On Rex

Subject:

Comments:
: Rex tries to be a Superman (be good in everything) to seduce the important person in his life father; explicit and almost erotic love affair in which Rex doesn't see easily that the 'love' is not there in the other person (think of pedohile persons thinking the child wants sex too). Rex is dramatizing things in reality in a way that makes him important; he wants to be the adored center of attention, he has emotional and impressionistic language, shows easily emotions (that alone excludes E1!) like crying and anger, is chaotic and impulsive, is insatiable in his need for receiving love, he's easily moved, charming, extrovert, optimistic. Does that sound E1-ish to you? I think he has so many histrionic traits that (unhealthy) E2 could be the answer. E1's are emotionally closed and task focussed. : Jan : : Analyze This - Jan's real life cases: the story of Rex : : This is a very interesting case too. I am looking forward to your postings regarding Rex's probable E-type and/or Oldham style (O-type). Try also to type his father. : : Good luck : : Jan : : Diagnostic Phase : : Session 1 : : T: W hat brings you in to see me? : : P: WeIl, basically it's a very specific sort of problem. Since coming here to work and starting school, I have been made reaware of my difficulty in public-speaking situations and felt the frustration and demoralization of feeling so ill at ease in these situations, which are now fairly common or frequent, that I feIt that I needed some consuItation on how to better understand what I'm experiencing and how to better manage those situations. : : T: What kinds of problems have you been having, specifically? : : P: Well, essentially it is a tremendous amount of anxiety in these public-speaking situations. In any situation where I'm presenting myself orally, there is a high probability that I would feel such a lot of undue anxiety before the experience that it makes me uncomfortable and may interfere with the quality of the presentation, at least initially. : : T: What kinds of symptoms? P: Symptoms like perspiration, stage fright kind of things, the dry mouth or almost a kind of feeling shaky, or feeling, almost in its worst manifestation, a paniclike symptom of shortness of breath. The intensity of any given episode, it varies. Racing heart, the whole continuum. Again, these symptoms are not absolutely predictable and that's kind of a puzzling feature of this in some ways. : : T: How does this affect you in a classroom situation? : : P: Well, it may make me hesitant to speak at all in situations where class participation is a requirement. My own life experience over 38 years of being intelligent and extremely articulate in situations where I'm not inhibited in this way and on many such situations makes it particularly frustrating for me to perform, to present myself in a less than adequate way. I tried using tranquilizers to calm myself down. I ultimately rejected the dependency on the Valium, for example, to see me through those situations. I really felt unfree in a certain way, and dependent. I then discovered propranolol and found that a far more acceptable way of med- icating theproblem. However, it doesn't completely dampen down the symptoms of discomfort. So, I feel very, very vulnerable. It is a very extreme sort of vulnerability that I've worked on in conventional kinds of talk therapy. And despite all the concentration and effort, I've not been able to get a handle on the problem. : : T: What would you like to happen if this therapy were successful? : : P: Well, I would like to be able to feel some significantly greater sense of control and assurance about public-speaking situations, or situations where I'm presenting myself even to small groups. It's not that I want to eliminate tension altogether because I think that often it fuels good performance in whatever context. I want to know going into those situations, that some disaster is not going to befall me, that I'm not going to unravel in front of an audience, that I'm going to be able to present my ideas, my thoughts, or myself, uncontaminated by what I regard as an enormously excessive and completely unwarranted anxiety. : : T: Have you had any experience ofunraveling? : : P: I have had one experience where I was speaking to a professional group of about 15 people in a small room and quite by surprise, with the suddenness of a panic attack, had this anxiety well up and had to interrupt my presentation. It was the worst nightmare one can imagine in a situation like this. That this could happen reinforces the sense of doubt that compounds the problems of going into the next situation. : : T: Tell me a bit more about the impact of this anxiety, or whatever, in the classroom situation. : : P: Well, uh. .. T: Now, you're talking about a case method pretty much, are you not? : : P: What typically will happen is that I'll formulate an idea, an opinion and feel inclined to voice and then go through a sort of rehearsal, on my own, about expressing that opinion, begin to be quite self-conscious about my role participation in the class. When I go into the mode of preparing to participate, it's as if I'm going on a stage, that I am the lead actor in a role. : : T: An actor . : : P: I know that there are 15, 75, or 100 out there in the class and no one is really performing in a lead role. Yet, I transformed that into a kind of dichotomous situation in which I'm the performer and everyone else is the audience and is a critical, scrutinizing audience to boot. So, by the time I'm called on, if I can sustain my desire to go through this and get recognized to speak, I've got a feeling that all eyes shift to me. My heart's pounding, and I feel very unnatural ... : : T: Almost an opening-night mentality. : : P: Opening-night mentality. In a class, if I can get around to making the second comment, there's a good chance that I'll feel significantly more relaxed. But the opening-night mentality is exactly an excellent metaphor because that is precisely how I feel going into these : : situations. Though my interpretive comments about a case may be only 1 of 35 comments voiced in the course of an hour and a half, it feels much, much more momentous to me. The funny thing about it is that it's a somewhat variable experience. If I am able, for some reason, to feel at ease and feel that there is no critical dimension to this classroom situation, that things are basically alright for me regardless of what I say or whether I say anything or not, I can hold forth and feel fine. : : T: If there were just you and the professor in the class, do you think you'd feel the same amount of anxiety? : : P: No, I wouldn't feel the same amount of anxiety. Although, if I endow even another individual with this critical, judg mental, powerful kind of critiquing role capacity, I can make myself uncomfortable and significantly less at ease. Yet, what I do is even transform that situation, at least momentarily, into one in which I'm double clutching onto some sense of it. : : T: You have to perform. Have you explored this problem in previous therapies? : : P: Urn huh. ...During my last therapy I explored it with some concentration and, I would say, to some good effect. However, not with any sense of mastery. I felt better able to handle myself, but I also felt still uncertain. ... : : The balance of this first sesslon, and part of the second, were consumed with history taking, covering much of the ground summarized in his autobiographical statement. My impressions of Rex were that he was a charming, energetic, and troubled man. He exhibited an intense, extroverted, optimistic personality style. He brought considerable resources to the treatment : processmotivation for relief, willingness to work, a flexible defensive structure, verbal facility, intelligence, and a history of positive experiences in psychotherapy. The down side seemed to me to be that his positive, outgoing style might cover : : significant underlying issues; that his active life might