Case Illustration
Robert, a tall, lanky 23-year-old in his final year of college, walks tentatively into the office. He looks worn down and defeated, and when asked, “What brings you here?” he responds, “I feel like I’m not really living life” and goes on to say, “It’s like I’m just going through the motions and struggling to get by … I’ve felt this way for a long time.” He carries himself a bit hunched, as if in a permanent protective stance, a shape that also suggests he is trying to minimize his presence in the world. His speech is clear but slow and methodical, with little inflection and revealing little affect. He feels stuck in terms of what direction to take in his career; he is considering becoming a teacher or a creative writer but can’t decide which to pursue.
Robert describes himself as socially isolated: “I keep people at arm’s length; I really have no social skills.” He lives with roommates but detaches himself from them. He was a straight-A student in high school and has continued this in college, and prides himself on his academic success. However, early in the treatment he underscores that such success is a protective cocoon for him, a zone of security that shields him from feelings of intense failure in the social and relational realm.
Although he identified as heterosexual, Robert never had a romantic relationship. He describes himself as shy and socially withdrawn, and I learned that he fears being assertive or enthusiastic because others might not like what they see and reject him. I reflected back to him that “it’s safer to remain aloof than experience derision and abandonment.” He also fears he would exhaust others or they would see him as selfish, a “pest,” “crazy and irrational,” “weak and vulnerable,” and “draining” if he asserts his needs or shows his enthusiasm.
He was dyslexic, and he stuttered as a child, something that contributed to his social reticence because his peers frequently teased him for being a “moron.” While no longer a frequent occurrence, he still stutters on occasion and fears stuttering, especially in intimate relationships where emotions come into play.
As we explore his state of depression and apathy, he states, “I won’t let myself be happy, it scares me.” I suggest that he may actively snuff out flickers of happiness or hopefulness lest he experience unexpected loss or rejection. As I listen to his descriptions, I conjure up an image of his life as a flat line highway, punctuated only by dips into anxiety and depression, with any upward slope into joy quickly diverted back into featureless desert-like flats, or, worse yet, into chasms of darkness and isolation. When I share this image, he nods in defeated agreement.
Consistent with a developmental-psychoanalytic approach, I explore Robert’s recollections of his childhood. While growing up he was close to his mother. He adds that she was concerned about his “depression” and encouraged him to go into therapy when he was 14 years old and then again a year ago, which lead to his finding me. During his childhood he saw his mother as generally calm and attuned to his emotions and needs, but she also displayed occasional angry outbursts, mainly in response to her frustration with his “emotionless” father. He elaborated that his father was a very reserved person who did not show emotions, was generally pessimistic, and had a touch of paranoia about others.
In our second session Robert tells me of a seminal event, one that he experienced with such shock and intensity that his “whole world crumbled.” He was about six years old when his parents announced their intention to divorce. He described vividly how he was in his basement playing with the train set his father had given him and assembled with him several months prior. He was playing alone, feeling secure and happy when his mother called him upstairs for a family meeting. His parents explained to Robert and his 12-year-old brother that they were splitting up; they took pains to emphasize that it was not the children’s fault and that things would be okay. Robert sat and listened in shocked silence, trying to make sense of the chasm that he felt widening beneath him. Sometime after this event, perhaps days or maybe weeks, he recalled an unrelated incident. He was crying because he was upset about something, and his brother pulled him aside and admonished: “Don’t complain so much, mom and dad are going through too much already, you’ll just upset them more, especially mom!” Robert took that advice with utmost seriousness for years to come, carefully shielding his family and then others from any display of emotion.
Curative Factors in the Treatment
I will now take a step back and consider Robert’s presenting complaints—depression, social anxiety, isolation and lack of social skills—and focus on the curative factors that I believe were operative during the course of four years of weekly psychoanalytically oriented psychotherapy. There are six therapeutic techniques that I believe were critical to the process which led Robert to a greater sense of comfort and security with the spontaneous expression of emotions in both work and relationships. They are:
1)
I provided a supportive, affirming, and containing environment in which I pointed out signs of hidden, protected emotions and desires;
2)
I helped Robert embrace both sides of the underlying wish to “live life” and connect to others. That is, I helped him to own both his longing for contact and his wish to isolate himself in order to protect against the loss of intimate contact;
3)
I explored the texture of his early attachments and critical events in his life, including how, as a child, he managed his desires and feelings; I helped him understand how, as an adult, these early adaptations shaped his approach to himself and others and constricted his relationships;
4)
I cultivated an environment in which expressing transference feelings was acceptable; I helped him connect the transference to internalized expectations of others formed during his childhood;
5)
I encouraged him to share dreams and memories in order to reconstruct his childhood, including the expression of long buried feelings, including anger and grief; and
6)
I used my intuition, formed through immersing myself in Robert’s internal experience, contemplating the nature of his transference projections as well as my countertransference thoughts and emotions, to guide me in responding to rigid enactments of old, maladaptive patterns.
