central defence mechanism of splitting between good and bad objects. This has led Mr. M. to partially develop a diffuse sense of identity. But Mr. M. is also capable to tolerate in him the expression of depressive affects. His main defenses against his paranoid anxiety and his aggressive wishes are essentially manic defenses, splitting, masochistic as well as obsessive defenses. His principal strengths are his intelligence and his remarkable creativity.

Mr. M.’s trauma is relational, particularly in relation to his father. It was therefore important to focus on the therapeutic relationship, to provide him with a “good-enough environment” so that he would be able to trust someone who was willing to listen to him and to care for his internal world. Because of his career choice (writing poetry and music), it seems that Mr. M. was asking to be heard/seen and that he was looking for a relationship with a person of words (like himself) unlike his father who seemed to be a person of action, always belittling his writings. The patient has a good insight about his inner conflicts.

During the first 2 months of therapy, the focus was on not only trying to build a “good enough” working alliance with Mr. M but also bringing him to make a link between the experience of his father as being a “fascist” and the way he has introjected his father to the point where he adopts such an attitude towards himself.

      (Third session)

Mr. M.:  “Coming here makes me anxious. I was thinking about something to talk about. I feel like I don’t have anything to talk about and eventually I will be wasting your time…as if I wasn’t that important…”

D:  Last time you mentioned that everything coming outside of you (music for example) was bad and today you’re telling me that you have the feeling of being worthless…where does this come from?

Mr. M.: Probably from my childhood. Maybe we should start there, when I was 11 years old... My father would hit me a lot. There were no explanations about the punishments. I was mostly afraid of him. I needed to internally kill myself to grow. My mother put her own family before us. She has 5 sisters and a brother. She needed to help. She wasn’t there for us but you grew to accept it. What else could you do? I’ve accepted it.”

I was curious about that sentence he said quickly...”I needed to internally kill myself to grow”. But in my countertransference, I tried as much as I could to let him be without questioning him too much...I didn’t want to sound intrusive. However, I kept that strange sentence in my mind, tolerating doubts and ambiguities in me. I made a link with his fascination with the idea of death and how for him, in order to live he needs to kill something in him...Does he need to kill the wounded child in him in order to grow? Is it also an intolerable pain inside that he tried to attenuate or to kill/numb for so many years by using different types of drugs and alcohol? In supervision, we discussed how it seems that there’s an intellectual acceptance for what he went through, an irreconcilable sadness in him. He never had a sense of safety. Therefore, It was important to make interventions that show interest and represent empathy of how it was like for him when he was 11 years old not being able to predict his father’s behavior.

And then slowly, he felt less anxious, opening up. On this particular session, the 5th one, he would mention how when he creates (music or poetry), he would need to use a pseudonym.

Mr. M.: For my music and writing, I use a different name Nate. J.

D: Could you tell me where that name comes from?

Mr. M.: “I always liked the name Nate. It reminds me of autumn. I love forests.          J. is like something coming to life “germinating” being productive. Nate is an escape from myself.

D: “It’s also like a nascent part of you. As if you have the impression that nothing good could come out of you/your name and that might explain perhaps the need to create a new name in order to be productive. As if Mr.M. couldn’t be the one creating”.

About his constant need to apologize for everything:

D: “How can we understand it?”

Mr. M.: “with my father, there was no explanation, only punishments. He never treated me like a human being. It was a very strict dysfunctional environment to the point where I even started apologizing for being”.

D: “It must have been very difficult for you”.

Mr. M.: “I always felt sadness inside. It wouldn’t go away. And I couldn’t concentrate. I would read and read but words wouldn’t come to my mind…I guess I was too sad to concentrate. And I kept it to myself because I really didn’t know who I could trust. Everybody seemed unreal and false. I’m trying to trust you”

D: “How did you want to concentrate with all of these emotional difficulties?”

Mr. M.: “I couldn’t…I felt depressed all of the time as a kid”.

