Damon Krohn dissertation

Institute for Clinical Social Work

Therapeutic Action: The Experience of Emerging Adults in Psychotherapy

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Damon Krohn

Chicago, Illinois June, 2016

Copyright © 2016 by Damon Krohn All rights reserved

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Abstract

This study using psychoanalytic case study methodology was designed to explore in depth the subjective experiences of five participants who engaged in psychotherapy as emerging adults. Additionally, this research aimed to explore the participants’ perspectives related to therapeutic action—or what they specifically found helpful or not helpful in treatment with their therapists—in the context of their idiosyncratic developmental histories and past significant relationships with parents.

I found that, for these five women, while they all seemed to evoke specific enactments in treatment, they generally reported little conflict with their therapists, and had a new relational experience that contributed to them viewing their therapists mostly as good objects: as supportive, available guides who helped them develop selfunderstanding, and relinquish ties to archaic, unconscious relational models that helped them operate in new, different ways with intimate others. Moreover, they used the therapeutic relationship as a kind of therapeutic scaffolding that served to support their identifying, articulating, and working through parental relationships as part of the developmental task of individuating from parents. These women reported that their experiences within the therapeutic relationship—and how their therapists handled or mishandled the relationship—constituted the most salient factor in contributing to how they viewed therapeutic action, and what they found helpful or not helpful in treatment.

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For my late, beloved mother, Patricia Krohn: there are no words to express the inspiration you have given me for this project, and in every aspect of my life. I miss you dearly.

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Acknowledgments

I completed this project with the support from many important people I met during my training at The Institute for Clinical Social Work. I want to thank five members of the Institute’s faculty, who served not only as great instructors, but also as committed clinical consultants, guiding mentors, and finally as my dissertation committee and dissertation readers: Ida Roldån, Michael Hoffman, Dennis McCaughan, Carol Ganzer, and Scott Harms Rose.

I am grateful to my two readers, Ida and Michael, who provided important feedback towards the end of this project. I wish to individually acknowledge the members of my dissertation committee for their help with this project: Dennis, who never ceased to respond to my work with a concise, thought-provoking perspective that grounded me, and re-focused my attention on the participants; Carol, who not only provided insightful feedback on the project every step of the way, but also who has managed to become an invaluable mentor to me, both in my clinical practice and in professional writing; and Scott, who from my very first clinical consultation at the Institute, and particularly in this project, has managed to understand my thinking, focus my ideas, challenge me to excel, and serve as a professional model. Thank you all.

DK

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Table of Contents

Page Abstract……………………………………………………………………………….…iii Acknowledgments……………………………………………………………………….v Chapter I. Introduction……………………………………………………………….….1 Formulation of the Problem Significance for Clinical Social Work Study Objectives Statement of Assumptions Theoretical and Conceptual Framework

II. Literature Review………………………………………………….…….…11 Adolescence as Historical Phenomena Psychoanalytic Views of Adolescent Development Adolescence in Contemporary Research Emerging Adulthood Psychoanalytic Literature on Young Adulthood Summary of Adolescent and Emerging Adult Literature General Viewpoints Related to Therapeutic Action The Emerging Adult Population and Psychoanalytic Outcome Studies Table of Contents--Continued vi

Chapter

Page The Legacy of the Medical Model The Emerging Adult’s Perspective on Therapeutic Action

III. Methodology……………………………………………………………….53 Type of Study and Design Scope of Study Data Collection Methods and Instruments Data Analysis Statement on Protecting the Rights of Human Subjects

IV. Findings………………………………………………………………..…..61 Participant A: Cathy Participant B: Amelia Participant C: Hillary Participant D: Jasmine Participant E: Tonya

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Table of Contents--Continued

Chapter

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V. Discussion…………………….............…………................……………….323 Transference in the Absence of Conflict Enactments in Treatment The Therapist as a Good Object Having a New Relational Experience Recognition’s Effect: Considering Alternative Identities Evaluating Treatment: Defining Therapeutic Action Limitations to Findings Clinical Implications and Further Research Conclusion Appendices A. Research Flyer…………………………………………………….……….354 B. Individual Consent for Participation in Research………...………….....356 C. First and Second Interview Guides………………………………………360 References…………………………………………………………..…………366

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1

Chapter One

The introductory chapter will describe the specific problem under study, as well as outline the reasons for exploring this particular area of interest. Then the significance of the study for clinical social work will be discussed before delineating the study objectives. Last, any relevant assumptions of the researcher will be reported, ending with a description of the theoretical and conceptual framework that will be used to interpret the findings in Chapter four.

Formulation of the Problem The particular area of psychoanalytic research I chose to study stemmed from my interest in therapeutic action, and specifically about what may or may not be helpful in treatment with a given patient population, for example emerging adults. As I explored the literature, I found that theories of therapeutic action largely neglected the patients’ perspective related to what is helpful or not helpful in treatment, regardless of theoretical orientation (see Lilliengren & Werbart, 2005). As a result, the main problem this qualitative study addressed includes the tendency in the psychoanalytic literature to leave out the patients’ viewpoint on what feels helpful or not in their experience of psychotherapy, resulting in a dearth of research on therapeutic action from the perspective of emerging adults. While there is much debate and dissent among

2 psychoanalytic theories about what ultimately leads to the good life, there is a scarcity of literature that actually asks patients about their experience of treatment. Additionally, while existing quantitative research helps describe what may contribute to successful psychotherapy outcomes for large populations, that information is highly general, and leaves a gap in understanding in more detail what might be true for specific individuals in their subjective experiences of treatment.

In an attempt to address this problem, the current study builds on existing literature by exploring in detail what five participants who received psychotherapy during emerging adulthood (the time period between the ages of 18-25) found helpful and not helpful in treatment from their unique perspectives, in addition to understanding their overall subjective experiences in psychotherapy. Psychoanalytic case study methodology was used to understand—within the reported, lived experiences of these five participants—what informed their specific narratives related to their experiences of treatment.

This study also attempted to understand if, or how, participants’ unique developmental histories informed their subjective experiences in treatment. This is especially important because the two studies that do actually ask emerging adults what they found helpful or not helpful in treatment (see Lilliengren & Werbart, 2005; Philips, 2008) do not go into depth about participants’ histories and how they may have shaped their subjective experiences in treatment, or how they possibly influenced their thoughts related to therapeutic action. In this research, psychoanalytic case study methodology provided a framework to explore each participant’s developmental history in great depth, and consequently offered a way to construct an understanding of how one’s past

3 experiences affected how each participant viewed her subjective experience of psychotherapy, including what each person found helpful or not in treatment.

Significance for Clinical Social Work More than three decades of general outcome studies have supported the efficacy of various forms of psychotherapy, including short- and long-term psychodynamic psychotherapy (see Shedler, 2010). Even though a large number of outcome studies have demonstrated the effectiveness of psychotherapy in treating a variety of symptoms across populations, these quantitative studies are typically based on research with large numbers of participants, and so do not often include the individual participant’s perspective on what was helpful or not helpful in treatment (Lilliengren & Werbart, 2005). In fact, the participant’s viewpoint on what is useful or not in the context of psychotherapy has been largely neglected not just in the psychoanalytic literature, but also more broadly in the psychotherapy literature, regardless of one’s theoretical orientation (Bohart & Tallman, 2010; Duncan & Miller, 2000; Lilliengren & Werbart, 2005).

The research that has taken into account the participant’s viewpoint on helpful aspects in treatment contributed in part to what is now considered “the common factors” across therapies and across individual research participants, which includes the patient experiencing the therapy relationship as a supportive one and having a space for selfexpression and self-understanding (Lilliengren & Werbart, 2005). While these findings have started to shed light on what some participants find useful or not in treatment, they are very broad and general, and also minimize individual factors, leading some researchers to begin looking at the subjective experience of a specific individual (at a

4 particular moment in his or her life) who seeks treatment, and actually explore the patient’s perspective on therapeutic action (Lilliengren & Werbart, 2005).

To date, only two studies in the psychoanalytic literature have directly asked emerging adults for their perspectives related to therapeutic action (see Lilliengren & Werbart, 2005; Philips, 2008). While these studies have attempted to address the tendency to omit the participants’ ideas on this clinical issue, there continues to be a shortage of qualitative research that has asked emerging adults about their experience in treatment, including what they found useful or not useful. Without asking for the emerging adult’s perspective on therapeutic action, I believe we lose a significant data source, one that could potentially influence how therapists view helpful aspects of treatment with this population. As a result, the current study is significant for clinical social work because it addresses this tendency in psychoanalytic research to seek general information and leave out the individual participant’s perspective on therapeutic action, or what feels helpful or not helpful for a given patient at a specific time in treatment.

A second significance of this study was to understand the possible link between a participant’s developmental history and its impact on one’s subjective experience in treatment. A basic assumption of psychoanalytic theory is that past relationships, particularly early experiences of parental caregiving in childhood, shape all later experience and how one relates to significant others in the present (Shedler, 2010). As Freud (1914) argued over 100 years ago, past ways of relating to parental figures and significant others are unconsciously repeated and consequently “live on” in the present.

From a therapeutic standpoint, participants’ developmental histories will affect how they relate to a therapist and as a result impact what they find helpful or not helpful in

5 treatment. As previously mentioned, two studies have been conducted with emerging adults that asked for their perspectives on what was useful or not in their treatments (see Lilliengren & Werbart, 2005; Philips, 2008). However, those studies did not delve into the developmental history of each participant, and consequently did not shed light on whether or how one’s childhood experiences impacted how he or she viewed what was useful or not in treatment, something this study addressed. In other words, this study aimed to understand how participants who received treatment during emerging adulthood used their developmental histories to make use of therapy. How did one’s development and past reported experiences influence what each person found helpful or not helpful in treatment? How did one’s childhood and past significant relationships impact his or her subjective experience of psychotherapy? This study answered these questions in the context of participants’ narratives of childhood and their treatments.

Study Objectives The main objective of this study was to understand the emerging adult’s perspective on therapeutic action, that is, what the participants found helpful or not helpful about their experience in treatment in the context of their idiosyncratic development and past relationships. What is helpful for an individual may be contingent on his or her life experiences, information that must be obtained through a detailed inquiry into one’s past, including one’s important relationships growing up with parents and significant others. In order to elicit this information, psychoanalytic case study methodology was used to facilitate an in-depth exploration of the participants’ histories,

6 and how their significant relationships and past experiences impacted how they viewed therapeutic action.

After I assembled a psychoanalytic case study for each participant, a second objective was to broaden my interpretive lens and compare across individual treatment narratives to construct psychoanalytic themes relevant to these five participants. While the data obtained from the cross-case analysis cannot be generalized to other individuals who had treatment during emerging adulthood, I wanted to look more broadly at the narratives to explore possible psychoanalytic themes that emerged collectively for these specific participants.

Statement of Assumptions This study used the following assumptions: 1. Participants interviewed in the study have progressed to a level of verbal development where they can articulate and reflect on their experience in psychotherapy.

In other words, their experience can be known, captured, and shared with another through the use of language.

2. Because relational psychoanalysis as conceived by Mitchell (1988) will be used as the conceptual framework to interpret the data, it is assumed that the pursuit and maintenance of relationships is a primary motivation for individuals throughout life, and in particular during emerging adulthood.

3. Because psychoanalytic theories assume a developmental model, this study emphasized childhood experience and significant past relationships in contributing to what participants perceived as being helpful or not helpful in psychotherapy. In other

7 words, it was assumed that a participant’s past experiences in childhood would be a salient factor in influencing what she found helpful or not in treatment, in addition to impacting the kind of relationship a participant established with her therapist.

4. It is assumed that there are a number of possible factors that impacted how a participant who received psychotherapy during emerging adulthood viewed what felt helpful or not helpful in treatment, factors that may have been unique to the patient, to the therapist, or to the third space created and shared by the dyad. However, in an attempt to convey a sense of transparency, it should be noted that my own personal experience in psychotherapy during emerging adulthood has led me to believe that one component of treatment with this population that can be helpful includes those emotionally charged moments in psychotherapy where the therapist reacts spontaneously in a way not dictated by clinical theory or technique, but rather by one human being relating to another in a genuine, authentic way. These moments are not calculated; instead they must emerge spontaneously in the context of a therapeutic relationship characterized by understanding and authenticity. For me personally, these moments in treatment with my own therapist were immensely useful as they helped me feel deeply cared for and responded to, something that then altered the way in which we related to one another.

5. Instead of subscribing to a singular route to therapeutic action, it is assumed that there are multiple ways for a psychotherapist to be helpful (Aron, 2000). This stance implies that there is some uncertainty throughout the treatment process about what exactly will be helpful or not helpful for a given patient, an assumption that is in line with a relational psychoanalytic viewpoint that does not subscribe to a one-person, objectivist medical-model perspective (Hoffman, 2009).

8 Theoretical and Conceptual Framework In this study, I use relational psychoanalytic theory to interpret the data.

However, because relational theory has expanded a great deal over the past 20 years, it is crucial to explicitly state that I use Mitchell’s (1988, 1993) work as the primary theoretical lens, a framework that combines the interpersonal tradition developed most notably by Sullivan with a strong influence on development and a child’s early life, and particularly one’s internal object relations, and how they continue to impact an individual’s relationships over time. From there, I also make use of other relational writers, most notably Stern (2010), someone also heavily influenced by Sullivan.

Mitchell’s (1988) relational model presumes that repetitive patterns within human development derive from a tendency to preserve the connections and familiarity of one’s personal, interactional world. From this perspective, an individual will connect with others by unconsciously projecting and re-creating both familiar and familial constricted relational patterns, experiencing new relationships in ways dictated by past significant relationships (Mitchell, 1988). The challenge for the therapist is to help the patient relinquish ties to these repetitive, unconscious relational patterns, thereby allowing an openness to engage in new interpersonal relations, ones that offer new possibilities for relating with an intimate other (Mitchell, 1988).

Because this study was interested in the subjective experience of individuals who had psychotherapy in emerging adulthood and what they found helpful or not helpful in their treatments, it is necessary to articulate what is helpful in psychotherapy from a relational perspective. Mitchell (1988) argued that a patient enters treatment operating within constricted relational patterns, and seeks connections with others by projecting and

9 re-creating the same interpersonal dynamics in the present, inevitably experiencing all relationships along old lines, including the relationship with his or her therapist (Mitchell, 1988). As Mitchell (1988) stated, “operating with old illusions and stereotyped patterns reduces anxiety and provides security not simply because the illusions and patterns are familiar, but also because they are familial and preserve a sense of loyalty and connection” (p. 291). The central mechanism of change from his perspective includes an alteration in the basic structure of the patient’s relational world, something that is accomplished by articulating and elucidating these patterns in the therapy relationship, ultimately enabling a patient to engage in novel interpersonal relations where new experiences of self and other become possible (Mitchell, 1988). This study, therefore, paid particular attention to each participant’s relational patterns and how they may have impacted one’s subjective experience in treatment, including how those patterns possibly manifested in the therapeutic relationship.

Additionally, relational theory assumes that early experiences—from infancy and young childhood through early adulthood—help to shape how individuals understand who they are and how their relationships will play out with others. These relational assumptions, both conscious and unconscious, influence not just what people expect from current and future relationships, but also can lead them to repeat certain kinds of relationship patterns in the present, including ones that are problematic and self-defeating (Mitchell, 1988). Therefore, from the point of view of relational theory, it makes sense to understand what relationship models each participant developed in childhood that may have impacted her psychotherapy experience, contributing to how that experience felt to each participant. While quantitative research has yielded general results related to the

10 efficacy of treatment, there has not been qualitative research into the particular meaning that specific individuals have made from their psychotherapy experiences, based on the conscious and unconscious models of relationships that they may have developed over time. As a result, this study attempted to address this gap in the research, and understand how a participant’s past entered the treatment, potentially shaping each individual’s perception of therapeutic action.

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Chapter Two

Literature Review The literature review will begin with a brief description of adolescence as a social construction, describing how the developmental period taken for granted today became a prominent feature of American life. After placing the concept of adolescence in a historical context, discussion will move to examining psychoanalytic conceptions of adolescent development, specifically ideas related to puberty, separation/individuation, detachment, and identity. From there, adolescence will be looked at from the lens of contemporary developmental psychology research, ideas that challenge some of the longheld psychoanalytic convictions related to adolescence and young adulthood. The review will explore emerging adulthood and then examine available psychoanalytic research on young adulthood, a topic that has not received considerable attention within psychoanalysis. In fact, psychoanalysis has not written extensively about any postadolescent development, something that will be discussed in greater detail in the review.

From there, the literature review will explore therapeutic action in general, looking at three broad ideas discussed heavily in psychoanalysis related to what is helpful or curative in treatment, or what brings about change. As the review will highlight, ideas related to therapeutic action have largely been considered solely from the viewpoint of the therapist, leaving out the patient’s understanding of helpful aspects of treatment (see Lilliengren & Werbart, 2005). Last, the discussion will end by looking at emerging

12 adults’ perspectives on therapeutic action and what they reported as having been helpful or not helpful in treatment, a topic that has not been heavily discussed within psychoanalysis and psychotherapy research in general.

Before delving into the relevant literature available on emerging adulthood, the reader must know that the current study will not emphasize reviewing efficacy or outcome studies that have been conducted with the emerging adulthood population, nor will it emphasize reviewing quantitative outcome data that aims to offer generalizable findings across patient populations. Instead, my goal as the researcher was to understand what individuals who received psychotherapy at a specific time in their lives found helpful and not helpful about their subjective experience in treatment in the context of their particular developmental history. The latter construct is highly idiosyncratic, not generalizable or measurable, and very different from the general construct of efficacy or outcome research. In addition, the two types of research include stark differences in underlying epistemological assumptions. However, the forthcoming literature review does include some references to efficacy, outcome, and change implicit in quantitative studies since that is predominantly what has been conducted in the literature to date on emerging adulthood.

Adolescence as Historical Phenomena The review will begin by discussing the concept of adolescence from several points of view: adolescence as a social construction, adolescence as discussed within the psychoanalytic tradition, and adolescence examined from the lens of contemporary general psychological research. The literature will include data from traditional case

13 studies that have shaped much of psychoanalytic theories, in addition to empirical research conducted on this population. While these sources look at adolescent development in different ways and from discrepant, at times conflicting, epistemological positions, they all offer insight into the changes that accompany this time period, and in combination offer a rich, nuanced perspective on adolescent development that will help the reader become acquainted with the ideas that have been written about this population.

It should be noted that emerging adulthood is not a term generally recognized or used in psychoanalysis. Rather, psychoanalytic research has historically made a distinction between childhood, adolescence, and adulthood. Emerging adulthood, a developmental time period first coined by Arnett (2000), is a concept borrowed from developmental psychology that includes individuals between the ages of 18 and 25, a time period distinct from both childhood and young adulthood. However, because the majority of psychoanalytic research on youth focuses on adolescence with very little inquiry into emerging adulthood, it is essential to start there. The literature review begins with an examination into adolescence as a social construction.

Today we often think of adolescence as the developmental period preceding adulthood, a time when youth are able to suspend long-term commitments in favor of transient explorations into potential areas of interest and relationships. Youth are afforded, in many cultures, a kind of transitional space to try out and discover what might be enduring responsibilities and roles later in life (Arnett, 2000). However, for a long period of time in the United States, that was not the case. Thomas Hine (1999), writing about the history of American youth in the nineteenth-century, wrote:

14 Although the upper classes were prolonging the immaturity of their offspring by sending them to school, most young people were seeing their childhoods shorten…Many parents were dependent upon their children. Almost always, this dependence was economic. Prevailing wage scales did not allow a man to make enough to support his family. Moreover, many employers preferred to hire families, and their wage scales made teenage sons particularly important for the families’ livelihood. Many parents had little choice but to depend on their children, either because the exigencies of life on the frontier and the farm, or the wage scales of mines and factories forced them to (pp. 120-121).

Hine goes on to discuss how the advent of high school changed the roles and responsibilities of the American teenager. It wasn’t until the 1930s when a majority of youth enrolled in high school, mainly because the Depression had made jobs unavailable to them (Hine, 1999). In addition, it wasn’t until after World War II that the idea of high school for all took hold in the United States, starting a cultural revolution where teenagers started to receive secondary schooling, resulting in many suspending their engagement in work-related roles and responsibilities (Hine, 1999). Galatzer-Levy and Cohler (1993) state that “urbanization, education, the demands of complex technology, more emphasis on personal choice, and more accessible higher education helped make youth a common, distinctive period for many Americans only in the past half-century” (p.

197). In addition, social mechanisms such as compulsory schooling, child labor laws, and a separate juvenile justice system coalesced into a definition of adolescents as neither adults nor children (Elliott & Feldman, 1990). These sociocultural practices have

15 changed the responsibilities and requirements of contemporary adolescents and allowed for a temporary suspension of adult roles as youth transition out of childhood.

The invention of high school facilitated interest into the life of the American teenager. One of the most prominent individuals to begin exploration included G. Stanley Hall, the founder of adolescent psychology, someone who pioneered inquiry into every facet of the youthful mind, creating persistent and, at times, destructive clichés (see Hine, 1999). Hall (1904) depicted adolescence as a time of storm and stress and asserted that adolescence is a period during which all individuals experience some degree of emotional and behavioral upheaval. As Hine (1999) states, Hall “presents such a litany of risks in adolescence—ranging from preoccupation with one’s skin to suicide—that readers wonder how they survived its perils.” (p. 160). While this view of adolescence appears sensationalized, other writers have described how many of Hall’s (1904) ideas have been supported in contemporary adolescent developmental research. For example, Arnett (2006) argues that Hall viewed adolescence as a time when depressed mood is more common than at other ages, something he contends is similar to findings from current research that report a mid-adolescence peak in depressed mood, with levels rising in early adolescence and then falling after the mid-teens. In addition, Arnett (2006) argues that Hall’s observations regarding crime in adolescence—as well as his contention that adolescents become more oriented toward peers and typically engage in at-risk behavior with their peer groups—hold true in contemporary research.

While some of Hall’s (1904) ideas hold true today and others seem too pessimistic, his in-depth exploration into the life of the adolescent propelled others to accept his definition of this developmental period as one worth examining, and paved the

16 way for further inquiry into the adolescent mind. Discussion will turn to a focus of psychoanalytic inquiry into adolescent development.

Psychoanalytic Views of Adolescent Development Puberty.

Adolescence has historically been considered in the context of puberty. For Freud (1905), the onset of puberty was important because of the increase in drive activity that had implications for the psychosexual development of the adolescent. He described puberty as the time when a shift occurred that subordinated the erotogenic zones to the primacy of the genital zone, resulting in the individual finding new sexual objects outside of the family (Freud, 1905). The psychoanalytic recapitulation theory of adolescence postulates that the Oedipus complex that was resolved in childhood reappears at puberty and manifests in the adolescent seeking extra-familial sexual objects (Blos, 1979; Freud, 1905). While Freud (1905) described this process as different for males and females, puberty was defined as the time that gave infantile sexual life its final shape. Anna Freud (1958) subscribed to her father’s (1905) theory of psychosexual development but focused more on the change in ego functions that arise from the onset of puberty, and the resulting changes in the intensity of the drives. She argued that the ego, threatened with anxiety by the increase in drive development, struggles with the id for dominance, ultimately employing several defense mechanisms to manage the increase in drive activity (Freud, 1958). She, too, believed that the adolescent seeks external sexual objects to deal with his or her increase in libidinal activity, though her focus was more on how the ego managed this increase in the context of defense mechanisms (Freud, 1958).

17 Katchadourian (1990) argues that in contemporary society, there is a growing fear that adolescents are sexually crazed, promiscuous, and irresponsible, a misleading belief that can result in problems related to adolescent sexual activities being over-exaggerated.

Katchadourian (1990) argues that the most important sexual milestone that heterosexual adolescents meet includes the initiation of sexual intercourse, a behavior that has physical, psychological, and cognitive implications. For example, after the onset of puberty, the adolescent begins to develop a basic perception of oneself as a sexual being, a process that starts to facilitate the formation of a sexual identity that ultimately becomes a salient aspect of the self (Katchadourian, 1990). This process can be difficult as adolescents must simultaneously integrate a new perception of their body while also postponing having children (Galatzer-Levy & Cohler, 1993). In addition, it is not just that puberty results in biological changes in the adolescent; rather, puberty and physical maturation influence social status, making it imperative to consider the adolescent’s experience of bodily changes and the meaning they generate as a result (Galatzer-Levy & Cohler, 1993). Whether one considers the increase in drive activity and the reemergence of the Oedipus complex the onset of adolescence (Freud, 1905), or entering the teenage years and high school (Galatzer-Levy & Cohler, 1993), the biological and social changes that accompany puberty have profound implications for the development of the adolescent’s identity and sense of self.

18 Individuation.

No other psychoanalyst has written more about adolescent development than Peter Blos, who viewed adolescence as the second individuation process that resulted in psychic restructuring facilitated by necessary developmental regression (Blos, 1979). He wrote: I propose to view adolescence in its totality as the second individuation process, the first one having been completed towards the end of the third year of life with the attainment of object constancy. Both periods have in common a heightened vulnerability of the personality organization. Both periods have in common the urgency for changes in psychic structure in consonance with the maturational forward surge. Last but not least, both periods—should they miscarry—are followed by a specific deviant development (psychopathology) that embodies the respective failures of individuation. What is in infancy a “hatching from the symbiotic membrane to become an individuated toddler” (Mahler, 1963), becomes in adolescence the shedding of family dependencies, the loosening of infantile object ties in order to become a member of society at large or, simply, of the adult world. (Blos, 1967, p. 163).

Blos (1967) contended that the disengagement from internalized infantile love and hate objects facilitates a process by which the adolescent seeks external and extra-familial love and hate objects, namely peers. This disengagement from parental objects is complemented by a period of depressed affect following the loss of internal objects, a necessary developmental regression that can result in adolescents seeking external sources of gratification, or withdrawing from objects and investing more in the self, at

19 times to an extreme of unhealthy self-absorption (Blos, 1967). This loss can result in what Blos (1967) referred to as affect and object hunger, where the adolescent experiences a need to feel intense affective states like pain and elation. While this process can result in emotional turbulence, Blos (1967) believed it was an imperative phase of adolescent development. He stated, “The relentless striving toward increasing autonomy through regression forces us to view this kind of regression in adolescence in the service of development, rather than in the service of defense” (Blos, 1979, p. 180).

As a result, from his perspective, transient emotional disturbances in the service of individuation are normal and crucial for the psychological growth of the adolescent (Blos, 1967).

Not only does the adolescent disengage from infantile internalized objects, but there is also a period of ego regression in normal adolescent development (Blos, 1967).

In childhood, the parental ego is available to the individual and serves as an ego extension; however, during adolescence with the disengagement from infantile dependencies, the “accustomed ego dependencies of the latency period are repudiated as well” (Blos, 1967, p. 163). Blos (1967) believed that there was a period of ego weakness in adolescence due to a combination of the increasing drives from the onset of puberty coupled with the withdrawal of parental ego support. In response to the loss of the parental ego, the adolescent in transition often seeks extra-familial ego supports, namely peers. For Blos (1979), these two processes, while temporarily regressive in nature, are crucial for the adolescent en route to achieving stable ego functions needed for character formation and the transition into adulthood.

20 Detachment.

For Blos (1967), normal adolescent development involved a necessary period of regression as one disengages from infantile objects and from parental support. The process of individuation occurs as the adolescent develops a clearer sense of self as psychologically separate from parental figures (Steinberg, 1990). For Anna Freud (1958), normal adolescent development included not a period of individuation but a necessary interruption of peaceful growth inherent in the detachment from parents.

Specifically, Freud (1958) went so far as to say that having steady equilibrium during adolescence is in itself abnormal. She stated: I take it that it is normal for an adolescent to behave for a considerable length of time in an inconsistent and unpredictable manner; to fight his impulses and to accept them; to ward them off successfully and be overrun by them; to love his parents and to hate them; to revolt against them and to be dependent on them‌. Such fluctuations between extreme opposites would be deemed highly abnormal at any other time of life (Freud, 1958, p. 276).

Freud’s (1958) view of adolescent development was in line with Hall’s (1904) storm and stress model and even took it one step further, implying that the absence of storm and stress for the adolescent was abnormal and problematic. For example, Freud (1958) argued that adolescents who exhibited no evidence of inner unrest and who were compliant, considerate, and submissive were showing a delay of development, and that they have built up excessive defenses that act as barriers to the normal maturational process of adolescence. For Freud (1958), an individual exhibiting this behavior needs therapeutic help to remove his or her rigid defense structure. Clearly, Freud (1958)

21 believed that unrest and conflict were healthy and inevitable in the adolescent years, and that harmony and attachment were unhealthy. Freud’s (1958) depiction of adolescence painted a picture of intra-familial conflict and tension where the young, rebellious adolescent couldn’t and shouldn’t be tamed. Instead, a compliant, thoughtful adolescent should be met with skepticism and parental worry (Freud, 1958).

Identity.

Instead of writing about the individuation process (Blos, 1967; Blos, 1979) or conflict and detachment in adolescence (Freud, 1958), Erikson wrote about identity formation across the life cycle (Erikson, 1959). The purpose of Erikson’s (1959) work was to bridge Freud’s theory of infantile sexuality with his current knowledge of a child’s physical and social growth in his family and in culture and society. Erikson (1959) argued that it was crucial to understand the internal life of the individual in the context of his or her location in society. For the purposes of this discussion, Erikson’s (1959) views on the psychosocial crisis in adolescence will be examined.

Erikson (1959) coined the psychosocial crisis in adolescence identity versus identity diffusion. After the onset of puberty, Erikson (1959) argued that adolescents are primarily concerned with attempts at consolidating their social roles, and are preoccupied with how to connect previously developed roles and skills “with the ideal prototypes of the day” (p. 94). The danger of not resolving the psychosocial crisis in adolescence and forming a stable identity includes what he called identity diffusion, where an adolescent is unable to settle on a personal and occupational identity, and instead overidentifies “with the heroes of cliques and crowds” (Erikson, 1959, p. 97). In addition, one can

22 encounter identity foreclosure, the distress and anxiety of not knowing one’s identity and not engaging in self-exploration, something that can result in an adolescent choosing an unsuitable identity out of anxiety and desperation (Galatzer-Levy & Cohler, 1993). To achieve an identity that is not defensive in nature, Erikson (1959) argued that societies afford adolescents with what he referred to as a psychosocial moratorium, a more or less sanctioned period between childhood and adulthood where youth are given time to experiment and find a niche in society. The adolescent process is complete when the individual has subordinated his or her childhood identifications to a new kind of identification that is socially acceptable (Erikson, 1959). If this is not accomplished, identity diffusion and difficulties ensue, prolonging the adolescent’s progression into adulthood (Erikson, 1959).