This final mode of engagement had power in part because it shifted the frame, contained a personal signature of the therapist (see
Stern et al., 1998), and modeled the open expression of affect that Robert had long disavowed, including fear, anger, joy, and an appreciation of intimacy. I will attempt to demonstrate how all of these therapeutic factors were key to Robert’s improvement.
During the first three months of treatment, Robert arrived at a number of crucial insights though primarily using the first five modes of intervention. These included understanding that his social detachment was in large part rooted in his relationship with his parents and his brother, including the traumatic event of their divorce, which led to making himself “as small as possible … I try to make as few waves a possible,” including never asking professors for assistance and never asserting his needs in relationships. He desperately wanted to ask questions in class, but instead made himself “invisible” because he feared he would exhaust the teacher or annoy other students with his “selfish questions.” In addition, he feared that his professors would not want to waste their time on him, or if he did open up with a question, “they’ll chip away at my façade of knowing everything.” In this instance, I helped Robert to see the protective grandiosity of pseudo-omniscience he had constructed, which allowed him a measure of self-preservation but at great cost to his being known and seen.
This dynamic of shielding others from his feelings and needs for fear that he would overwhelm them with his intensity, or, at the other pole, isolating himself from intimacy for fear that others would overwhelm him with their endless needs—the classic “schizoid dynamic” (
Guntrip, 1969)—was most evident in the transference when he asserted halfway into a session “you must be exhausted by me, trying to draw me out, trying to understand me.” I responded, “You feel I’m exhausted, can you say more?” To which he said, “Yes … I think you don’t really care about me, you’re just waiting to get through the session for your next patient.” I responded, “With me too, you feel that your needs are too much, much like you feared overwhelming your parents with your needs and feelings after they divorced.”
In fact, as we explored his compromise to attachment, he veered toward assertions such as “maybe I’m different than other people, maybe I really don’t need anyone … Yes, I think I’m self-sufficient and that’s just how I am.” Such assertions emerged with vitality in the transference when, in the session after I had been away on week’s vacation, he stated “I think I should come every other week. I’m just too busy and I don’t think it’s worth it to come weekly.” I pointed out how he was perhaps retreating from appearing to need me as a response to my being unavailable for a week, and how that perhaps his assertion of independence and sudden improved functioning was a cover for more vulnerable, but less acceptable, feelings of dependency. While he outwardly rejected my interpretation, he agreed to continue to meet weekly. By reframing his intentions to cut back and asserting my commitment to him and the treatment, I passed his unconscious “test” of whether or not I found him strange and draining and reassured him that I would not slowly abandon him (as he felt so many others had).
While at times it seemed his desire for security so dictated his actions that it blinded any awareness of his need for attachment, rudiments of his wish to connect were not difficult to point out. I nearly always did so with a caveat to the vulnerability that this desire entailed and how it made sense that he might feel the need to deny such strivings. About nine months into the treatment I drew upon a metaphor that kept nagging at me as I listened to him. I said, “it’s like you have a warehouse of thoughts and feelings, and when you venture out into the world you leave them all behind, with heavy steel doors keeping the contents concealed; you won’t show people what’s inside, because you’re afraid they won’t care and will ignore you, or if they do care they’ll soon find your needs overwhelming and give up on you.” He embraced this metaphor and expanded upon it, stating, “yes, you’re right, it is like that, but I think that if I actually open up the warehouse to someone, all they’ll see is an empty cavern.” In response to my gently pushing back to remind him of his emerging awareness of sequestered emotions and needs, he conceded “well, maybe it’s not completely empty, but I’m afraid that all I have to show is junk.” The shame that he experienced about exposing his needs, emotions and desires was palpable, and I often came back to reminding him of how shame overwhelmed him and caused him to retreat.