preclude his following the demands of this type of therapy; that : : psychotherapy of any sort might occasion significant regression; and that his five experiences with previous treatment had little effect on his presenting symptom even though Rex believed that the therapy had been valuable. : : From my perspective it seemed that previous insights had not led to a reduction in his symptoms, especially in new and challenging situations. I wondered whether successful treatment of his performance anxiety might result in his being able to achieve new insights into the psychological origins of the problem. On the basis of this initial appraisal, it seemed appropriate to focus the initial phase therapy on the target symptom of performance anxiety with the recognition that it might be appropriate to integrate psychotherapy into the process, depending on his response to the behavioral treatment : : Behavior Therapy : : Sessions 2 to 5 : : Sessions 2 and 3 were devoted to describing and practicing the treatment techniques we would use to relieve anxiety and increase the frequency of his classroom participation. The first was a modified, abbreviated version of systematic desensitization. Af ter developing a capacity to put himself in a state of relaxation, Rex was asked to imagine an increasing hierarchy of anxiety-producing classroom situations. As he feIt the first twinge of tension, Rex was taught to evoke the relaxation state. He was instructed to practice this on a daily basis. By the third meeting, Rex reported that he used the approach successfully prior to his speaking in public. He had yet to talk in class, but feIt optimistic. At this point, Rex was taught a second technique aimed at the classroom inhibition. He was asked to observe opportunities to speak in class. When he saw such an occasion, he was encouraged to record it by making a small circle in the margin of his notes. Af ter cautioning him to try to avoid feeling that he must speak in class, or say something significant, I asked him to draw a line through the circle ifhe found himselftaking one of these opportunities to participate in discussion.Three weeks later in our fourth : : meeting, Rex not only was able to observe opportunities to talk, but was beginning to participate more in class. This was helped, he thought, by the continuing systematic desensitization. The data show a relatively modest improvement through March in both the recognition of oppor tunities to talk and the taking of these opportunities to participate in the class discussion. By April Rex feIt sufficiently confident about controlling his performance anxiety that he was able to end the recording process. No effort was made to analyze these patterns since it is my feeling that if the technique is effective from the client's point of view, it remains better unexplored for the moment. It is interesting to note that Rex's subjective sense of improvement was far in excess of the objective merits of the data, especially in class B. This seemed in keeping with his subjective, impressionistic personality style. AIso, it is true that the record may not reflect the quality ofhis remarks and the response of his professors and classmates. Two negative developments were that he was beginning to be driven by the desire to improve his record of classroom participation each day and week. I suggested that he stop recording his : : classroom performance. He gave this up with no difficulty. AIso, Rex had some trouble in meeting his own performance expectations when he had to speak spontaneously. He had been interviewed by a radio station with another student and found that he had initial difficulty re- sponding to the questions because he was not prepared for them. Though on the whole Rex feIt his performance anxiety had diminished markedly, he still feIt that somehow he was not meeting his own expectations. He "knew" from his previous therapies that this was because he had internalized a powerlul and demanding father, whom he could never satisfy. I noted, but did not respond to, this invitation. Instead, I suggested that we continue to focus on Rex's behavior and meet in six weeks to examine his progress. Three weeks later Rex came into my walk-in clinic. He said that he wanted to tell me that he had progressed from saying virtually nothing in class to being one of the leaders. However, he still had physiological signs of stress-especially high heart rate and heavy perspiration. We discussed what some of the reasons might be for these continuing stress reactions. We touched on his recognition of his own extremely high ambitions for himself and a tendency to cast any performance situation into heroic terms: the stakes were very high, a kind of academic superbowl in which he had to do well, to vanquish or be vanquished. He had been noticing this tendency for the past month or so as he was recording opportunities to talk in class. He always thought it had to do with his powerful and demanding father, but now he was not so sure. It was at this moment we discussed meeting regularly. From March through May 1985, we scheduled almost weekly appointments. : : Psvchotherapy : : Bession 6 : : In this meeting we focused on the origins of his high ambition. Previously, Rex had thought this stemmed from a desire to please his father, a man whom Rex remembered saying that it did not matter how weIl he did as long as Rex did his best. That put no ceiling on how hard he should try or how weIl he should do. But since doing the behavioral work, this was less clear. At this point, I shared with Rex a hunch that had been growing in my mind since the fourth meeting. This comment and related events seemed to have a significant impact on the direction of therapy-though not quite in the way I anticipated. : : T: I have been thinking about your description of your father as a powerlul and admirable man whom you feIt that y ou could not satisfy. Yet, you have also described him as an alcoholic, unstable, and often indifferent. I wonder how much of your perception of him is real and how much is illusory .I wonder how strong he really was. What do you think? : : P: I don't know. He was a singular tigure for me. There was no one with whom to compare him except the other boys' fathers. He was clearly a lot smarter and more cultivated than the fathers of the boys I knew. So, he just loomed very large for me. I remember him being pretty affectionate in my early days and fun to be around. Later on, he was signiticantly less predictabIe and my expectations began to change. I wanted, in some ways, more from him as kind of a sponsor, or a parent, or a friend, or whatever, and it just wasn't there. : : T: What was your actual relationship like with your father in the early days and as you grew through adolescence? : : P: I think I have mentioned to you that my mother was a very passive person so that all of my focus as a child, or much of it, was on my father and was on him almost in a reverential way. Also, it was made known to me at an early time that he had had lung surgery relating to tuberculosis and that one and a third lungs had been removed. He'd spent a year and a half in a sanitorium. And therefore, he was a frail individual. I can remember my mother stressing to me during certain play situations when I was about 6 or 7 years old, and there were other kids playing, that I had to keep an eye on my dad. That if we played too roughly with him, he could overextend himself and lose his breath and collapse. : : T: Lose his breath. : : P: Yeah. He just didn't have enough wind. He would become winded. And my understanding at the time was that the consequence of him becoming winded could be quite severe. Although she never said he would die, I felt that this great man, my father, could be overtaken by my play. : : T: you had to be careful, otherwise ... : : P: I also had the impression, which was not entirely untrue at the time, that my father was a very principled and ethical man, that he was a very self-sacrificing person. He was a person