Erikson (1959) wrote about identity in the context of the social surround, always assuming that the external circumstances of a particular time had a profound impact on the identity of the individual under study. Specifically, his ideas regarding identity versus identity diffusion were written in the fifties, when many adolescents left home for a period of time, sought apprenticeship, and then returned home. However, more contemporary psychoanalytic writers have examined identity from other perspectives.

Brandt (1977) argues that adolescents achieve identity when they give up their childhood dependency on earlier relationships and see themselves as different and separate from their parents. Specifically, he contends that adolescents achieve a sense of identity when they see their parents as real people and also maintain, if they chose, the relationship in a new way (Brandt, 1977). His view of the identity crisis in adolescence is one where individuals must find themselves alone, without the support of parents (Brandt, 1977).

23 Other writers have discussed Erikson’s (1959) psychosocial moratorium, the time when adolescents are free to experiment with different roles and find a niche in society.

Galatzer-Levy and Cohler (1993) argue that empirical studies demonstrate that the passage from childhood to adulthood has become more fixed today than at any previous time in history. They contend that “although adults may envy adolescent “freedom”, most contemporary American adolescents feel anything but free. They feel deeply burdened by unending demands to train for adult roles whether in school or in their personal lives” (Galatzer-Levy & Cohler, 1993, p. 171). As a result, while contemporary adolescents may experience a psychosocial moratorium today, the choices available to them look very different given the current focus on postsecondary education and the highly advanced training needed to compete in a global, technology-focused economy.

Newfound cognitive abilities that accompany adolescence result in changes in self and identity development. Harter (1990) argues that there is a developmental shift from concrete descriptions of one’s social and behavioral exterior in childhood to more abstract representations of one’s internal life in adolescence. In late adolescence, this newfound capacity manifests in beliefs and moral standards that gradually become integrated into one’s personal philosophy and impact identity development (Harter, 1990). The adolescent forms a self-concept, one that is compared to others and one that relies on normative societal standards that incorporates attitudes and beliefs from significant others (Harter, 1990). Galatzer-Levy and Cohler (1993) contend that during adolescence, cognitive capacities shift drastically, with most individuals able to utilize their new skills to plan, to see others’ viewpoints, to recognize the validity of an argument, and to think about thinking, something referred to as meta-cognition. These

24 cognitive changes impact one’s self-concept, something that is socially constructed and developed through the incorporation and repudiation of possible selves (Harter, 1990).

Changes in cognition provide another means of identity exploration as adolescents develop the capacity for abstract thinking, a skill that provides them with the opportunity to fantasize about potential areas of interest without actually pursuing them.

In summary, psychoanalytic views of adolescence focused on the psychological implications of the physiological and cognitive developmental issues inherent in this time period, starting with the emergence of puberty, the process of separation/individuation and detachment, and the changes that result from struggling with identity formation.

Psychoanalytic views generally painted a conflicted picture of adolescence, one that included necessary conflict and tension. However, other writers have challenged these views and described a different story of the American adolescent, one that is less conflictual and more optimistic. The review will now consider adolescence in the context of more recent research, some of which comes from developmental psychology.

Adolescence in Contemporary Research Psychoanalytic models have had a profound impact on views of adolescence, leaving what some have referred to as the psychoanalytic legacy (see Steinberg, 1990).

However, some contemporary developmental psychologists have challenged the impact left by early psychoanalytic theorists. Steinberg (1990) states: A key legacy of the psychoanalytic view of adolescent development is the belief that family relationships deteriorate during this period and that adolescent rebellion, conflict with parents, and detachment are all normative‌The weight of

25 the evidence to date indicates that the portrait of family storm and stress painted by early analytic writers is unduly pessimistic. Several large-scale surveys of adolescents and parents indicate that approximately three-fourths of families enjoy warm and pleasant relations during the adolescent years (p. 260).

Offer, Ostrov, and Howard (1989) described this tendency over two decades ago, arguing that while many mental health professionals contend that adolescence is the most stressful and turbulent stage in the life cycle, this belief has little empirical support.

Specifically, they found that the prevalence of mental disorders among the adolescents they studied was about 20%, almost identical to prevalence rates shown by adults (Offer et al.). Steinberg (1990) argues that research on representative populations of adolescents and parents indicates that harmony within the family is far more pervasive than contentiousness, and that the values and attitudes of adults and adolescents are more alike than different. His research found that only a small proportion of families (somewhere between 5% and 10%) experience a dramatic deterioration in the quality of the parentchild relationship during adolescence, challenging both Hall’s (1904) contention that adolescence includes a period of storm and stress, and also Freud’s (1958) argument that little tension and conflict is in itself abnormal.

More recent research on adolescent development differs from psychoanalytic views of detachment, storm and stress, and inherent conflict. Steinberg (1990) posits that the findings, which are mainly empirical and less drawn from case studies, begin with the assumption that major realignments in family relationships do occur during the adolescent years, but these realignments do not necessarily occur in the context of emotional detachment from parents. Steinberg (1990) argues against Freud’s (1958) idea

26 of detachment by reporting that there is considerable evidence against the view that detachment from family is desirable. Specifically, he states that “teenagers who report feeling relatively close to their parents score higher than their peers on measures of psychosocial development, including self-reliance and other indicators of responsible independence; behavioral competence, including school performance; and psychological well-being, including self esteem” (Steinberg, 1990, p. 263). When there is conflict between adolescent and parent, it often revolves around disagreements over family rules and other mundane features of daily life—conflict that does not typically threaten the relationship between parent and child (Csikszentmihalyi & Larson, 1984; Steinberg, 1990).

Steinberg (1990) argues for a move toward interdependent relationships and contends that healthy families consist of adolescents who remain responsive to parental authority and continue to seek the advice of parents in the context of greater freedom.

Hine (1999) bolsters this argument by arguing that evidence indicates that parents who take a lively interest in their children’s lives have adolescents who are less likely to commit crimes, use drugs, or become pregnant prematurely. Studies of high school students show that many adolescents continue to rely on parents, value a close relationship with them, and seek more mutual interactions with them (Galatzer-Levy & Cohler, 1993). In addition, parents who are authoritative (i.e. warm, firm, and psychological autonomy granting) have adolescents who continue to show advantages in psychosocial development and mental health over peers raised in non-authoritative homes (Steinberg, 2001).

27 As a result, there is evidence that suggests that adolescents undergoing a process of separation/individuation (Blos, 1967) from parents can be adaptive and healthy if that process is experienced in the context of a warm and supportive relationship between parent and child (Steinberg, 1990, 2001). While detachment is not desirable, it seems that room for individuation is crucial during this time. In addition, major transformations in the parent-child relationship take place in adolescence that do not necessarily threaten the emotional bond, but can lead to a temporary period of perturbation or realignment in the family system (Steinberg, 1990).

In summary, contemporary developmental psychology research on adolescent development does not corroborate earlier psychoanalytic contentions of necessary detachment (Freud, 1958) or Hall’s (1904) idea of inevitable storm and stress. Rather, research depicts the healthy adolescent as having appropriate autonomy in a warm, firm, and supportive environment with parents. There is a delicate, oscillating tension between granting autonomy and expecting compliance from an adolescent. While disagreements, realignment, and some conflict is inevitable as an adolescent navigates the push and pull of autonomy versus dependence from parental figures, oppositional behavior and emotional turmoil is not the norm (Steinberg, 1990). Rather, closeness and interdependency more appropriately capture the healthy adolescent’s experience.

So far, the literature review has discussed adolescence as a cultural phenomenon as well as psychoanalytic viewpoints regarding major developmental issues inherent during this time, including the onset of puberty, the process of individuation versus detachment, and the exploration of identity. In addition, research from developmental psychology was explored that challenged some of the enduring misconceptions about

28 normal adolescent development left over from the psychoanalytic legacy and Hall’s (1904) monumental exploration into adolescence. Because psychoanalysis does not recognize the term emerging adulthood, there is little psychoanalytic research into the developmental issues experienced during this time. Do adolescents and emerging adults navigate the same developmental issues? What is the difference between adolescence and emerging adulthood? These questions will now be explored. As Galatzer-Levy and Cohler (1993) state, “Psychoanalytic data and theories about youth, and the rest of postadolescent development, are also largely lacking� (p. 197). As a result, discussion will turn to the available literature on emerging adulthood, research that stems mainly from findings in developmental psychology.

Emerging Adulthood Emerging adulthood, a term coined by Arnett (2000), is a developmental time period distinct from both adolescence and young adulthood that includes individuals between the ages of 18 and 25. Arnett (2000) argues that because marriage and having children are now delayed in industrial societies until the mid-to-late twenties and early thirties for most people, it is no longer normative for the late teens and early twenties to be considered a time period for entering and settling into long-term adult roles. As a result, he argues for a distinct time period that better captures the late teens and early twenties, a period that includes frequent change and exploration (Arnett, 2000). He states: I argue that this period, emerging adulthood, is neither adolescence nor young adulthood but is theoretically and empirically distinct from them both. Emerging

29 adulthood is distinguished by relative independence from social roles and from normative expectations. Having left the dependency of childhood and adolescence, and having not yet entered the enduring responsibilities that are normative in adulthood, emerging adults often explore a variety of possible life directions in love, work, and worldviews. Emerging adulthood is a time of life when many different directions remain possible, when little about the future has been decided for certain, when the scope of independent exploration of life’s possibilities is greater for most people than it will be at any other period of the life course (Arnett, 2000, p. 470).

Arnett (2000) goes on to specify and provide evidence to indicate that emerging adulthood is a distinct period from adolescence and young adulthood demographically, subjectively, and in terms of identity exploration. These areas will now be explored.

Demographically, the vast majority of American adolescents between the ages of 12 and 17 live at home with one or both parents, are unmarried, are in school, and have no children (Arnett, 2000). However, by age 30, new demographic norms are established and roughly three-fourths of 30-year-olds are married with children, in addition to being out of school (Arnett, 2000). The years between these two time periods, emerging adulthood, is distinct as a result of an individual’s demographic status being difficult to predict on the basis of age alone, something Arnett (2000) attributes as a reflection of the experimental and exploratory quality of emerging adulthood. Because emerging adults tend to be less likely constrained by role requirements than both adolescents and young adults, their demographic status is both distinct and more unpredictable than these other

30 age periods, particularly in the area of living status, where emerging adults have the highest rate of residential change (Arnett, 2000).

Arnett (2000) argues that, from a subjective viewpoint, emerging adults see themselves neither as adolescents nor entirely as adults. He posits that while most emerging adults believe that they have left adolescence, many do not think they have completely entered young adulthood, citing research that found that the majority of young people between the ages of 18 and 25 do not believe they have reached full adulthood, whereas the majority of people in their thirties think that they have (Arnett, 2000). In addition, emerging adulthood is the time period that offers the most opportunity for identity exploration, specifically in the areas of work, love, and worldviews (Arnett, 2000). While the majority of research on identity formation has focused on adolescence, particularly research in psychoanalysis, Arnett (2000) argues that several research studies indicate that identity achievement is rarely reached by the end of high school, a process that results in the majority of emerging adults dealing with identity exploration and formation between the ages of 18 and 25.

As a result, while emerging adulthood is not a universal developmental period in every culture, Arnett (2000) argues that in countries like the US that postpone entry into adult roles and responsibilities well past the late teens, it is a fitting description for the young individual who has left adolescence, but who hasn’t reached adulthood and more stable, enduring roles and responsibilities. With more than 60% of young Americans obtaining postsecondary education, emerging adulthood is a time when many individuals are learning skills necessary to gradually transition into adulthood (Arnett, 2000).

31 While there has been some psychoanalytic research into young adulthood, which will be discussed shortly, very few psychoanalytic studies have specifically explored emerging adulthood. Shulman, Blatt, and Feldman (2006) examined, from a psychoanalytic perspective, emerging adults in Israel as they attempted to understand why some are successful in establishing age-related tasks and pursuing them effectively, while others have difficulties in maintaining commitment to their engagements. In a study consisting of 70 emerging adults, these researchers used a qualitative approach to understand “the possible ways in which young people manage their lives, set their plans and pursue them, understand their behavior and deal with the changes that are required when facing new tasks related to their developmental stage of life� (Shulman, Blatt, & Feldman, 2006, p. 162). The researchers found two modes of operating that emerging adults employed to adapt to developmental issues. One, called the doing-oriented mode, consisted of participants who were preoccupied with an urge to attain and assert their independence through behaviorally and actively demonstrating their accomplishments to themselves and to others (Shulman, Blatt, & Feldman, 2006). Interestingly, the authors found that these individuals, while fascinated and driven by the drive for independence, rarely understood and assessed the meaning and impact of their actions for themselves and others (Shulman, Blatt, & Feldman, 2006).

Conversely, the reflective-oriented mode consisted of emerging adults who were similarly engaged in the establishment of their independence, but who were very aware of their behavior and motivation for engaging in a particular developmental task (Shulman, Blatt, & Feldman, 2006). Unlike their doing-oriented peers, the reflective-oriented individuals connected their intrinsic motivations and search for meaning with their

32 external conditions and urge for independence (Shulman, Blatt, & Feldman, 2006). The authors concluded that all of the emerging adults in their study had the sense that they were at a turning point in their lives that required them to actively direct their lives and determine a proactive plan for doing so. However, some individuals in the doingoriented mode lacked flexibility to connect a plan with their inner motivation and external reality, resulting in what the authors considered self-idealized behaviors that may reflect infantile narcissism (Shulman, Blatt, & Feldman, 2006). These individuals maintained a defensive mode of addressing the pursuit of independence, one that refrained from reflecting on their experiences by being continuously highly active (Shulman, Blatt, & Feldman, 2006). While the study sheds light on one aspect of emerging adult development, further research is needed to determine if youth in the US manage the urge for independence during emerging adulthood in a way similar to or different from the Israeli individuals who participated in this study.

Psychoanalytic Literature on Young Adulthood As previously mentioned, there is a paucity of psychoanalytic research on emerging adulthood and post-adolescent development in general (see Galatzer-Levy & Cohler, 1993). While psychoanalysis has not recognized emerging adulthood and consequently has not studied it in depth, there has been some research into young adulthood, a time period that is similar to, yet distinct from, emerging adulthood (Arnett, 2000). Psychoanalytic viewpoints into developmental issues inherent in young adulthood will now be considered.

33 Escoll (1987) considered young adulthood roughly the college years and contended that the young adult is often in a state of flux, presenting oneself as similar to an adolescent. However, he argued that young adults show more integration and are more stable than adolescents, something that facilitates analytic work with the young adult population (Escoll, 1987). Escoll (1987) was interested in the treatment of youth and specifically looked at whether or not young adults in psychoanalysis develop a transference neurosis. He argued that they do, in fact, develop intense transference reactions throughout treatment that become a major part of the analysis; however, due to the young adult’s heavy involvement with an array of new people, he contended that there is always a risk of displacing the transference elsewhere onto other objects in the environment (Escoll, 1987). As a result, while he believed that a strong transference could develop in analysis with young adults, he argued that the traditional definition of transference neurosis as a new version of an older illness displaced onto the analyst does not fit completely when treating this population (Escoll, 1987).

Perelberg (1993), in a discussion of a psychoanalytic conference on young adults, described three developmental tasks experienced in this time period, namely the capacity to love, to work, and to achieve autonomy from external and internal objects. In addition, the young adult must develop a sense of temporality, a process that she argues differentiates young adults from both adolescents and older adults (Perelberg, 1993).

Specifically, the young adult “must renounce his own parents (and eventually his analyst), take them as sources of identification, develop his own sense of temporality and history and thus acquire an individual project� (Perelberg, 1993 p. 98). The experience of time facilitates the inauguration of a project for the future, something she likens to a

34 rite of passage (Perelberg, 1993). This sense of temporality is important to the young adult because it differentiates him or her from both adolescents, who do not have the same perspective of time, and older adults, who do not stress the future in the same way (Perelberg, 1993). As a result, in her viewpoint, psychoanalysis can facilitate this process for young adults and help them through this specific rite of passage (Perelberg, 1993).

Perelberg (1993) also discussed how the young adult must achieve the capacity to love, something Erikson (1959) discussed decades before in his studies on identity and the life cycle. Erikson (1959) described the psychosocial crisis of young adulthood as intimacy versus isolation. He argued that youth who are unsure of their identity shy away from interpersonal intimacy and may isolate themselves, or, at best, find stereotyped interpersonal relationships that lack spontaneity, warmth, and authentic closeness (Erikson, 1959). In addition, Erikson (1959) argued that individuals lacking identity could make repeated attempts to engage with improbable partners, something that ultimately results in isolation. To avoid this, he believed it was crucial for the young adult to consolidate a sense of identity, one that facilitates the ability to engage with intimate others in a deep and meaningful way (Erikson, 1959).

Erikson (1959) discussed the psychosocial crisis of young adulthood as the achievement of intimacy in relation to a significant other. Other writers have discussed how the transition into young adulthood impacts the relationship between parents and children. Galatzer-Levy and Cohler (1993) argue that a healthy relationship between parents and children in young adulthood is characterized not by psychological separation but by a complex form of interdependence. They challenge the separation-individuation theories of Mahler and Blos and contend that those theories do not account for the

35 interdependent ties of adulthood, arguing that the goal of young adulthood is not psychological autonomy from parents and significant others, but maintenance and development of interdependence (Galatzer-Levy & Cohler, 1993). In addition, continuity in attitudes and values between parents and children is more characteristic in young adulthood than conflict and lack of harmony (Galatzer-Levy & Cohler, 1993). The authors conclude that autonomy and independence are not the goals of development, and contend that the centrality of autonomy and separateness in psychoanalytic conceptions of development reflect the values of a Western culture, not the realities of young adulthood (Galatzer-Levy & Cohler, 1993).

Summary of Adolescent and Emerging Adult Literature Thus far, the literature has discussed main ideas in relation to adolescence, emerging adulthood, and young adulthood from a variety of sources. Just as there is a dearth of psychoanalytic research on post-adolescent development, there is a tendency in psychoanalysis, regardless if one is treating an adolescent, an emerging adult, or an older adult, to neglect the patient’s perspective on what is helpful or not helpful in psychotherapy, resulting in the potential for a one-sided presentation of what needs to happen in a successful treatment for a given patient population (Bohart & Tallman, 2010; Duncan & Miller, 2000).

Psychoanalytic theory has long privileged the position and point of view of the therapist, minimizing the essential role of the client in contributing to positive therapy outcomes (Bohart & Tallman, 2010; Duncan & Miller, 2000). Consequently, clinicians can risk making assumptions about what one needs in treatment based on developmental

36 presuppositions they hold about a particular age period. What if the assumptions regarding a specific developmental period are inaccurate? What if there is a large discrepancy between what the patient finds helpful, and what the therapist views as helpful in treatment? These questions are crucial to consider as they potentially shed light on what needs to happen in treatment with emerging adults. Before discussing the few studies that did actually ask emerging adults what they found helpful in psychotherapy, the literature review will first look at therapeutic action in general, a topic that has seen considerable inquiry in psychoanalysis. After discussing what psychoanalytic writers say about therapeutic action broadly across psychoanalytic camps, the review will end with a discussion of the few studies that explore therapeutic action from the emerging adult’s perspective.

General Viewpoints Related to Therapeutic Action Instead of delving into how each theoretical orientation within psychoanalysis views therapeutic action, the review will highlight three broad curative factors that have seen considerable attention since the advent of psychoanalysis. These factors include: the examination of transference; interpretation, and the impact of the analytic relationship; and the use of countertransference. Transference has been a salient aspect of any psychoanalytic treatment since Freud first discovered the phenomenon over a century ago. As Mitchell and Black (1995) state: Although initially encountering transference as an obstacle, Freud came to feel that the displacement of forbidden impulses and fantasies onto the person of the analyst is essential in helping the patient to experience and work through the

37 issues as lived and deeply felt realities rather than intellectual abstractions and memories (p. 234).

Freud contended that the job of the analyst is to fill in gaps in memory, undo repressions, and make the unconscious of the patient accessible to consciousness, something that was achieved in part through the analysis of transference and well-timed interpretations (Freud, 1914). In addition, Freud (1914) believed that a patient will unconsciously repeat characteristic ways of relating through the transference, something the analyst must work to uncover at the right moment in treatment. While there are discrepant views related to the understanding of transference (transference as distortion versus transference as in part reality-based), all schools within psychoanalysis discuss the importance and relevance of attending to this clinical phenomenon.

A second component of therapeutic action that has been heavily discussed includes the role of interpretation versus the impact of the analytic relationship.

Greenberg (1996) contends that, historically in psychoanalysis when discussing therapeutic action, there has been a great deal of polarized discussion about the impact of interpretation on the one hand, and the role of the therapeutic relationship on the other.

Freud believed that the central mechanism of change included “the lifting of repression through insight produced by interpretation� (Mitchell & Black, 1995, p. 237). From this classical perspective, analytic cure involves the release of impulses, fantasies, and memories from repression, something that becomes possible by the analyst interpreting both the content of the repressed, in addition to the ways in which the patient defends against that content entering consciousness (Mitchell & Black, 1995). Other writers have discussed the importance of the analytic relationship in bringing about change. From this

38 perspective, the analyst provides the missing parental responsiveness that the patient lacked in childhood or actually creates, in the analytic situation, real experience that evokes the missed provision of childhood (Mitchell & Black, 1995). While interpretation is certainly not excluded from this position, the focus is more on the analytic relationship and how it provides or creates what the patient missed in his or her development, and how that manifests in the here and now between the analytic dyad.

A third broad component of therapeutic action includes the use of countertransference. While Freud viewed countertransference as an obstacle to the treatment or as an intrusion into the analytic process, Heimann (1950) argued, “the analyst’s countertransference is an instrument of research into the patient’s unconscious” (p. 81), a viewpoint that engendered an explosion of psychoanalytic inquiry into the topic of countertransference and its clinical utility. As Mitchell and Black (1995) state: Many authors take the position that the utility of countertransference lies in the information it provides regarding the patient’s side of the interaction. By exploring his own feelings, the analyst gathers clues to what the patient might be feeling and doing (p. 247).

While some analysts disagree on whether or not countertransference feelings can and should be shared with a patient in treatment, most contemporary analytic clinicians regard the analyst’s countertransference as important data in understanding the unconscious dynamics of the patient, data that can help the therapeutic dyad better understand the unconscious configurations that shape and govern their interaction (Mitchell & Black, 1995). Others believe that the use and disclosure of

39 countertransference feelings and reactions, if used appropriately, are one of the most effective techniques in treatment (see Maroda, 1991).

In recent decades, there has been a shift in psychoanalytic viewpoints of therapeutic action to a more pluralistic understanding of ways to help a patient (Aron, 2000). Gabbard and Westen (2003) highlight this trend by saying: Contemporary psychoanalysis is marked by a pluralism unknown in any prior era, and this extends to theories of therapeutic action. We no longer practice in an era in which interpretation is viewed as the exclusive therapeutic arrow in the analyst’s quiver (p. 823).

They argue that there is no single path to therapeutic change, and that psychoanalysis in general is witnessing a movement toward greater humility reflected in a tolerance for uncertainty and complexity related to what is helpful or not helpful for a given patient (Gabbard & Westen, 2003). Additionally, they point to a trend in contemporary psychoanalysis for a more open and flexible approach to thinking about helping the other (Gabbard & Westen, 2003).

In summary, the above section examined three broad ideas related to therapeutic action that have been widely discussed within psychoanalysis, ending with the thought that the field is moving to the idea that there are multiple ways for a therapist to be helpful. However, it is important to consider if what is helpful or not helpful in treatment depends on the unique patient population one is treating. The review will now consider the few psychoanalytic outcome studies that have been conducted specifically in relation to emerging adults.

40 The Emerging Adult Population and Psychoanalytic Outcome Studies There are two outcome studies to date that have looked at emerging adults who have received psychoanalytic psychotherapy. Philips, Wennberg, Werbart, and Schubert (2006) studied 134 emerging adults at termination of individual or group psychoanalytic psychotherapy. The researchers studied the emerging adult patient characteristics at intake and analyzed various outcome measures at termination, with the average time spent in treatment lasting 15 months (Philips, Wennberg, Werbart, & Schubert, 2006).

Several outcome measures were used to assess changes in treatment, with the results showing that the patients exhibited positive changes on all outcome measures with the largest effect sizes on two global measures, namely global functioning and self-rated health (Philips, Wennberg, Werbart, & Schubert, 2006). While the research found that long-term psychoanalytic psychotherapy was helpful for the emerging adults who participated in the study, the researchers did not speculate on what they thought was helpful in treatment, nor did they elicit the emerging adult’s perspective on helpful and not helpful aspects of the psychotherapy process.

A second study explored psychoanalytic psychotherapy with young adults who grew up with a mentally disturbed parent (Philips, 2008). In a sample of only three emerging adults, researchers interviewed both patients and therapists pre-and posttherapy and asked them a variety of questions, including their perspectives on both helpful and hindering aspects of treatment (Philips, 2008). The treatments all consisted of long-term psychoanalytic psychotherapy, with two of the three participants reporting feeling satisfied with treatment after termination (Philips, 2008). Of the two patients feeling satisfied with treatment, the first said that her experience in psychotherapy helped

41 her think more clearly, while the second patient said that her treatment helped her identify her typical patterns of thought and taught her new ways of looking at situations (Philips, 2008). From the therapist’s perspective, all three patients exhibited characteristic patterns of behavior that contributed to obstacles in the therapeutic work, what the researcher described as the patients’ tendency to re-enact early relationship themes with their mentally-disturbed parents in the context of the therapeutic relationship (Philips, 2008).

The study concluded by reporting that in psychotherapy with emerging adults who have mentally disturbed parents, the therapist must tolerate the patient’s negative transference and tendency to act out, and ultimately help them by interpreting their enactments of earlier, problematic ways of relating (Philips, 2008). While the above study is different from other research in that it asked both therapist and patient their ideas related to therapeutic action, little is known about the participants that might shed light on the reasons for subscribing to a particular viewpoint of helpful or hindering aspects of treatment. A fuller picture of one’s developmental history may lend itself to a greater appreciation of why a given patient believed in one curative aspect of treatment versus another. In addition, the patients’ report of what was helpful in treatment was very broad, making it difficult to understand what specifically facilitated change.

The above studies, while few in number, are helpful in highlighting the effectiveness of psychoanalytic psychotherapy with the emerging adult population.

However, there continues to be a tendency in psychoanalytic conceptions of therapeutic action to leave out the voice of the patient, contributing to few research studies that elicit feedback from the person receiving help. Why is this the case? Before looking at the

42 available research that does actually ask emerging adults their perspectives on helpful aspects of treatment in some depth, the review will consider a trend that has contributed to a one-sided conversation of therapeutic action, the legacy of the medical model.

The Legacy of the Medical Model Within psychoanalysis, the patient’s sense of what is helpful is rarely explored, contributing to the potential for a problematic disparity between what the patient understands as being therapeutic and what the clinician sees as beneficial to the patient, a position that is reinforced in the one-person medical model of classical psychoanalysis (Satran, 1995). An exception to this idea includes Tessman’s (2003) research that asked psychoanalysts to reflect in-depth on their experience in analysis and what was satisfying or helpful about their treatment, though that study did not include emerging adults. Still, in general professional research and discourse have long privileged the viewpoint of the therapist in bringing about change (Bohart & Tallman, 2010; Duncan & Miller, 2000).

Most theories of treatment describe therapeutic action and change resulting from the expert therapist employing his or her favorite interventions on the dysfunctional client, a position that neglects the crucial finding that client participation and involvement is one of the most important factors in making therapy work (Bohart, 2006). However, it is not just psychoanalysis but psychotherapy in general that has left the patient’s perspective out of the therapeutic process (Duncan & Miller, 2000). A major influence for the lack of patient involvement includes the legacy of the medical model, which sees the patient as diseased and in need of being fixed by the expert therapist prescribing the standard

43 technique (Duncan, Miller, & Sparks, 2007). Duncan, Miller, and Sparks (2007) highlight this trend and argue: The importation of medical diagnosis into psychotherapy positions clients as passive holders of disease to be fixed by the skilled interventions of the clinician.

This positioning of clients is particularly unhelpful and flies in the face of what is known about the importance of client factors in psychotherapy. The bulk of outcome research in the past 45 years confirms the critical role clients play in their own change (p. 36).

The authors go on to argue that change in therapy does not result from any technique or “evidence-based” treatment; rather, change results principally from factors common to all therapeutic approaches and from the client’s ability and participation in the treatment (Duncan, Miller, & Sparks, 2007). Despite the client and factors in the client’s life accounting for more variance in therapeutic outcome than any other factor in treatment, the therapist and his or her techniques are seen as the primary curative factors in psychotherapy, something that has intensified the use of evidence-based treatments and treatment manuals (Bohart & Tallman, 2010). However, meta-analytic studies have shown that specific techniques contribute little to therapeutic success (Bohart & Tallman, 2010). Rather, “clients’ active engagement in the process, the quality of their participation, is the single best indication of the likelihood of success” (Duncan, Miller, & Spark, 2007, p. 39). Bohart and Tallman (2010) corroborate this position and argue that it is the client who largely makes therapy work, what they refer to as “the client as the active self-healer,” a stance that they argue requires active collaboration between client and therapist (p. 95). In order to elicit the participation of the client, to understand

44 what client’s find helpful and hindering in treatment, one must include what Duncan and Miller (2000) consider the client’s theory of change.

Duncan and Miller (2000) posit that research makes clear that the client is the single, most potent contributor to outcome in psychotherapy, with treatment model and therapeutic technique only accounting for roughly 15% of outcome variance. They argue “just as clients have traditionally been miscast as villains or town idiots in therapy, clients’ perspectives regarding therapy frequently wind up on the cutting room floor” (Duncan & Miller, 2000, p. 174). To ensure that client perspectives are heard and valued in treatment, they include what they call the “client’s theory of change,” or the client’s perception of his or her problems as well as ideas related to the resolution of those problems, ultimately accommodating any applicable theories into the client’s personal beliefs related to what can bring about change (Duncan & Miller, 2000, p. 174). For Bohart and Tallman (2010), this requires the therapist to collaborate with clients and utilize and mobilize their inner resources. For them, the “client’s abilities to use whatever is offered surpass any differences that might exist in techniques or approaches.

Clients use and tailor what each approach provides to address their problems” (Bohart & Tallman, 2010, p. 94). As a result, from their perspectives, neglecting the client’s idea of therapeutic action will only be detrimental to treatment.