I felt we were on track as Robert shifted towards increased ownership of his conflicts and needs. He allowed himself to become immersed in and was willing to examine the transference relationship as a means of understanding his approach to himself and significant others. Supporting evidence for this trend came about 10 months into our weekly sessions when he relayed the following dream:
I am coming to your office, but when I walk in the building instead of coming the usual way I go past the third floor[my floor] to the attic [the floor above mine is attic-like]. I’m lost, I can’t find my way. It’s dark and I can barely make out old boxes filled with stuff stacked and scattered all over the rooms. Cobwebs are covering everything. I can tell that no one has opened the boxes for a long time. I’m thinking I can’t find my way to your office, but I’m also not sure I want to. Then I notice that there are wire fences creating a maze of rooms, all of them with boxes filling the floor space. I don’t want to open the boxes, there’s so many and they are covered with dust, and I weave through the different rooms and finally see a light and an opening, and I arrive in your waiting room. I’m anxious as I wait, sitting there all alone, staring at your door, not sure I want to be here, waiting for you to open your door.
He had few associations to the dream but was curious to learn what I thought about it. My interpretation focused mainly on his ambivalence about exploring his emotions and past experiences (as represented by the dust and cobweb covered boxes filled with stuff from the past) and his ambivalence about getting close to me (the wire fences, being lost on his circuitous route to see me, feeling shut out waiting all alone staring at my door yet also not sure if he wanted to see me at all).
As the therapy developed over the next year of treatment, paternal transference themes were pervasive, particularly around his expression of anger and frustration with me for being “withholding” and emotionally unavailable to him. For example, in one session he said, with an undertone of longing and sadness: “I feel so alone … and I feel that you are withholding. I’m calling out, but you don’t respond. It’s like I’m in the middle of the ocean, and you’re a ship. You pass by me once a week, but you don’t offer me anything real…. It’s like you’re a wall, I’m calling out for help and feedback. Do I see the world correctly? Do others see me as I see myself? I get no answer.” In response I asked, “Is this a familiar feeling to you?” and he responded, “Yes … I’ve felt this way all my life.” We explored how at moments like this he experienced me as similar to his father; this exploration helped Robert uncover not only his longing for connection with his father but also his anger with him for being unable to reciprocate. Validating both his awareness of his need for connection and his courage to reach out, I emphasized how he was doing something different this time by actually calling out to me, revealing his need for closeness instead of locking himself in a voiceless prison.
Over the course of the next several months of treatment I helped Robert take ownership of his long-denied need for intimacy and feelings of grief related to many years of living in isolation. Across a series of sessions, he stated that he could more clearly see how he continually avoided social interactions and he revealed that he developed this, in part, during childhood as a way to fend off the cruelty of kids mocking his stuttering. I reflected and added the following, “you closed yourself off at the expense of never revealing your social nature, your spontaneity, your humor.” As I said this, a flood of tears, something that was rare for him to share with me, rolled down his face, and he said, “It sucks to have to hold back and hide myself … but I have to do it, or I think I do, ’cause I don’t want to be rejected.” In the next session we quickly and seamlessly returned to these painful, long-buried feelings, and he continued: “When I look deep inside, I despise what I see—a stupid, confused, scared little kid” and he recalled being relentlessly ridiculed as “stupid” when he stuttered as a child. I asked, “What would you say now if you met a child like that, one who was scared, stuttered, and felt confused and stupid?” He sat silently, reflecting upon my question, clearly conjuring up that little child he once was, and then a flood of tears cascaded down his face “I’d tell him to be mute … it’s not worth the pain (of reaching out)… I don’t, uh, he doesn’t have the resilience.” As I sat with his feelings of grief, shame and fear, which clearly registered on my face as tears gathered in my eyes, he momentarily shifted, and said, in a defiant tone, “Maybe I would say ‘it’s okay, I am human and I stutter, so what?’” But then he quickly retreated, saying, “I’ve hit a brick wall. It’s beyond my ability. I don’t think I can accept that scared, confused, stupid little kid. It’s like me trying to run a 4-minute mile. Some people can, but for me it’s literally impossible.” At this point I reminded him of a metaphor I had introduced several months before, about learning to swim after sitting for years on the side of the pool. Embracing the metaphor he asked, “Will you be there for me when I jump in the water, will you show me the way?” As the session came to a close he said “I want the swagger of self-confidence that you have.” I responded by noting that he, unlike the little boy, was not afraid to ask for help, and, therefore, had some of what he wished for. He agreed, but then added, “Yeah, I did, but it’s different because it’s safe here”.