Two week before Christmas Holidays, (we were at two months of therapy) he started feeling sad and was sensitive about the vacations, our separation.

Mr. M.: “Ultimately our time together will end and I feel that depending how much I open up, what is it gonna change? All the friendships I’ve had when I was young ended, my uncle died when I was 11 years old, it’s difficult for me to get attached to someone. The idea that it’s gonna be over is frightening”. You know, my favorite book is “the Little Prince...it’s a book I loved reading when I was a kid.”

D: “You probably remember then when the little prince met the fox. Even though they were going to part, the little prince accepted to be tamed by the fox and he became unique in the world to him…Perhaps it is difficult for you to get attached to people because of the fear that you might lose them but then you don’t let other people get closer to you”.

We both sat there...in silence for the last five minutes of the session. I felt that Mr. M. was touched by my words as much as I was touched by his silence and the deep look I saw in his eyes. I imagined him, as a child, talking to himself with the language that he had invented for himself and telling himself stories...and suddenly he brought up the Little Prince living in another universe, not getting attached to anyone but discovering the world alone. Here we were sharing a story together... And it was another way for me to be empathic.

The week before the holidays, he was almost silent during the whole session and he spoke about his feeling of loneliness, of not belonging anywhere. I respected his silence because it seemed to me that it was a defense (he was closing himself up) against the pain he probably felt regarding our separation, a defense I felt I had to respect. Mr. M. had been informed numerous times of my absence over the Christmas holidays. However, during the holidays, he came to his appointments twice, although I wasn’t there and he left me a message, each time, apologizing for having forgotten. The supervision helped me realize that it is possible that the clinic environment had become a kind of womb to him, a safe space in which to be and feel nurtured.  

The week after, session 10, he apologized for coming while I was away, mentioning how depressed he was during the holidays.

Mr. M.: “I’m sorry about what happened. I forgot that you were going to be on vacation. I came and I waited.”

D: “I’m really sorry you came and waited and then left. But maybe we can take some time to understand what happened?”

Mr. M..: “I have no idea what you mean…I don’t know…don’t these things just happen?”

D: “Maybe before the holidays you were talking about how difficult it was for you to get attached to someone and during our last session you were silent and sad. Do you think it has anything to do with the separation during the holidays?”

He stayed silent and then said…

Mr. M.: “Did you go away?”

D: “You’re wondering where I was maybe while you were here waiting for me...”

Mr. M.: “When I came I wasn’t angry…You would have been anywhere not necessarily on vacation”

D: “Anywhere but here”…

He laughs and said “yeah I can’t believe I forgot”

And he changed the subject...I didn’t want to interpret further what had happened during the holidays. I respected his need to switch to another subject.

Four and a half months after the beginning of the sessions, Mr. M. felt more comfortable, he stopped deprecating himself and became more assertive with others. He applied to a job in a library and sent a copy of a book he wrote lately to an Editor. We started working on his depressive side, “true self” (Winnicott) in relation to the mask that he wears sometimes.

12th session

Mr. M.: “I remember once I was speaking to my mom about the sadness I feel inside. She didn’t answer me. Maybe she thought it didn’t matter. I asked her where does sadness come from? Don’t laugh, it’s embarrassing”

D: “Well I think that’s a very deep question”

Mr. M.: “Well, I was a very serious kid. I asked her how come I wasn’t as happy as my friends. And she didn’t answer. I felt alone and that my feelings were disregarded. But Mr. M. and Nate are the same person. Nate writes, sings, so that’s the mask, the fantasy world. But that person can also be sad. They interact with each other. It’s the same Me”

D.: “Then it seems that the need to create Nate apart from Mr. M. was a way to protect your self.”

Mr. M.: “Right, maybe in order to survive, I had to separate these two parts. Mr. M. needed Nate. What people want to see is more of Nate.”

D.: “But here sometimes, I see Mr. M. too...like right now.”