of enormous patience. He, you know, he seemed to me, of course from the child's uncritical standpoint, to be an affectionate man. He sang to me, read stories to me, was probably more involved with me as a child than a typical father was at that time, and was a gentle man, in many ways. He would tell me, at certain points when I was entering school and competing or expressing myself in schoolwork or sports, that he couldn't do-he could never have done what I was doing, that I had already : : outperformed him by those early years. I had a sense that he was a, you know, titanic tigure in terms of intelligence and moral stature. But frail, physically. ... : : T: Vulnerable? : : P: Yeah, a certain degree of vulnerability . Also an intensity. I had an intensity early on about competing that would be a puzzle to any observer or any non-professional observer. As a nine-year-old in fourth grade, I contracted chicken pox and had to be taken home from school, and threw a tantrum when I got home. I feIt quite bereft when I discovered that I could not make up the math and spelling tests that would be taken during two weeks that I was not there, and therefore, I could not sustain my role of starson the charts on the front wall of the classroom. : : T: Y ou had to have those gold stars. : : P: Hight across the line, and not miss one. And the same thing sort of translated into sports. : : T: How does that connect with your father? : : P: I think at some points he seemed to try to cure my intensity, which was baffling to me. I would study fairly hard and late into the evening because I had tests coming up and I could remember him coming in and telling me I had to go to bed. This ran counter to some of the messages that I had gotten before. : : T: How so? : : P: My dad prohibited me from playing Little League baseball, which he thought was excessively competitive and parent-dominated. He thought that parents became overly involved in watching their children play, and he didn't want me to be subjected to that kind of pres- sure. Later I had a chance to observe my father when he did permit one of my younger brothers to play Littie League baseball. And my father, par ticularly, stood on the foulline shouting at my brother, who was a pitcher, and instructing him af ter every single pitch about how to adjust his form or follow through, or whatever. So, clearly, looking back on it, although he claimed to be uncontaminated by competitive instincts himself, his tendency to project onto his kids was so intense that his fear may have been that he couldn't have controlled himself, going to a Little League game where I was performing. : : T: It would have been too difficult for him to hold back the intensity? : : P: Yes. And I guess on one other point, one of the earliest experiences I had in observing him around competition. He was very involved in following the St. Louis Cardinals when they were the underdogs. And I remember sitting with him in a room watching the games on TV and seeing him hold his hands together, sort of lace his fingers together and sort of shuffle his thumbs and become red in the face and get terribly, terribly worked up as these games went down to the final inning. And I can remember the Cardinals losing sometimes and going to bed crying myself, because I feIt that there had been a significant setback or defeat for him. Somehow, he would never interpret that experience for me as a child the way I would for my children now. It was a colossal, almost a moral, confrontation between one team and the rest of the world. I feIt that there were some very major issues at stake, and it is ridiculous, but that is how I observed him making meaning for me of an event. : : T: So, the times you saw your father exhibit heightened emotions-anger, depression, whatever were around sports. ... : : P: WeIl, no, politics too. If we watched a political convention together, I saw the revulsion with which he viewed a person like Richard Nixon and sensed again that in that political arena there was something very significant at stake. So the times that I saw my father exhibit heightened emotion in sports or around intellectual or political issues, there appeared to be something very significant at issue there, and again, those situations were never really interpreted to me as a child. I just ob- served the meaning my father made of them. : : T: How does this influence you now? P: My way of entering into, initially, situations in a classroom or speaking before certains kinds of audiences, has a lot to do with how I view what is at stake there. I really just feel I handicap myself enormously by bringing certain kinds of unclarified values, assumptions, or expectations or perceptions to bear in those contents. : : T: Where is your father in this? P: WeIl, he may be within me. He was there occasionally, in , when I was driving just after the birth of my second daughter, to address a fairly large audience of foundation executives and trustees. ... : : T: Yes. P: On the way there, I realized that my father wouldn't have feIt entitled to be in that room with those trustees and executives. He would have felt unworthy or incapable, or something like that. So, you know, in my little inner dialogue talking back to him, I tried to teIl him that he was entirely worthy to be in that room. Then, it was very sad for me. In fact, I wept as I drove over there because I feIt how sad it was for him not to feel that sense of worth. : : T: How about the recognition of your sense ofloss? : : P: How about ...meaning what? T: To some degree, you might have been experiencing loss of the idealized father . The tears might have been for yourself. : : P: I think that is very possible. [weeping] Even talking abut it now, it is a situation that I feel a lot of emotion about. I just feIt, in some ways, sorry for him. I think driving to the speech was a situation where I felt sorry inside for him, but, as you say, maybe I am sad for myself. : : T: Yes. P: You know, it's been a shock to me to realize that he wasn't the sort of figure I had imagined. : : Father's fragility, and the early awareness that Rex had to be careful not to overtax him, provided some support for the hypothesis of his vulnerability. So, too, did Rex's description of bis excessive, emotional outbursts around Little League games, the St. Louis Cardinals, and poli- tics convey a sense of an inadequate man living through others, investing them with heroic stature. Rex's recognition of his father's inadequacy was powerfully communicated when he broke down weeping while talking about the fact that he was now functioning in a world that his father could never be a part of. Yet, this interview also shows another dimension to their relationship prior to adolescence-'a warm, caring, highly supportive bond'. As we shall see later, it was when this contact was eroded by his father's drinking and instability-as weIl as his mother's illness-that Rex's problems began in earnest. In this sixth session we began to examine the reality of Rex's perception of his father and made some progress in recognizing his father's fragility. Then : : between these meetings, as sometimes happens, an unexpected event occurred, which furthered this recognition. Rex : : received a deposition from a family lawyer vigorously contesting his mother's will, which left her money and possessions to the children. : : Session 7 : : P: I was struck by our conversation about this notion of the illusion of a strong father . : : T: Let's talk about that. : : P: That's a really critical thing, and, ironically, we had this session scheduled just a few days after I got a transcript of a deposition that my father had given relating to an estate settIement involving my mother, a contested estate settlement. I didn't bring it, but I may bring it simply to convey to you some sense of my father . : : T: That would be very interesting, I think. : : P: Although the transcript wasn't particularly interesting reading and was, some places, very choppy and incoherent, it