Monday, December 26, 2016

by request, some clinical examples for the previous post

One patient, Sarah, brings up how she missed her midterm because her son was sick and the professor wouldn’t let her take the exam at a different time. He also wouldn’t let her other assignments soak up what the exam was worth for her grade. She had taken this class twice before and failed it, this would be the third time. I ask her if she could get a note from the hospital and she said yes. I tell her that she wasn’t being treated fairly and she could either ask the professor about this in person or go to the dean. Sarah isn’t sure at first. She brings up worries about coming across as “rude” to the professor. Next session she begins by talking about how her boss scheduled a training for her during time she needs to study for her finals. She reports that she tried to tell her that she needed to study but she says her boss told her that work needed to be her priority and that she, herself, had been in college and worked at the same time, and did just fine. Sarah says she agreed to work, but as she talks about it, she shows frustration and angrily scoffs that school was her priority and not the “stupid job.” I ask her about talking to her boss and letting her know school is her priority and that she needs to study and not waste a lot of time and money on a failed class (or one with a low grade). Sarah again expresses that this seems “rude” and that she feels a resistance to saying something, but knows that she should. She then reports that she didn’t talk to the professor yet either.

Instead of “coaching” her, I ask her what would happen if she failed the course for a third time, and got a bad grade in the other course because of the training for her job. Sarah imagines that she gets frustrated with things and then drops out of college and doesn’t go on to become a nurse (as she wants to do). I ask her what kind of life she would have. She says she would have just a “normal, bum life” at a job she doesn’t like that doesn’t pay well. I ask for clarification about what “bum life” means and she says she’ll be “miserable, not have any money, not have a nice home, and no cool stuff” (she didn’t say this all at once. I constructed this list from all the things she said). I ask her to turn these into you-statements, about someone else from her past, and who comes to her mind (i.e. “you are miserable, you have a bum life, you have no money or cool stuff”). She reports that her mother comes to mind and talks about how her mother has been an addict and hasn’t really had a comfortable or stable life. I ask, “how does it feel if you say, I don’t deserve to have a better life than my mom?” Sarah says it doesn’t feel true, but makes a face as she says it. I clarify that people are made up of many different feelings and asks her if it feels true for a part of her. She agrees that it does and says “a little part of me feels bad for my mom.” She discusses how she’s “looked down on her” for a long time. She talks about how she would have liked her mother to have a good life so she could have been her “idol” and shown her how to have one too. She complains about her grandmother who raised her and how she “never proved anything” to client and was never her idol. She says that she doesn’t look up to anyone. She returns to talking about her mother, and as she does I notice that she often starts and then has to restart her sentences and that she’s making slips that show she is talking as if she is her mother or saying something about her mother that is really about her. She catches herself and corrects herself, but I use this as an opportunity to say that client sometimes feels like she should be the idol for others and like she’s become her own idol and taken the place of her mother. Sarah acknowledges this and brings up her desire to have a relationship with a “real man” and gets into some issues with her boyfriend.

In a future session, I ask her to return to her mother and talk more about her ‘bum life.” Sarah recounts how her mother would show up at her grandmother’s make promises and leave. She dwells on a particular memory of how she got to live with her mother for a few months and her mother brought home a man and she walked in on them having sex, and yelled at her mother, and how her mother got angry with her and locked her in her room. Sarah gets in touch with strong anger. I encourage her to say what she would have liked to say to her mother and she swears at her profusely. After this Sarah begins to feel some remorse. She begins to bring up how her mother had been really hurt by her father cheating on her and leaving her, and how she began to deal with this by drinking and sleeping with men. She begins to reprocess her mother as being more human and weak, and how by sending her to live with her grandmother, her mother was doing what was best for Sarah. In the session that follows, she reports that she called her mother for the first time in years and apologized to her. She establishes a relationship with her mother and also becomes more focused on her school work. She also reports that she has a cleaner house and feels more productive there and at work.  

Another patient, Glen, gets into his second motorcycle accident. He inherited a decent amount of money, bought a house, and several motorcycles. I ask him if he’s thinking about selling the bikes and he strangely responds that he told himself he’d learn to love motorcycles or “die trying.” I ask him to imagine he dies and to tell me who he thinks will be at his funeral. Glen mentions some family members and some others, and I ask him how people in his family might feel. He says they would feel regret, and specifically his mother. He says “she would beat herself up so bad. It would break her, tear her to pieces.” I ask “Does it feel true for a part of you if you say "I want to see my mom broken to pieces"? He answers in the affirmative and says she hasn't been the best mom. I ask for examples and he recounts the time she sent him away when he was 12 to live with his father out of state. He brings up another time when he called her to tell her the first time he shot up meth. He said that she initially seemed concerned but then she asked him if he had any more, because she wanted to get high. He also brings up when he was in jail and she never visited him (and adds that no one else in his family came either).

When we get to the affect, Glen initially reports feeling anger, but under this he gets to sadness and aloneness. He describes feeling “truly alone in the world,” and talks about how much his mother’s indifference hurt him. Then, after this, he gets to remorse, and feeling like he was “a brat” and always said he wanted to go to his father’s and that she probably didn’t know how to handle him. He then reports that he feels ‘peaceful and calm” like he never has, and not only did he not report any self-sabotage behavior for months after, but he also became more productive the week after the session and wasn’t procrastinating anymore.