Mr. M.: Maybe Nate prevented me from going insane in an insane environment. I had two choices…to go insane or to protect myself. Mr. M. is extremely vulnerable and Nate had to protect him. I don’t like people to see me sad…with you It’s fine. I know you won’t judge me”

D: “And I would like to get to know more the wounded and sad child that you hold inside you and to discuss with you about where sadness comes from…”

After 5 months, the transference has slowly changed and became intensified. Mr. M. asked me more and more personal questions. At the end of the 15th session, he asked...

Mr. M.: “There’s something I’ve been wanting to ask you but I keep on forgetting because it’s probably not important. Am I your favorite patient?”

D: “What makes you ask that question?”

Mr. M.: “The method is very interactive, very comfortable. The other therapist was old and I would just sit there and she wouldn’t talk much. It was helpful but I don’t remember what I learned about myself. I just became less introverted. I’m just wondering if I’m your favorite patient.”

 After that session, I felt lost...not knowing what was underlying his question. Supervision helped me see that perhaps what he’s asking in the surface is if I will be able to handle him, to tolerate his strong feelings for me. But in his transference, at a deeper level, perhaps he was asking me if he was my only patient? If he was unique to me (like the Little Price and The fox became unique in the world to each other)? Maybe he was also asking if he was only a patient to me?

The next session he said...

Mr. M.: “I had too much coffee today. I tried those Caramel Macchiato at the Starbucks aren’t they delicious? I don’t really go to the starbucks I wanted to try today. I got a look from the server as if he was telling me “Isn’t that a feminine drink?”

D: “Last time, I had a starbucks coffee with me”...

Mr. M.: “Yeah, I’ve noticed that. But it has nothing to do with you (laughs). I was just there by coincidence. I remembered your drink and I said “Am I not allowed to try one?” There’s nothing there really. I’m getting a car next week….

Again, I respected his need to change subject, without insisting on interpreting the transference.

Then on the next session, 17th session he started the session by referring to the movie “A dangerous Method” which has an explicitly sexual content. He was stimulated by the relationship that Jung had developed with Sabina Spielrein and wondered how that would affect a psychotherapy.

Mr. M.: “I always found it strange that it’s one sided. It makes me feel uncomfortable at times. Spending lot of time with somebody and knowing nothing about them. It’s uncomfortable and strange. I understand that’s how it’s done. I know because I saw that movie twice. Nothing worked because there was no boundary. It wouldn’t be effective to break the barriers. Do some therapists do that or is it conventionally a patient/doctor relationship? In the movie, it becomes personal maybe too close, acting on the desire and it becomes dangerous. So there’s always a barrier.

D: “So it seems like a part of you would like to get closer to me but there’s another part that knows about the barrier…perhaps there’s some kind of frustration there?”

Mr. M.: “I did that in my first therapy. I asked her personal questions and she said:” sorry that’s not how things work”. I just wanted to get to know her it was really frustrating that it was only me. I wanted to build a friendly relationship not like in the movie because it’s more romantic. I notice you didn’t answer my question. Fine I’ll drop it it doesn’t need to be answered. I also think that my opinion doesn’t matter because…

D: “Actually it does matter”.

Mr. M.: “The lack of barrier destroyed her… I tend to deprecate myself all the time. I’m a stupid person (laughs). Ok, I’m not funny.

D: “I find it difficult to laugh when you deprecate yourself".

Mr. M.: “Yes you’re right I should stop making fun of myself. I’m working on it trying to find some tranquility inside, some peace inside.”

He was questioning the fact that It’s a one sided relationship and that maybe, he would like to get closer to me the same way he wanted to get closer to his previous therapist. However, he seemed able to recognize the utility of the barriers between us while at the same time a part of him wished to cross them. I made him realize that I took what he was saying seriously, and that talking about the transference is completely different from acting out on it… that his questions were welcomed and that it wasn’t about answering them but rather elaborating on the ideas that were coming up to his mind.

The month after, he finished recording his second album and he said:

Mr. M.: “For my father, I felt my choices in life don’t mean anything. Every time I try to create something, he destroys it. But I wouldn’t be able to create this album if I didn’t think it was good. I like what I do, not everybody likes it but it’s fine.”