feIt very devastating for me to have a written text, a sort of written record of my father's deception and lack of focus, lack of memory, lack of analytical ability, all packaged for me. It made me feel, initially, very sad, like a. ..you know, as if I'd been punched in the stomach. And there was nothing ...I could have wept over it. : : T: That was upsetting. : : P: In any case, going back to this illusory, the issue ofthe illusory father. ..I was looking over my notes from my last therapist. I used the word '.benevolent" to describe him. That's not quite the same as ..idealized" or .'illusory ." : : T: Not quite. : : P: But somehow, I think ...I think when it got to be a teenager, my father just wasn't there anymore. : : T: Not like before. : : P: It was just kind of a cold and remote situation. The main point is that although I felt that he was a basically good guy in most ways, he was less and less able as a father to an adolescent to meet my needs. So I began to look to a particular coach or a teacher, or I began to almost take on the identity of certain types of people I read about (do you remember the movie Single White Female? JdB). I was particularly drawn to the scholar/athlete types. I would read these articles about them in sports magazines. Although I lacked any details by which to model myself after them, I tried to almost build my character around those people. My frames of reference began to be less and less those of my father who, I am almost certain, was less attentive to what I was experiencing than he used to be. Even my accomplishments were less noteworthy to him. I could not imagine going and telling him that I had any confusion about sex, that I thought about drinking a beer, and drank a beer at the football game, that I lost some money. I just kind of wrote him off. (this is very typical for the character style of Rex; JdB) He was not a person I felt comfortable going to. Increasingly I would rely on the mentor, the English teacher , the track coach, my girlfriend, or her parents. : : T: Did they get invested with the same? : : P: They got invested with the idealized parent virtues. I felt comfortable going to them. They seemed compassionate and intelligent. They were genuine mentors or sponsors of mine. I would be looking for thit relationship. With that I could work wonders. I remember getting an F in a history class because I was caught cheating on a term paper . The teacher, who was a young, attractive guy, told me that he would al most forget the first quarter's grade and see what I could do the second quarter. He was a very demanding teacher and I almost got a perfect score the second half of the quarter because I had a defined task. I feIt he was rooting for me and I feIt that there was a chance of scoring a noteworthy success. What I could not live in was this limbo state of uninvolvement and unrecognition, which really kind of characterized where I was with my father . : : T: Uninvolved? Unrecognized? How so? : : P: WeIl, I think it has taken me a few years as an adult to learn this stuff. If you had an independent conversation with my father today and asked him what he was proudest of in me, he would probably recall a race I won in high school. That to him is worth calling forth in conversations now. It is as if nothing happened between that time in 1963 and the present, despite the fact that my academic record in college was way more significant than that race. He is not aware of those things. He'll remember my winning. But I was living in a kind of emotional desert between the events of that time. We were close. When I was competing in high school and was racing about every week, I feIt pretty close to him then. Af ter the season ended, we were adrift again. Then, as time went on, I became increasingly aware of his alcoholism, his behavior. ... : : During this and the following five sessions, Rex began to perceive the association between his disintegrating relationships with his father and a sick mother, and a growing pattern of disorganization and impulsive behavior. Several excerpts from these meetings follow. : : Sessions 8 to 12 : : P: While I was in high school, I had no clue that he had a problem with drinking whatsoever. I just knew that as a junior and senior, I had a lot of restless energy and anger, I was prone to playing pranks or being mischievous, I was running away from school and. ... : : T: I would like to hear a bit more about that. : : P: When I was in junior high school, I followed all the rules. I was considered an exemplary person, not just an achiever . But when I got into high school, particularly as a junior, I began to feel that that was less satisfactory. I increasingly tested the limits. I would just stop doing school work and instead of getting A 's, I began getting D's or F's and get progress reports sent home. Things ofthat sort. I began to miss more days of school, cut more classes, and then I got to a point where I think I was feeling very desperate about where I was going to be. A friend of mine, almost on the spur ofthe moment, decided to take his father's truck and we drove to New Orleans. It came at a time when I was class president. In reality, had anybody intervened for me, I probably could have pulled that semester out ofthe fire academically and gotten back on track but I was. ... : : T: No one was there? : : P: I really had no emotional reference points. One expectation of mine sub-consciously might have been that someone would come in and actively intervene for me ar take my part, or whatever , and sort of shepherd me through a process and exhibit some affectionate love on a consistent basis. What in reality happened was that my father would either send me off to a psychologist, which he did once in highschool, and I had a big burst of strong academic and athletic achievement while I feIt connected to that. Or he would simply talk to me or question me in the most tedious and infuriating way, as ir I had failed him and was infected by some kind of malaise that was my own making. He had a habit of stacking coins while we talked. He would just stack his coins, fumble with his keys, and kind of hold me captive in a way until he feIt he had elicited all the information he wanted in one ofthese question- and-answer sessions. I just feIt it was a form of persecution. I feIt such rage sitting there listening to him question me under those circumstances. : : T: TeIl me some more about running away. How long were you away? : : P: I was only away three or four days. Anyway, when I came back, I found I had really wiped out the semester. I had gone too far. I had lost the student office and so forth. At that time the school year was winding up and there was an assembly for our class. I dressed up in a suit and tie and wrote something out that I wanted to say to my classmates. When I got to the auditorium, the school advisor would not let me go on stage to make this presentation. So, off to the side in this auditorium I flung my notebook down the hall. I walked up to one of the main buildings and proceeded to punch my hand through the window in the school, and I have little patches on my wrist today that testify to that. I mention that because thatmarked, in some ways, the beginning of an intensification of this whole downward spiral. I had other episodes ofbreaking windows or breaking things that were of value to me. Just really turning up all that anger, just really continuing to sort of increase the volume of this anger. I would get into really just darnaging myself. : : T: How so? : : P: I broke trophies that I had won. These were really hard-earned. I didn't have a whole library full of trophies, so the ones I had that I broke, I was breaking something very dear to me. I wouldjust smash them. Like an Old Testament prophet, I was in a complete rage. I would be really kind of desperate. : : T: Did you ever hurt yourself further? P: It is embarrassing to mention it, but I can remember taking a knife and just poking it into skin, not creating