Saturday, December 24, 2016

The economics of punishment and apathy in psychic bisexuality

We’ve now seen that the unconscious need for punishment shows up in two ways. In the first group, the death of the client is a punishment to uncaring parents, on one hand. On the other, it is an introjection of the absence of parental care or love-- an economics of apathy. It’s as if it’s easier for them to treat themselves with indifference than to recognize the parental apathy. In the second group, the loss of a good life and children is a punishment the client feels they deserve because they tried to do this to a boyfriend who himself represented the earlier relationship with their mother. At the same time, there is a noticeable longing for a strong parental figure who would in turn show them how to be strong or give them power.

I think this pattern is best understood in the binary of passive-aggression and what I call active-affection. We are all familiar with passive-aggression. In the examples, causing one’s death to make one’s parent feel remorse is surely an example. Also some echoistic patients forget to do things in a passive-aggressive way, but one that, is unconscious. In contrast, the passive-aggressive mother who tells her kids to go out and have fun while she sits at home all alone, is often a more self-conscious version that I see with (object) egoists.

A more general example of this trend in the personality is in misanthropic echoists. They defend against wanting approval or to depend on others and will come into groups and tell others that people are rotten and untrustworthy. I would call this passive-egoism. There are many narcissists who don’t trust others either, but they are much more covert about it and don’t have to convince others about it, in order to believe it themselves. 

In contrast, active-affection is seen in the personality when you have narcissists who are generous to people in their family (and sometimes someone outside of it) in order to keep the beneficiaries in their power. If they act against the narcissist’s desire, they can be quickly cut off, or become recipients of his or her vindictiveness. However, there are (object) echoists who can be vivacious, charming, and fun with someone so long as they think the person is popular, cool, or has some prestige. But they can quickly lose this affection when the person isn’t deemed as important or special. Again, the first group isn't conscious of their active-affection and will say they love their children.  

In a more general example, there are active-altruists who identify with certain bosses, educators, leaders, or ideologies which they can do work for, above their own self-interest. However, in distinction from echoistic devotion, these egoists often are bothered by people having other leaders or ideologies that they don’t have. Their way of doing things or understanding things is “the way” and they may sacrifice and serve, but it is as much a No to other ways, as it is a yes to their way.

Just as passive-aggression must be indirect because the idealized parent can’t be directly confronted, active-affection as we see in one of the examples above, means that idealized self in the narcissist must be longed for and thus the parental-substitute is indirectly longed for as a source of greater strength.     

Saturday, December 17, 2016

Time and Sleep: Being loved and failed.

Another patient missed his previous session and had missed a session before. Instead of just treating this as transference, I tried to determine if this was a way of Being for him. Usually it's not difficult to tell if the patient is regressed, and living day to day— hour to hour is usually more precise— because he doesn't have a job, and usually strikes one as manic or depressed. This client had a job, was in a long-term relationship, and was more functional. However, he did admit to part of him feeling like he lives day to day and was just “going through the motions” in his life. He reported that he often misses appointments or plans and simply forgets and doesn't have any apparatus in place for scheduling things out of the normal daily routine. I began to build a metaphor with him. I told the patient that he has an interesting relationship to Time and that outside of the daily routine, it was like he expected Time to take care of him, and remind him of any special occasions that he might forget. I compared it to how I let my mother wake me up for school without setting an alarm for myself. He accepted the metaphor and I asked him to tell me his thoughts about how Time sometimes fails him and doesn't remind him of special events. He said that it's like Time "dropped the ball," “was forgetful herself," and that he can feel "disappointed" when she "fails" him. I took up the words that he affirmed in the co-construction and asked him to put them together as object-statements: "you dropped the ball, you are forgetful, you disappointed me, you failed me." He said them and said his mother came to mind. He said his grandmother was more of a mom than his mother was. His mother "hadn't been a mother" and "didn’t do her job". He got into particular moments of her selling drugs and using them. We analyzed them and he got in touch with strong disappointment with her but and feelings "that she's better than how she was acting." After he processed the feelings, he got in touch with new feelings of being "more proud of her now" and that "she's back to what she should be." He even expressed, spontaneously, that if he would share these thoughts with her "she'd probably cry". I investigated any resistance for client to act on this impulse but he didn't feel any and declared that he was going to say something to her.

I've discussed sleep before as something important or missing that can be gone, and also as something being interfered with. I've also seen sleep work like the above example. The patient is working through difficult material and feels sleepy, sometimes to the point of "not being able to keep their eyes open." In this moment you can similarly build the relation that sleep wants to take care of them and help them to deal with the psychic tension and pain involved but at the same time, sleep is failing them because they can't do the work they need to get better or improve. I don't have my notes with me to give a clinical example here, but I think my point gets across. 

It's important for the patient to build co-construct this and use his or her language. 

Of course you shouldn't force this too soon either. Wait for a pattern, and don't jump on the first time!