In summary, the above approach provides a radical difference from one-person medical models used by some psychoanalytic theories that do not consider the patient’s perspective on change, but instead presuppose that the analyst or therapist knows what is best for the patient. Consequently, understanding and eliciting the patient’s idea of what is helpful or not in treatment has largely been omitted from psychoanalytic discourse and

45 research. However, there have been a few studies that specifically ask the client’s ideas related to therapeutic action. Two of those studies have been conducted specifically with emerging adults, while the other study includes both younger and older adults. Those findings will now be considered.

The Emerging Adult’s Perspective on Therapeutic Action In a study to understand clients’ perspectives on significant experiences and moments in treatment, Levitt, Butler, and Hill (2006) interviewed 26 adults from the ages of 18 to 79, participants who had individual psychotherapy across all major treatment orientations for at least eight sessions. Grounded theory was used to create a hierarchy of categories that represented what clients found important or significant in their treatments (Levitt, Butler, & Hill, 2006). The participants in the study spoke of the significance of the therapeutic relationship and the importance of their experience of care within that relationship more than any other factor in treatment (Levitt, Butler, & Hill, 2006). While specific interventions used by the different therapists were described as helpful by the participants, the clients rarely attributed important changes or insight to one intervention or another (Levitt, Butler, & Hill, 2006). In addition, the participants did not describe symptom reduction as a main reason why their experience in therapy was important or significant to them, supporting the viewpoint that although the reduction of symptoms may be a positive effect of therapy, it may not be the primary benefit for many clients (Levitt, Butler, & Hill, 2006).

The above study is potentially useful clinically as it describes patients’ perspectives on what was helpful in treatment, something that is not considered enough in

46 the literature. However, because the participants ranged from 18-79 years of age, it is difficult to determine if the significant moments in treatment described by the participants are something that is potentially relevant to the emerging adult population, or all adults in general. In addition, the study did not go into details about the participants’ unique developmental histories, which if known, could potentially illuminate why a particular patient found one aspect of the treatment helpful versus not helpful. Regardless, the study is important as it gives voice and expression to the patient and consequently helps one think about clinical work from a different perspective.

A second study looked at emerging adults and their ideas of cure prior to receiving psychoanalytic psychotherapy (Philips, Werbart, Wennberg, & Schubert, 2007). Forty-six emerging adults were interviewed before receiving individual psychotherapy to elicit their ideas related to problem formulation as well as their ideas of cure, with the qualitative analysis revealing that the majority of the emerging adult participants held ideas of cure that, broadly speaking, included processing and understanding their problems (Philips, Werbart, Wennberg, & Schubert, 2007). In other words, the emerging adults wanted a new, fresh perspective on their problems and what they could do about them. What was interesting to the researchers is that the emerging adults “did not emphasize the interpersonal relationship as a possible curative agent in therapy. Many young adults wanted support and confirmation, but they directed this wish towards friends and family, and not manifestly towards the therapist� (Philips, Werbart, Wennberg, & Schubert, 2007, p. 226). In addition, the participants did not express thoughts about working within the therapeutic relationship as a route for reaching

47 insight into their difficulties, an assumption held by many analysts who conduct transference analysis (Philips, Werbart, Wennberg, & Schubert, 2007).

Instead, the ideas of cure described by the participants depicted the wish for a professional relationship with a therapist who could help them see things differently, as opposed to having an emotionally-charged relationship between patient and therapist (Philips, Werbart, Wennberg, & Schubert, 2007). The authors speculated that young people today may be more independent or self-sufficient than young adults a few decades ago, and consequently less inclined to become dependent on another person like the therapist, a clinical phenomenon they interpreted as a resistance to forming a transference (Philips, Werbart, Wennberg, & Schubert, 2007).

The above article is potentially useful for the therapist as it elicits feedback related to emerging adults’ perspectives on ideas of change in therapy. One implication of the study is that it may be critically important for therapists to understand that their ideas related to therapeutic action may be different from those of the populations they are treating, something the researchers contend could be helpful to address in treatment at a relevant time (Philips, Werbart, Wennberg, & Schubert, 2007). One limitation of the study includes the fact that it asked emerging adults their ideas of cure before they embarked on a long-term psychoanalytic psychotherapy. While this may be important to know, it is also helpful to consider how an emerging adult could change his or her perspective on therapeutic action during and after treatment. Understanding emerging adults’ perspectives on what felt helpful and not helpful after treatment is something the current study addressed. In addition, while this study did provide demographic information as well as information on the diagnosis of each participant (Philips, Werbart,

48 Wennberg, & Schubert, 2007), little is known about the developmental history of the participants or their psychological functioning, something that could potentially shed light on why a particular person subscribed to one idea of cure versus another.

The last study highlighted in this literature review is one that is most similar to the current study. The researchers explored emerging adults’ views of curative and hindering factors in psychoanalytic psychotherapy by interviewing participants at termination of their treatments (Lilliengren & Werbart, 2005). In describing the rationale for their study, Lilliengren & Werbart (2005) argue: Theories of therapeutic action tend to be therapist centered and are often built on the therapist’s view of the therapeutic process. The patient’s perspective on what works in therapy has been largely neglected and has not been the basis for the building of clinical theory, regardless of psychotherapeutic orientation (p. 325).

Some research has examined patient reports of helpful aspects of treatment, what are often called the common factors, which includes a strong therapeutic alliance and supportive relationship, along with the patient having a space for self-expression and selfunderstanding (Lilliengren & Werbart, 2005). However, these common factors are not always included in the therapist’s conception of therapeutic action, something that prompted these researchers to conduct a study on patients’ experiences of curative and hindering aspects of therapy, and then use that data to construct a tentative model of therapeutic action based on the viewpoint of the emerging adult (Lilliengren & Werbart, 2005). To achieve this goal, emerging adults engaging in psychoanalytic psychotherapy at the Institute of Psychotherapy in Stockholm, Sweden, were interviewed at termination.

49 The research study was a naturalistic, prospective, and longitudinal design of 22 emerging adults whose presenting problems commonly consisted of depression, anxiety, problems in their relationships with parents, and low self-esteem (Lilliengren & Werbart, 2005). All participants received individual psychoanalytic psychotherapy, with the mean time in treatment being almost 19 months (Lilliengren & Werbart, 2005). The researchers interviewed the participants using the Private Theories Interview, a semistructured interview aimed at understanding a patient’s private theories of pathology and cure, as well as one’s descriptions of changes during and after therapy. In addition, the emerging adults were asked about their retrospective view on what contributed to positive changes in their treatment as well as what hindered their progress in psychotherapy (Lilliengren & Werbart, 2005).

The qualitative analysis resulted in three categories that were defined as curative factors and two categories defined as hindering factors of treatment (Lilliengren & Werbart, 2005). The curative factors were defined as talking about oneself, having a special place and a special kind of relationship, and exploring together (Lilliengren & Werbart, 2005). The first curative factor reported by the emerging adults, “talking about oneself,” included the idea that expressing themselves in therapy was helpful.

Specifically, this included expressing, reflecting, and labeling their thoughts and feelings, as well as a mode of talking that the researchers said resembled storytelling, in which emerging adults could remember and ultimately work through their personal histories in the presence of the therapist, the listening other (Lilliengren & Werbart, 2005).

The second curative factor included the category entitled “having a special place and a special kind of relationship” (Lilliengren & Werbart, 2005). This relationship

50 included three main components: a special emotional atmosphere, the therapist being an outside person, and having time and continuity in treatment (Lilliengren & Werbart, 2005). The special atmosphere consisted of “being accepted, respected, supported, and seen by the therapist” (Lilliengren & Werbart, 2005, p. 330). In addition, the emerging adults reported that sharing their problems, being listened to, and being taken seriously by their therapists contributed to positive change (Lilliengren & Werbart, 2005).

The last curative factor, “exploring together,” consisted of the therapist and emerging adult engaged in mutual collaboration that included a distinct exploring quality involving the therapist asking questions, summarizing what the patient said, providing new perspectives, and making connections to the past, among other things (Lilliengren & Werbart, 2005). Not only did the therapists help the emerging adults make connections involving the past and present difficulties, but they also encouraged the patients’ own exploratory and self-reflective activity (Lilliengren & Werbart, 2005). In addition, the therapists helped the emerging adults challenge self-defeating thoughts and negative interpretations of the self and the world, and ultimately urged patients to find their own voice, something that contributed to the participants reflecting on what they really wanted in life (Lilliengren & Werbart, 2005).

The two hindering aspects of individual psychoanalytic psychotherapy reported by the emerging adults included the categories labeled “talking is difficult” and “something was missing” (Lilliengren & Werbart, 2005). At the same time that talking about themselves was helpful for many emerging adults, it was also reported as a hindering aspect of treatment, as some participants reported that talking about themselves could be both anxiety-provoking for them as well as energy consuming (Lilliengren &

51 Werbart, 2005). The last category, “something was missing,” included the emerging adults seeing their therapists as too passive, wishing for more feedback and direct advice, and wanting more structured activities between sessions (Lilliengren & Werbart, 2005).

The above research is unlike other studies as it elicits the emerging adult’s perspective on curative and hindering aspects of individual psychotherapy as well as provides a tentative model of therapeutic action, one based on the viewpoint of the patient. Based on the data from this study, the researchers argue that the helpful aspects of treatment reported by the participants are in accord with the interpersonal rather than the intrapsychic conception of therapeutic action (Lilliengren & Werbart, 2005). In addition, an implication of the study includes the idea that “the similarities and discrepancies between the parties’ implicit theories of cure need to be discussed from the very beginning of the treatment. Such a exploration and negotiation is in itself a powerful agent of change” (Lilliengren & Werbart, 2005, p. 336). The authors point to the importance of understanding the patient’s theory of cure and using the resources available within that individual, information that could be beneficial to the therapist trying to help an emerging adult experience positive change (Lilliengren & Werbart, 2005).

One potential limitation to the above study includes the fact that little is known about the 22 emerging adults who participated in treatment. If more were known about their developmental histories, it might be possible to understand more about why one emerging adult found something curative or hindering in psychotherapy based on his or her unique past.

52 What the current study added is an in-depth exploration into the psychological lives of the participants, and a detailed inquiry of how their unique developmental histories influenced their subjective experiences in treatment, including their ideas about what was helpful or not helpful in psychotherapy. Not only did this study include the participants’ perspectives on what was helpful or not helpful in psychotherapy, but also the case study approach used here facilitated a rigorous exploration into the participants’ internal worlds, and informed interpretation of how those worlds shaped their treatments.

To date, there are no known psychoanalytic case studies that have explored the perspectives of emerging adults in relation to therapeutic action. As a result, this study addressed this gap in the literature.

53

Chapter Three

Methodology Type of Study and Design Because the nature of this qualitative study had to do with the interplay between a participant’s idiosyncratic developmental history and significant past experiences with her perspective on what was helpful and not helpful in psychotherapy, and the way in which these factors guided and subjectively shaped how one viewed therapeutic action, a psychoanalytic case study methodology was used, modeled on that employed by Rose (2004). While I will describe the methodology in greater detail in subsequent paragraphs, in brief it meant that I met with the participants multiple times each, and used a semistructured clinical interviewing method to elicit my participants’ narratives regarding their subjective experience in treatment, including what felt helpful and not helpful in psychotherapy. In addition, an open-ended interview was used to obtain a clear picture of each participant’s developmental history, including her past experiences with parents and significant others over the life span. I listened to the narratives from a psychoanalytic viewpoint, meaning that I attended to both manifest and latent content in response to my specific questions to understand the conscious and unconscious factors that impacted how each participant viewed her experience in treatment during emerging adulthood.

The use of case studies has received renewed interest in the past decade (Fishman, 2006). As Fishman (2006) has noted, “there has been a revival of interest in the case

54 study’s potential to create viable scientific, psychological knowledge that is not inferior to experimental, group-based knowledge, but rather complementary to such knowledge— especially in the area of psychotherapy research” (p. 1). Hoffman (2009) argues that some researchers have historically viewed case reports as hypothesis-generating studies that are inferior to systematic, hypothesis-testing research. Instead of viewing case studies as pilot studies or hypothesis-generating studies, Hoffman (2009) contends that case reports generate important plausible possibilities for practicing clinicians to have in mind in their work with patients. With regard to systematic, allegedly hypothesis-testing research, Hoffman (2009) argues that they also generate possibilities for clinicians to have in mind in their clinical work, and therefore should not be accorded higher status and authority than case studies.

Case studies have played a key role in developing theory in psychotherapy and psychoanalysis since Freud’s classic cases of Dora and Little Hans. This qualitative methodology derives from social work’s tradition of understanding and helping others through the simple, ordinary communicative act of storytelling, considered in the social sciences as narrative inquiry and analysis (Riessman, 2008). Narrative analysis is a main method of conducting case-centered research in which the investigator is concerned with how a participant uses language and imagery to communicate subjective meaning about an experience in one’s past, and how it has manifested in one’s life over time (Riessman, 2008). Narrative inquiry and analysis also interrogate cases in an attempt to look beyond the surface of a text, story, or significant experience (Riessman, 2008). A way to look beyond the surface of a participant’s experience includes coupling narrative analysis with psychoanalytic case study methodology, which adds the use of a psychoanalytic

55 interpretative lens through which to understand the data. As Hauser argues, “The perspectives and methods of narrative psychology and ethnography have long been congenial to psychoanalytic investigators and practitioners, concerned as they are with the meaning and interpretation of “thick” clinical and ethnographic observations” (Hauser, 2002, pp. 399-400). Psychoanalytic case study methodology allows the researcher to understand and interpret the manifest and latent content of thick clinical data related to the narrative of each participant.

As in most psychoanalytic case studies, the data generated from the interviews included my interpretive role as the researcher. However, this does not mean “anything goes” in regards to a particular interpretation made in the study. Speaking of the role of interpretation, Siegel, Josephs, and Weinberger (2002) state: It valorizes the personal, subjective role played by the analyst who reads a session through the lens of a particular theory, searching for particular patterns. At the same time, within each psychoanalytic school, certain rules constrain the interpreter by furnishing the standards by which the correctness of an interpretation can be judged. These rules allow the possibility of a text’s taking on an intersubjectively shared meaning within a particular psychoanalytic community that both accepts certain rules as authoritative and is defined by them (p. 421).

As a result, an interpretation made of the data has to reflect the participant’s story, has to fall within the standards of a psychoanalytic school, and has to include my subjective response (i.e., countertransference) to the material and the participants.

56 This study focused on depth of inquiry, rather than breadth. The raw data included verbatim transcriptions of multiple interviews that were digitally recorded coupled with my own detailed field notes that I wrote following each interview session.

The field notes were written immediately following each interview and included my countertransference responses to both verbal and nonverbal communication from each participant. The combination of both sources of data provided a plethora of dialogue to be examined through a psychoanalytic lens. As Siegel et al. (2002) write, “Countertransference process notes allow the immediacy represented by the analyst’s ‘being there’ to enter the documentary record. In combination with a verbatim transcript, these documents would represent the most immediate record of the psychoanalytic dialogue produced thus far” (p. 416). As a result, examining the raw data in conjunction with my own countertransference provided the opportunity to look at and beyond the text to discover conscious factors and the underlying, unconscious patterns that impacted how each participant viewed her experience of treatment.

Scope of Study I interviewed five individuals who received psychotherapy during emerging adulthood over several weeks at a private location convenient for each participant. To attract potential participants, I advertised at several local universities. I offered $50 payment as compensation for completing five one-hour interviews. I took the first five participants who responded to the research project and met criteria for inclusion.

I used brief assessments over the phone with respondents to determine appropriate inclusion in this study. Appropriate participants included individuals who received

57 psychotherapy during emerging adulthood, which consists of the time period between the ages of 18 and 25 (Arnett, 2000). Other qualifying factors for inclusion included the ability to reflect on one’s experience through the use of language, that participants had been in weekly treatment for at least six months, and that participants had ended their treatment within 5 years of the study. This was added in an attempt to help ensure that participants spent considerable time in their own treatment and could meaningfully reflect on their experience. In addition, creating a 5-year cap helped ensure that individuals were either in emerging adulthood or were not too far removed from this time period at the onset of the study.

Data Collection Methods and Instruments Throughout the data collection process, I elicited the personal narratives of the five selected participants using semi-structured interviews, conducted over several sessions. As a starting point, I used an open-ended interview designed to understand the developmental history of each participant, including her relationships with parents and significant others over the years. In addition, I used the Private Theories Interview (PTI) developed by psychoanalytic researchers at the Institute of Psychotherapy in Sweden (Werbart & Levander, 2005) and modified the interview to suit my particular research needs. The PTI is a semi-structured interview that focuses on the participant’s own attempts to give meaning to, and make sense of, her distress (Werbart & Levander, 2005).

Concrete examples that illustrate these explanations are elicited from the subject as the researcher attempts to not only understand how the participant conceptualizes her problems and how they have arisen, but also tries to understand what that individual

58 found helpful or hindering in addressing those problems in the context of treatment (Werbart & Levander, 2005). In addition, the interviewer listens for one’s narrative about what changed throughout the course of treatment, and how the therapist contributed to that change, positive and/or negative.

Conducting multiple interviews with the same participant allowed a deepening of engagement over time, providing us with the potential to elaborate and re-elaborate themes that emerged through the participants’ narrative about their experience in treatment, as well as facilitated a deep understanding of each participant and her developmental history. In addition, employing the use of multiple interviews facilitated my own psychoanalytically informed assessments of each participant, and how one’s psychological functioning and history impacted her subjective experience in treatment.

Last, multiple interviews allowed me to go back and revisit ideas, feelings, and reactions of my own that were stimulated throughout the interviewing process and explore them with participants, if applicable. This exploration allowed me to clarify and/or modify specific themes that emerged through each narrative.

Following each digitally recorded interview, I wrote extensive field notes that included physical descriptions of the participants, impressions of their psychological states and functioning, my own reactions and feelings in response to the narratives and to the participants themselves, and any other nonverbal communication I registered throughout the interviewing process. The field notes provided another source of data in addition to the stories of the participants, data that included my countertransference feelings and reactions during each interview. Because contemporary psychoanalysis— and in particular relational psychoanalytic theory—subscribes to the idea that

59 countertransference feelings and reactions are important sources of data, tracking these reactions were an important part of the interviewing and data collection process (Maroda, 1991; Mitchell, 1988).

Data Analysis The data was first analyzed on an individual, case-by-case basis. Using psychoanalytic principles (mainly relational psychoanalytic theory described by Mitchell, 1988), I studied the participants’ narratives and attempted to construct an understanding of the conscious and unconscious factors that impacted how the participants made sense of their subjective experience in psychotherapy, and how their developmental history impacted what they found helpful and not helpful in the context of treatment. I was particularly interested in my participants’ relational patterns and how those patterns guided and impacted what each participant needed in treatment from her therapist. As a check on validity, I asked members of my dissertation committee to look at the data to help control for excessive intrusions of my own biases, knowing that controlling completely for bias would be impossible but that rival interpretations of the data should be explored (Yin, 2003).

Next, after analyzing each case, I opened my lens to look at the collective data, no longer needing to keep the data intact as personal narratives, but instead looking for themes across narratives (Rose, 2004). Once again, I asked members of my dissertation committee to look at the data to help check for researcher bias.

60 Statement on Protecting the Rights of Human Subjects The Institute for Clinical Social Work is aware of and endorses both its professional ethical responsibility and the federal mandates for the safeguard of the rights and welfare of human subjects in research that fall under the auspices of the institution.

The Institute will implement this mandate to protect the community through its Institutional Review Board for the Protection of Human Subjects.

61

Chapter Four

Findings

In this section, a psychoanalytic case study will be presented for each of the five participants. Within each study, the data is organized along the following categories: childhood and adolescence; emerging adulthood; treatment in emerging adulthood; therapeutic action: what participant reported; psychodynamic assessment and interpretation of each participant; psychodynamic understanding of therapeutic action; and current functioning. Also, two additional categories were used for those participants who reported experiences in treatment that were not helpful, or reported experiencing impediments to therapeutic action that contributed to a negative perception of treatment.

Those categories include: impediments to therapeutic action: what participant reported; and psychodynamic understanding of impediments to therapeutic action.

Also, a reminder is needed in relation to the theoretical lens through which I interpret the following data. As mentioned in the previous chapter, I interpret and assess each participant’s narrative using relational psychoanalytic theory. However, because relational theory has expanded a great deal over the past 20 years, it is crucial to report that I use Mitchell’s (1988, 1993) work as the primary theoretical lens, a framework that combines the interpersonal tradition developed most notably by Sullivan with a strong influence on development and a child’s early life, and particularly one’s internal object relations, and how they continue to impact an individual’s relationships throughout life.

62 From there, I also make use of other relational writers, most notably Stern (2010), someone also heavily influenced by Sullivan.

A note on confidentiality: I have changed all identifying information, including all the participants’ names, as well as all names within the participants’ narratives.

Participant A: Cathy Cathy is a 27-year-old Caucasian female. She is of average height and weight, has pale skin scattered with freckles that looks like it easily burns, wears no make-up, has brownish red hair pulled back in a pony-tail, and wears black-rimmed glasses. She has a focused, resolute demeanor coupled with a strong ability to articulate herself, a presentation that initially made her seem to me like a very serious person. Meeting Cathy for the first time in a library was particularly fitting, given the fact that she reminded me of a student. Specifically, upon meeting her, I immediately associated to an individual with a proclivity for getting lost in a book, devouring the information the pages had to offer. In fact, this initial association proved apt, as Cathy revealed in the first few interviews that a large part of her childhood consisted of continual reading that manifested in her checking out several books each week at the local library. She said that she never stopped reading, her bedroom scattered with the weekly picks from the local library.

In the first interview, Cathy greeted me with a strong handshake and a smile, gestures that implied to me that she had a lot to say, and was eager to participate in the research study. She seemed ready to talk, and full of energy. After going through the necessary research protocol, I asked Cathy to start the interview by articulating what

63 seemed significant and memorable to her about her childhood, and about her life in general. She began telling me her story, starting with her experience growing up in the Midwest. She spoke clearly, and seemed quirky yet comfortable in her own skin. For example, she had a dry sense of humor, and would report seemingly funny experiences in a matter-of-fact manner. She had no reservations about sharing her experience, seeming eager to describe the benefits she said she received from two separate treatments in emerging adulthood. Cathy reported that her treatments helped her become a person who is, in her words, “self-actualized but at risk of self-sabotage.”

Childhood and adolescence.

Cathy grew up in a family of four in the Midwest, in a small town she described as “pro-Bush.” Her parents both had advanced degrees and worked as professionals in the community, both in environments that provided social services to individuals from populations that are often marginalized. She said that her parents were eager to help others, often inviting indigent folks from the community to eat with them on major holidays, extending their definition of family to strangers who needed assistance. Cathy recalled how her parents shared the household responsibilities, both seemingly wedded to having an equal division of labor at home. This was something Cathy said she noticed at an early age, and something that has stuck with her throughout her own dating history, as having egalitarian relationships modeled after that of her parents is particularly important to her. She described both parents as feminists, cognizant of stereotypical gender roles in the family and working hard to establish a system at home that took that into consideration. Cathy said her parents got along well and rarely argued, describing them

64 as “best friends.” Cathy’s sister, the reported popular kid throughout school, is 7 years older than she. They were not particularly close growing up, though Cathy said they would watch television shows together centered on pop culture. Cathy said that she and her sister had very different interests, and didn’t connect until recently in Cathy’s life.

Growing up, Cathy said she was more interested in books and reading, her sister on social activities.

Cathy described her childhood as very driven by activities: she said she read vigorously, engaged in sports, arts and crafts, play dates with friends, and tried and quit several activities she found initially interesting, yet didn’t capture her interest long. She said she was an inquisitive, precociously verbal child, at times checking out 30 books at a time at the local library, engulfing herself in whatever subject caught her attention at the time. She reported being overly sensitive and “extremely empathic,” always, in her words, “hyperaware” of her mood as well as the emotional state of her family members.

She said her extended family also lived in the area, so the weekends and holidays consisted of large family gatherings with lots of food and activities. She said she was never bored, always finding something to explore or attempt to read and understand.

Cathy reported having a close relationship with her mother and described her as one of the “nicest people” one can encounter, eager to offer support and a helping hand, particularly to those less fortunate. However, she also said her mother was highly sacrificing, dedicated to serving and helping others, at times to the point of Cathy feeling neglected at home; she said her mother failed to establish boundaries with the extended family and consequently became what Cathy called “a martyr,” at times serving her own parents and family members at the expense of attending to Cathy’s emotional needs.

65 Cathy also reported feeling close to her father growing up, and sharing his interest in reading and engaging in activities. She described him as “wonderful,” someone Cathy said she admires, and the person she reported feeling closest to in her family. However, she said her father also had a temper and would yell and scream with Cathy’s older sister, a pattern of relating that would leave Cathy feeling scared, anxious, and result in her occasionally retreating from him physically and emotionally. She said that he never physically hit or abused Cathy or her sister, but she described feeling “terrified” and retreating into the protection of her bedroom when she witnessed her father and sister arguing. Cathy reported that these events took an emotional toll on her, and she said she started a pattern of searching for ways to self-soothe in the absence of connecting with family members, regulating her emotions initially through staying silent in her room, and later by cutting and attempting to escape her pain with drugs and alcohol.

In summarizing what stuck out to her in childhood, Cathy described herself as a “strange kid with fierce emotions.” She said she first realized that something was amiss, that something was “wrong” with her, at age nine, while on a family vacation. It was Easter, and she said she was the first family member awake, eager to discover the treats that waited in her Easter basket. When Cathy discovered that she was the only one awake and that everyone else in her family was still sleeping, she said she felt devastated and crushed that her family didn’t share her thrill and excitement for the holiday. From this event, Cathy said she concluded that she was too “emotional,” that something about her was different from other family members, and that something was wrong with her for getting so upset over something that, in hindsight, was very minor. Cathy didn’t know exactly what led her to interpret this moment in such a devastating way, other than

66 reporting that this memory made her feel too “emotional” and like she was “very different” from other family members, something that made her feel isolated from them.

After that event, Cathy started to feel what she referred to as “the darkness,” and she said the darkness “started to spread.”

Cathy described her adolescence as a “tumultuous time” in her life. At 12, she said she got her period for the first time, felt suicidal and wanted to kill herself for the first time, and started cutting. When I asked Cathy what constituted triggers for her suicidal behavior and reported decline in functioning during this time, she said that puberty and the resulting change in her “hormones” made her feel depressed.

Additionally, she said her “best friend” of several years started to spend time with another girl in their grade, something that Cathy said contributed to her feeling depressed and especially rejected by her friend. Regarding her mood, Cathy said it oscillated from anxious and sleep-deprived to immensely depressed depending on the day, and she reported feeling suicidal whenever she was about to get her period, what her psychiatrist later diagnosed as Premenstrual Dysphoric Disorder (PMDD), a condition not well understood that can exacerbate depressive symptoms. While Cathy had friends, she described always being in conflict with some girl, always experiencing some form of what she referred to as “girl drama.” The intense anger she reported feeling when fighting with peers scared Cathy, and she dealt with these feelings by trying to bottle them up, or by making the pain visible via cutting. She reported that cutting and making the pain visible calmed her, though she couldn’t articulate why it had this effect on her.

Despite feeling depressed, suicidal, and anxious, Cathy said she excelled academically, enjoying large amounts of academic success and recognition for her intelligence.

67 On the surface, Cathy said, high school should have felt great for her. She did well academically, had friends to spend time with, had parents who loved her and supported whatever activities she wanted to engage in, and she was recognized at school by teachers for her academic ability. However, internally, she said she identified as a teen with pink hair who hated everyone, including herself. She used the adjectives “dark” and “pain” to highlight her high school years, and said she was diagnosed as having Borderline Personality Disorder (BDP). Specifically, she said she struggled to manage her intense feelings and often felt a severe fear of rejection, manifesting in provocative behavior aimed at pushing people away and testing them to see if they really liked her, or if they would get sick of her and leave. She said she felt a “gaping hole of an abyss” of depression and anxiety inside her, a feeling that she carried with her everyday, some days worse than others. Every month or so, she reported that she’d have to cut, feeling set off by an event, typically something minor like an argument with a friend or hearing that some girl was talking negatively about her behind her back. She recalled “always” feeling suicidal, writing stories in her personal journal where she’d imagine attending class, looking up, and seeing her dead body sitting next to her, with a rope around her neck and cuts on her arms. She said she finally felt unable to manage her depressive and suicidal feelings and, at 18, made a suicide attempt.

Emerging adulthood.

Cathy said multiple events led to her suicide attempt, in which she cut her wrists deeply and was taken to the hospital by her father, who happened to come home early from work that day, only to find Cathy bleeding profusely from both wrists. While one

68 might interpret her father coming home early as good luck, Cathy believed that her father, like Cathy, has “the Sight,” a condition that allows them to know when something bad is about to happen, and feel a particular way if someone close to them is feeling ill or is in some kind of trouble. The Sight, Cathy insisted, allows her to empathize with others and understand their suffering, at times to the extent of depleting herself of her own internal resources to self-reflect and take care of herself. Right before her suicide attempt, Cathy recalled her moods being so low that they could be “physically painful,” causing her stomach and “skin to hurt.” Additionally, she reported having continual conflict with peers, at times perpetuated by what she said was her intensity and “need” to generate conflict to see how they would respond to her. She said she wanted to “test others,” attempting to see if she would be rejected by them, or to determine if they really liked her and would remain friends with her, something Cathy said she hoped for and secretly craved. Moreover, she said that one girl in high school was trying to “take” her friend away from her, monopolizing her time so she wouldn’t have any time left to spend with Cathy. Last, Cathy reported that her boyfriend at the time broke up with her, and she also switched antidepressants, two things she said caused her to feel more depressed.

All of these events, Cathy reported, contributed to her suicide attempt. She said she was released from the hospital after a week of having individual and group therapy, as well as undergoing a complete psychiatric evaluation to determine what medication was most appropriate for her. The hardest aspect of the hospitalization, Cathy recalled, was revealing to her parents that she had been cutting herself for years, a revelation that she said shocked and hurt them. She reported that even though she missed time away from school during her senior year after her suicide attempt, she said because her grades

69 were “superb” that her teachers were flexible in allowing her to make-up the homework she had missed. A month after leaving the hospital, she reported being accepted to a prestigious university, and went away for college.