anything requiring stitches but little gouge marks. Not repeatedly, it wouldjust be one gesture of exasperation. : : T: So you were really upset. : : P: Oh, yeah. I just didn't know where to turn. : : T: When you think back on those days, they sound extraordinarily painful because ofwhere you were and all ofthat. You describe it as though it were a gradual process. I am wondering if something might not have set you off for that run to New Orleans. : : P: It's hard for me to recall. I know that the exact, specific precipitating event was that I had missed a whole day of school and feit that some ofmy teachers would call home. ... : : T: How were things at home at that point. Do you recall? : : P: My mother's physical problems increasingly limited her. She was obviously the first person I saw when I got home. I can remember one day saying to her as she sat on the couch, "Why don't you ever ask me what has happened for me during the day?" I got really angry, and she burst into tears. So I would feel in a kind of rage and feel the guilt about making her cry and I wouldjust go back into the bedroom. I really do not re- member any substantial interaction with my dad around areas of importance to me in my life. I just remember it being a kind of wasteland, not a whole lot going on. Unless something extraordinary was happening, a race I was running, there wasn't a lot going on. : : T: So unless you were performing in some way, winning, there was not much between you and your father. And it was different earlier? : : P: Much different. Much better . T: Because? : : P:The main thing is that I feIt myself, at least as a child, in a kind of symbolic relationship almost with him. It was as if he commissioned me to go out and do some of these things. By a fairly early age, I internalized this. So, whether he was literally saying one thing to me or not, I brought my own feelings to these experiences. A teacher might be the surrogate parent, or whomever I was relating to. All they had to do was push some button with me and I was there-I would perform for them. That is kind of how it was. : : These excerpts reveal the change in Rex's relationship with his father and mother. He moved from a rich, almost symbiotic, connection with his father to an emotional desert. This was complicated and exacerbated by his mother's deteriorating condition due to muscular dystrophy. In this context, Rex began to recognize the meaning ofhis own aberrant behavior during this period, as the following excerpt illustrates. : : P: From 11 to 12 on I wasn't getting much guidance whatsoever. I was operating on some of these myths or assumptions that I had formed earlier about my father and about what a person ought to do in any given situation. I was really inventing these things or picking them out of literature or films or wherever I was getting them, church or. ... : : T: You weren't getting much from home. P: Because I wasn't getting much emotional contact back, I shifted gradually to a more extreme failure mode, I think. Later on, I got into this in my junior year at high school. And that just brought out-I mean he would ask me questions and give me these long lectures and so forth, which would be absolutely tedious and infuriating for me. There was never a meeting of the minds and emotional connection at all, which particularly amazes me now because I have young children and I really have daily contact with them. I know pretty much how they feel every single day. I don't think he knew how I feIt at all for long stretches of time. : : T: There was no awareness. ... P: None. ...He wasn't cruelor abusive or anything in a direct sense, but he just wasn't involved. I could go through a whole semester practically flunking out when things were going bad for me, and he wouldn't have a clue about this because he would never ask and never know what I was doing until the reports started to come back and then he would be kind of outraged. But he would never express the outrage in a way such as, "Goddamit, what the hell is going on?" or even something softer but equally direct. I just feIt kept at arm's length. Essentially, I tried two modes. The one mode that worked initially for me, which was the success mode, seemed to be what he wanted of me and that worked for a while, but then when that seemed to be the status quo, that's when I tried being bad. But that didn't work either. [Weeps silently] : : Though we didn't discuss it further at this moment in treatment, it seemed obvious to both of us that Rex's tears were for the father he lost sometime around the beginning of adolescence. Achievement could not win him back and neither could being a bad boy. My thought was that he coped with this loss during the high school years in a number of ways: (1) finding a series of surrogates to please by being : : altematively good and bad; (2) looking for contemporary role models to emulate; (3) acting out his anger toward his father and numerous self-destructive episodes; and ( 4) creating an illusion of his father as someone who cared about his success, someone he feIt driven to satisfy. We touched on all of these issues to some degree. A dream that we discussed in session 11 opened the way to recognizing his : : angry feelings. : : P: I had this dream the other day that seems important. I had gone to some event with a date. We are out late. We pull in the driveway. I am kind of beginning to present in my mind what my explanation for being late, and so forth, is to my father. He comes out. My dad approaches me, and as I am about to launch into my explanation, he begins to teIl me that in the course of pulling into the driveway himself, in his own car, he had all accident. He holds up one of his hands, and the fingers of the hand are basically cut off at the first knuckle-a bloody stump. He is very calm trying to teIl me that it was a minor accident of some kind, but his hand is mangled. I remember, in the dream, holding my head in my hands and saying, "Your hand has gotten so mangled over the years," and just feeling very demoralized about this last catastrophe. I think that is pretty much where the dream ends. I have not had a dream about my father for all awfully long time. I am sure our work is kicking up some stuff, and the fact that it was almost a kind of amputation of a hand-it is something I can't fully understand -but it feIt in some way : : significant. : : T: In what sense? : : P: In some ways, it is true to life. My father, as all alcoholic since I have moved out ofthe house, has had a number of bizarre accidents, I must say. He'll try to separate two dogs fighting near his house and end up getting all scratched or gouged up. He falls from time to time and ends up requiring stitches in an emergency room. It is somewhat in character that he would have an accident like this. It is somewhat in character that he would display the injury almost as a source of curiosity-almost detached fascination. There is almost a self-mutilating quality to these accidents. This was a mutilation, not another term I am trying to come up with. I think in a way I have felt that each of these revelations about his character has been a display of an inner mutilation that I have had to come to terms with over a period of time. : : T: Which hand was it? : : P: I was trying to remember this. I was tempted to say right hand because of the symbolic. I'm not really sure. It may have been the lef t hand because he was facing me and I think he held it up. : : T: Left hand, right hand? : : P: I'm right handed. The other thing that struck me about the dream, or the feeling I have from it, is this feeling of personal devastation. I feel shocked, but also it was almost the accumulative effect of this, which is referred to when I say, "Your hand has gotten so mangled over the years." It is a combination of anger and sadness. In the dream there was a similar feeling of incredulity mixed with anger. It seemed like a very, very critical wound for me. It didn't look like something that could be fixed. I didn't