Tuesday, July 29, 2014

small study in psychosis

A psychotic patient began treatment with erotomania. There was a man in her building who was her "husband". She initially talked about her comfort with him and that they liked the arrangement of living in separate apartments and having some space between them, but that they would one day live together. After a month or so someone appeared, "the enemy," who was trying to interfere with the relationship and bring up a man that she had been intimate with. Soon the husband dropped out of her sessions but the enemy grew in power. My patient said she used to be able to lose weight just by picturing herself as thin and the enemy wasn't letting her and was putting bad thoughts in her head about her ugliness and obesity. In her 'private language' the enemy was trying to "put a statement on her" and she feared to talk about many things because it would attract the enemy. 

Alot of the therapy involved 'holding statements' that tried to capture her ontological position and expressing frustration on her behalf. 'What made the enemy chose you?' 'You can't escape the enemy, you can't even talk about them, and so you're stuck with this curse you did nothing to deserve and just have to wait in your house alone and don't get to have a life'.  

Soon she was able to get angry at the enemy for choosing her and interfering with her life. This opened two avenues. The first was father-substitutes from the past. Doctors and police officers who mistreated her came up in the sessions. She couldn't talk about what happened for long before experiencing thought-blocks and we would sometimes sit in silence for minutes. Additionally, a volar triangulation appeared. Her neighbor's apartment was sometimes growing and encroaching into her apartment. Her neighbor, a woman, was "a whore" in my patient's delusuions and sometimes her pimp would be by and my patient didn't like it. The enemy still appeared during this time and her anger at him or her continued and the angrier she got the less the enemy appeared in the sessions. 

The next and last development (before I moved and had to end treatment) was that her neighbor, the woman, sat beside her and she was fearful that others would think she was a lesbian. At this time the husband (erotomania) was no longer part of her delusions and she was also expressing worries that she would always be alone. She also no longer mentioned her magical abilities to wish herself thin and was talking about practical things she was doing to lose weight. Her neighbor's apartment was no longer encroaching on hers and her concern was whether she should stay at home in her apartment or whether she should go out more. 

She was still in fear of someone putting a statement on her and still paranoid about others in general but in a few months there was a palpable change in the content of her delusions and her desire for engagement with the social body. Also very important was a change in her facial and ocular armoring. Many psychotic people have mask-like faces and far-away eyes. Her eyes opened significantly more and became much more bright and haunting. Also, in her moments of silence, expressions of pain and sadness began to show up in her face. 

I also have to say that I experienced some of the worst projective identification with her that I've ever experienced. I was fine with my patient before and my patient after, and I also had a colleague who was able to vouch for my feeling with this patient. She was able to suck all of the energy from you. My eyes would grow very heavy during the session and I wanted to escape into sleep.

She wasn't the first patient I've had this feeling with but was the one I felt it most strongly with. I did ask her at some point if I should be feeling tired and sleepy during one point. She smiled and said no, and I couldn't tell if her smile was meaningful or not. The strength of my objective counter-transference changed soon after but I don't know what this came from.  

I wasn't sure how to conceptualize this sleepiness. Was she putting her bad conscience into me and I wanted to process it by escaping consciousness and going to sleep? It was clear that with her "whore" and lesbian neighbor that she was avoiding bad conscience. Additionally, in out last couple sessions she began to give me advice for my life and she had a low ego ideal/deutero fixations that seem to be a necessary part of projective identification defenses. 


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