Cathy reported that her problems took on a different form in college. She recalled engaging in casual sex and abusing drugs and alcohol frequently. She drank alcohol and smoked marijuana, developing an addiction and then a dependence to marijuana, reporting that her use “kept shit at bay,” covering up her depression and anxiety. When asked to describe her relationship with her mother during her college years, Cathy seemed angry as she described her mother’s outward disapproval at Cathy’s use of birth control to prevent pregnancy. In addition, Cathy felt infuriated from her sense that both parents failed to teach her about healthy boundaries and how to make good choices around sex, instead assuming that Cathy would figure it out on her own and make the appropriate choices. Cathy reported that her mother made her “feel like shit” for losing her virginity, yet failed to arm her with information needed to make healthy choices around sex and partying. However, it wasn’t just Cathy’s mother who she felt failed her in college: she reported that her father also failed to help teach her how to protect herself, and, as Cathy recalled, also assumed that she’d make appropriate choices without ever having a discussion about these issues before she left home. She said it was as if they believed she was already equipped to manage any potential difficulties on her own. On the contrary, Cathy said, she couldn’t protect herself at times, culminating in her being sexually assaulted. She said she had been taken advantage of and raped by a man after she blacked out and lost consciousness. She blamed her parents for being sexually assaulted, reporting that they didn’t do enough to prepare her to protect herself in college.

70 Looking back at emerging adulthood and her important relationships, Cathy recalled experiencing conflicting thoughts and feelings related to her parents. On the one hand, she described both of them as extremely loving, supportive, and models for having an egalitarian relationship characterized by warmth, openness, and closeness. She said she confided in her mother and valued her mother’s concern for those in need. She said she respected her father and shared her political leanings and ideas about governmental policy issues with him, calling him her “best friend.” She reported that her parents have been the most influential people to her in her life. On the other hand, she said she felt as though her parents made a huge error as she prepared to leave for college, failing to talk to Cathy about protecting herself as she encountered young men, sex, drugs, and partying all around her. She also said she held onto the ramifications of her father’s temper, feeling scared and distressed when she or other people became really angry. In addition, she believed that she, like her mother, struggled with setting boundaries, similar to how she described her mother’s tendency to be a martyr and take on too many responsibilities at the expense of her and her immediate family’s needs.

Cathy felt that her frustration with her parents manifested in her experiencing “rage dreams” centered on them, a disturbing experience that played a significant role in pushing Cathy to seek treatment in emerging adulthood post-college. First, though, Cathy said that she needed to address other issues as she found herself in a new environment, yet once again struggling with familiar, negative thoughts and feelings, the same feelings of depression, anxiety, impulsivity, and relational conflict she said she hoped to leave behind back home.

71 Treatment in emerging adulthood.

Cathy’s first treatment during emerging adulthood occurred at age 20, while in her second year of college, at a counseling center located on campus. This treatment would ultimately last 2 years. She said she was drinking heavily, having sex, was addicted to marijuana, and also cutting again. In addition, she reported suffering from intense obsessive-compulsive tendencies, pulling her hair out and picking at her skin.

From what she described, it seems that she felt unable to regulate her emotions, and needed various means to calm herself, most notably what she called excessive alcohol and marijuana use. When asked what led her to seek treatment in emerging adulthood, Cathy reported the following: I think realizing how much I was drinking and smoking, and how it was masking dark feelings I was still having; still feeling depressed, and also I was starting to realize that I hadn’t run away from stuff, I hadn’t left it behind, and I hadn’t ever really processed my suicide attempt when I was 18. I immediately went off to my dream and college but then that shit followed me; it just took a different form.

Cathy said she had wished to leave her problems back home, hoping that the realization of her dream of getting accepted into a prestigious university would wipe out her past problems. Instead, she said her difficulties continued, leading her to try to drown out her negative feelings via a drug-induced oblivion. This behavior reportedly caught up with her, and after another break-up, more conflict with friends and roommates, and another cutting episode, she sought treatment at the university counseling center. She said she was assigned to a clinical psychologist named Mary.

72 Cathy said she remembered that Mary’s office was full of light, and, since it was on the top floor of one of the tallest buildings around, overlooked the campus. She said she arrived on day one of her treatment, determined to process her suicide attempt, understand herself better and why she continued to encounter so many relationship difficulties, and potentially address her substance abuse problems. Additionally, she wanted to understand why she couldn’t be alone, what terrified her so much about being by herself. However, as Cathy noted, “the first order of business was dealing with the fact that I tried to kill myself years prior.” Cathy reported that Mary began eyemovement desensitization and reprocessing therapy (EMDR), a treatment developed to help individuals dealing with Post-Traumatic Stress Disorder (PTSD) and specifically with intrusive thoughts, feelings, and images from past traumatic experiences.

Cathy said her sessions with Mary were very structured and followed a particular plan. First, Mary began EMDR with Cathy to process her suicide attempt, as Cathy stated that she “was stuck in some mental loop” and the EMDR “unlocked parts of my brain and pushed stuff out.” She recalled that Mary felt that EMDR could help her feel less stuck, and determined that treatment would start with EMDR interventions at the beginning of her sessions. Cathy recalled Mary telling her that, initially in treatment, Cathy needed to deal with the trauma of her suicide attempt and surviving an attack on her own life. She remembered Mary saying that she could no longer avoid talking about the suicide attempt, and the incessant darkness and depression that contributed to her wanting to end her life.

In the next section, I’ll provide more details related to Cathy’s subjective experience in psychotherapy with Mary, and specifically discuss what she particularly

73 found helpful in treatment. First, though, I’ll briefly discuss her second treatment, one that occurred after her college graduation.

Cathy’s second treatment occurred after she finished college and moved to a new city. She was 23, said she had high expectations for herself in a new place, and wanted a fresh start. However, she said she found herself feeling suicidal again after experiencing a difficult work environment that led, she reported, to her having “a nervous breakdown” and quitting her job, only to go back home to “recover” for a brief period of time. Her work environment produced “acute anxiety” for Cathy, and she said that the high expectations in her sales position made her feel so overwhelmed at work that she couldn’t function, making her feel like a complete failure. She thought she was ready to be a “functioning adult,” yet she said she started to struggle with identity issues. Specifically, Cathy said she was more interested in social causes and attending protests and rallies than focusing on becoming more competent in her new job, and establishing her professional identity. Additionally, she said she was preoccupied with attempting to understand the type of person she wanted to become, and found herself thinking about existential issues like how to find purpose and meaning in her life.

While looking for another job, Cathy said she started to drink and smoke marijuana again heavily, started picking her skin and pulling her hair again, and felt extremely anxious and depressed. With very little money, she said she needed treatment on a sliding-scale reduced fee. She said she went online, and found a psychoanalytic institute offering psychoanalytic treatment at a reduced rate, and shortly thereafter started her second treatment in emerging adulthood, one that consisted of weekly sessions that lasted 2 years.

74 Not only did Cathy report feeling unstable, but what really disturbed her and played a major role in her seeking help, according to her, included the “rage dreams” and nightmares she was having in connection to her parents. As Cathy reported: My God, I was having these horrible nightmares about my parents. These crazy rage dreams. Where I was saying and doing horrible things that I don’t ever feel, or say, or do, in real life. And it was so disturbing. It’s weird what hides in the corners of our minds. It makes me feel like, am I secretly really evil?

Cathy reported one dream in which she told her parents that she hoped they would die a slow death, something she said that disturbed her so much she woke up from the dream in a state of panic, and couldn’t calm down until she spoke with her parents and told them she loved them. Cathy said she was attempting, with a new start in a new city, to relinquish her identity as a “stoner” and become an adult. She said she found herself passionately involved in sociopolitical causes, and felt truly comfortable in her own skin for the first time in her life during the Occupy Wall Street protests of the Great Recession, 2008-2012. However, Cathy said she soon found herself feeling stuck professionally, and her depression worsened. She said she couldn’t let go of her tendency to cope with stress and her mood by using substances, and worse yet, found herself inundated with disturbing dreams in which she acted out her aggression on her parents.

She said she didn’t understand her feelings of rage at them, and needed to know why those dreams continued. She recalled feeling ready for a different kind of treatment, one that would explore the deeper, more distressing thoughts and feelings she had but didn’t want to consciously acknowledge. She called the institute, had a meeting with an intake worker the next day, and was assigned to a psychotherapist named Vanessa. Unlike her

75 treatment with Mary, Cathy reported that her treatment with Vanessa was unstructured, and that she would just show up to her sessions and start talking about whatever was on her mind.

So far, I’ve shared some details related to Cathy’s two experiences in treatment during emerging adulthood. Next I will offer Cathy’s report of her subjective experience in each treatment, including her thoughts related to therapeutic action and what she found helpful with each therapist. I will begin with her first psychotherapy experience with Mary in college, and then turn to her second treatment with Vanessa.

Therapeutic action: what Cathy reported.

Treatment with Mary.

Cathy felt that the EMDR treatments with Mary helped considerably, as she said she started to experience a decrease in the intensity of the intrusive thoughts she had related to her suicide attempt. A typical session would include Cathy bringing in some feeling or memory that came up in session, or in-between sessions, about her suicide attempt that was still disturbing to her, and that Mary would use the EMDR treatments to focus on those specific experiences. Those particular interventions, according to Cathy, unearthed “clear images and sharp feelings” related to her suicide attempt, which then were processed by the therapeutic dyad to help Cathy not only work through those feelings, but also to understand how they continued to impact her in the present. Not only did the EMDR treatments force her to talk about and understand what led to her suicide attempt, but more importantly, Cathy reported that the treatments engendered thoughts and feelings related to the events associated with that time in her life, and what

76 she thought contributed to the desperation that manifested in a tidal wave of self-hatred and self-destruction. Cathy said that this exploration led to thoughts about the people she believed let her down during that time, and eventually to conflicting thoughts and feelings related to both of her parents.

Cathy discovered she had intense feelings of anger about feeling that her parents were not emotionally and physically available enough to her throughout her childhood, particularly when she was struggling immensely in high school before her suicide attempt. She believed that her parents, and particularly her mother, failed to adequately attend to her psychological deterioration during that time, in part due to her mother’s inability to set boundaries with her siblings, resulting in her mother caring for Cathy’s grandparents in the absence of help from other family members. She didn’t believe that her parents inflicted direct harm onto her. Rather, Cathy understood that they believed that she would be fine if left to her own devices, something that failed to hold true as they seemed to have missed signs of severe psychological problems and persistent emotional break-down.

Cathy said that discovering and articulating anger towards her parents helped her understand why she could fly off the handle, bursting with anger at those close to her, at times unprovoked, leaving Cathy herself dumbfounded at the intensity of her feelings.

What also proved invaluable to Cathy, she said, included Mary’s insistence on structure and accountability that manifested in Cathy utilizing homework assignments in-between sessions, and ultimately agreeing to a treatment contract recommended by Mary. Cathy said her homework assignments consisted of cognitive-behavioral treatment (CBT) interventions that attempted to illuminate her automatic negative thoughts and challenge

77 them with healthier, more realistic thoughts. She said her thoughts were, in her words, “catastrophic,” all-or-nothing proclamations about her inability to be loved, or her horrendous lack of worth as a person.

Cathy reported that Mary also insisted on very specific and structured dialecticalbehavioral therapy (DBT) interventions, often given to her as homework assignments to be completed outside of sessions. Cathy recalled how Mary believed that these interventions would help her better manage her affect, and how she could deal with her fear of rejection in a way that didn’t push friends and lovers away from her. Cathy described herself as having borderline personality traits, particularly driving other people away and struggling with impulse control. She reported that the DBT techniques were designed to help her pinpoint her distress, understand it from hers and the other person’s perspective, and ultimately find appropriate ways to self-soothe that didn’t include impulsive behaviors aimed at getting the attention she craved. Cathy said she would dissect, in minute detail, her interactions and reactions with friends and boyfriends, helping her develop more self-control. DBT reportedly helped Cathy calm the intensity of what she felt, and deal with overwhelming emotions that made her feel depressed and suicidal and ultimately contributed to her turning to drugs to mitigate her pain.

The most salient aspect of treatment, according to Cathy, followed a break from psychotherapy, during which she missed a session with Mary and didn’t call her for twomonths straight. Cathy reported that she decided that she didn’t want to quit smoking marijuana, and that she didn’t need therapy. In addition, she said she had been lying to Mary about the extent of her alcohol and marijuana use, and minimized her dependence on marijuana. She reported feeling guilty about lying to Mary about her substance use,

78 and worried that Mary would find out about the true extent of her use, resulting in her reportedly feeling anxious at times when meeting with Mary. She also said she felt too ashamed to discuss her pattern of pulling her hair out and picking her skin, two problematic behaviors Cathy said occurred when she experienced an intensification of her anxiety.

Two months passed and Cathy reported feeling extremely stuck academically and anxious about her professional future, fearing that she was going nowhere in her life, something that created intense anxiety for Cathy as she anticipated graduating from college the following year. As a result, she said she decided to go back into treatment with Mary. This time, she said, Mary put her on a treatment contract, something Cathy said was the most salient and most helpful aspect of her entire treatment. Cathy reported that Mary used the treatment contract to hold her accountable, particularly related to her compliance with attending weekly treatment, in addition to her need to address her dependence on marijuana. The treatment contract, according to Cathy, helped her understand that Mary was serious about helping her, and that Cathy needed to take treatment just as seriously as Mary did. As Cathy reported: I had no discipline. She held me accountable. She was, she pushed back really hard on me saying I’m going to smoke pot only one day a week. That’s not how it works. If you have it, you’re going to smoke it. Um, so she really didn’t push me so hard that I would stop coming to treatment by saying I can’t treat you if you’re high; she wasn’t going to drug test me, but really tried to get me to see the folly of that…So that was great, her strictness and accountability was very helpful.

79 Cathy said that Mary’s treatment contract intervention was the first time she had been held accountable in her entire life as an adult, providing a space where she could then begin to take herself seriously. She said she stopped lying about her marijuana dependence and also told Mary about picking her skin and pulling her hair, something that led to her having a successful group therapy experience for OCD behaviors alongside continued individual treatment with Mary.

Cathy reported ending her treatment shortly before graduation and moving out of her college town. She had spent 2 years with Mary, and felt very grateful to her. When reflecting on her treatment experience, Cathy didn’t report much of anything that was not helpful to her. She did say that she thought Mary could have possibly talked to her more about situations in which she was smoking marijuana, and friendships she would need to re-examine if she really wanted to address her marijuana dependence and alcohol abuse.

However, Cathy said that she is “tremendously” satisfied with her treatment with Mary, the one she said who pushed her, challenged her, and helped her take responsibility for herself. Cathy reported that Mary set limits, conveyed a need for her to take herself and her recovery seriously, and held her accountable for her actions and behavior for the first time in her life.

Treatment with Vanessa.

When reflecting on her second treatment, Cathy used several words to describe Vanessa, including “wise,” a “wizard,” and a “magician.” When asked to elaborate on why she considered Vanessa a “wizard,” and what she looked for in entering her second treatment in emerging adulthood, Cathy reported the following:

80 She’s like a wizard-lady. She would sometimes say very little, but say exactly the right things, at the right times…we finally pinpointed where these rage dreams were coming from, and it was because my parents had not adequately prepared me to leave the house and have a healthy idea about how to manage all the drinking and drugs and sex at college. And I was angry they assumed I wouldn’t get into that; how dare you assume that! How dare you not prepare me for that!

So she basically helped me see that I can hold them accountable for that during these sessions. I’m allowed to be angry about it.

Cathy recalled how she felt intense guilt at being angry with her parents, and felt as though she shouldn’t feel angry. Through her treatment with Vanessa, Cathy said she allowed herself to experience feelings of rage in relation to her parents (that emerged originally only through her dreams) and figured out how to see them as human, as inadequate, imperfect people. In short, she said she could see them as flawed, even though she continued to feel anger, particularly at her mother for being, in her words, a “shrinking violet” and not asking her siblings for help with caring for Cathy’s grandparents while Cathy said she suffered at home during high school, feeling invisible to her mother. Consequently, Cathy said a salient focus of her psychotherapy with Vanessa included first acknowledging her anger and rage, and then finding a way to feel and express those emotions in the context of treatment.

At treatment unfolded with Vanessa, Cathy reported more and more of her dreams and nightmares related to her parents. Vanessa, training at a psychoanalytic institute, seemed to welcome Cathy’s dreams, particularly those concerning her parents that Cathy found most anxiety-provoking and unsettling to her. In recalling a salient moment in

81 treatment, Cathy described a specific session that jumped out and was fresh in her mind.

She reported: I remember a particular session where I was like screaming at her (Vanessa) as a proxy of my parents, saying why didn’t you prepare me for this!? Why did you, you guys let me get raped!? Like, why did you think I was perfect, and why did you ignore me when I was hurting!? Why didn’t you stand up for me, why did you do this or that? Um, and that was after a particularly terrible rage dream, experiencing that anger in real life in real time; there it is, you’re allowed to feel it; it’s scary, but you survived and your parents are still alive!

Cathy clearly had unspoken, unconscious anger and rage at her parents, and was able for the first time to process those feelings through the transference, using Vanessa as a safe, non-retaliatory medium to express feelings that had previously been unconscious.

Cathy said that Vanessa, unlike her parents, could see that she was struggling immensely, and responded to her not by ignoring her or assuming that she was fine, but by inquiring into her feelings and subjective experience, something Cathy said her parents failed to do in high school and college. She recalled how, in high school, she believed her parents were scared of asking questions in fear of breaking her, or worried that discussing her problems at home would add more stress to Cathy’s life. However, Cathy said she felt that she needed more from them during that time. She reported that Vanessa wasn’t afraid to ask her how she was feeling, and that she didn’t shy away from inquiring into Cathy’s more disturbing thoughts and feelings. In addition, Cathy said she felt that Vanessa understood, based on the questions she asked her, that Cathy was already damaged, feeling “shattered” by years of depression, anxiety, and relational conflict.

82 Cathy struggled to report anything that was not helpful in treatment with Vanessa.

She did say that Vanessa was quite lax, and didn’t push her or insinuate that Cathy had a drug and alcohol problem that needed to be addressed. As a result, Cathy reported that Vanessa could have been harder on her about her substance use, though the main focus of treatment included discovering and making sense of her aggression and rage. Overall, Cathy felt Vanessa was “incredibly talented” in walking her through feelings related to her parents that were previously unconscious, and helping her understand and process those feelings as they emerged through her dreams, and then were discussed in the context of treatment. She described Vanessa as a “guide,” someone who walked her through disturbing feelings aimed at her parents, ultimately helping her process and understand unconscious aggression and rage that emerged through her dream life.

Psychodynamic assessment and interpretation of Cathy.

Thus far, I’ve discussed details of Cathy’s reported experience in childhood and adolescence, as well as the significant moments she recalled from her experience in emerging adulthood, and in college. From there, I provided details related to both of her treatment experiences in emerging adulthood, and later discussed her report of therapeutic action, or what she found helpful in psychotherapy with each therapist. Next I will offer a psychodynamic assessment and interpretation of Cathy, one that will be used to inform my psychodynamic understanding of her experiences in treatment. This assessment emerged from my interpretation of Cathy’s narrative from childhood and her subjective experience in both treatments, in addition to countertransference data I observed and felt throughout the interviews with her.

83

Childhood and development.

While the symptoms’ cause can’t be determined, it seems likely that Cathy developed borderline personality traits beginning around adolescence, a condition that has contributed to unstable relationships, anxiety around abandonment and rejection from close others, conflict with peers, and frequent depressive and suicidal tendencies. This led to Cathy’s long-term difficulties with self-harming behaviors and eventually a suicide attempt. It’s unclear exactly when Cathy was given this diagnosis in her adolescence, though she said she first heard about borderline personality in high school, ostensibly from her psychotherapist. Regardless, it does seem, from her reported experiences throughout her childhood, that Cathy probably suffered from borderline personality traits, and that her difficulties intensified when she started puberty, and Cathy said she constantly felt “suicidal around the time of the month,” something she said a psychiatrist in high school diagnosed as PMDD. These difficulties added to what sounded like already existing problems with affect regulation and impulsivity, with Cathy beginning to use various means, most notably marijuana and alcohol use, to self-soothe.

It seems possible that Cathy’s probable borderline functioning limited her ability to not only experience positive emotions and positive interactions with family members and peers, but also it limited her ability to interpret and perceive experiences with others in realistic ways, compromising her ability to engage with others in a manner characterized by healthy expression of her needs. Stern (2010) argues how transference, from his theory of unformulated experience, is understood not as a distortion, but as “unconsciously selected perceptions that are quite real, but that represent only one, or a

84 few, of the possibilities that might be actualized” (p. 7). In other words, he argues how an individual experiencing problematic relational patterns can turn away from possibilities for feeling, thinking, and relating that could make possible a new experience of the other (Stern, 2010). In Cathy’s situation, it’s plausible that her borderline functioning contributed to her selected perception in which she turned away from positive experiences with close others, precluding her from engaging in healthier relationships not characterized by conflict and chaos. For example, Cathy’s reported experience is that her parents were unavailable to her before significant transitions, particularly when she was leaving for college and she felt that both her mother and father failed to adequately prepare her to protect herself in a new environment, especially related to issues around sex and partying.

Following Stern’s (2010) model, it’s possible that Cathy unconsciously turned away from possibilities for engaging with her parents in ways in which they could have provided more guidance, possibilities that might have included discussions related to protecting herself. In other words, Stern’s (2010) position implies that this dynamic between Cathy and her parents was far more complicated that simply assuming her parents failed her—that Cathy also unconsciously played a role (i.e. like not asking her parents about sex, drugs, and partying in college) in turning away from moments in which she could have related to her parents in a different way, one that might have led to the very discussions and direction she felt she needed from them. Another way to look at this dynamic is from Mitchell’s (1988) contention that individuals are loyal perpetuators of constricted relational patterns, unconsciously playing a major role in repetitive, problematic interactions with significant others. From this viewpoint, Cathy shared

85 responsibility for not receiving the type of guidance she said she needed from her parents, despite her belief that her parents failed her at a pivotal transition in her life. Also, what’s interesting is that Cathy’s narrative suggests that her only source for learning about sex, alcohol, and drugs was her parents, which would mean that she managed to ignore the multitude of messages in both high school and college about self-care. In other words, it’s possible that she has simplified and ignored reality in the service of confirming and perpetuating a narrative that she uses to confirm her sense of herself.

As previously mentioned, Cathy’s sense is that there were times growing up when her parents attended to the emotional needs of others while neglecting her own, leaving her ill-prepared to manage her depression in high school as well as protect herself in college. While it’s clear that, on several occasions throughout her development, Cathy felt that her parents were not responsive to her in ways she felt she needed—given Cathy’s struggles with borderline functioning, it’s also possible that no amount of attention, responsiveness, or availability from her parents would have felt sufficient to help manage Cathy’s psychological difficulties. In other words, it’s plausible that Cathy’s borderline functioning limited her ability to manage emotions and conflict, leaving her without the psychological resources to cope with frustration, conflict, and disappointment without resorting to dramatic, attention-seeking impulsive behaviors designed to enlist the attention and engagement of others.

It seems likely that Cathy’s borderline functioning contributed to her re-creating interpersonally the internal turbulence she felt throughout the course of her development.

Bollas (1996) argues that the borderline personality experiences the primary object as disruption represented as emotional turmoil, so, in unconsciously seeking turbulence with

86 others, one is establishing the primary object. This results, from his perspective, in an individual being constantly tempted to find this turbulent object experience, an “unconscious addiction” to searching for shocking, intense feelings that “revive” the emotional turmoil (Bollas, 1996, p. 7). From this perspective, Cathy’s possible need to unconsciously seek emotional turbulence contributed to her report that she found herself perpetually experiencing conflict with her peers, what she referred to as constantly having “girl drama.” In fact, Cathy said she would “test” people to see if they really liked her, purposely creating tension and conflict with certain peers to see if they’d remain in a relationship with her. As a result, it seems that Cathy had an unconscious need to re-create conflict and emotional turbulence to feel “normal” when engaging with others, attempting to “revive” the experience of her primary object (Bollas, 1996, p. 7).

Personality patterns and characteristic defenses.

It’s possible that Cathy’s predominant self-other configuration formed in childhood included an experience of the self as chaotic, something that also created conflict and confusion in her relationships (Mitchell, 1988). Bollas (1987) argues that the borderline patient has a chaotic internal world, one that often creates a prolonged sense of confusion and disorientation for the therapist, a dynamic that makes interacting with the individual extremely difficult. Specifically, it’s plausible that Cathy’s chaotic internal world contributed to her experiencing conflicting needs and desires when engaging with close others, creating feelings of confusion and disorientation as important others attempted to understand what Cathy needed from them, as well as how to connect with her (Bollas, 1987). It’s possible that this dynamic created frequent conflict in Cathy’s

87 relationships, and contributed to some peers needing distance and separation from her, and some feeling confused about what she wanted or needed in a relationship with them.

Not only did Cathy’s chaotic internal world create conflict in her peer relationships, but also it seems plausible that it manifested in other specific relational patterns when interacting with significant others. For example, Cathy characterized herself as an intense person, an individual with an “all-or-nothing” perspective on life, something that she said can be helpful and push her to be productive and driven, or something that can be her worst enemy, preventing her from achieving her personal and professional goals. I experienced Cathy’s intense, all-or-nothing way of engaging with others in a few interviews, particularly when she discussed her anger at her parents. I will say more about my countertransference feelings and reactions to Cathy in an upcoming section; however, it seems likely that Cathy’s chaotic internal world and intense presentation contributed to a craving for recognition and attention from others, even if that very attention was problematic, as in conflict with a peer. I imagine that Cathy’s turbulent presentation made others also have intense, all-or-nothing reactions to her. On the one hand, it’s plausible that certain people who also unconsciously needed conflict were drawn to her, perpetuating a cycle of conflict in her close relationships. On the other hand, it seems likely to me that others were repelled by her relational dynamic, and wanted distance and separation from her. I will say more about this conflict, and how I believe it impacted her treatment, in a later section. For the time being, it seems likely that Cathy’s chaotic internal world contributed to frequent tension with peers, and unconscious gratification as she re-created the very constricted relational patterns that wreaked havoc on her close relationships (Mitchell, 1988, 1993).

88 In terms of predominant defenses, it seems plausible that Cathy used splitting throughout her development to manage intense, opposing thoughts and feelings related to her parents, and particularly her mother. As do other authors, McWilliams (1994) argues that individuals who struggle with borderline functioning are prone to use splitting, in which one separates experiences into all-good and all-bad categories, with no room for ambivalent feelings. She contends that splitting is used especially when individuals are preoccupied with themes of separation and individuation from primary caretakers, and struggle with how to experience and make sense of their intense, often conflicting needs and desires for connection and dependency (McWilliams, 1994). In a relational context advocated by Mitchell (1988, 1993), one could consider this process as the hope and dread of connection, the self’s longing for emotional closeness and dependence on the other while simultaneously needing separation and distance, a dynamic that creates relational conflict and ambivalence when connecting with intimate others. Regardless, it seems that Cathy’s use of splitting created intense, opposing versions of her experience of both parents, and particularly her mother. For example, in one interview Cathy became noticeably angry as she discussed her perception that her “shrinking violet” mother failed to prepare her to protect herself in college, something Cathy felt led to her being raped.

In the very next moment, Cathy then seemed to prop up her mother and idealize her, reporting that although her mother felt unavailable to Cathy before college, that she’s “just fantastic” and one of the “the nicest people” Cathy has ever known. It seems that this moment in the interview was one example of Cathy’s use of splitting, and her struggle in reconciling ambivalent feelings related to her mother.

89 McWilliams (1994) contends that individuals who suffer from borderline psychopathology are preoccupied with themes of separation and individuation. It’s plausible that Cathy struggled with issues of separation and individuation from her parents, longing for closeness and dependence one moment and wanting distance and separation the next moment, experiencing her parents as abandoning when she felt they weren’t attentive enough to her (McWilliams, 1994). From a developmental perspective, it’s possible that Cathy struggled with establishing interdependence with her parents during high school, or experiencing greater autonomy in the context of continued support and dependence on them (Steinberg, 1990). In an attempt to manage these conflicting wants and desires, it’s possible that Cathy used splitting, seeing her parents as all-good and available to her when she wanted more dependence and closeness to them, and casting them as all-bad when she felt they were unavailable and didn’t provide the attention and recognition she craved. However, it seems that Cathy struggled to articulate these needs to her parents, something I imagine contributed to what Bollas (1987) argued as the borderline patient’s chaotic internal world creating confusion and disorientation in the other. In other words, it’s plausible that Cathy’s parents felt confused and disoriented when engaging with her at times, particularly in high school, contributing to difficulties in understanding what exactly she needed from them in a given moment, and perhaps leading them to pull away from her, out of their confusion, precisely at a time when Cathy might interpret their pulling away as abandonment.

Looking at Cathy’s adolescence from a relational perspective advocated by Mitchell (1988), I imagine that she found herself re-creating this dynamic with her parents, a

90 pattern of engaging with them that left her feeling disappointed and abandoned by them, and it’s possible she repeated this with others.

It seems likely that another predominant defense employed by Cathy throughout her development includes that of projection. Projection is the process by which an individual rids herself of an unpleasant or intolerable internal experience, locating it externally in the other. McWilliams (1994) contends that, in malignant projection, what is projected consists of disowned and highly negative parts of the self, a process that often creates misunderstanding and extreme difficulties in relating to others. For Cathy, it seems possible that she had an internal object of an unavailable parental figure, an internal experience that was easily evoked and projected onto external objects, contributing to Cathy’s sense that others, like her parents, were unavailable to her, something that manifested in specific relational patterns between Cathy and others.

While Cathy felt that her parents were unavailable to her, contributing to her sense that they failed her when she needed them the most, this is difficult to reconcile with Cathy’s other reported experience of her parenting. I imagine it’s possible that Cathy projected this unavailable object onto others, like peers for example, and unconsciously “nudged” them into acting in that role. For example, it’s possible that some of Cathy’s peers felt overwhelmed by her reported attention-seeking behaviors aimed at generating conflict and “nudging” others into getting the recognition she craved, and responded by maintaining distance from her, or ending the relationship altogether, creating an enactment that bolstered Cathy’s unconscious sense that others reject her or are otherwise unavailable. I will say more about how I believe this process shaped her

91 treatment in a later section on the psychodynamic understanding of her experience in psychotherapy.

Fantasies/experiences of relationships.

Mitchell (1993) argued that one’s fantasies and experiences in relationships must include a focus on the conscious and unconscious strategies one has learned as a result of engaging with significant others, and how they continue to play out in the context of one’s interactions. For Cathy, it seems plausible that an underlying assumption she held included the idea that others, particularly her parents, were not responsiveness enough to her, and consequently failed her in some important ways throughout her development.