know what he was going to do with his hand, but it was a mess. : : T: Anything else? : : P: Right. One of my fantasies ...I think that his business is virtually gone. I honestly don 't know how he is going to live out his life economically. He does have a lover with whom he lives, who is a teacher. They have a house that's paid for, but it is a pretty sorry picture financially. I don't know how it is going to work out. Over the last several years, he has receded to become less alive-literally less alive and less alive for me. Although in a focused context like this, his existence moves up a little more vividly and the dream obviously reemerges. ... : : T: Damaged? : : P: Right. Right. : : T: Could y ou have had anything to do with . : : t? : : 1 . P: With his hand in this dream? Not the way the dream. ... : : T: I know about now. I'm wondering about that temporal period. : : P: In my actual life, could I have had anything to do with his own destruction? : : T: Or did you on some level? P: Well, it's important for me to remember that early on my charge was that this guy's fate was in my hands. In a certain sense, that if I was playing with him and overtaxed him, he could collapse. I was responsible for him. He couldn't do it. My sense was that alert to his own devices, he would play too hard and he would kill himself, basically. So, I had to monitor how easily he was breathing because of his tuberculosis. : : T: So, his life was in your hands? : : P: Right. I felt that he was physically frail. I was told that it was worse for him to get a chest cold. You can't evaluate these things when you're a kid, but I felt that he was a noble spirit, a fine mind encased in a fragile body, and that he was vulnerable-he had vulnerability. : : T: Did y ou ever reel angry at him and not be able to express it? : : P: By the time I was about 15 or 16, when it was time to use the car. At that time, he was more inclined to speak more sharply, lay down the law a little bit more. I would react to that. I would feel angry. By the time I was a junior or senior, we had a couple of, at least one physical contact where he would shove me across the room. I remember when I was trying to make up ground in a class-this class I had gotten an F in and I was trying to get the grade up as high as I could and I had an exam coming up the next day and I knew I was missing one set of notes. I was attempting to leave the house at about-it was late-9:00 or 9:30 P.M. to get some notes to review before the test, and he insisted that it was too late to go out and he shoved me back down into the chair. I am sure I burst into tears at that point. I was bereft, angry, humiliated, and so forth. My reaction was to feel just outraged. It was just a terribly snarled-up period of time in terms of how we would communicate. It was just miserabIe. : : T: It sounds very tough. What do y ou do when y ou know y ou can hurt somebody? : : P: It just lays you out, totally lays you out. When he got mad at me when I was a teenager, I was bereft, angry, humiliated. I was crying and feeling outraged. It was just miserabIe. : : T: Yes. : : P: I turned a lot of rage and anger on myself. No question about it. My previous therapy dealt with this. : : I didn't feel particularly pleased about my response to the dream. Just why I became so obsessed with whether the injury occurred to his father's left or right hand remains a bit of a mystery to me. Otherwise, we seemed to be out of rhythm during this encounter, perhaps both working too hard to try to di still what we both believed to be important, symbolic material in the dream. As frequently happens in the course of therapy, however, when we fumble with what seems to" be an important issue, other chances present themselves. Here is an excerpt concerning the dream from the next meeting. : : Session 12 : : P: When we stopped last time, oneof the things we had talked about was this dream. I made a couple of notes after our session because you had said you might want to return to this dream and also you were wondering about the as- sociations that might happen. : : T: Let's return to that dream if you're comfortable with that. : : P: Basically, this dream had to do with my father's hand being maimed, disfigured in some kind of bizarre way. After the session, I was thinking about my associations with the hand. The two or three associations I had are biting the hand that feeds you, give me a hand, the right hand of God. There were two or three quick reactions, and there may have been one or two others. I think there are a lot of obvious symbolic references to the hand, and those are three. The parent is the person who feeds you, or is supposed to, both physically and psychologically. This is set, not only against the context of our work, but against the point of this estate settIement in St. Louis in which I am, for the first time in my life, formally in an adversarial relationship with my father. He is on one side and I'm on the other. Unless there is a compromise settlement, one of us will win and the other will lose. : : T: Where are you now? : : P: I find myself taking almost an uncharacteristically hard line. : : T: Do you have any further associations to the dream other than. ... : : P: Not really, as we talk about it now. I guess I'm struck by some feeling of guilt, almost irrational guilt, with the fact that my father has his hand injured. I had nothing to do with causing it, but as I'm talking about the dream, I feel some guilt-some responsibility. : : T: In the dream. What might that be? : : P: WeIl, the thing that I felt uneasy about in the dream was that I got separated, that I separated myself from my father. I guess if I had thought it through, I might have imagined that had I stayed with him, he wouldn't have had this injury. That it happened because he went his own way and by the time I reconnected with him, something had already gone wrong. In fact, if I had linked that up to actual realities, obviously, very early on I did have a sense of some responsibility in certain situations for protecting my father's health while we were playing or having games. My mother gave me the very strong impression, as I said earlier, that if I overtaxed him he would collapse. So, there have been different points in which I have felt responsible for him and I think that's part ofit in the dream situation too. : : T: What else? : : P: Well, I think guilt, and outright expressions of anger were very much frowned upon or discouraged. I think they were felt almost to be morally wrong. There was never any discussion of this, but it was as if really direct anger was almost a transgression, it was irrational. : : T: As a youngster, what were your feelings about what might happen to someone if you got very angry? : : P: I think that initially I probably, as a youngster, didn't have any terribly complicated feelings about that. I just directly expressed the anger. A lot of it, I remember, would be associated with competitive situations. : : T: What about anger toward your parents? : : P: I guess I am sure that there would be a physical punishment with some withdrawal or there would be very, very strong disapproval. I think that there was no feeling that that was at all appropriate or accepted. What would happen, even though I've never tested it too often, I suppose I may have felt that my parents would be less friendly to me or less kindly disposed to me for a period oftime, I don't know. : : T: Did your anger have the power to hurt people? : : P: Well, I don't know. Ijust can't be clear enough about it. I remember one incident in which my mother and father had one of their few arguments. My mother may have thrown something at my father and started crying. His response would be to be wounded or abused by the anger. Anger was not, after a certain age, a young age, was not part of my emotional repertoire by and large. I thought that I was a real nice guy, a person who never had conflicts with anybody. As a kid, I can remember one incident where another