While Robert had clearly made significant strides in his life, including developing his first romantic relationship, he continued to experience deep conflict about intimacy and emotional exchange. After about six months of enjoyment with his romantic partner, he started to feel suffocated in the relationship, and described feeling “like a fly in the wind” of her emotions and needs. He started to pull away from her and broke off the relationship. Similarly, the tone of the therapeutic relationship was increasingly marked by Robert’s frustration with me for not being more emotionally responsive and not offering him any “practical skills” or “homework.” He noted that he was still, after two years of treatment, experiencing great difficulty reaching out to peers and potential mentors. He insisted that knowing why he was afraid to reach out was insufficient to motivate him to act differently, and he asked for guidance and tools to navigate these interactions. In response, I began to feel confused by his persistent frustration with and wish for more from me.
While it took some time and a different approach (improvisation) for me to fully grasp the nature of the dynamic that was unfolding, in retrospect I believe that this was a mutually constructed enactment—My conscious attempt to be therapeutic by remaining calm, thoughtful and optimistic in response to Robert’s anger and requests only served to reinforce his expectation that people are emotionally unavailable. For his part, Robert was consciously asking for help but unconsciously feared showing me the emotional intensity of his need (by focusing instead on his need for practical skills). We were increasingly locked in a dynamic which perpetuated Robert’s perception that I was just like his emotionally aloof and dismissive father, and where I perceived his fear of intimacy as the major barrier to his seeing me as different.
It was about three months later, or two and one half years into the treatment, when I began to have a better handle on the nature of the enactment that we had unconsciously created together. In one session Robert proudly shared a success at work and, when I responded with what he characterized as a rather flat response, he let me know that he was annoyed at my lack of emotional display, even calling me “fake” and “withholding”. Crucial to this interaction was the fact that I was puzzled by his perception of me as fake and withholding because I didn’t see myself that way. In fact, I experienced him as predominately this way. As if providing support for my perception, in the very next session he came in talking about his goals for therapy: “to feel confident, to have energy, to have friends.” When I noted that he stated these goals with very little energy or emotion in his voice (here again, focused on the goal for him to be more emotionally alive), he agreed, saying “I have no inflexion or enthusiasm in my voice.” We then explored the shame that he felt about needing therapy, and he stated, “I don’t like that I need someone to help me go through my boxes every week.” I noted the paradox of his situation—the shame of needing someone kept him from being emotionally alive, yet only through being in relationship (with me or others) could he feel alive and reach his goals. He agreed, but stated that he was too afraid to need someone and impose his emotions on others, in large part because he feared being seen as stupid and would then be rejected.
At this point, Robert unwittingly provided me with an opportunity to respond to the growing enactment when he told me of a failed attempt to connect in conversation with a male coworker whose pregnant wife was about to give birth. He explained that the conversation fell flat and he ended up walking away as he did not know what to say to keep things going. He then made a crucial request: “Will you role play with me? I think if we did it might help me to develop the social skills I’m lacking.”
Here I might have engaged him in a discussion of how his failure to connect with his coworker was related to his continued frustration to feel connected to me on a deeper level; however, I did not see this path at the time. Instead, I followed my intuition and diverged from my typical path of exploring his internal and our relational dynamics. My growing awareness of his inability to engage with others with emotion and enthusiasm, combined with my puzzling over how and why he was frustrated with me for being “flat and withholding” and not giving him “tools” for social interaction, led me to join him in what I hoped would be a playful exploration of his challenge with emotionally connected interchanges.
In the role play, he asked that I play his coworker while Robert played himself. He approached me as he would his coworker, and, not surprisingly, our conversation lacked affect and direction, falling flat and ending in much the same fashion as he described occurred in real life. Our role play mirrored his real-world experience, with the result that he felt isolated, emotionless (recall his presenting complaint—“I feel like I’m not really living life … it’s like I’m just going through the motions and struggling to get by.”) Interestingly, I felt that I too had become a two-dimensional being, lacking the depth of emotion that I usually feel in conversations with others.