Along those lines, it seems likely that another component to that assumption includes the idea that while others have failed her, it is others who also have to rescue her, and protect her from her own self-destructive tendencies. It seems possible that this manifested in Cathy expecting more attention, recognition, and protection from her parents than she felt she received. Additionally, it seems likely that this assumption unconsciously perpetuated Cathy’s identification as being a victim, as a self acted upon by others who disappointed her, failing to provide what she felt she needed. In other words, this underlying assumption contributed to Cathy viewing herself as a victim, unaware of her unconscious role and her loyalty to maintaining the very problems that lead her to seek treatment, as Mitchell (1988) described it.

It seems likely that an unconscious belief formed in childhood that shaped many of Cathy’s interactions with others included the idea that the self was damaged, what she consciously described as being “strange” and feeling “different” from others, including

92 her own family members. In one particular interview, Cathy described herself as “different” and “strange,” and said she felt this way for as long as she could remember. It seems plausible that on a conscious level, Cathy felt drawn to an identity as a “strange kid,” different from her peers and family members. For example, she described herself as “strange” in one particular interview, and appeared to me to feel proud of this identity, as though it set her apart from others in a unique, positive way. Cathy seemed to have a narcissistic investment in viewing herself this way, possibly needing to see herself in some ways as unique and special, especially as she attempted to manage her severe depression and suicidal thoughts. However, it’s possible that her identity as a “strange kid” concealed the underlying, more painful unconscious belief that the self was damaged, something that manifested in Cathy re-creating specific problematic relational patterns with others (Mitchell, 1988, 1993).

Cathy described how she would “test” others to see if they “really” liked her, even reporting that she’d fabricate conflict with peers in an attempt to see how they’d respond to her, and to determine if they “really” wanted to be her friend. Not only did Cathy report that this pattern created conflict and tension with some peers, but also it resulted in some people needing distance from her, or ending their relationship with Cathy altogether. It seems possible that Cathy may have wanted to tests others’ acceptance of her, or their affection for her. She implied this in one interview, reporting that occasionally she would “push” some of her closest friends to see how they would respond to her. Consciously, it’s possible that Cathy felt she was creating conflict to ensure that her closest friends would accept her, or even “prove” their affection for her. On an unconscious level, it seems highly likely that she was re-creating problematic relational

93 patterns and “nudging” some peers into rejecting her, creating an enactment that ultimately bolstered her unconscious belief that the self was damaged (Mitchell, 1988).

How I understand what brought Cathy to treatment.

In her psychotherapy with Mary, Cathy said she sought treatment due to a realization that the substances she was using, namely alcohol and marijuana, were “masking dark feelings” of depression. Cathy said that after she moved away from home and started college, she initially believed that her problems would simply go away, and that she would feel better. It seems that Cathy initially operated with the illusion that being in a new environment would solve her past difficulties. Instead, she found herself struggling once again, something that seemed to shatter her illusion that moving away from home would fix her problems. Cathy said she was in great pain once again, and so sought help.

Cathy reported that she sought treatment with Vanessa due to having “rage dreams” towards her parents, dreams where she was “saying and doing horrible things” to them, an experience so anxiety-provoking to Cathy that it could jar her awake during sleep. After a particularly distressing dream, Cathy remembered calling her parents to tell them she loved them, needing assurance that they were fine. From a psychodynamic perspective, it seems plausible that Cathy sought treatment to manage the guilt she felt about having rage and aggression towards her parents, feelings that only emerged in her dream life. While she consciously reported feelings of disappointment, frustration, and moderate anger for feeling as though her parents failed to prepare her before college, she had never reported conscious feelings of intense rage and hate towards them until these

94 feelings manifested in her dreams. It’s likely that these feelings were difficult for Cathy to tolerate, given her propensity for splitting, and contributed to confusion and intense levels of anxiety, impacting her decision to seek her second treatment in emerging adulthood.

Countertransference.

From a psychodynamic perspective, an important data source includes my countertransference feelings and reactions to Cathy throughout the interviewing process, feelings that help shed light on Cathy’s internal world, as well as her functioning in relationships with others (see Maroda, 1991). My initial impression of Cathy was that she was an intense person. For example, when I asked her about her current life and interests, she described her passion for human rights activism in such a fervent and articulate manner that her discussion drew me into her story. I experienced this same level of intensity in subsequent interviews, especially when Cathy discussed any experience from the past that engendered emotion in her. For example, when Cathy discussed a particular argument with a peer that occurred years ago in grade school, she seemed angry to me, her voice rising and her hand gestures becoming animated. I noticed in these moments that I felt somewhat uncomfortable with Cathy’s anger, due to the intensity of her feelings, and wanted some distance from her. On the other hand, when Cathy described feeling sad or depressed in high school, she appeared very depressed, and I noticed that I picked up on and sensed some of her depressive feelings.

In those moments, I felt sorry for Cathy, and noted that I wanted to make her feel better, and often felt an urge to console or reassure her.

95 I believe that the above dynamic I felt when interviewing Cathy highlights something important about her internal world, and how that world impacts her functioning in relationships. Specifically, there seemed to be an extreme aspect to Cathy’s feelings, whether she was discussing her anger and frustration on the one hand, or describing her depression and sadness on the other hand. Specifically, I noticed that, when Cathy seemed more passionate and angry even, I felt somewhat uncomfortable, and wanted space and distance from her. In those moments, Cathy seemed to be too intense for me, making me associate to someone that required a significant amount of energy to tolerate. I thought about how Cathy’s intensity could be difficult to match or manage, and wondered if her disposition made it difficult, at times, for some people to engage with her, contributing to Cathy’s sense that others have rejected her or abandoned her.

Conversely, when Cathy discussed the depression she felt and her experience of feeling neglected by her parents, I noted that I easily viewed her as a victim, as someone whose parents grossly failed her. In those moments, I wanted to protect Cathy, and desired emotional closeness, instead of a need to establish distance and separation from her.

What do these extreme, conflicting experiences mean in relation to Cathy? I believe that I experienced, in part, what close others feel when attempting to engage with her. When she’s operating within her intense, passionate demeanor, a person might be captivated by her, or need to retreat from her, as I felt in the interviews. When she seems more depressed and hurt by others, someone might not want anything to do with her, or might want to protect her, something I felt on occasion when listening to her story. In other words, my shifting feelings when interviewing Cathy made me conclude that it

96 could be difficult to engage with her, unless one could tolerate both the intensity of her feelings as well as their changeable nature.

I also felt that Cathy continued to struggle with integrating ambivalent feelings towards her parents. Cathy reported that her second treatment in particular helped with her feelings towards them, especially her rage and aggression. While at times she seemed to understand why she experienced rage dreams in relation to her parents, my experience in interviewing Cathy was that she continued to struggle with what to do with, or how to manage, conflicting feelings towards them. There was a particular moment in the first interview where Cathy described her intense frustration with her parents, and immediately shifted direction, discussing her profound love and gratitude for them. For example, during that interview, Cathy described the feelings of anger, frustration, and disappointment she experienced when she felt her parents neglected to attend to her needs in high school. As she recalled her experience, she became noticeably angry, appearing on the brink of screaming at them before stopping herself and quickly changing topics. I noted in my field notes that this same pattern occurred in two other interviews, making me think that Cathy didn’t know what to make of her feelings, and that she continued to experience overwhelming anger and frustration at her sense that they failed her. I will say more about how I think these feelings shaped Cathy’s experience in treatment in a later section.

I also noticed that I felt frustrated at times when interviewing Cathy. A part of my frustration was directed at Cathy’s parents, particularly when I sensed her sadness and her reported experience that they didn’t do enough to help with her depression and suicidal tendencies in high school. However, as I sat with Cathy over time, I felt more

97 feelings of frustration in relation to Cathy and what seemed to me to be her inability to consider her own role in her depression, suicidal behavior, and self-destructive tendencies. It was as though she was, at times, seeing herself only as utterly helpless, perpetuating an identification as a victim that seemed to make it impossible for her to help herself, as well as develop the agency needed to take control of her life. It’s plausible that this dynamic operated in high school, and, coupled with Cathy’s likely borderline functioning, contributed to her feeling as though her parents didn’t do enough to help her manage her psychological problems, leaving her with the sense that she was left to her own devices. From a clinical perspective, I seemed to experience both concordant and complementary countertransference reactions (Racker, 1968) in very quick shifts, informing my sense that it might be difficult to be in a relationship with Cathy.

In concluding the section on countertransference, it seems likely that Cathy’s turbulent internal world has impacted every aspect of her functioning, from her difficulties in affect regulation and impulsive behaviors, to her reported experience of having continual conflict with significant others over the years. Additionally, it seems possible that this issue has resulted in Cathy requiring more attention, recognition, and responsiveness than others are often able to provide, potentially pushing others away, and thus contributing to her sense that people are unavailable or fail her in some way, a feeling of deprivation that manifests in her employing additional attention-seeking behaviors to engage the other. Also, it seems that she attempts to re-create interpersonally what she feels internally, unconsciously re-creating conflict and tension with others (Bollas, 1996; Mitchell, 1988). It’s possible that her chaotic internal world

98 leads her to oversimplify her experience of others by placing them into one of only two categories—good or bad. If this is true, it seems possible that this unconscious tendency creates stability from her internal chaos, but it also makes for an inability to manage the complexity of the real world and real others, in which coping with ambivalence leaves her feeling frantic and anxious, and so she shifts between the only tools she has—seeing others all all-good or all-bad. I will say more about how I believe this core issue impacted her experience in treatment in an upcoming section.

Psychodynamic understanding of therapeutic action.

As mentioned in a previous chapter, psychodynamic understandings of therapeutic action attend to not only what the participant reports as being helpful and not helpful (i.e. the participant’s conscious, subjective experience), but also pay attention to what may be inferred or interpreted from what is not said, or what may be meaningful outside of one’s awareness (i.e., the participant’s unconscious experience). In addition, a psychodynamic case study assesses a participant’s thoughts and feelings related to therapeutic action in the context of his or her history, as an assumption of relational psychoanalytic theory is that early experiences impact later functioning, particularly early experiences with caretakers (Mitchell, 1988). As stated before, this study looks not only at therapeutic action from the perspective of the participant, but also takes the data analysis a step further and understands it in the context of the idiosyncratic development and history of each participant.

As mentioned in the introduction to this chapter, I will use relational theory as conceived by Mitchell (1988) to interpret the data. His perspective assumes that early

99 disturbances in significant relationships with caretakers distort subsequent relatedness by laying the foundation for, and setting in motion, a complex system through which a child constructs his or her world of being and relating to important others (Mitchell, 1988).

Individuals will cling to old, problematic patterns of relating that are familial and familiar because these object ties preserve a sense of loyalty and connection to important others, namely parents, across the life span (Mitchell, 1988). This results in people unconsciously re-creating past constricted relational patterns in their present relationships, preventing them from having new, different interactions with intimate others (Mitchell, 1988). Because I am choosing primarily Mitchell’s (1988, 1993) ideas as the framework through which I’m looking at the participants’ data, it’s important to highlight the ways in which early childhood experiences impact later functioning. With these assumptions in mind, Cathy’s thoughts about her subjective experience in both treatments, as well as what she found helpful, will now be explored.

Treatment with Mary.

In the previous section, I described how I believe Cathy formed an internal object of an unavailable parental figure, and possibly projected this onto real people. As a result, it’s plausible that Cathy unconsciously projected this object onto Mary and assumed that she, too, would be unavailable and fail her in some way. From a slightly different perspective argued by Bollas in relation to borderline functioning (1987, 1996), it’s possible that Cathy attempted to seek chaos and emotional turmoil with Mary, recreating interpersonally what she felt internally. From Stern’s (2010) perspective, this could have resulted in Cathy employing “unconsciously selected perceptions” to “look”

100 for data from her interactions with Mary that would contribute to her interpreting their relationship in rigid ways shaped by past experiences (p. 7). From yet another perspective, Cathy’s possible preoccupation with themes of separation and individuation possibly contributed to her feeling worried about Mary’s ability to attend to her and recognize her needs, experiencing anxiety from her reported experience of feeling abandoned by both parents at significant times in the past (McWilliams, 1994).

Instead, Cathy reportedly found Mary available and very attentive to her, specifically due to her sense that Mary immediately helped her begin to manage her feelings. Several interventions were aimed at this goal, including: EMDR and processing her suicide attempt; CBT worksheets that made Cathy challenge her negative automatic thoughts about herself and identify healthier alternatives; and several DBT assignments that illuminated the ways in which triggering and distressing events made her crave attention and recognition immediately from close others. Typically this took the form of Cathy enacting problematic patterns with friends and lovers through impulsive behaviors that unconsciously but predictably produced rejection. In general, Cathy struggled with what to do with her intense emotions, a difficulty she worked on through several discrete interventions with Mary, all designed to help her calm down before becoming reactive.

In a previous section, I described how I believe it’s possible that Cathy historically experienced others as unavailable, and unconsciously “nudged” them into acting on that role. Specifically, if she attempted to get attention by engaging in dramatic behaviors, it’s possible that some people responded by needing distance from her, or ending their relationship, corroborating Cathy’s unconscious sense that others are unavailable to her or reject her. It seems possible that Cathy’s reported experience that Mary was

101 immediately attuned to her helped prevent these enactments from occurring, and started to help Cathy find other, alternative ways to manage her intense emotions.

Difficulties with affect regulation have been a long-standing issue for Cathy. She recalled the torment she felt whenever she witnessed her father arguing with her sister, an experience that made her reportedly feel threatened and, in her words, “terrified,” recoiling into the safety of her bedroom where she attempted to distract herself and suppress her feelings of terror and anxiety. While she said this interaction didn’t occur daily, it also wasn’t an isolated incident. From a relational viewpoint, these overwhelming experiences formed one piece of what Mitchell (1988) referred to as a complex tapestry of relational configurations formed in Cathy’s childhood: one in this situation where she learned to avoid expressing her overwhelming feelings, suppressing them in an un-processed form until they found expression in dramatic, attention-seeking behavior, emotional outbursts designed to express her needs and elicit immediate recognition from others. In reality, these behaviors pushed people away, exacerbating her tendency to be rejected or experience relational conflict.

Cathy’s father’s reported temper, combined with her mother’s self-sacrificing personality and reported martyred behavior, possibly set in motion a complex pattern of relational models at the extremes: Cathy could become either the sacrificial lamb, avoiding and suppressing all feelings and desires in a maternal model of helping others, or become the explosive father-figure, destroying all attempts at negotiation and the healthy expression of one’s anger. Implicit in these extremes is Cathy’s inability to express her feelings and needs in a balanced way. In other words, these experiences possibly resulted in relational models where expressing needs occurs only through either

102 a silent, complicit manner, or through loud protest and screaming. While both of these methods resulted in Cathy feeling deprived and depressed, or angry and rejected by peers, they both potentially felt familiar and familial (Mitchell, 1988). Consequently, one interpretation of why Cathy needed Mary’s multiple interventions aimed at affect regulation, and why she found them particularly helpful, includes the fact that these techniques provided a new, alternative route for Cathy to express her feelings and needs in relation to intimate others, starting with learning how to self-soothe before reacting.

It’s possible that these interventions eventually provided an alternative model of interacting with others, one where the self could explicitly articulate her feelings and needs, instead of enacting them through various acting-out, impulsive behaviors (Mitchell, 1988).

The most helpful aspect of treatment from Cathy’s perspective was Mary’s use of a treatment contract, something that was designed to promote accountability and adherence to weekly sessions where Cathy would work on herself and her relationships, in addition to being forthright about her marijuana use, instead of lying about her dependence. This intervention was particularly helpful because, in Cathy’s mind, it was the first time she felt she was held accountable by an adult. From a psychodynamic perspective, this seems particularly helpful due to Cathy possibly forming a maternal transference to Mary, one that eventually allowed her to feel recognized and attended to in ways in which she felt she wasn’t responded to by her own mother. If she did form a maternal transference, it’s possible that initially in treatment, Cathy unconsciously expected Mary to be unavailable to her and fail her, similar to her reported experience of her mother, particularly in high school. It’s possible that Cathy’s two-month absence

103 from treatment was an unconscious attempt on her part to elicit criticism and evoke conflict with Mary, as well as a repetition of a disengaged parental figure, an attempt to create an enactment and perpetuate her tendency to re-create chaotic, conflictual relationships with others.

When Mary responded to her absence not with criticism or conflict, but with deep concern about Cathy’s well-being coupled with her desire for Cathy to adhere to weekly treatment, it’s possible that Cathy experienced a new type of responsiveness from a maternal figure, one that she felt she missed from her own mother. Specifically, there’s something to be said here about Cathy’s seeming interpretation of her mother’s disengagement: she experienced the lack of structure as implying a deficit of affection for Cathy. Mary’s highly structured interventions represented a polar opposite approach; it’s very possible that this felt to Cathy like very loving and attentive maternal care. In other words, Mary holding Cathy accountable for attending weekly sessions with her implicitly conveyed the idea that she would remain available and responsive to Cathy, likely providing what Hoffman (2006) refers to as “new, growth-promoting experience” (p.

723) with a maternal figure.

A main focus of treatment from a relational perspective includes broadening one’s relational matrix to allow for new experiences of self in relation to others (Mitchell, 1988). In tailoring interventions aimed at establishing accountability for Cathy, it’s possible that two other salient experiences occurred: a) Cathy did not feel left to her own devices, psychologically speaking, as she had reported feeling at significant moments in her development. She asked for help, something she didn’t do with her parents, and found herself in treatment with someone who was curious about her internal world, which

104 also seemed like a new experience for Cathy, as her narrative implies that her parents misinterpreted her academic success as psychological health; and b) Cathy was helped to explicitly discuss what she needed with someone she trusted, instead of resorting to acting-out behaviors and attempting to shut others out or draw them closer. In addition, it seems that Mary’s interventions helped contain Cathy enough for her to begin thinking about questioning the idea that she is unable to take care of herself, an idea that served as a way to maintain attachment and ties to her family, by operating within a self-other configuration where the self is damaged (Mitchell, 1988, 1993). Her identifying as the, in her words, “sick baby” of the family helped perpetuate Cathy’s problematic tendency to get attention and recognition from others at all costs, even if that included testing others by pushing them away to see if they “liked” her, or to see if they’d continue to be friends with her.

Treatment with Vanessa.

A major focus of Cathy’s second treatment consisted of dream interpretation, particularly those dreams related to Cathy’s rage and anger at her parents for what she experienced as their gross inability to prepare her for college, as well as their reluctance to inquire about her psychological life and functioning when she was feeling depressed and suicidal starting in high school. She felt that they missed warning signs, and Cathy had a significant amount of rage and aggression that she wasn’t aware of until it manifested in her dream life.

From a psychodynamic perspective, delving into Cathy’s dreams, and more importantly, having Vanessa serve as “a proxy” in the transference in which Cathy could

105 directly feel and express her rage and disappointment with her parents, were two of the main reasons that therapy with Vanessa seemed helpful. It’s likely that Cathy needed to articulate her negative feelings, particularly her repressed anger and rage, towards her parents from someone who wouldn’t retaliate, without her father losing his temper or her mother retreating to the guilt-inducing state of martyrdom. This seemed particularly helpful because Cathy reported feeling guilty about having anger towards her parents in the first place, due to in part her conviction that they provided her with a multitude of opportunities and resources throughout her life. It seems imperative that she was allowed to first identify and then express her rage, anger, and disappointment in the absence of her parents being defensive. In other words, Cathy learned to identify and express a much broader range of her own feelings. Through understanding the transference, it seems that Cathy paradoxically found a scary yet safe place to let go of what she learned was hiding in the corners of her mind.

From a relational perspective, Cathy exhibited a constricted relational pattern in which she learned to enact, rather than directly express, her frustration and anger with intimate others (Mitchell, 1988). Cathy seemed to carry around a deep sense that her parents failed her, that they inadequately prepared her for high school and college, leading her to lose control and be sexually assaulted. However, she never articulated these feelings and instead enacted these problematic relational patterns with peers and boyfriends, pushing the limits with others to see if they would respond to her in ways that Cathy hoped would make her feel cared for, attended to, and accepted. From this perspective, it’s possible that she unconsciously created conflict and chaos in her close relationships to “test” important others. Would they ignore her pain like her reported

106 experience of her parents? Or, would they see that she was hurting, and respond to her with interest, care, and compassion—as she later seemed to feel that Mary and Vanessa did. On a conscious level, this behavior reportedly led to people becoming frustrated with Cathy, and either ending their relationships with her or taking breaks from her, perpetuating an unconscious assumption that others are unavailable and rejecting.

A basic assumption of relational theory is that individuals are active and loyal perpetuators of conflictual, problematic relational patterns (Mitchell, 1988). While Cathy’s parents may have failed to meet her needs in some ways, Cathy seemed unconsciously dedicated to maintaining her identification as the damaged self, and acted out in relationships as a result. As she noted, she held her parents and others “emotionally hostage,” creating conflict and problems when she felt she needed attention and recognition from those she loved. When Vanessa asked Cathy to understand, feel, and directly express her aggression and rage towards her parents, she allowed Cathy to begin experiencing herself not as a damaged individual unable to do anything except act out impulsively, and push others away as a result, but as an adult who could explicitly express feelings in the context of a close relationship.

Last, it seems plausible that Vanessa accepted and normalized Cathy’s feelings of rage towards her parents, something that seemed to mitigate her guilt for being angry with them. In other words, from Cathy’s report, it seems that Vanessa wasn’t perturbed by her feelings, whereas Cathy reported previously feeling so upset about them that she even called her parents to speak with them after one particularly upsetting dream. Cathy recalled a significant moment in treatment, one where she was “screaming” at her parents for her belief that in not preparing her adequately, they “let” her get raped, reporting that

107 Vanessa “allowed” her to express those feelings. If Vanessa’s response did help normalize her feelings, it’s possible that Cathy felt as though she could honestly express herself, still feel accepted by an intimate other, and experienced less guilt as she articulated her rage. However, it also seems that Cathy continued to use splitting, creating stability from chaos by oversimplifying matters and casting her parents as allbad, while simultaneously removing herself from her role in having issues in college. It’s possible that Cathy was not ready to surrender her two-dimensional picture of her parents, or wasn’t able to imagine that she contributes to her difficulties. Instead, from a developmental perspective, it’s possible that she needed what she referred to as a “guide,” someone who remained calm and present while she felt intense, frightening emotions related to the people who raised her.

Current functioning.

Currently, Cathy describes herself as a new person. She said she is in a Master’s program studying public policy, has a full-time job, and has high hopes for herself and her ability to make a positive impact on the world. She is intelligent, articulate, and passionately speaks her mind, something that could be endearing, or, I imagine, in its more intense forms a turn-off for some people. When describing what feels different since her two treatments, Cathy said that she now takes more responsibility for herself, and is working towards no longer holding her parents entirely accountable for her past problems. In addition, she said she is no longer dependent on marijuana, and reported that she stopped creating conflict with peers and significant others. She said she has a healthy, fulfilling relationship where she actively expresses her needs and desires with

108 her boyfriend. She attributed the development of more positive self-worth to having had two successful psychotherapies in emerging adulthood. Despite reporting that she has improved as a result of her two treatments, Cathy said she continues to struggle with selfsabotaging behaviors, in particular her understanding that she is not a person of moderation, and wonders how she’ll manage, in her words, “to exercise moderation as a person of joyful excess.”

In summary, Cathy’s narrative is one characterized by long-standing difficulties with depression, anxiety, relational conflict, and substance dependence. While Cathy, by no means, seems devoid of problematic and self-sabotaging tendencies, she reports fewer symptoms of depression and anxiety, no suicidal thoughts, and little conflict in her close relationships. In our last interview, Cathy discussed her ongoing need to continue forming a new identity, one that includes a different, more realistic image of her parents and their future relationship. While Cathy said that she wants to stop blaming her parents entirely for her past difficulties—based on my experience interviewing her multiple times—it seems that this will be a challenge for her, one that seems contingent on her taking more responsibility for her struggles in childhood, and particularly in high school and college.

Participant B: Amelia Amelia is a 28-year-old Latina female. She is short, has light skin with dark, curly hair, and wears dark-rimmed black glasses. She has a welcoming smile, and greeted me in the initial interview outside of her apartment with an excited embrace. She had two small dogs at her side, yipping and vying for her attention. She laughed at her

109 dogs, a contagious, booming giggle that made me smile and associate to a little kid laughing on a playground. She seemed very outgoing and full of energy, speaking fast, yet clearly. She comported herself in a straight-to-the-point manner. My initial impression was that there seemed like something incongruous about Amelia: on the one hand, she ostensibly appeared collected, carrying herself in a way that made me think of a confident, self-assured individual. On the other hand, she also appeared scattered and a bit disheveled, wearing loose, oversized clothes that didn’t seem to fit, making her appear younger than her age. Perhaps she was solely wearing comfortable clothes, or perhaps her attire represented something about her internal world. I wasn’t sure what to make of these contradictory thoughts and feelings I had in the first few seconds of meeting Amelia, and wondered how, if at all, these musings might relate to her narrative in some way. These feelings would reappear in later interviews, and made more sense to me the more I got to know Amelia and her narrative.

In the first interview, I met Amelia at her apartment, at her request. Her studio was a mess, with clothes scattered everywhere around her living room and kitchen. She noticed that I was observing the unkempt space, and said that she was in the process of taking photographs of clothes and selling them online with a friend. She stated that it was one of her interests, among many others. She reported working in retail, despite being trained as a lawyer. She immediately offered to make coffee or tea, and seemed to have a warm, caretaking aspect to her. She asked to start the interviewing process right away, as she was making coffee in her kitchen. This made me feel rushed, and, after describing the research protocol and informed consent process, we jumped right into her past, starting with what she remembered about her childhood.

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Childhood and adolescence.

Amelia said she was born in Arizona, an only child in a family of three. She said she did have an older half-brother from her mother’s first marriage, though he was almost 20 years older than Amelia. When recalling significant memories and salient moments from her childhood, Amelia associated to the painful experiences she said she experienced as a result of her parents’ behavior. Amelia said her mother was 40-yearsold when she had her. She reported that her mother was raised in a military family by two alcoholic parents with mental health problems that were never treated, instead masked by incessant alcohol abuse. Amelia said her mother was raised in poverty on a small farm, encountering physical and emotional abuse at the hands of Amelia’s grandparents, who drank heavily all day, everyday. She said her mother eventually escaped the home and went to college, graduating and later marrying a man who would reportedly physically and sexually abuse her, and cheat on her with strippers and prostitutes. Amelia’s mother had a son with him before eventually divorcing him and moving to Arizona, where Amelia said she met Amelia’s father, an immigrant over a decade younger than her mother who had traveled to the US illegally from Colombia.

Amelia said her childhood was filled with chaos, abandonment, and unpredictability, characterized by never-ending conflict between her parents during their 15-year marriage, ten of which were spent in divorce court, fighting over custody of Amelia. She recalled their relationship becoming so contentious that her father moved out, and found his own apartment away from Amelia’s mother. Starting at 4 years old, Amelia said she moved every year for 10 years, until finally re-locating permanently to

111 the Midwest when she was a teenager, as a result of Amelia’s mother’s attempt to leave Arizona and break all ties and connections to Amelia’s father.

Amelia reported that her father was abusive, grossly neglectful, and completely out of control. She described him as suffering from Bipolar Disorder, Borderline Personality Disorder (BPD), and being prone to intense manic episodes, where he became aggressive and abusive towards Amelia’s mother. She reported that during one manic episode, her father tried to kill her mother by attempting to run her over in his car. In addition, Amelia said that he regularly beat her mother, abusing her physically, emotionally, and verbally. She recalled early memories of him egregiously neglecting her starting when she was 4 years old, later learning from her mother that he left her with his girlfriends for hours at a time, left to fend for herself. She said he would make her take public transportation alone as early as 5 years old, and frequently leave her abandoned on a street corner several blocks away from where Amelia’s mother was coming to pick her up after her visitation was over with her father. Additionally, Amelia said he would neglect medical care for her. Specifically, she said that he would regularly deny Amelia her asthma medication, causing her to nearly asphyxiate on three separate occasions, all of which required hospitalization. During those moments, Amelia said he would take her inhaler away, telling her that she was faking her issues with asthma to make him feel guilty for leaving her mother. She said that his gross neglect and, in her words, “sadistic denial” of something that she needed to live almost cost Amelia her life, something that haunted her for a long time and reportedly manifested in her having a difficult time trusting authority figures, particularly men.

112 At age 9, when her father had dual-citizenship in the US and Colombia, Amelia said he would periodically take her back and forth from the US to Colombia to visit family on his side. Amelia said she felt terrified because, as her parents’ relationship fell apart, her father threatened to kidnap her in the middle of the night and take her to Colombia, never to return to the US. When her father was finally limited to courtmandated restrictive visitation and couldn’t, as a result, take Amelia to and from Colombia, she reported that he didn’t want to see her at all, and she hasn’t seen him since that time. However, she said her father would periodically pop up in her life after hacking into her email or somehow finding her phone number, attempting to reconnect with her, something Amelia said created intense anxiety for her as these attempts at communication with her brought back thoughts and memories related to his previous neglect of her. In addition, Amelia said that he wanted to reconnect with her solely to complain about her mother, something that she said made her feel as though he didn’t care at all about her, instead wanting to talk to her to ask questions about her mother.

Throughout childhood, Amelia said she had intense, conflicting thoughts and feelings related to her mother. On the one hand, she described her mother as strict, critical, “beyond mean,” and burdened with sadness from being abused by Amelia’s grandparents for years. She reported she thought that her mother’s history of abuse manifested in her losing control and screaming at her without provocation, making Amelia feel as though she couldn’t do anything right. On the other hand, Amelia said that her mother is a survivor, and believed she tried her best considering all the abuse she endured. As Amelia recalled:

113 She’s so sick. She’s so sick, but you know, I watched her struggle to put food on the table; to get clothing on my body; to try and be the healthiest she could be. I literally witnessed this very sick person doing everything she could to give me some semblance of a life in her own twisted, single, aloneness. Her own psychological universe, which was so dark.

According to Amelia, there was something “magical” about her mother. She recalled that her mother could create play-like scenarios using her creative ability where she would turn living in a hotel room or a run-down apartment into what Amelia described as a magical, fantasy-land decorated with scarves and clothing, a scene that she said made her feel somewhat better, and temporarily forget about their dire living situation. That being said, Amelia said she had a plethora of “interesting” experiences growing up, due to her mother putting her in summer camp literally the day Amelia got out of school, until the day before the next academic year started. Additionally, Amelia recalled that her mother, being a successful educator, would obtain different teaching grants, allowing her and Amelia to spend time travelling to different parts of the world.