person was accusing me of something. My response was to be extremely angry , but what I did was bang myself on the head with a little toy gun. : : T: How about now? : : P: I am much more readily able to call forth anger correctly. I still. ..I guess I have some lingering feelings about the desirability of expressing anger . Some part of me would rather not. But, it doesn't take too long for me to be aware that I am feeling angry and to let that feeling, in some measure, come into play. It is not a buried feeling any- more. : : In the last session, Rex and I talked about the course of treatment. Two issues that were on my mind were how this therapy compared with previous treatment in his thinking and the extent to which the positive effects would be durable. : : Session 14 : : T: What are your feelings about this experience compared with previous therapies, if it is possible to summarize, or even compare them? : : P: I think my therapies have been effective. I have had a bond with the person with whom I was working. T: Certainly, by everything you've said, I'm led to believe that previous therapies were highly effective by the standards I know of. : : P: Right. They were ...I suppose a lot of it has to do with timing. This therapy has been a very, very focused and intense kind of process as far as I'm concerned. : : T: Compared with. ...? : : P: Compared with experiences that were more open-ended. For example, I never imagined that I would be able to continue to work with you beyond a couple of months or so. I knew we had to get something done quickly, and I was assured that we would get something done. I also brought in a presenting problem that was very ripe for a solution. I had no ambiguity about wanting to deal with it compared with previous situations where I might have not even been sure initially what the issues were. By and large, I've been fortunate in identifying very strong people as therapists and working pretty much without reservation with them without some kinds of resistance or defensiveness or whatever . : : T: What have your feelings been about our relationship and what we've been doing? : : P: In terms of idealization, I think that as our work progressed, my sort of affection for you increased significantly. There was a sense, because I was on the firing line, testing out our methods of a real partner experience here. That meant a lot to me. No question about it. Early on, I wasn't sure whether you would ever really get to know me in a personal sense or whether I would be just another one of a number of clients or students rotating through this office. It made a significant degree of significance to me to feel personally linked to you in this work. There is no doubt that that attachment, that bond, is something that I still feel very strongly. Al though it rises and falls, I am expecting more out ofthis than I might have origina1ly. I am going deeper into it than talking about a particwar behavior and a behavioral strategy for dealing with it. I feellike I'm in it deeper emotion- a1ly. : : T: Deeper than what? : : P: We're looking at a whole range of issues instead of simply the phenomenon of public presentation. Because we've widened the focus, I feel much more exposed, more vulnerable, more wounded in a sense, having to recapitulate quite raw, unhappy past experiences. ... : : T: Well, we have about 10 minutes left. I guess I'd like to think back to the beginning of our work together and think about the question of the extent to which this work has met your expectations, what you see beyond this. : : P: Well, I would have to say that this work has met or exceeded my expectations. : : T: In what ways? : : P: In the sense that we've been working with almost a perfect kind of laboratory, that being the classroom and the case and so forth. Results from our work almost had to be manifested or I would have suffered some consequence, either lowered grades or at least temporarily reduced self-esteem, or something like that. After years of disappointment in trying to address this problem in some systematic way, thishas been the first time that I felt some substantial measure of control in the way I approached this public-presentation thing. I've charted my participation in class so that I have a complete record of the : : frequency of participation and opportunities for speaking. And I've gone from almost zero participation, or very episodic participation, to very regular participation in almost every class and sometimes multiple comments per class. In fact, my impression is that in one of the classes I have come to be regarded as one of the more thoughtful contributors to class discussion. : : T: I wonder how durable you imagine the results of this work might be. I'm not fishing for compliments. I'm just curious. : : P: I expect the results to be very durable. Obviously, I've had a problem that has afflicted me for 15 years or so. So, I've been aware that it has been most acute in the last 10 years or so. : : T: I think we noticed it in your junior year or one of those years from an earlier session. : : P: Right. Right. And there have been some false starts and some disappointed hopes in attempting to deal with that problem, but I've never had such a dramatic turnaround before, as has taken place in the few months of our work. I'm also very drawn to certain kinds of exercises, methods, or techniques that have a kind of specificity. Those sorts of approaches appeal to me, and I like using them and incorporating them into my daily routine, and so I feel good about what we've done and what I've done in- dividually and look forward to the grat- ification that comes from continuing to use it and benefit from it. So, I really feel ...I never had the benefits of previous therapies erode or reverse when they've really taken hold, and the work that I concluded in 1982 is just as valid for me now and has not slipped away, and I don't expect this to slip away either. : : T: What do you think next fall is going to be like? : : P: Well, I really have confidence in the enduring effects ofthis method and I'm going to try to work with them. There are areas that I would like to continue to explore, and I've talked about the desire to enhance the technical ap- proaches with some additional insight or understanding, and I may want to come back to you. : : : : CLIENT IMPRESSIONS : : Following are Rex's written impressions of his treatment: : : Treatment can be divided into two phases. First-phase sessions, scheduled at two- to three-week intervals, imparted, refined, and reported on desensitization/ behavioral modification approaches to the problem presented. These sessions were cordial but brief (usually less than 45 minutes) and somewhat impersonal. Again, emphasis was placed on techniques of proven effectiveness rather than on de- veloping an interpersonal context for the therapeutic relationship. I was struck by the economy of these early sessions, but was reassured by the therapists confidence in the methods I was to implement. On the negative side, I worried that student volume at the University Health Center dictated a certain assembly-line quality to care. I wondered whether Doug was really engaged in our work, whether he was relating to me as an individual. : : As sessions progressed, a second treatment phase began. This phase featured three developments. First, his techniques did work (although some setbacks were occasionally experienced), and I developed an increased sense of confidence in, and gratitude toward, him. Second, Mike (this type has an inclination to use people's names frequently; JdB) began to reveal more of himseif and divulged some similarities in our back- grounds, which created a much greater sense of intimacy and collaboration. Third, we began to augment behavioral strate- gies with discussion of what Mike called the "existential" issues. Sessions were scheduled more frequently, usually lasted the conventional 50 minutes or longer , and were much more wide-ranging in terms of topics covered. I