D: “What’s important is how you feel about it and that it’s a real experience”.

Earlier during this session, he was telling him how his dad used to deprecate his artistic talents:

Mr. M.: “Once my dad slammed the door on my face and he said “you don’t like art” and this in the beginning of this year not when I was 6 or 8. He knows I write and I like music. He knows it was my decision in life to do this. I found a T.V. on the side of the street so I took it. I wanted to do something with it. He started yelling that he doesn’t want it in the house. He took it and threw it out of the house. And then I went to go and get it back. As I was coming back he said “you don’t like art” and he slammed the door on my face. Who talks to somebody like that? Plus I am his kid. Who does that to their own kid? Knowing that this is what you kid wants to do for the rest of his life. You’re basically shutting the door on this kid’s dream, literally. Just because my interests are different than his”.

For the first time since the beginning of the sessions, he was capable narcissistically to value his own work, independently from what his father used to tell him. I tried here to positively reinforce his Ego.

After 6 and a half months, the end of March, he started worrying about the end of the therapy because he was leaving soon to pursue his studies abroad.  When asked about how he felt about it, he said that he felt “heartbroken”. And he went on, mentioning that he is interested into a girl and that he would like to ask her out on a date. It’s as if the transference switched into a lateral one in the sense that he displaced his wish to get closer to me into his relationship with that other girl. In supervision, we discussed the fact that he is now facing a mourning process (soon anticipating that he will have to leave his therapy with me).

Mr. M.: “I feel I’ve been stuck in a shelter for a long time and any knock is terrifying because It could be everything you ever wanted right behind that door. It’s so sad…”

D: Terrifying?

Mr. M.: “Because at the same time it’s lonely in there. I’ve been feeling lonely for so long. And it’s not safe to be lonely. In the shelter it’s safe but loneliness is not safe. It’s comfortable. Sometimes too comfortable but that’s not safe that’s dangerous coz you could get hurt. Just the act of being alone is hurtful. When I’m around people I like I tend to push them away; It’s more not letting them in. I stutter a lot, I shake. I feel I’m gonna feel so much that I’m gonna scare her. Being myself would scare her away".

D: “It seems to me that you try to be involved in a relationship with others, but you find it frightening, and you make yourself safe by moving away, by making distance from them. So there’s a constant movement back and forth with you never being content in either place.”

Mr. M.: “I’m not happy in the shell, not happy outside the shell. I just don’t know what to do, how to be. It seems so easy for other people to be happy and to just be; what is it that I don’t understand?”.

He finally was able to ask her out but the day of the meeting they were supposed to go and have a coffee, she sent him a message telling him that he could join her and that she’s with her friends and...her boyfriend. He stated that he doesn’t understand how come she didn’t tell him about her boyfriend although, according to him, he was clear enough to let her understand that he was asking her out on a date. This situation where it’s not very clear about his appointments has happened many times in the past.

The last three sessions, he was depressed and I felt that he closed himself. I tried to see whether it was related to the end of the sessions in July.

D: “I’ve noticed that the last few sessions you’ve been starting the sessions by saying that you have nothing to say. Do you think that it might be related to the fact that we’re finishing in July and that you might be closing up?”

M.: “it’s not entirely wrong but I’m starting to feel better about being assertive with the people that I know.  But I have nobody I actually talk to about anything deep. And even if I had someone close I don’t know if I’d feel comfortable to talk about these kinds of subjects. I’m more assertive in the sense where I would be the one making plans.”

It seems that Mr. M. recognizes that he is still in a state of despair and loneliness at times, able to tolerate depressive feelings in him, and that he struggles with how to be with others in social settings...However, he is stating that despite that, he is asserting himself more and putting himself out there in an effort to connect with others in spite of his anxiety. It seems that he has started doing this partly from the increase in sense of self and the slow repairing process to his ego that he has acquired from psychotherapy with me.