Consequently, she said her time with her mother was filled with extremes: from traveling with her to new places; to being away from her mother all summer long in camp; to moving from place to place for several years, until they finally found a house that became their permanent home. What is striking to me, from Amelia’s report, is the disconnect here: her mother is described as a very successful teacher, yet they lived in what Amelia called “dire circumstances,” often without permanent housing. To me, these descriptions seem difficult to reconcile, and I imagine they represent one example of Amelia’s use of

114 splitting, a concept I will discuss in an upcoming section on my psychodynamic assessment and interpretation of her.

Despite engaging in an abundance of what she called “interesting” activities growing up, Amelia said she often felt isolated and alone. A salient memory from Amelia’s childhood included her association to being alone often, left to her own devices to entertain herself. This was particularly prominent when Amelia’s father left the country when she was nine, and she reported several instances when she would be home alone after school until her mother came home from work. To occupy her time, Amelia would sing, watch television, take long walks with her dog, read, and put on plays, pretending she was performing in front of an audience. Like her mother, Amelia said she was creative, and found a way to make a terrible situation somewhat playful and entertaining. This seems like another discrepant description—she described having fun in a “terrible” situation. However, as Amelia entered adolescence, she said that her life changed for the worse, and her relationship with her mother became even more contentious and problematic.

Amelia said she hoped for a fresh start after leaving Arizona and moving to the Midwest with her mother. She said her father was out of the picture for the most part, aside from his occasional attempts at hacking into Amelia’s email or obtaining her phone number to call and leave a message castigating her mother. She reported that her mother found work as an educator, and they moved to an impoverished area in the Midwest.

Amelia said they found a shackled, barren house to live in, and attempted to start over.

During her early teenage years, Amelia recalled finally connecting with her halfbrother, though he was many years older than her, in and out of town touring with a rock

115 band. Amelia said they would smoke cigarettes and drink beer together, and he taught Amelia how to play the guitar. She recalled how these moments with her half-brother made her feel happy, one of the few times in her adolescence she said she truly enjoyed.

On the contrary, Amelia said the rest of her adolescence was tormenting, as she encountered what she described as “brutal” verbal attacks from her mother, in addition to constant turmoil and conflict with her. When describing a typical interaction with her mother during adolescence, Amelia reported the following: My mom was screaming, slamming things, throwing things, calling me names, and usually when my mom starts in on me I sort of shut down. I don’t really respond or say anything. But when I was in high school I was a lot more volatile, and I would eventually just start screaming at the top of my lungs, and throw shit, and you know just freak out, and that would finally get her to stop. And a lot of times, even that wouldn’t get her to stop, and she would chase me around the house.

To make matters worse, Amelia said they lived in an unfinished house without a door on her bedroom, providing her mother with unlimited access to her room, leaving Amelia feeling that she had no privacy. I imagine that this experience contributed to subsequent issues of her own with loose boundaries—an experience I felt in the initial encounter with Amelia—where I felt rushed into interviewing her in her unkempt apartment with clothes scattered everywhere, something that seemed to pull me into her chaotic functioning. She said her mother would constantly call her names, specifically making remarks about her weight. She said her mother was, in her words, “fat phobic.”

She reported that her mother persistently commented on her body, to the point where

116 Amelia said she developed intense hatred of her physical appearance, reporting that she “didn’t eat a full meal for 2 years, from 15 to 17.” It got so bad that Amelia said she took a fork from the kitchen and carved the word “fat” into her legs. Even though she reportedly was anorexic and starving herself, Amelia said that her mother provided positive reinforcement for her to continue her problematic behaviors, telling her that she finally looked “decent and not fat.” However, appearing attractive, as Amelia recalled, was a double-edge sword, as any interest from boys resulted in her mother calling her a “whore” and commenting on her clothes and physical appearance, leaving her reportedly feeling lost and inundated with feelings of self-hatred.

Amelia reported that she was deteriorating each month during her teenage years, and finally hit rock bottom at age 15. She said she was being treated for endometriosis, something she said caused regular physical pain for her. She said she also felt depressed and anxious, was anorexic and bulimic, and felt completely alone. In addition, she remembered having no privacy, and recalled watching her mother cry hysterically each night, ostensibly dealing with her own depressive symptoms. She said she had finally had enough, and reported attempting suicide by taking over 150 of her mother’s pain pills. She said that she shouldn’t have survived, but did as a result of emergency intervention. According to Amelia, the worst part of her experience after her suicide attempt was not the inpatient hospitalization. Rather, she said it was dealing with her mother’s disappointment and anger towards her at the hospital. As she recalled: Part of the problem when I was suicidal and everything is I watched her and have continued to watch her save and help other girls who are from abusive families who are suicidal, but when it came to her own child she was not able to have any

117 empathy or feeling for me. Right, she had no sympathy for me. And all I wanted from her, and I’ve told her multiple times, all I wanted from you is to say it’s going to be okay and it’s going to be fine; and instead you called me names, you swore at me, you screamed at me, and you continued to berate me until the day I left your house and moved to college.

Amelia said her biggest struggle was that, ironically, she believed her mother’s ability as an educator helping vulnerable children didn’t translate into her helping her own child, leaving Amelia to deal with the feeling that she wasn’t good enough for her own mother’s love, and that there was something desperately flawed about her as a result.

Instead of expressing concern, Amelia said her mother arrived at the hospital furious, screaming at Amelia and asking her how she could do such a thing to her, becoming so upset to the point where Amelia said her mother had to be physically restrained and removed from the hospital room by the staff.

While Amelia said she never made another suicide attempt, she reported that her high school experience wasn’t much better. She recalled being too nerdy for the cool Latina girls, and too Latina for the preppy White girls. She said she tried to reach out to other peers and establish friendships, but that she was always rejected. Luckily, she said she found one close friend, and tried to spend as much time with him as possible. In addition, she said she spent much of her free time alone, entertaining herself by reading and learning different instruments. Despite her home environment reportedly being chaotic the vast majority of the time, Amelia said she excelled academically in high school for two main reasons. First, she reported having an above-average intelligence, and said she learned how to perform well on standardized tests, given the sheer volume of

118 exams she said she took while enrolled in advanced-placement courses. Second, Amelia said that her mother’s own struggle with severe depression could result in her coming home from work and isolating herself in her room, leaving Amelia with a quiet house to read and study, moments she said she really enjoyed. She said she applied to several different colleges, and was accepted into a prestigious university. She reported feeling excited to leave her mother, especially eager to leave what she referred to as her mother’s “intrusive” behavior.

Emerging adulthood.

Despite leaving her mother’s torment and moving away to a new town, Amelia said she initially continued to struggle with her mother’s intrusive behavior. She recalled her mother leaving messages on her dorm phone daily, and writing letters to Amelia if she didn’t respond to her phone calls. In addition, when her mother would visit, Amelia said she would pore through her belongings when she wasn’t looking, or when she was in the bathroom, reportedly trying to uncover anything that she could use against Amelia to initiate an argument. At one point, Amelia said she went through the pockets of her clothes and found cigarettes, and proceeded to start a fight about Amelia and her irresponsible behavior. Additionally, Amelia said she found her diary, and reportedly read her entries, uncovering private information Amelia said she didn’t want to share with anyone, especially her mother. After that incident, she said she was done, and finally had enough. She said she stopped picking up her mother’s phone calls, and limited contact with her, going almost 2 years without much interaction with her.

119 Amelia described her college years as one big party. She said she was in a really small academic program with some peers she felt connected to, something she had never felt before in her life. Despite partying frequently, Amelia said she excelled academically, reporting that she primarily studied feminist political, legal, and social theory, a specific major that required her to primarily read heavily and engage in class discussions, something she said she really enjoyed. She reported drinking often, and said she engaged in heavy drug use as well, such as using cocaine. She said she slept with many men, often having one-night stands. She described her college years as ones where she wore her “trauma glasses.” According to Amelia, this meant that she was “very reactionary, really self-destructive, not very happy.” In hindsight, she said she realized that she had a plethora of problematic relationships, either one-night stands with men or what she called “toxic relationships” with women she thought were her close friends, but who she said really were also very self-destructive. She recalled spending time with women who had also been traumatized, and engaging in never-ending partying with these women in an attempt to temporarily forget the past, to forget what Amelia described as their “horrific histories” filled with abuse and neglect. She recalled being a caretaker for many of her friends. She described having “leeches,” women who would look to Amelia to provide them with emotional support, and women who would want her to take care of them at the expense of expressing her own wants and needs.

Amelia said she finished her coursework in 4 years, and graduated from college.

While in school, she said she became interested in non-profit law and women’s rights, and decided to pursue law school to potentially work for a non-profit. She said she applied, got accepted, and moved to a new city. In law school, she recalled finding

120 herself excelling academically, despite engaging once again in self-destructive behavior, especially around men, partying and substance abuse, and sex. When I asked her how she succeeded in law school despite engaging in problematic behaviors, Amelia said that the majority of her coursework included reading heavily and writing papers, something she said she had mastered in college. Additionally, she said she was able to read and digest complex material quickly, allowing her to cram nights before a major exam or paper was due. Moreover, when I asked her why she thought she was so self-destructive, she said that she “purposely” put herself in terrible situations, knowing that she shouldn’t involve herself with particular people, but wanting to prove certain things to herself, though she never explained exactly what she was trying to prove. What she could say was that she felt everyone in her family had dismissed her, and only saw her as the smart and “nerdy girl,” an image she said she attempted to shed in college. In her words, she said she put herself through a “boot camp,” engaging in destructive activities to come “out of the ashes in a certain way,” though she couldn’t articulate exactly what this meant to her. From my perspective, her reasoning seemed like a rationalization of her problematic behavior, an attempt on her behalf to convince herself that there was something helpful or growth-promoting that motivated her behavior.

In a later section, I will discuss my thoughts related to Amelia’s characteristic defenses. Nevertheless, she said that law school reminded her of her childhood in that she re-experienced similar oppressive emotions she faced in the past. Specifically, she said that during law school, she felt as though she had to be someone different, that she had to “temper” herself down, an experience reportedly similar to what she said she felt

121 in relation to her mother. To deal with her frustration with school, Amelia said she partied often, and started dating.

Amelia said her boyfriend Mike was “fun,” a bartender who was well connected in the music scene. However, she said he was also an alcoholic and drug user, someone who would become blackout drunk and say horrible things to Amelia, cutting her down whenever he became intoxicated enough to lose control, something she said occurred often. In addition, she reported that he raped her once, an incident where Amelia said she blamed herself for his actions, and initially thought that if she weren’t so defective as a person, that she never would have been raped. While dating Mike, Amelia said she finished law school and passed the bar exam. However, her idea of finding work as an attorney in a non-profit or as a human-rights lawyer fell through, as she said there were no jobs available to her after graduation. While I accept that there might have been few job prospects, I suspect that other factors also played a role in Amelia not finding work as an attorney. For example, Amelia said that she has “never been able” to see herself as a lawyer, reporting that she believes she’s “intellectually capable of it, but it’s this whole other side.” She didn’t say exactly what she meant by this statement, but I suspect that one factor that prevents her from working as an attorney includes her feelings of low selfworth that contribute to her feeling inadequate as a person, something that I believe results in her self-destructive and self-sabotaging behaviors. I will say more about my assessment and interpretation of her functioning in an upcoming section.

122 Treatment in emerging adulthood.

Amelia was 23, out of law school, and described herself as underemployed, working a retail job to make money. She recalled two particularly distressing experiences with Mike that she said contributed to her ultimately seeking treatment with Dr. Cohen. One afternoon, Amelia said Mike became belligerently intoxicated, swearing and yelling at her, calling her names and acting out of control. Amelia said that Mike told her she was worthless, and said that she would let him do anything to her if he wanted, implying from her perspective that she was a “slut.” She felt infuriated, said she immediately punched him in the face, and left his apartment. Later that night, Amelia said she went online to search for psychotherapists in the area, particularly looking for those who specialize in treating traumatized adults suffering from PTSD (Post-Traumatic Stress Disorder). She said she found Dr. Cohen’s professional website, and thought about making an appointment with him. However, before she did, Amelia said she wanted to see if she could make things work with Mike. She said she had convinced herself that he hadn’t raped her, and suggested to him that they seek couples counseling to work on their problems. She said Mike declined her suggestion, instead buying a concealed weapon’s license and three guns shortly after their conversation. Amelia said this was particularly alarming to her, and to this day she said she believes that if she hadn’t seen Dr. Cohen and ultimately ended her relationship with Mike, that he probably would have killed her one drunken night.

In describing what she hoped to get out of her treatment, she recalled the following:

123 I think I just wanted some validation that I wasn’t, that I’m not a crazy person.

You know? I just wanted to hear out loud what I should do, because I knew something was really, really wrong but like I said, about my relationships with men, I get into this red zone; and I can’t really, for a person who is so extremely logical in every other aspect of their life, I can’t; I seem to have this real mental block, or at least I used to when it came to making decisions about my relationships with men.

Amelia said her treatment with Dr. Cohen saved her life, an experience she said helped her make sense of what she referred to as the “trauma glasses” she previously wore that she said clouded her ability to make healthy relationship choices for herself.

Amelia said she saw Dr. Cohen twice weekly for 2 years. In addition, for the first six months of her treatment, she said she received eye-movement desensitization therapy (EMDR) by one of Dr. Cohen’s associates, as Dr. Cohen seemingly was not trained to administer EMDR. Amelia said Dr. Cohen wanted her to have EMDR to help her deal with the intrusive thoughts and memories she said she was having on a daily basis, memories and thoughts that Amelia said centered on the horrible things both of her parents had said or done to her in the past, in addition to intrusive thoughts and images surrounding the rape incident with Mike. A main aspect of her treatment, she recalled, included dealing with the abuse and neglect she experienced by her parents, and the lasting impact those moments had on her psyche, and how she saw and felt about herself as a result of those incidents. Amelia said another salient component of her treatment included dealing with her depression and self-destructive tendencies, especially those involving unhealthy relationships with men. She remembered driving almost an hour to

124 Dr. Cohen’s office, making the drive in her old car that she said barely operated. On the ride there, she recalled smoking cigarettes non-stop, listening to loud rock music, and, at times, feeling hungover or slightly intoxicated from the night before. In her words, she said she was a “hot mess,” wearing party clothes, her hair disheveled, and her make-up scattered on her face. However, Amelia said Dr. Cohen never commented on her appearing unkempt, something she said she appreciated. She remembered Dr. Cohen’s office being well-lit, with bookcases filled with books on every wall.

Amelia said Dr. Cohen looked very “unassuming” to her, an older, Jewish man in his eighties. She said he had his PhD in clinical psychology, and that he was initially trained in psychoanalysis before later specializing in shorter-term treatments dealing with traumatized individuals, along with conducting psychological testing. Amelia said he was a trauma survivor himself, having endured the Holocaust as a young boy. Amelia reported that he reminded her of a grandfather figure, wearing pristine suits in his office with glasses and a bald head. While this may seem unimportant to some people, Amelia said that Dr. Cohen’s physical appearance was extremely germane to her sense of comfort in his presence, due to her past history of abuse. Specifically, she said she was hypervigilant around people, particularly men, worried that she could be potentially assaulted and attacked at any second. Because of the abuse she had endured throughout her life, Amelia said she had trained herself to physically size-up men in her presence, and to determine quickly whether or not she believed she could physically handle them if they were to attack her. Consequently, Amelia’s feeling with Dr. Cohen that she could, in her words, “take him if needed” was important to her, and made her feel safe enough to meet with him.

125 Amelia said she felt a connection with Dr. Cohen from the very first session. She said she began discussing her mother’s verbal abuse, and sharing the recent incident where Mike raped her, though Amelia said she had led herself to believe that she initially wanted sex with him. She described this event to Dr. Cohen, reporting that she felt ugly, and that she didn’t want to be touched by anyone. She shared with Dr. Cohen the details of what happened between them, going back and forth about whether or not Mike raped her. Amelia said that Dr. Cohen listened quietly to her, and finally replied, saying, “you know, that’s the legal definition of an assault.” Being trained as a lawyer, Amelia said she felt that Dr. Cohen spoke to her in her own language. Immediately, Amelia said she cried hysterically, feeling understood for the first time. They then spoke about working together, and what Amelia’s treatment would entail.

Therapeutic action: what Amelia reported.

Amelia reported several aspects of her treatment with Dr. Cohen that she found helpful. First, Amelia reported feeling as though Dr. Cohen treated her as an equal, as someone intelligent with an important perspective to share. She reported: Probably the most important thing is that he has been able to treat me as an equal and engage with me about things other than my emotional state, which has been really important for building trust. And that really is the most remarkable thing that has happened because I don’t think that I’ve ever been able to trust a man for any reason…there’s like a certain man who always speaks to you as a child. My dad is one of those people. I can’t stand being infantilized, and I’ve never been able to have a partner that didn’t talk down to me, and I just can’t take it. It really

126 makes me crazy. So, the fact that he could speak to me as an adult, that was probably the first time that anybody had ever said anything to me like that, you know?

Amelia said that Dr. Cohen was the first man to not infantilize or patronize her, a new experience that was powerful to her. In addition, she said that he discussed Amelia’s interests and could engage her around topics that were important to her, including women’s rights and political and legal theory. In addition, she said that he believed that she was very intelligent, an assumption that Amelia said was never given to her by others, especially men. Despite always excelling academically, Amelia said she never felt smart, and believed that others saw her not as an intelligent woman but as a sexual object for their use and exploitation. Amelia reported that Dr. Cohen’s ability to respect her agency and intelligence proved especially helpful to her, and gave her the confidence and trust she felt she needed to begin sharing her story with him.

A second aspect of treatment with Dr. Cohen that Amelia found helpful includes his positive, supportive attitude towards her that contributed to her feeling, in her words, “empowered.” Amelia recalled how Dr. Cohen conveyed a sense of confidence in her, something she said she had never experienced before with a man. She said: He always told me that I could accomplish anything that I wanted to accomplish and if I wanted to be President I could be. Or I could be anything, and I think that’s amazing that he’s such a support system. He always, always, hammered into every conversation we had. You have the potential to do great things, if only you would give yourself the leeway and the belief to do it.

127 Amelia said she had never had anyone believe in her the way Dr. Cohen did, with steadfast conviction that she could accomplish great things, if only she could deal with her past trauma, particularly what Amelia described as her “toxic relationships” with men centered on sex and drinking, relationships that corroborated her problematic belief that she was worthless. She said she couldn’t relinquish her self-critical thoughts, and found herself in problematic relationships going nowhere, in addition to taking jobs that she said didn’t utilize her intelligence and training as an attorney, instead working in various retail positions. She said she did, however, help start a non-profit dedicated to helping underserved women get access to healthcare, and completed all of the necessary legal paperwork for the company, though the non-profit has not received any serious funding, resulting in Amelia continuing to work in retail. Dr. Cohen, for the first time in her life according to Amelia, provided an alternative perspective, one that included a belief that she was smart and good enough to do anything. In addition, she said he was supportive of her making affirmative choices for herself, even if those choices resulted in consequences other people around her didn’t approve of or like, especially her mother.

A third salient aspect of treatment with Dr. Cohen that Amelia found helpful included his soothing presence, something she said helped her deal with the inner chaos and turmoil she reported experiencing throughout her entire life that continued to create havoc in her present functioning. Amelia described Dr. Cohen as “calming,” “comforting,” and “collected.” She recalled coming to sessions in a state of panic, with several pressing issues that she needed to talk about and address with him. She said that he would listen to her issues, pick them apart one by one in a calm, methodical manner, and enlist Amelia’s thoughts about the root of each issue, and how she should go about

128 dealing with each problem in a healthy way, offering whatever ideas he had. Amelia remembered how several of her problems centered on her mother, and how she would handle conflict with her if she attempted to communicate with Amelia. She said Dr. Cohen would use stories, often ones found in Judaism and the Torah, to help her see how she might address a problem, or to shift her perspective on how she might be seeing a particular issue in a problematic way. Amelia said that Dr. Cohen’s ability to help her calm down transferred to other areas of her life when she wasn’t in session with him. For example, she recalled how when she is currently feeling stressed, she hears his voice and can immediately calm down. Additionally, she said that when she encounters a stressful situation, she thinks about what Dr. Cohen would say, and attempts to conjure up his healing voice that she said she internalized in the 2 years of work together.

A concluding aspect of treatment that Amelia found helpful to her included Dr. Cohen’s ability to be available and responsive to her, at times during moments of great distress. First, Amelia said that Dr. Cohen gave her several books on trauma and abuse to read at her leisure in-between sessions, something she said made her feel more connected to him as she read through material that spoke to her childhood experience. In addition, Amelia reported that she would email Dr. Cohen occasionally when she came across something she read that particularly spoke to her, or, when she felt distressed and wanted to hear his perspective on a troubling feeling or situation she recently experienced. She said he would email her back, and always end emails by reminding her “she was a good person capable of great things.” She said she could also call him and leave a message in an emergency, and he would return her phone call when he was able. She said that his availability and responsiveness to her made her feel as though he was never too far from

129 her, either an email or phone call away, something she said made her feel less anxious when making important decisions. For example, Amelia remembered calling Dr. Cohen once when trying to decide whether or not she should quit a retail job she disliked. She said she knew what she needed to do, but wanted to hear his perspective before making the actual decision. Amelia said that Dr. Cohen validated her feelings, spoke to her calmly, and told her that she should quit. She said she knew what to do, but that she wanted to hear herself think it through with someone she had grown close to and trusted with her life.

Amelia reported ending her treatment with Dr. Cohen after 2 years when she moved to a new city. As she said, she was “100 fucking percent, 200 percent” satisfied with her treatment. After 2 years, she said she had made considerable progress. She reported several positive changes: no longer experiencing incessant intrusive thoughts and images related to her past, something she attributed to her EMDR treatments; her relationships changed with men, in that she said she had fewer one-night stands; she said she got rid of problematic friendships with women; and said she started to develop selfworth, particularly the idea that she is capable of meeting her professional and personal goals, something Amelia said Dr. Cohen consistently preached.

When asked about anything in the treatment that was not helpful, Amelia recalled one session with Dr. Cohen when he seemed frustrated with her and asked her why she didn’t just have men pay her to have sex with them, insinuating that she was acting like a prostitute. She said she felt judged and patronized, and “screamed” at him not to tell her what to do. While she said she felt really angry in the moment, Amelia said she trusted Dr. Cohen enough to understand, after she calmed down, that he wasn’t trying to be

130 malicious, but that he was attempting to question her perspective and attitude on having casual sex. In hindsight, she believed he made a good point, and wanted to convey to her how self-destructive her ideas toward sex were at the time. As Amelia said, “that’s the first time I’ve ever let any man tell me anything. And that’s a big milestone.”

Psychodynamic assessment and interpretation of Amelia.

Thus far, I have provided details related to Amelia’s reported experience in childhood and adolescence, as well as what she recalled about her narrative in emerging adulthood. Additionally, I described her subjective experience in treatment with Dr. Cohen, and reported what she specifically found helpful throughout the course of her two-year treatment. Now, I will offer my thoughts related to a psychodynamic assessment and interpretation of Amelia, and then use this assessment to inform my psychodynamic understanding of her reported experience in psychotherapy.

Childhood and development.

It seems plausible that multiple factors contributed to Amelia’s developing what I believe are Borderline Personality traits, which have manifested in a number of psychological difficulties throughout her development, most notably her tendency to experience relational conflict and engage in unstable relationships. Amelia never reported receiving this diagnosis, though she said that both her mother and father had Borderline Personality Disorder, though it’s unclear who, if anyone, diagnosed them.

Amelia seems to struggle with issues related to separation and individuation.

McWilliams (1994) argues that a predominant characteristic of borderline functioning

131 includes an individual’s preoccupation with the theme of separation and individuation, a dilemma that helps to make sense of the changing and often confusing quality of one’s functioning in relationships. This preoccupation creates conflicting thoughts and feelings for the patient, especially around issues related to establishing closeness and maintaining distance with others, as this individual often experienced confusing, competing, and unpredictable responses from parents related to wanting and needing both dependence and independence from them (McWilliams, 1994). Mitchell (1988, 1993) discussed this conundrum as the hope and dread of connection, or the conflict experienced by competing desires of the self, needing both closeness and dependence, in addition to autonomy and independence, in the same relationship. In the next two paragraphs, I’ll provide details of Amelia’s reported experience that shed light on the possible difficulties related to this preoccupation.

Amelia described her father as egregiously neglectful, a person out of control who would regularly leave her alone to take care of herself as a child. She said that her father struggled with frequent manic episodes, and had both Bipolar Disorder and Borderline Personality Disorder. Additionally, she reported that he could be sadistic, associating to a memory of his denial of her asthma medication on more than one occasion, something that could have killed her. Moreover, she reported that he would frequently abandon her, leaving her in his apartment alone for hours, or making her ride public transportation on her own as a young child, without any idea of where to go. She said she never felt as though she could rely on him, and found his behavior erratic, unpredictable, and grossly irresponsible. Amelia remembered often feeling anxious when spending time with him, particularly when he’d abruptly leave the apartment without telling her where he was

132 going, or when he’d be home. Regarding her mother, Amelia described her as, in her words, “self-serving” and “very demanding,” someone who was often verbally abusive, castigating Amelia with constant criticism. She also said that her mother struggled with Borderline Personality Disorder, and reported that while she didn’t have manic episodes like her father, she has struggled her entire life with severe depression. Additionally, Amelia reported that her mother was very intrusive, recalling a memory in high school where she would scream and chase Amelia around the house, demanding to have a conversation. She said she felt, at times, that her mother treated her like an object, and, in her words, “projected” her insecurities onto Amelia. She reported that her interactions with both parents made her feel as though she couldn’t depend on either one for emotional support, yet said she was “forced” to interact with her mother, given the fact that she was her primary caretaker. Conversely, after Amelia’s father left the country, she said she only interacted with him on random occasions when he attempted to contact her on the phone or through email, each time reportedly trying to find out information about her mother, instead of inquiring about Amelia’s life and how she was feeling.

From these reported interactions with her parents, it’s plausible to understand why Amelia could be preoccupied with themes of separation and individuation, manifesting in conflicting feelings related to establishing closeness and distance from others (McWilliams, 1994; Mitchell, 1993). If she allowed herself to feel connected and close to a significant other, she could find herself feeling engulfed, infantilized, and used to serve the interests of the other person, similar to what she implied when describing her childhood experience with her mother. Conversely, if Amelia allowed herself independence and separation from the other, that person could leave and abandon her

133 without notice, similar to what she felt when describing her experience with her father.

From this perspective, establishing and maintaining a close relationship potentially becomes very difficult, engendering ambivalent feelings related to both depending on, and needing distance from, significant others. Amelia reported that she struggled to connect in relationships with men, having several one-night stands instead of engaging in committed relationships. From the perspective discussed above, it seems possible to interpret Amelia having one-night stands as a manifestation of this conflict originating in her childhood experience with both parents, and the resulting preoccupation with separation and individuation, or the hope and dread of connecting with another person (McWilliams, 1994; Mitchell, 1993). In other words, it seems possible that Amelia craved closeness and dependence with a male figure, but felt ultimately safe only if there was no risk of establishing emotional intimacy, as her predominant model for relating with men included one where she was abandoned, both physically and emotionally. It’s possible that she desired a committed relationship, yet unconsciously expected men to abandon her, similar to her reported experience of her father, resulting in her managing this possible conflict by engaging with men solely through casual sex. It’s possible that she believed that sex was the only medium through which she could control how she received closeness and short-term affection.

Not only does Amelia seem preoccupied with the aforementioned conflict, but also it seems plausible that Amelia’s relationship with her parents throughout her development left her with an internalized persecutory object, something that probably impacted her functioning in every subsequent relationship. Tsigounis and Scharff (2003) describe the persecutory object as “a part of the self that is imbued with a sense of

134 harassment, suppression, subjugation, tyranny, torture, vengeance, and self hatred.” (p.

3). The persecutory object is created when the person who is the object of one’s dependence (i.e. one’s parent) is oppressive or neglectful, resulting in an individual taking in the experience in order to control it inside the self (Tsigounis & Scharff, 2003).

During her childhood, Amelia felt that both parents often were abusive or neglectful, making it plausible from Tsigounis and Scharff’s (2003) point of view that Amelia needed to internalize them in order to control her anxiety about their failing her. This would create a persecutory object, leaving her with an abundance of self-hatred and selfcriticism that affected how she viewed and felt about herself. While Amelia discussed several early childhood experiences in which both parents felt abusive, she recalled two salient memories in relation to her mother that made her cry in the interviews, experiences that she said continue to make her feel depressed, and evoke thoughts of selfhatred. The first, according to Amelia, included what she said was her mother’s hateful and critical response to her in the hospital after Amelia’s suicide attempt. Instead of reacting with concern, she said her mother called her names, swore at her, and “berated” her in front of the hospital staff. The second experience, according to Amelia, included the pain she felt when she realized that part of her mother’s professional career included helping at-risk youth, particularly those from abusive families. It seems possible that these two reported experiences, among others, left Amelia with feelings of self-hatred and self-criticism that contributed to her depression, low self-esteem, and self-destructive tendencies. I will say more about how I believe Amelia projected this internal persecutory object onto real people in an upcoming section, and discuss how I think it impacted her functioning in relationships.

135 It’s highly plausible that Amelia’s internal world is unstable and chaotic, contributing to conflict and tension with close others. Bollas (1987) contends that an individual struggling with borderline functioning has a chaotic internal world, something that creates confusion and disorientation for the psychotherapist, particularly as he or she struggles to connect with, and make sense of, the patient’s attempt at establishing a relationship, as it often includes shifting needs and desires that can perplex the other.

Bollas (1987) argues that the provider can be confused for a long time, as he or she struggles to make sense of their chaotic internal world. McWilliams (1994) corroborates this point, arguing that individuals who struggle with borderline functioning often have an experience of the self full of inconsistencies, a dynamic that can create confusion and conflict in close relationships. When describing her childhood, Amelia said that “chaos reigned,” and recalled rarely experiencing stability and predictability, to the point where she said she didn’t know where she’d be sleeping some nights. It seems likely that this environment, combined with Amelia’s reported experience that both parents were often unpredictable and unstable, resulted in the formation of Amelia’s own chaotic internal world, where conflict and instability became a normal experience for her. Additionally, it’s possible that Amelia’s experience of the self included several inconsistencies, leading to competing thoughts and feelings about what she wanted in relationships with close others (McWilliams, 1994). Amelia reported that she often experienced conflict with peers, and struggled to establish and maintain friendships. From this perspective, it seems plausible that she unconsciously needed conflict and chaos when engaging with others. In Mitchell’s (1988) model, Amelia sought connections by projecting and recreating familiar, constricted relational patterns established in the past.