began to cry dur- ing one of the phase II sessions, indicating the greater intensity and trust ofthe work at this point. I began to refer tó treatment as a joint venture (our work) rather than as something I was pursuing alone. Also, I began making postsession journal entries recapitulating important points. Although treatment began in January 1995, I did not make my first journal notation until March. During the second phase of treatment, such entries were common, again attesting to the more complex tex- ture of these sessions. I initiated the discussion of "existential" issues in the hope of enhancing behavioral techniques with insight. This effort has laid the groundwork for additional understanding, but has produced less dramatic or conclusive results than the behavioral work. This technique-orinented work was perfectly suited to my situation because it had a focused, almost surgical, quality that quickly produced relief. I remain confident, as we wind down our work, that the talk-oriented therapy will contribute significantly to my healing and growth process. It is important to me that this work culminate in some new understandings because the review of past personal history has rein- flamed some very painful psychic wounds. : : : : THERAPIST IMPRESSIONS : : My overall sense of the treatment process with Rex is that it was both successful and incomplete. I believe that he shares some of these feelings. Perhaps that is not surprising considering we met only 14 times and the academic year has a way of bringing premature termination to clinical work. At the time I did not know whether he would return in the fall. With respect to the therapy itself, I enjoyed working with Rex. Like many students in settings such as these, he is bright and exhibited considerable verbal facility, which lubricated the therapy process. I was bothered occasionally by his extraordinary verbosity and psychological mindedness. The first made it hard to keep him on a track which seemed productive. Rex's self-interpretations were sometimes at odds with mine. However, I did think he responded well to my directional comments. : : On the plus side was his strong positive transference, especially toward the end of the behavior therapy phase of our work. But even in the beginning there were many times when Rex picked up words or concepts very quickly that I used. Also, he was used to feeling positively about previous therapists, and he was relatively faithful about carrying out behavioral exercises necessary for a successful outcome. : : Also on the plus side were my sympathy for his problem and confidencethat I could help him. Though I do not recall telling him this, I am a former stutterer who experienced great frustration around speaking in classes, had an alcoholic father, was an athlete, and had a high school career paralleling Rex's. He obviously sensed this shared experience in my remarks. As I had successfully treated a number of Harvard students with performance anxiety with this and other behavioral tech- niques, his presenting problem did not cause me excessive concern. That confidence apparently transmitted itself to Rex. : : As to the treatment itself, I am always struck by the economy ofbehavior therapy in alleviating symptoms. Within two months his performance anxiety was sharply reduced. We might have stopped there but for the fact that he began to recognize that his present anxiety was driven by several intrapsychic forces. Rex's first spontaneous insight was becoming aware of his tendency to cast every situation into heroic terms in which he had to perform well. As the therapy pro- gressed, it became apparent that this tendency was rooted in the desire to attract his father's affection. This is why "doing well" in any performance situation never alleviated the anxiety the next time. No matter how well he performed, the emotional desert between them remained in his unconscious. The vain hope of reconnecting with his father through his achievements caused him to continue to keep expecting more and more of himself. : : The second spontaneous insight, which emerged very quickly, was his becoming aware of his illusion of father's competence and ambitions for him. According to Rex, it was not until our work together that he realized that he himself had created the image of the powerful father who continually demanded that Rex excel. In fact, the father was increasingly indifferent from early adolescence onward. Rex created this image in order to remain connected to his father . Whether these insights would have surfaced during a course of psychotherapy, it is difficult to determine. My experience is that they were not likely to have come up so early and may not emerge at all. They surfaced initially in the context of the behavioral practice a,nd our discussion ofhis reactions to it. Also, I had the feeling that psychotherapy with Rex would be a wide-ranging enterprise, covering an enormous territory. It was doubtful whether there would have been sufficient focus on any specific material for these insights to emerge as significant issues. They had not in the past. : : POSTSCRIPT : : Rex and I resumed contact in the fall. We met biweekly until terminating the week prior to Christmas. By the end of the first month, Rex believed that his problems speaking in class-and elsewhere-were behind him. Now that he feIt more comfortable about entering into discussions he could choose nat to speak without becoming uncom- fortable. This was a vastly different experience than believing he could not talk without embarrassing himself. A relatively small event opened the way for further understanding of the origins of Rex's tendency to transform the mildest competition into an Olympic struggle. The event was Rex's comment in passing that he had just finished a letter to his father and enclosed a newspaper report of an address he had given to a group of Boston executives. : : As we discussed why he wanted to send the clipping to his father, Rex again went over his desire to obtain his father's love through his achievements. At this point I recalled his father's earlier comments that Rex recounted in the spring: by the time Rex was an early adolescent his father told him that Rex had already exceeded him. Remembering his mother's cautions about his father's frailty, I wondered whether Rex's continual bombarding of his father with his achievements might have been - and might continue to be- a sublimation of both normal competitive instincts as weIl as aggressive impulses deriving from years of frustration. This seemed to hit home. : : : The remainder of our sessions dealt with one form or another ofhis aggressive feelings. Numerous dreams occurred involving his father: in one his father was mangled; in another the family station wagon, usually driven by his father, went out of control and crashed on the freeway. Toward the end of our work together , Rex had two dreams in the same week about expelling something noxious and ugly inside him. The first involved trying to vomit something up but not being successful. In the second dream he was sitting on the toilet after defecating. When he tried to wipe himself, he spread the fecal material rather than being able to clean it away. As he folIowed his associations to these dreams, Rex concluded he seemed to be trying to rid himself of his anger by expeIling it in some way. But plainly this was not working. Shortly, Rex recognized that a key message in these dreams is that he did not want to totally purge himself of his aggression. He wanted to use this energy , integrating this force into his per- sonality. Indeed, in the previous week, Rex recalled making a presentation and being provoked by a prickly member of the audience. Rex handled the confrontation with humor, which diffused the badgerer . This was the first time he had ever been able to do this. This was the first time, Rex mused, that he didn't worry that his anger might have lethal consequences.

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