Curious to understand his experience of the role-play, I asked him to reflect on what was going on inside his mind at the time. He replied, “I totally spaced out … I lost interest and focused on other things.” He added, “I felt like I was
useless to you, so I stopped paying attention.” It occurred to me that this feeling might represent an intensification of the transference dynamic where he felt that I did not care about him, that I was a father who has more important things to do and who feels worn out by Robert. But instead of responding on this level I felt a draw to play this out in the transitional space of the play (see
Winnicott, 1971). I said, “Yes, I sensed that you were ‘spacing out,’ and it felt to me that you did so because you were afraid to make yourself vulnerable to your emotions … doing so would mean you needed something from me, that you were connected to and needed me. Perhaps that idea scared you, so you shut down and spaced out.” He agreed. Then I said, “Okay, let’s try it again, but this time I want you to focus on the emotional thread of the conversation, follow the feeling tone of the interchange. I think that may make a difference and help you stay connected.” He agreed and we gave it a try.
When Robert opened the discussion during our second role play
I shifted by intentionally letting my guard down. This shift was crucial and was the basis of what I believe constitutes an improvisational moment. I shifted out of my usual therapeutic stance and entered into the “transitional space” (
Winnicott, 1971); I became the subject, in a sense metabolizing Robert’s projected affects (fear and excitement) by “play acting” emotional vulnerability. I drew upon my own emotionally vivid experience of the mix of excitement and fear that I had anticipating becoming a father for the first time (which had occurred some 10 years earlier). In response to his question about how I (as his coworker) was feeling about the fact that I was soon going to be a father, I said, “Well, you know it’s pretty amazing, it’s something I’ve imagined for a long time, and I feel mixed, I mean the thought of holding a baby in my arms is just amazing (smiling widely, pausing while I recreated the image in my mind’s eye) … I can imagine my baby responding, smiling at me … I can almost feel them in my arms.” He responded, also smiling, “yeah, wow, that sounds really cool.” I continued “but at the same time I wonder am I holding them right, I’m kind of scared, wondering if I’ll get it right? … It’s such a huge responsibility … so yeah, really both of those feelings.” This time Robert was much more animated, a smile slowly washed across his face, he fluently engaged and we carried a back-and-forth conversation along these lines for several minutes, including, at one point, his empathic statement “that must feel really good,” smiling in response to my sharing my excitement about becoming a father. The transformation in his presentation, including the flow, emotional tone and engaged eye contact of the conversation, was striking.
In processing the role play Robert stated that it worked out much, much better. When I asked him what he did differently, he said, surprisingly, “I was thinking about experiences I had as a child with my parents, times that I enjoyed, and I thought of the qualities in them that I liked. That helped me connect on an emotional level.” He also noted that I was different in the role play, more emotive, and that made a crucial difference in his ability to attend and stay engaged in the conversation. Over the remainder of the session we explored some of the “new,” positively toned memories of his parents that emerged during the role play. Perhaps more importantly, he began to articulate his experience of me as more emotionally animated and how this affected him.
In the following session Robert said he was so affected by the role play session that he experienced an “epiphany” during the week:
I realized that I always rely on others to show some emotion before I feel safe to show my own emotion. I was driving in my car and I had this revelation while thinking about the role play and how it was only when you showed more emotion that I felt I could show emotion too. It actually made me feel angry to realize this pattern because I don’t like being that way—I don’t like depending on others to determine if I feel it’s ok to show my emotions … it was an epiphany because after realizing what I did I vowed to no longer depend on others before showing my emotions!
He went on to elaborate how he was intent on taking the risk to lead with his emotions in relationships. He had already started using the insight and motivation gained from our work, and to illustrate he said, “You know the coworker who you role-played? Well he plays in a band and I saw him play a few nights ago. And usually I wouldn’t say anything to him, but this time I went up to him and said, ‘you know, you were phenomenal,’ and he was really pleased. I felt really good telling him that, and I could tell he appreciated it.” The shift in the transference-countertransference pattern, sparked by my introducing improvisation into the relationship, clearly catalyzed in him a new self-experience, generated new insight, and infused him with a newfound investment in embracing his impact on others, intentionally “making waves” and relishing the results.