136 Last, it seems plausible that Amelia’s reported traumatic experience of gross neglect from her father and incessant verbal abuse from her mother manifested in her unconsciously repeating problematic relationships. Freud (1914) argued that people unconsciously repeat certain dynamics that originated in past interactions with significant others, instead of consciously remembering those experiences. Along those lines, Davies (2004) contends that adult survivors of abuse can unconsciously perpetuate problematic relationships by identifying with the abuser, or the victim, or both, and re-enact these object relationships in the present.

From this perspective, one can view Amelia’s relationship difficulties from different angles. For example, if she identified with her sense of her father’s neglectful and abandoning presence, it’s possible that Amelia participated in one-night stands to get what she needed from men, and then discarded them when she was done. Or, it’s possible that she identified as the victim from her relationship with her mother, repeating interactions in which she served as another person’s receptacle for feelings, similar to how she described her relationship in childhood with her mother, in which Amelia felt that her mother “projected her insecurities” onto her, becoming preoccupied with Amelia’s weight and physical appearance. Another possibility is that Amelia moved between these various identifications and projected roles during one-night stands, which could account for them—she craves the model of relationship that’s familiar from her tie with her father, and so seeks out a man; then she becomes enraged at their likely unavailability and identifies with a sense of being victimized, and so leaves. All of these possibilities manifest in some unconscious repetition of these early relationships, resulting in perpetual relationship problems and self-destructive tendencies (Davies,

137 2004). I will say more about how I believe the unconscious repetition of problematic interactions was enacted with Dr. Cohen in a later section on Amelia’s treatment experience. Additionally, I will describe how I think her borderline functioning shaped her treatment.

Personality patterns and characteristic defenses.

As previously mentioned in the first case, from Mitchell’s (1988) perspective, one’s personality is viewed through the predominant self-other configurations, or selfstates, that emerged in relation to past experiences with significant others. Being in a position to interact with an individual over time, as in conducting multiple interviews, provides some access to participant’s functioning in an interpersonal context. As a result, while I’ll share more of my countertransference feelings related to engaging with Amelia in a later section, it’s helpful to spend some time discussing my interaction with her in this section, particularly as it relates to my experience of her typical relational patterns in the interviews.

In the initial interviews with Amelia, she seemed to operate within a self-state where she seemed outgoing, outspoken, and articulate. In a word, confident, seeming self-assured and presenting herself in such a way that made me think that she easily connected with other people, due to my initial interaction where she immediately began talking about her experience in treatment, as well as her interest in reading clinical psychology and philosophy. It was clear to me right away that Amelia was well read and intelligent, especially when she discussed her varied interests, and talked about them in a well-spoken, articulate manner that suggested to me that she had read broadly. However,

138 as she began discussing her experience in childhood, another predominant self-state emerged, and the confident, ostensibly self-assured individual I sensed initially after meeting her seemed to fade into the background.

Amelia’s predominant self-state in subsequent interviews seemed to include one where she was more conflicted, disorganized, and insecure, seeming somewhat confused, especially as she attempted to make sense of her childhood, particularly her experience with both parents. A contributing factor to Amelia seeming to operate within this selfstate included my own difficulties in following her story, as her reported narrative in childhood seemed to be filled with chaos, instability, and unpredictability. Additionally, Amelia’s report of her developmental history occasionally showed a lack of distinction between the past and the present, something characteristic of a disorganized attachment style, and also borderline symptoms. Moreover, Amelia described how she moved from apartment to apartment, her mother attempting to find housing for them while dealing with an unstable, abusive relationship to Amelia’s father, a man who Amelia said would appear in her life one moment, and then vanish the next without any forewarning. These stories from her childhood were difficult for me to follow, particularly because there seemed to be some major event that often occurred between her parents, like Amelia’s report of her father trying to run her mother over with a car, that made us veer into a discussion of that parental conflict, instead of addressing the original question in the interview.

Amelia described herself and her childhood experience predominantly in the context of her relationship to her mother, her primary caretaker. This is not out of the ordinary, as Mitchell (1993) argued how the self, or one’s self-other organization that

139 constitutes a predominant self-state, is always defined is relation to an important other.

For Amelia, this involved describing herself in the context of how she operated with her mother, a relationship that seemed to be characterized by intrusiveness, loose boundaries, and impulsivity. For example, Amelia described how her mother would, at the last minute, find a place for them to sleep, and then decorate the hotel room or apartment in such a way that made it feel more comfortable to Amelia. While she attributed this to her mother’s creativity and artistic ability, to me it seems impulsive and unpredictable, lacking the necessary planning and foresight to ensure a stable environment for her daughter. Moreover, Amelia seemed conflicted about how to make sense of this experience, conveying a sense of appreciation for her mother’s creativity, while also seeming frustrated as she described the abhorrent living space that became their temporary shelter. I share this particular story because, from my perspective, it highlights the predominant self-state I experienced in the interviews with Amelia, one where she seemed chaotic, conflicted, scattered, and somewhat confused, interpreting what felt to me as impulsive behavior as creativity. In a sense, chaos seemed to be a typical experience for her, one that came through in the telling of her story and shaped the predominant self-state I often experienced when interviewing Amelia.

It also seems plausible that there was a self-destructive aspect to the self-state mentioned above, one that manifested in Amelia ostensibly having a cavalier, dismissive attitude related to putting herself in at-risk situations. For example, Amelia reported engaging in several self-destructive patterns, particularly in high school and college. It seems possible that she was filled with self-hatred and self-criticism, a part of herself that contributed to her putting herself in situations where she could have been hurt, yet

140 adopting a dismissive attitude to the prospect of being in danger. In the previous section, I described how I believe Amelia developed an internalized persecutory object. It seems likely that this internal object often filled Amelia with a sense of self-hatred and selfcriticism, contributing to what seemed like a dismissive attitude towards engaging in problematic behaviors, particularly around partying and having random, casual sex with men. All of these reported experiences, including my own interactions with Amelia throughout the course of five interviews, lead me to conclude that she often operated within a self-state characterized by disorganization and instability, in addition to a sense of the self permeated with feelings of self-hatred, of not warranting being treated differently, treated lovingly.

In terms of characteristic defenses employed throughout Amelia’s development, it seems plausible that she often utilized projection, specifically the projection of her internalized persecutory object (Tsigounis & Scharff, 2003). As mentioned in the previous section, I argued that Amelia’s relationship with her parents left her managing the anxiety caused by their failures by developing an internalized persecutory object. It seems possible the chaos that seemed to follow Amelia meant that this internal object was easily evoked and projected onto real people, contributing to Amelia locating these feelings outside the self, attributing them to others, particularly men. From this viewpoint, it’s possible that Amelia projected her hateful and critical feelings onto men, manifesting in specific relationship patterns. For example, Amelia described feeling initially anxious, and then really angry, when attempting to feel emotionally close to men.

She didn’t recall feeling this way during one-night stands, but did report experiencing these feelings when she attempted to have an actual relationship. While there are

141 multiple interpretations of this relational dynamic, from the perspective of her use of projection, it’s plausible that Amelia attributed her own feelings of self-hatred and selfcriticism to her partner, making her feel attacked and angry, manifesting in her initiating some conflict or argument that possibly led to the end of that relationship. In other words, it seems possible that her use of projection contributed to repeating her early relationship to her mother, one where she felt berated and attacked by the other (Mitchell, 1988).

It also seems plausible that Amelia used dissociative tendencies throughout her development. By dissociation I mean the concept as argued by Stern (2010), whose definition broadens the defense and posits that it’s unconsciously used to avoid assuming a certain kind of identity, or self-state known as not-me, one that emerged from past interactions with important others that caused distressing feelings, like overwhelming anxiety or feeling threatened or ashamed (Stern, 2010). For Amelia, it’s plausible that a state of not-me initially emerged with her father, one where her vulnerable, child self attempted to connect on an intimate, emotional level with an important male other, only to feel abandoned and rejected. For example, Amelia reported that even after she witnessed her father’s reported abuse of her mother, in addition to her experience feeling repeatedly abandoned and neglected by him, that she initially held onto hope that her father would someday change, that he’d get better and be the person she wanted.

According to Amelia, this contributed to her attempting to connect with him and have a relationship, despite experiencing what she called his unpredictable behavior. However, she said that after he left the country, she realized that he was never really interested in having a relationship with her, and said she felt intense anger towards him, and also felt

142 ashamed of herself for giving him multiple chances to be a better father. After these reported experiences, it’s plausible that Amelia used dissociative tendencies to avoid this specific self-state created from her experience with him, one where the self is vulnerable and open enough to emotionally connect with a male figure, only to be abandoned and rejected. If this is true, then it’s possible that this self-state became not-me, contributing to Amelia engaging in relationships with men solely via one-night stands, where she could then guarantee that she wouldn’t be abandoned or rejected, consequently maintaining distance from the vulnerable self (Stern, 2010). In other words, it’s plausible that one-night stands helped to ensure that little, if any, emotional intimacy developed between Amelia and her partner, helping her defend against future potential abandonment and rejection (Stern, 2010).

Last, it seems highly likely that Amelia utilized splitting throughout her development to manage her intense feelings. McWilliams (1994) argues that splitting is a defense often used by individuals with borderline functioning, an unconscious process that results in one segregating experience into all-good and all-bad categories, with little room to experience feelings of ambivalence and ambiguity (McWilliams, 1994).

Evidence of splitting seemed to emerge most prominently in Amelia’s description of her peers. In a few interviews, Amelia described the type of female friends she had in college, reporting that they partied incessantly, had psychological problems and relationship difficulties, and were very self-destructive, some putting themselves in risky situations involving partying and men. Not only did Amelia seem to be unaware of the possible projective components of her descriptions, but also she described all of her friends in such a way that provided no room for ambivalence or contradictory feelings

143 related to each peer. My experience in the interview when she described her college friends was that she seemed angry to me, her voice becoming louder with a critical tone.

In addition, from my perspective, she seemed dismissive of them, casting them aside as damaged women. It seemed, at least in the interviews, that she struggled to reconcile ambiguous thoughts and feelings related to these friends, instead viewing them solely as defective and problematic. It’s also entirely possible that in dismissing her peers, she is identifying with her parents and thus dismissing a version of herself. I will say more about Amelia’s possible use of these defenses, and how I think they shaped her experience in psychotherapy, in an upcoming section on her treatment with Dr. Cohen.

Fantasies/experiences of relationships.

As previously mentioned in the first case, relational theorists like Mitchell shift the focus of fantasy to examine how people actually operate in relationships, and the strategies they have learned for relating to other people (Mitchell, 1993). As a result, this section will examine Amelia’s reported experiences in her early relationships, and the resulting strategies she possibly learned from engaging with significant others.

It seems plausible that Amelia’s early relationship with her mother contributed to a specific me-you pattern, or self-other configuration, one that then resulted in an unconscious repetition of this dynamic, and specific strategies Amelia learned and adopted from interacting with her (Mitchell, 1993). Specifically, it seems possible that Amelia operated within a particular self-state or me-you pattern where she became the receptacle for her mother’s negative feelings, a possible container for her mother’s reported hateful and critical insecurities, particularly around issues related to Amelia’s

144 physical appearance and weight. For example, she reported that her mother never moved on from the relationship with Amelia’s father, instead resigning herself to being alone, something that Amelia said resulted in her mother becoming obsessively focused on her.

In fact, she said she feels that her mother “projects everything” onto her, a dynamic that if true, likely resulted in Amelia feeling used as an object, creating a doer/done-to mode of operating that may have contributed to a one-sided relationship where she served the needs of her mother, while discounting her own (Benjamin, 2004).

This dynamic was probably even represented symbolically in Amelia’s home during adolescence, in which she said that her bedroom had no door, contributing to what she reported as her mother’s intrusive tendency to enter her bedroom whenever she wanted to initiate an argument. This behavior reportedly made Amelia feel helpless, as though she felt she had no choice but to engage with her mother. Also, her mother’s behavior modeled the use of poor boundaries, something I imagine contributed to Amelia’s own subsequent issues with loose boundaries, an experience I discussed in a previous section related to my initial interview with her, one where I experienced her loose boundaries and felt pulled into her chaotic functioning. From these reported experiences, it seems plausible that Amelia felt disinclined to articulate what she wanted or needed in a relationship, convinced that people who were important to her might use her to serve their own needs. One can interpret her brief sexual relationships with men from this position, as it’s possible that Amelia engaged in one-night stands due to her unconscious re-creation of a relational pattern where she was used as a receptacle to serve the other’s needs, providing the other with gratification while perpetuating her tendency to be treated as an object. In other words, when she had one-night stands, she seems to

145 have re-created a dynamic in which she expected to feel used by another person, and to feel helpless to change that pattern. She corroborated this hunch in an interview, reporting that she has always felt used by men, and that she has yet to meet a man she dated that she believed treated her as an equal, or saw her as more than a sexual object.

It’s also possible that Amelia operated within a particular self-state in relation to her father, one that also impacted her subsequent relationships, and contributed to specific learned strategies when interacting with men (Mitchell, 1993). Amelia said that her most painful memories of her father included those moments when he’d abandon her, leaving her to her own devices while he spent time with his girlfriends. Additionally, she recalled with feelings of sadness and anger her report of his reckless neglect. From these interactions, it’s possible that Amelia developed an underlying assumption that not only do men have ulterior motives, as she reported feeling in the few memories when she said her father was nice to her, but also that men will leave her, that they will vanish whenever they choose. If this is true, it seems likely that Amelia learned that men are unpredictable and unavailable, resulting in a possible dynamic where Amelia became distrustful of them and refused to depend on them, unconsciously choosing one-night stands over real connection in an attempt to avoid re-experiencing those feelings, and to exert a kind of emotional and relational control. Moreover, it’s possible that a cycle being repeated from Amelia’s childhood experience with her father includes her longing to see the missing, tantalizing object, getting her hopes up that this time the tantalizing figure would stay, then feeling that her hopes were dashed and she felt abandoned again. It’s the crushing totality of this cycle that I believe gets unconsciously repeated, and something that seems to contribute to her being unable to deserve better treatment.

146 Last, it seems plausible that Amelia operated within a self-state where she learned to identify with the aggressor, particularly in her peer relationships. Davies (2004) argues how one relational pattern that can be seen in adult survivors of abuse includes their identification with the abuser, or the aggressor. In the interviews with Amelia, I experienced, on a few occasions, her seemingly operating within this identification, particularly as she described her relationships with peers, both in childhood and in college. There seemed to be an angry, castigating presence to her, one that I imagine she experienced in relation to her mother, based on her reported interactions with her.

Nonetheless, Amelia could be very critical of her peers, and when she was describing some of her friends in college, I noted in my field notes that I moved back in my chair, needing some distance from what I perceived as her aggression. I noted that her presentation in that moment made me somewhat uncomfortable, and I needed distance from her, both physically and psychologically, moving my chair back and switching topics after she finished her point. I imagine that this identification concealed her fragility, her insecure self that felt berated by her mother, yet identified with her in certain relational contexts, and managed her insecurity by reversing it to become the aggressor (Davies, 2004). I believe that this possible identification, coupled with my sense that Amelia is very intelligent and articulate, can be extremely intimidating, and make one possibly need distance and separation from her.

How I understand what brought Amelia to treatment.

Amelia reported that she sought treatment because her life was in complete disarray. She said she had finished law school and passed the bar, but couldn’t find a job.

147 She reported drinking and taking cocaine daily, partying non-stop. Additionally, her relationship with Mike was in shambles, yet she encountered what she called a “mental block” and couldn’t end the relationship, despite her belief that Mike could have killed her if she stayed with him. While I believe that all of these experiences certainly impacted Amelia’s decision to seek treatment, from a psychodynamic perspective, unconscious factors also played a role. In thinking about these factors that possibly contributed to Amelia seeking treatment, I found myself replaying a particular experience I had several times while interviewing her. On several occasions, I found myself perplexed, amazed, in disbelief, and astonished again at her ability to consistently, over and over in her life, excel academically, despite seemingly experiencing chaos and instability around her, even excelling at a prestigious university and later finishing law school.

It seems possible that part of this ability emerged in response to her relationship with her mother, someone who Amelia described as very intelligent herself, and a successful educator who valued the importance of education, despite Amelia’s report that her personal life was in shambles. Through all of the chaos, unpredictability, and pain, it seems to me that the one constant in Amelia’s life included her ability to excel academically, throughout every phase of her life. Even as she reported repeatedly engaging in self-destructive activities and problematic relationships with both men and women, it seems possible that if academics were truly the one constant in her life that provided some semblance of stability and direction, Amelia could continue to function, albeit in a compromised perhaps, pathological manner. However, after graduating from both college and law school and having no further education to pursue, in addition to

148 being jobless, it seems possible that she felt completely lost, losing the one thing that held her fragile self together. Amelia laughed in one particular interview when she described her mother as extremely intelligent, though she quickly added that she’s, in her words, “smarter” than her mother. From this viewpoint, it seems probable that Amelia needed academic success to not only hold her vulnerable self together, but also to maintain some internally competitive, powerful advantage over her mother, something she lost after graduation and being jobless, unable to maintain her compromised functioning in the absence of academic success and achievement. It’s possible that academic accomplishment may be the one thing that feels completely under Amelia’s control, as other important factors in her life seem to feel mediated through relationships with others, almost all of them problematic, one way or another.

Countertransference.

My initial impression of Amelia was that she seemed confident, outgoing, inviting, and articulate. Additionally, she seemed intelligent, describing her varied interests in a well-spoken manner that suggested to me that she was well read, and ostensibly could have a discussion about many different topics. She told me about graduating from a prestigious university, one that I was familiar with, and one that is known for its academic rigor. I learned in a later interview that education was the only constant in Amelia’s life, something that provided some sense of stability for her. As the first interview started to unfold and Amelia began describing her childhood and developmental history, I noticed that my initial impression started to fade, and I sensed a different presentation, one where Amelia seemed scattered and somewhat chaotic. Part

149 of this new impression of her included the impact that telling her story had on me, in that her childhood seemed so unpredictable and chaotic that I had a hard time following her narrative, as her descriptions of her parents often veered into what seemed to me to be intense, disturbed memories, like Amelia’s report that her father once tried to run her mother over in a car.

Bollas (1987) argues how an individual with borderline functioning has a chaotic internal world, one that creates confusion and disorientation for the other, especially as he or she struggles to connect with, and understand, the other person. Based on her descriptions of her parents, my sense was that Amelia’s parents were both severely disturbed people with personality disorders. If this is true, I imagine their behavior created chaos and confusion for Amelia as she attempted to relate to them, and understand their reported unpredictable behavior characterized by impulsivity and gross difficulties in affect regulation. It seems plausible that Amelia internalized some of the chaos that, from her perspective, became her normal experience in childhood, contributing to my own feelings of confusion as I attempted to relate to and understand Amelia’s story, one that was initially difficult for me to follow and comprehend (Bollas, 1987).

I also felt helpless and a strong sense of isolation, at times, when interviewing Amelia, particularly as she described the instability she reported living in as a child.

When reflecting on my feelings of helplessness, it seems plausible that these feelings paralleled what Amelia reported experiencing in relation to her parents, a sense of helplessness and isolation in response to her feeling as though they were unavailable, inconsistent, and preoccupied with their own needs, and therefore unable to help Amelia

150 manage her feelings. From her reported interactions, I imagine that Amelia rarely felt soothed by her parents, something I believe impacted her difficulties with affect regulation, and her long-standing problems with substance abuse. Additionally, I noted in the first two interviews with Amelia that in my field notes, I wrote down feeling a sense of isolation on four separate occasions, all when she was re-telling her early experience as a child. Since countertransference feelings and reactions are important data to understand the internal life of the other, I reflected on these feelings, and believe they represent Amelia’s experience of feeling isolated and alone as she struggled to connect with her parents, especially as they both struggled with their own psychological problems, as well as the incessant marital issues Amelia said they had. It seems that her unreliable parenting resulted in feelings of both helplessness and isolation, and manifested in ambivalent thoughts and feelings related to both depending on, and separating from, close others. I imagine that this conflict played out in her relationships, re-creating constricted relational patterns that manifested in primarily one-night stands, something that provided Amelia with interactions devoid of the emotional intimacy that could evoke those conflicting feelings (Mitchell, 1988).

I also often felt overwhelmed when interviewing Amelia. Overwhelmed with sadness as she described her upbringing; feeling occasionally angry with her parents; feeling frustrated as I struggled to follow her, at times, erratic narrative as she described moving from place to place growing up; and feeling hope for her, happy that she received treatment in emerging adulthood as she attempted to get on track to be a healthier person, despite feeling betrayed by those who were supposed to love and protect her as a child.

Moreover, I felt overwhelmed during moments when I struggled to make sense of

151 Amelia’s occasional narrative incoherence, times when her report of events showed a lack of distinction between the past and the present. Additionally, I noted that my sense of feeling overwhelmed also resulted from Amelia’s shifting presentation, ostensibly happy and positive in one moment, and then angry and pessimistic the next. The reaction I had, I imagined, was similar to her internal experience: some moments she felt composed and healthy, other moments scattered, lost, and swallowed up by years of reported chaos and turmoil. I believe these shifting presentations I witnessed in relation to interviewing Amelia reflects her continued battle with her internal persecutory object, or the part of herself permeated with a sense of self-hatred and self-criticism (Tsigounis & Scharff, 2003). I sensed that Amelia continued to struggle with this object, one infiltrated by devils and persecutors from the past, internal remnants of her parents’ reckless behavior and neglect, internal critics attempting to sabotage whatever healthy attempts she made to live a more productive life. The one positive aspect of her life, it seemed from her narrative, included her innate intelligence, something that seemed to help her excel academically, and an aspect of her identity that she seemed to protect at all costs, even smiling at her report that she was “smarter” than her mother, something that I believe provided Amelia with motivation to maintain her high level of academic functioning and success.

I also got the sense that Amelia was full of contradictions, someone struggling to deal with and manage intense, opposing feelings of love and hate, joy and anger, and healthy versus unhealthy choices. McWilliams (1994) argues that people who struggle with borderline functioning are prone to use splitting, a defense that helps one manage anxiety by removing ambivalence, separating experience into all-good and all-bad

152 categories. I felt these contradictory feelings in every interview when she described an important relationship from her past, as she seemed to struggle with how she could reconcile experiencing two very different emotions towards the same person, and not being able to identify what thoughts and feelings were the result of her own internal life, and what cues she was getting from the other person. McWilliams (1994) describes this process as an individual with borderline traits experiencing problems with self-other differentiation, struggling to understand what’s happening internally, versus what might be occurring outside the self.

There seemed to be an intensity to Amelia’s feelings, a neediness I imagine resulting from years of reported parental deprivation and missed parental opportunities to recognize her and respond to her needs. Moreover, I sensed that Amelia struggled with what to do in relationships when she started to experience ambivalent feelings. She corroborated this hunch in one interview, stating that whenever she attempted to get close to another person, something felt off, and she “hated” the way it made her feel. She seemed uncomfortable with feeling vulnerable, laughing inappropriately on occasion when discussing her past abuse and neglect, later elaborating that her laughter served as a defense against the intense pain of her childhood. If she could laugh and joke about her parents, she said, she could pretend that things weren’t so bad, and could try to convince others that she was okay, that she wasn’t too scarred from her childhood. Of course she seemed scarred, and used jokes to conceal the pain that brewed beneath the surface.

Last, I had two opposing reactions when interviewing Amelia that I cycled between often, wanting to protect her at times, and wanting distance from her at other times. When reflecting on wanting to protect her, I associated to Amelia’s tendency to

153 unconsciously re-create self-destructive relationship patterns over and over as she protected herself in the only way she knew, despite consciously reporting that she desired a different, more intimate relationship. I imagine Amelia experiencing this conflict, at times feeling more able to break free from the chains of traumatic repetition (Davies, 2004), yet, for the most part, feeling pulled back into that which is both familial and familiar (Mitchell, 1988). I especially felt like protecting her when I saw, in one interview, the tears rolling down her face when she described her mother’s ability to help at-risk children as an educator for many years, but in Amelia’s eyes failed to help her own daughter, blinded by her own psychological difficulties. Conversely, there were times when I felt as though I needed distance from Amelia, separation to not only spend time with my own private thoughts to make sense of her chaotic childhood, but also distance from the intensity of her feelings. Specifically, there was a sense of deprivation I felt in relation to her, something that I imagine can make it difficult for others to engage with her, a sense of being swallowed up and engulfed in her pain, an experience I believe she felt in relation to her mother. In the interviews, this need for temporary distance manifested in physically moving my chair back, as well as psychologically needing space, occasionally having to change subjects and guide the interview in a different direction.

In summarizing the section on my countertransference feelings and reactions, it seems necessary to end with a concluding thought about what I think may be Amelia’s core issue. From Amelia’s re-telling of her narrative, combined with the data emerging from my countertransference feelings while interviewing her, it seems plausible that Amelia’s internal world makes it extremely difficult for her to be vulnerable with, and

154 connect to, intimate others on a deep, emotional level. It seems likely that she operates within a self-state where the self is damaged, chaotic, objectified as a container for the use of others, and filled with feelings of self-hatred and self-criticism. Conversely, it seems that others are felt as extremely critical, rejecting, and abandoning, apt to verbally assault her like her reported experience with her mother, or abandon her in gross neglect, as in her reported experience with her father. How does this internal world impact her functioning in relationships? Specifically, it seems that Amelia’s projecting internal object relationships onto the people she interacts with, and that she’s unconsciously selecting external others who are perfect to receive those projections. In Mitchell’s (1988) model, Amelia seeks connections by projecting and re-creating familiar, constricted relational patterns from the past, ones designed to protect herself from future potential abandonment, rejection, and criticism. This process inevitably results in the same outcome for every relationship, and contributes to her maintaining ties to that which is familiar. I will say more about this particular issue, and how I think it played out in the context of her treatment, in the next section on my psychodynamic understanding of her experience in treatment.

Psychodynamic understanding of therapeutic action.

It seems possible, based on Amelia’s report of her developmental history and subjective experience in treatment, combined with my psychodynamic assessment and interpretation of her functioning, that she unconsciously established a paternal transference to Dr. Cohen, initially expecting him to be unreliable, inconsistent, and rejecting, using Amelia for his own purposes, similar to her reported experience of her

155 father. From Mitchell’s (1988) perspective, it’s plausible that she unconsciously expected to find herself in a relational pattern where Dr. Cohen infantilized her and saw her as an inferior to him, something Amelia reported experiencing not only with her father, but also in every past relationship with men. Or, from the perspective of Amelia’s characteristic defenses, it’s plausible that her internal persecutory object was evoked and projected onto Dr. Cohen, something that contributed to her expecting him to be oppressive and critical of her, an unconscious re-creation of her reported relationship to her mother, one where she constantly felt berated by her, anticipating conflict and verbal assaults (Freud, 1914; Mitchell, 1988). In Mitchell’s (1988) model, it’s possible that Amelia projected and attempted to re-create familiar, constricted relational patterns in the present, something that would contribute to her falling into a predesigned role when engaging with Dr. Cohen, something that would lead to the repetition of relational patterns both familiar and familial. From the perspective of self-states, it’s plausible that Amelia found herself inhabiting one where a male other is expected to exploit and abandon her, manifesting in her feeling safe only if there was no risk of establishing emotional intimacy, intensifying her conflicted feelings related to depending on Dr. Cohen (Mitchell, 1988). In Stern’s (2010) model, Amelia’s “unconsciously selected perceptions” of Dr. Cohen could manifest in her interpreting his behavior in a rigid way, even “looking” for data that could bolster her unconscious perception of male figures (p.

7). It’s possible that these unconscious processes contributed to Amelia’s report of feeling extremely anxious as she walked into his office for the first time. However, instead of Dr. Cohen corroborating Amelia’s unconscious assumption, he responded to

156 her in a novel way, what Amelia described as a male figure finally treating her as an “equal,” or someone who did not patronize her.

It seems plausible that Dr. Cohen’s consistent responses to Amelia, in which she felt respected by him and treated as an intelligent equal, helped to eventually establish a different relational pattern that she could internalize as a new model for engaging with men (Mitchell, 1988). Before treatment, it’s plausible that Amelia’s predominant model for relating to men included one where they are experienced as abandoning and rejecting, and treat her as a sexual object, perpetuating Amelia’s tendency to have one-night stands that prevented feelings of emotional intimacy from developing. It seems possible, based on her reported experience of Dr. Cohen’s responses, that her interactions with him eventually provided an alternative model for relating to men, one that helped prevent her from re-creating constricted interactional patterns unconsciously designed to avoid depending on others (Mitchell, 1988). In other words, if Amelia could engage with men solely based around sex, or immediately create conflict and tension in a given relationship to unconsciously push others away, she could perpetuate her tendency to avoid emotional intimacy. In treatment with Dr. Cohen, it’s possible that Amelia could allow herself to feel vulnerable and dependent on a male figure for the first time in her life, a novel self-other configuration where the self can be vulnerable with a male other who is both consistent and available, instead of rejecting like her father (Mitchell, 1988).

It seems possible that Dr. Cohen’s initial responses to Amelia contributed to her experiencing him as a good object. In the previous section, I described how it’s plausible that Amelia repeatedly projected her persecutory object onto others she engaged with, a dynamic that resulted in her expecting Dr. Cohen to be abusive and critical of her, a

157 repetition of what I’ve described as her core issue. However, instead of berating her or putting her down like she possibly anticipated, Amelia reported that Dr. Cohen supported her, explicitly telling her that he believed she could achieve anything she wanted, if only she believed in herself. From the perspective of her use of projection, it’s possible that Dr. Cohen survived Amelia’s initial attack and responded to her in a new way, a dynamic that helped to begin detoxifying her internal persecutory object, and contributed to the provision of new relational experience that constituted establishing a good object (Tsigounis & Scharff, 2003).

If Amelia projected her persecutory object onto Dr. Cohen, it seems probable that she was initially suspicious of his supportive response and belief in her, either anticipating that his subsequent response would be critical, or that he was being nice to her in an attempt to get something from her, to manipulate her into serving his own needs. However, because Amelia reported that Dr. Cohen explicitly expressed his supportive thoughts and feelings about her into, in her words, “every” conversation, it seems possible that she began to experience him as a good object, a dynamic that contributed to the internalization of a novel relational pattern with a male figure, one that allowed for new experiences of the self (Mitchell, 1988). Hoffman (2009) argues that “doing battle” with bad objects (i.e. Amelia’s internal persecutory object) can require multiple responses from the psychotherapist, one possibility being an explicitly affirmative presence with patients, one that “can combat longstanding destructive influences on the patient’s sense of self” (p. 630). It seems possible that Dr. Cohen’s explicitly supportive presence and belief in Amelia helped begin to detoxify her

158 persecutory object, providing the opportunity for “change-facilitating new experience” (Hoffman, 2009, p. 627).

Not only did Amelia experience Dr. Cohen as supportive, but also she described his presence as calming, something that possibly helped to mitigate her internal sense of chaos. In the previous section, I described how I believe Amelia’s developmental history and early experience with her parents contributed to her having an unstable, chaotic internal world, one that creates confusion and disorientation for both Amelia and others (Bollas, 1987). From this perspective, it seems likely that Amelia unconsciously “looked” for chaos in her relationships, projecting and re-creating her internal sense of chaos onto others, either repeating this dynamic through the presence of conflicting, confusing desires of the self, or engaging with others who also seemed to have unstable internal worlds, as in her reported experience with the vast majority of her female friends (Mitchell, 1988). In Amelia’s words, her past experience left her carrying a “black, churning mess” inside of her, internal chaos that likely impacted every important relationship.

In her treatment with Dr. Cohen, it seems plausible that Amelia attempted to recreate another chaotic relationship, unconsciously anticipating conflict and instability.

Amelia reported that she even looked like a “hot mess” in many of their sessions, coming to her appointments after a long night of partying, wearing torn, “ripped” shirts, describing herself as “just a total mess.” From a relational perspective, it’s possible that Amelia was unconsciously attempting to pull Dr. Cohen into a transference enactment where he would be critical of her seemingly unstable appearance, as manifested in her physical presentation. It seems possible that Amelia attempted to re-create a relational

159 pattern reportedly experienced with her mother, one where she said that her mother would verbally attack her, particularly around issues related to her physical appearance and weight. Instead of re-creating this pattern and unconsciously participating in the transference enactment, Dr. Cohen did not criticize Amelia’s physical appearance, something that seemed like it could have easily happened, given her report of how she looked in sessions, especially in the early stages of her treatment. It’s plausible that Amelia unconsciously attempted to “nudge” Dr. Cohen into criticizing her, attempting to re-create another conflict-ridden, potentially chaotic relationship reportedly experienced with her mother. When he didn’t corroborate her assumption or participate in the enactment, it seems possible that his responses eventually provided an alterative interactional model for Amelia, a novel self-state where the self can interact with a calming other, one that in turn contributes to a less chaotic self presentation (Mitchell, 1988).

It seems possible that Amelia’s perception that Dr. Cohen was consistently available to her eventually seemed to provide a new relational model, one that specifically broadened her expectation of the other’s capacity to attend to her needs (Mitchell, 1988). For example, not only did Amelia see Dr. Cohen consistently throughout the duration of her twice-weekly treatment, but also she reported that she could email him or call him as a last resort if needed, something she said she found extremely soothing when she felt too anxious in-between sessions and needed some type of contact with him. Not only is it possible that this pattern contributed to Amelia experiencing Dr. Cohen as a good object, but also this dynamic helped mitigate the

160 anxiety Amelia possibly felt when engaging with others, due to a potential preoccupation with themes related to separation and individuation.

As briefly mentioned in the previous section, McWilliams (1994) argues that a predominant characteristic of borderline functioning includes a preoccupation with the theme of separation and individuation, a dilemma emerging from an individual’s often confusing and unpredictable responses from parents related to wanting and needing both dependence and independence from them simultaneously. In Amelia’s case, it’s possible that when she was separated and not in session with Dr. Cohen, she experienced feelings of intense abandonment anxiety, due to her reported experience of being left to her own devices by her father, contributing to Amelia feeling as though she couldn’t depend on paternal figures. Or, it’s plausible that when she was away from Dr. Cohen and needed to hear from him, she initially expected his response to be unpredictable and self-serving, similar to her reported experience with her mother. Instead, Amelia said that Dr. Cohen’s responses were always predictable, supportive, and focused exclusively on her, a pattern that possibly alleviated some of her anxiety when faced with separation from a parental figure. From a relational position, Dr. Cohen’s consistent availability eventually provided a new relational model, one that allowed for an experience of the self with a stable, trusted other, one who would not abandon her, or respond to her solely to serve one’s own needs (Mitchell, 1988).

It’s possible that Amelia’s relational experience with Dr. Cohen competed with her tendency to resist being vulnerable in relationships, specifically her tendency to avoid remaining in relationships long enough to establish emotional intimacy, as she could then risk being abandoned, rejected, or heavily criticized, like her reported experience with her

161 parents. In the previous section, I discussed how it’s possible that Amelia’s predominant self-state is one where the damaged self filled with criticism is objectified and used by an intrusive or abandoning other, contributing to Amelia’s unconscious need to avoid inhabiting what I’ve described as a self-state known as not-me, one where she finds herself vulnerable and dependent in a relationship characterized by closeness and emotional intimacy (Stern, 2010). It seems plausible that Amelia’s sense that Dr. Cohen treated her as an equal, consistently supported her and believed in her ability to make changes, and was always available to her allowed for the emergence of this vulnerable self-state, providing what Bromberg (2003) calls a “safe-enough” interpersonal environment where the “dissociated ghosts” of not-me can emerge (p. 707). In other words, it seems possible that the therapeutic relationship established between the dyad eventually provided a new relational pattern, one where Amelia could operate within a self-state where she’s dependent and vulnerable in a relationship with emotional intimacy, and responded to with curiosity and warmth, instead of intrusion or rejection.

Last, a particular experience in treatment reported by Amelia resulted in a specific enactment with Dr. Cohen, one that seemed to make Amelia aware of her destructive tendencies related to having sex with random men. From Amelia’s viewpoint, she initially found this moment in treatment not helpful. She recalled discussing with Dr. Cohen in one particular session her recent interactions with men, and reported that he responded to her by insinuating that she was acting like a prostitute, and that she should just be paid to have sex. Amelia said that his comment initially jarred her and made her feel patronized and angry, leading to an argument and, in her words, “yelling” at each other. Consciously, Amelia said that this interaction was not helpful, engendering

162 feelings of anger and frustration in that moment. On an unconscious level, it seems plausible that Amelia’s discussion of her promiscuous sexual behavior with men nudged Dr. Cohen into an enactment where he reportedly verbalized his opinion related to her destructive pattern having sex with men. I imagine, based on my own countertransference reaction in two interviews where I felt somewhat frustrated with Amelia for labeling a friend’s behavior as “destructive,” yet not acknowledging her own problematic behaviors, that Dr. Cohen felt frustrated himself, and finally commented on her problematic attitude towards sex. It’s possible to view the start of this enactment as a repetition of Amelia’s relationship to her mother, unconsciously re-creating a dynamic where the other experiences pressure to be critical of Amelia and her behavior (Freud, 1914; Mitchell, 1988). However, this enactment with Dr. Cohen ended much differently from her past interactions with her parents, something that I believe was absolutely crucial to her having a new experience in treatment.

When Dr. Cohen brought this problematic pattern to Amelia’s awareness and attention, she reported feeling initially angry, though later conceded that she believed Dr. Cohen was right, and more importantly that he was addressing this pattern out of concern for her. The latter part seems particularly important in my perspective, as Amelia’s reported experience with her parents was that they weren’t concerned about her, and brought up issues with her simply to generate conflict, or to hurt her. In this enactment, Amelia not only became aware of her tendency to perpetuate a destructive pattern with random men, but also she potentially experienced, for the first time, a trusted other feeling frustrated with her out of deep concern for her safety and well-being. In clinical terms, this enactment broke with every transferential expectation: Amelia yelled and

163 raged at the male object, who did not abandon her, scream back, or retaliate. Instead, he accepted her rage and stayed in an accepting relationship. This seems like a salient point in Dr. Cohen becoming the good object, providing a new relational experience for Amelia.

Current functioning.

Currently, Amelia said she has made several important changes since finishing her treatment in emerging adulthood. She said she removed herself from many relationships that she called “terrible,” and has worked towards minimizing her selfdestructive tendencies. In addition, she said she drinks less, and reduced her partying.

She reports fewer symptoms of depression and social anxiety, in addition to experiencing fewer intrusive thoughts and images related to troubling memories from her past. While she said she has made considerable progress in not engaging in self-destructive tendencies with men, she reported continuing to struggle with becoming close to them, feeling anxiety and anger when she attempts to connect in relationships. As she reported: I could say right now 100 percent I’m feeling really, really good; the minute I get involved with someone I freak out. It’s all inside, you know? And if I express to them what I’m thinking it freaks them out, because it’s like, you know, I’m overanalyzing everything to the point that it chokes them…I hate it, I hate the way it makes me feel. And I’m mean. And then I get really mean.

The first sentence of Amelia’s quote captures the conflict in her story. She wants to, it seems, see herself positively, yet to validate her assessment she relies on relational evidence, which demonstrates the polar opposite of her initial feeling. Amelia seems,

164 based on the reported clinical data, to have been able to have a real relationship with Dr. Cohen that was—for the first time—not all projections. It seems that she continues to work on repeating that novel experience outside of treatment, instead of re-creating familiar patterns of the past.

Participant C: Hillary Hillary is a 27-year-old Caucasian female living in the Midwest with her boyfriend of 3 years. She is of average height, has brown hair and brown eyes, and has a toned, athletic build. She described herself as successful professionally, working in finance at a large corporation, often working long hours during the week while also finding time to train as a long-distance runner. She describes herself as a “go-getter,” someone who is very goal-driven. She has an inviting, girl-next-door presence to her, and a contagious, welcoming smile. She seemed excited when I first met her, discussing her interest in participating in my research due to her positive experience in psychotherapy during emerging adulthood, one that she said made her develop positive self-worth for the first time in her life. She seemed confident, sure of herself yet not arrogant. She seemed eager to discuss her experience growing up and in psychotherapy during emerging adulthood, attributing much of her success in her latest relationship to issues she discussed and worked on in her treatment.

In the first interview, I noticed that Hillary was extremely articulate, and used language that indicated to me that she was well-versed in psychotherapy, and had spent considerable time in the past processing her feelings and subjective experience. For example, she talked about the value of “processing her feelings” and “developing insight”

165 into her difficulties, something that led to important changes in her relationships. This proved true, as I soon learned that Hillary had been in and out of psychotherapy her entire life, and said she had used treatment to deal with familial issues as they emerged throughout her development. Hillary said she has had long-standing issues with her father, something that became a predominant theme in her latest treatment.

Childhood and adolescence.

Hillary said she grew up in Nevada, in an underserved neighborhood in a rural town. The area she lived with her parents and a sister 5 years older than Hillary was not particularly safe. According to Hillary, her home was broken into a few times. In addition, the family cars were vandalized on occasion, and the car windows were broken once or twice. As a result, Hillary said that she and her family had to be extremely cognizant of intruders or other individuals trying to cause problems around their home.

She recalled being an extremely anxious child, never feeling at ease or completely safe.

Hillary reported that a salient memory from childhood included her feeling completely scared of dying, at a very young age, though she later attributed her fear to a manifestation of her anxiety, as opposed to a real fear of death and dying. However, she said she had terrible insomnia as a child, laying awake in bed convinced that someone was going to kill her, or that something bad was going to happen to someone in her family. She said she would jump at the sound of the phone ringing, startled and worried that someone was calling to tell her that her parents had been in a car accident, and that they were dead. In her words, she had a “profound fear of disaster,� prompting her parents to put her into play therapy with her first counselor at age eight. She remembered

166 playing cards and games, and feeling better after seeing her therapist, though she couldn’t recall exactly what she found helpful about her treatment at that time.

Hillary said her neighborhood in Nevada consisted of primarily retired couples, leaving her with few children to interact with her age. She reported that her older sister thought that she was more of an annoyance than anything, resulting in Hillary spending a large amount of time alone, entertaining herself. She said that her sister didn’t like her much at all growing up, until they finally connected when Hillary entered adolescence.

She recalled hanging out in her backyard alone, digging holes, reading, or setting up a tent and camping under the stars. While she said she was often on her own or, at times, with her mother during the summer months, Hillary said she found creative ways to have fun in her free time.

Hillary reported that both of her parents were teachers, and said that they grew up with little money in a modest home. She reported feeling close to her mother, and described fond memories of her mother’s patience when teaching her how to bake, one of the “greatest things” that Hillary remembered fondly about her childhood. In fact, she reported that the vast majority of her positive memories were with her mother. She recalled her mother “celebrating her successes” with Hillary, and smiled in the interview as she described a particular memory where her mother would buy Hillary a candy bar whenever she got paid, something Hillary said she looked forward to on the weekend as a special bonding moment between them. She said her mother was her main support system, selfless and willing to listen to her endlessly, always making time for her and telling her how proud she was of Hillary. While Hillary also stated that her mother could

167 be a little naïve and resistant to change, she said she felt comfortable and calm in her caring and loving presence, and had a special relationship and bond with her.

Hillary said her experience growing up with her father was a different story, a night and day difference from the care and warmth she felt from her mother. She described her father as “very hands-off,” an emotionally-unavailable man who she described as “withdrawn,” “absent,” and “very selfish.” When thinking about who took care of her when she was young, she associated to the different ways in which her parents comforted her when she felt anxious, and experienced insomnia and an anxiety-ridden fear of death. She said her mother would come into her room, lie with her on her bed, and remind Hillary that she was safe and protected by her parents. Hillary said her father, on the other hand, would simply peek his head into her room, and tell her to go to bed, refusing to come into her room to provide comfort and reassurance. In fact, she said when her anxiety got out of control at age eight, her father taught Hillary how to journal on her own, writing down her thoughts and feelings on paper. Even though she said her father had a Master’s degree in social work, and would periodically provide counseling to others in the community, particularly spiritual counseling, his way of trying to help with Hillary’s anxiety included teaching her to journal on her own, and, according to Hillary, wiping his hands of her difficulties. While she said she later in her life found journaling helpful, at the time, she said she felt abandoned and experienced his “intervention” as distant and cold, unavailable yet again. She said this pattern continued throughout her childhood, leaving her turning to her mother for support, guidance, and emotional connection in the absence of feeling close to her father.

168 Hillary said her teenage years were difficult for her, describing them as “pretty brutal.” She recalled making a significant transition to a private middle and high school when she was 12, something she said was a huge change for her, as she went from being around lower to middle-class peers and their families to peers from affluent families, able to spend thousands of dollars on private school tuition. She said she was able to go to school for free, as a result of her father’s position as a teacher at the school. She recalled initially feeling embarrassed of her family, and felt like she didn’t fit in, wearing clothes passed down from others while some of her peers discussed flying to California to shop for the latest fashionable wear. Hillary said her school was academically rigorous, and she said she put a lot of pressure on herself to do well and succeed in her classes.

Despite being in a difficult transition, Hillary said the move to a new school proved to be minor compared to what she would later experience in her 7th grade school year. When she was 12, she said her parents abruptly divorced, and she said her world changed completely.

Hillary said she was “completely shocked” by the divorce of her parents. She reported: Then my parents got divorced when I was 12, and that really, just was really, really bad. Like, because, they really didn’t, they never fought. I think I heard my parents fight one time, and then my Dad moved out. There was no, there was nothing for me to visually connect between like the occurrence and consequence…I took a nap and my Dad came and woke me up and said he was moving out, and it was like what? Like how, what? What do you mean? So that really rocked me.

169 She said the divorce resulted in her mother moving out of their childhood home, making Hillary split time living between two places. Because of witnessing little, if any, conflict between her parents, Hillary said she was especially confused about the divorce, and why it happened. She reported feeling lost and frustrated, and said she didn’t get a reasonable answer from either parent related to the cause of the divorce. She said she later learned from her older sister that her father had “lost interest” in her mother a few different times throughout their marriage, and that he may have had an affair. At the time, however, Hillary said she only knew that the change was difficult on her, and said she started to feel depressed after the divorce.

Hillary said she felt depressed for the first time at age 12 after the divorce, reporting that she struggled to adjust to her new life. In addition, she said she remembered her mother struggling as well, reporting that she believed that her mother was also depressed. Hillary said her mother moved into Hillary’s maternal grandfather’s home, causing Hillary to split time between his house, and the home she grew up in for the past 12 years, where her father continued to live. Hillary reported that she could “feel” her mother’s pain, and that her mother’s depression started to impact her, in that she felt depressed after hearing her mother cry profusely many nights. She associated to a particular memory where her mother thought Hillary was asleep, and began crying uncontrollably in the next room. Hillary said she had never heard that level of sadness before, and remembered, in that moment, questioning the meaning of life. As she recalled, she felt helpless, hopeless, and felt no escape from the pain of her parents’ divorce. She said she wondered if she’d ever find relief from her depressive feelings, and

170 felt a despair that her life would never get better. She felt angry, first at her father and then at herself, manifesting in other symptoms as she progressed through high school.

Hillary said her life started to unravel after the divorce of her parents. She reported that her anger at her father turned into anger and hatred towards herself, manifesting in self-image problems and a yearlong bout of anorexia, obsessing and restricting her diet as a form of self-punishment. She couldn’t recall exactly why her hatred turned towards herself, other than reporting that it was one of the few things she felt she could control at that time. She said she started to cope with her feelings by drinking alcohol and partying often, even getting arrested for driving under the influence of alcohol at age 16. She remembered fighting more with her father, and feeling frustrated and disappointed if she struggled academically. She said her father responded to any academic issues not with support and positive reinforcement, but by disapproval and silent coldness. She said she felt pushed aside, particularly after her father remarried another woman, not long after the divorce of her parents, and her step-mother moved into her childhood home.

Hillary recalled screaming at her father on several occasions during high school, throwing fits and even a “tantrum” once in an attempt to elicit some response, any response, from him. However, she said that “he wouldn’t take the bait,” and would remain reserved and detached, appearing unperturbed at her behavior. When she tried to talk to him about how the divorce impacted her, she reported that he had a “sneaky” way of “rationalizing everything,” making her attempts at communicating her feelings to him seem futile. Her saving grace, she said, included her relationship with her sister, one that was previously strained in Hillary’s childhood, but one where they became closer after

171 the divorce. In addition, she said she continued to connect with her mother, though her mother continued to struggle herself. Hillary said she continued to have a strained relationship with her father throughout high school, and felt more than ready to leave Nevada after graduation. She said she hoped for a fresh start, and found herself in college in a large city in California, ready for a new beginning.

Emerging adulthood.

After high school graduation, Hillary said she found herself in a different state, away from all family. Within the first few weeks of moving and starting college, she said she started dating a co-worker at a bar she worked at, a man named John who was several years older than she. This relationship, according to Hillary, lasted for her first 2 years of college, and was on and off again during the last 2 years of school. In hindsight, she said she missed, and downright ignored, signs that John was cheating on her, turning away from situations that pointed to the idea that he was not the man she imagined. However, she said she had wanted a sense of comfort in a new city, and thought she had found that in John. After dating for 2 years, Hillary reported that John had yet to find a stable career, prompting him to move back to the East Coast. Hillary said she felt devastated and abandoned, a similar feeling she said she imagined her mother experiencing when her father ended their marriage. She recalled begging John to allow her to leave California and move with him, but he refused. She said she felt depressed again, masking her pain and feelings of sadness and depression with copious alcohol consumption, trying to avoid experiencing the same level of depression she felt after the divorce. To mitigate her pain, Hillary said that John told her their break-up was only “temporary,� giving her hope that

172 after she graduated from college, they would get married and move in together. Hillary said she remembered the day she finished college and called John on her graduation day, expecting to plan their next move together. He said nothing, and declined her invitation to reconcile their relationship.

In her last 2 years of college, Hillary recalled struggling to connect with other men after her break-up, reporting that she dated but never allowed herself to get close to anyone, constantly preoccupied with the hope of reconnecting with John. At the first sign of emotional attachment to a potential boyfriend, Hillary said she would end the relationship, convincing herself that she was bored with the other person or needed to end the relationship, in the event that John reappeared in her life in the near future. She said she called her mother for support when she felt most depressed, though she said she filtered what she shared with her mother about the severity of her depression and alcohol abuse. She reported that she didn’t want to let her mother down or worry her, and consequently painted a picture that everything was fine. However, she said she felt anything but fine, and attempted to mask the pain she felt from being rejected by John.

From my perspective, it’s possible that her hopefulness about reconnecting with John resulted, in part, from her bafflement about the divorce of her parents. Specifically, it’s plausible that, just as some children want to undo divorces and get back the “missing” parent, Hillary had a kind of projected illusion that John would come back to her.

Hillary recalled having limited contact with her father during college, mostly connecting via email due to her father and step-mother moving out of the country after she graduated from high school, accepting yearlong teaching contracts in various parts of the world. However, Hillary said her father was still very much on her mind. She

173 remembered a particularly painful memory one night in her early 20’s, where she said she “randomly” recalled some vague details her sister had told her once about a lawsuit in her childhood. She said she felt confused, and couldn’t remember details related to this event, or when it even occurred. She reported that she immediately called her mother, and, from their conversation, learned that there was a lawsuit involving her father when her mother was pregnant with Hillary. Hillary said she found out that her father, counseling an individual through the church, did “something inappropriate” with a patient of his, causing his patient to then sue Hillary’s father and the church. While Hillary said her mother didn’t share details with her, or didn’t know additional facts about the lawsuit, she said that conversation “felt like the biggest slap in the face.” Specifically, Hillary reported that it confirmed her long-standing belief that her father was “never” really there for her, that he was too preoccupied with his own life, making Hillary feel “like he had turned his back on me, before I was even born.” This memory, according to Hillary, caused more pain and tension between her and her father, and, while she never talked about this experience directly with him, made her disconnect from him even more, only responding to his emails throughout college when she felt obligated to respond.

Despite dealing with feelings of depression related to John moving out of California and frustration and anger towards her father, Hillary said she did well academically, and graduated from college with a degree in economics and finance. She said her academically-rigorous high school had prepared her well for college, and that she enjoyed going to classes and spending time completing her homework, as it served as a distraction from her feelings. However, she said she felt lost after graduation, not sure what professional direction to pursue. In her past, Hillary recalled always finding some

174 sense of security in having a plan: she would go to middle school; then private high school; graduate from college; and then ultimately find a job. Now, she felt as though she didn’t have a clear plan, and didn’t know what to do or where to turn. In addition, the US was in a deep recession, leaving limited job prospects for new graduates, especially in the financial sector.

Through a connection with a friend, Hillary said she eventually started work at an unpaid internship, working almost 90-hour weeks between the internship and bartending on the weekends to pay rent. She recalled finding herself engulfed in the internship, working too many hours, and having an overwhelming amount of responsibility.

However, she said she felt obligated to work really hard, as the founders of the non-profit company she worked at convinced all of the workers that their production directly impacted the number of African refugees they could help. She reported experiencing panic attacks related to not being able to get enough tasks done at her internship, and started a pattern of drinking to manage her anxiety and insomnia. She said she also started overeating, and gained weight quickly. In addition, Hillary reported only a few close friendships, causing her to feel even more depressed and anxious. One day, when she said she finally had enough, she decided to quit what she described as a terrible working environment. She said she decided that she couldn’t continue to live the way she was, and began thinking about her dire need for psychotherapy, and her pressing feeling of being stuck and going nowhere in her life. She said she had a degree in finance from a reputable university, yet found herself serving drinks at a bar to pay rent.

175 Treatment in emerging adulthood.

After college, Hillary said she finally decided to seek treatment. She was 23, said she was feeling depressed and anxious, had just quit her internship, and felt uncertain about her professional future. She reported seeing a psychiatrist, and being prescribed the same anti-depressant she had taken to manage her depression in high school. Hillary said she found the psychiatrist unavailable, and reported that the medication offered little help. However, her psychiatrist did recommended that she seek weekly psychotherapy, and referred Hillary to a psychoanalytic training clinic where she could find affordable care with limited financial resources. When asked what finally led her to seek treatment, Hillary reported the following: I was just like, depressed in a way that I hadn’t been in my adult years—so that’s why I started. I think job stuff spurred it, but it really turned into more about my relationship with my dad. And my understanding of self-worth, and just so much more than just like a job. You know, I think the job; I think the business was really masking a lot of like hurt that I had.

Hillary said she knew that she needed help in getting out of her “dark place,” but felt that she couldn’t do it alone. She said that she had never really dealt with her parents’ divorce, and the implications of that event on her psychological functioning and on her relationship with her father. Additionally, she said she continued to feel depressed and hurt since the end of her relationship with John, and felt stuck with men, dating yet unable to allow herself to get close to others, starting and quickly ending any relationship at the first sign of emotional attachment.

176 Hillary said she was initially worried and skeptical about engaging in psychotherapy, due to her experience with the psychiatrist who recommended she seek treatment, in addition to her reported experience with one provider in high school who “constantly” checked her watch, making Hillary feel unimportant. Specifically, she said her psychiatrist would rush her in and out of medication management check-ups, spending, at the most, five or ten minutes with Hillary without asking many questions, and making medication decisions without knowing much of anything about her. She said those visits made her feel neglected, and, while she had experienced some positive treatment experiences during her childhood and adolescence, she worried about putting her faith in another provider. Nonetheless, she said she was at rock bottom, and, at 23, started what would become a yearlong treatment, initially seeing her provider weekly for the first few months, and later seeing him three or four times a week in intensive psychodynamic psychotherapy for the remainder of her treatment.

Hillary reported experiencing every emotion throughout her treatment with Andrew, an experience she referred to as “grueling” and “painful” at times yet “entirely transformative” and very helpful. She said she had a pattern of seeking older men as her healthcare providers, something that rang true yet again with Andrew, a man in his 40’s.

When asked what she hoped to get out of treatment, Hillary said she wanted to be able to function again, and to particularly feel relief from the severe depression she said haunted her daily. Instead, she said she understood much more, ultimately uncovering the meaning of her underlying hurt, and discovering how her relationship with her father impacted every subsequent relationship in her life, including relationships with men who tried to get close to her.

177 In the first few sessions, Hillary said she felt anxious, and took several minutes to calm down. She reported worrying about how Andrew would perceive her, and anxious about whether or not he’d understand her, and ultimately help her feel less depressed and anxious. She recalled driving an hour in traffic to see him, yet due to her limited financial resources, had to take advantage of the sliding-fee scale the clinic offered. She described his office as unremarkable, very “basic.” She reported that the first 10 to 15 minutes of the initial sessions were “very strained,” and she experienced intense anxiety as she felt compelled to rehearse what she needed to say, and to have material “ready” ahead of time to discuss. When I asked her about this pattern, Hillary couldn’t articulate exactly why she felt this need, other than reporting that she felt worried about how Andrew would respond to her. She said that while she believed it took her some time to feel comfortable with Andrew, her treatment changed completely after he recommended an increase in the frequency of her sessions each week. She said she soon found herself dealing with long-standing feelings and memories from her past relationship with her father, experiences that Hillary discovered through her treatment that continued to impact her relationships, and shaped what she learned to need and expect from others.

Therapeutic action: what Hillary reported.

Hillary reported several aspects of her experience in psychotherapy with Andrew that she found helpful. One salient part of her treatment that she said was especially helpful included her sense that she felt important to Andrew. Specifically, Hillary said she felt that Andrew was genuinely concerned about her, and that she was important

178 enough to him for him to remember details about what she told him in sessions, recalling the minute details she discussed about her life with interest and inquiry. As she reported: I remember feeling important to him. And I remember, I remember feeling like he was genuinely concerned about me…It was incredibly comforting to me how much he remembered about what I told him. Just the fact that he would remember very small details made me feel significant, and made me feel like my hurt was not unfounded…And, and like I’ve had therapists who check their watches, just constantly checking the time; it’s like sorry if this isn’t exciting enough for you, you know, it’s kind of what’s going on in my head. So, he was just really, really kind of welcoming in the sense where it was like no sadness was trivial.

Hillary said she felt as though Andrew was attuned to her, and that he was concerned about her as an individual, taking interest in her story while validating her emotional experiences. She said she felt that Andrew took her seriously, something Hillary said she had never experienced before in relation to an older man she opened up to and trusted. Initially in treatment, Hillary said she was concerned that she would come off as too emotional, a “hysteric” who was “hyper-emotional,” someone who couldn’t calm down and have a rational discussion. In other words, she said she was afraid that he would find her too demanding and too needy, and she said she didn’t want him to feel overwhelmed by her presence. However, she reported that she didn’t feel like a burden to him, and she felt that way each time he took her feelings and concerns seriously, never making Hillary feel as though her problems were trivial or too much for him to handle.

179 A second aspect of Hillary’s treatment that she reported being helpful included her belief that Andrew was available to her. Specifically, Hillary said she felt as though Andrew could respond to her and validate her feelings when she felt particularly depressed, or, when she experienced relational conflict with friends and needed his support, two experiences she said that really impacted her self-esteem and made her feel worthless, questioning her ability to function as an individual. Not only did Hillary meet with Andrew several times during the week, but also she said he made himself available to her when they were not in sessions, providing Hillary with specific times during the week in which she could contact him in an emergency, via phone or Skype. In addition, Hillary said that when Andrew would travel for conferences, he talked to her about his travel plans, and told her that she could call him if needed in an emergency. While Hillary said she only used this privilege once in her entire yearlong treatment, this gesture from Andrew further corroborated her belief that she was important to him, and made her feel as though she could access him if needed, even outside of their typical session times.

Hillary also said that not only was Andrew physically available to her, but more importantly, that he was emotionally available, understanding and validating her feelings when she experienced conflict with her two closest friends, or with women she originally thought were her closest friends. For example, Hillary recalled a significant moment early in treatment when she felt utterly betrayed by these women to the point where she considered moving out of the apartment she shared with them, and ultimately chose to do so shortly after this incident. During one particular session, she said she brought an email she had printed off from a conversation and showed it to Andrew. She recalled feeling so upset about what her friends had said about her that she could barely function. Hillary

180 said Andrew read the emails, asked her to reflect on her experience of the event, and conveyed “compassion� for her. Hillary remembered feeling compassion from Andrew, and said that this interaction was a defining moment in her treatment, recalling that she felt she needed extra support during that time, especially as she thought about ending those relationships. She reported that he had not minimized her reaction or told her that she was overreacting, something that made her feel cared for and responded to in a helpful way. Moreover, Hillary said she felt that Andrew expressed genuine concern for her, something that also made her feel cared for by him.

Another part of treatment with Andrew that felt particularly helpful, according to Hillary, included his assistance in helping her develop both self-worth and selfunderstanding, especially as they played out in the context of her close relationships.

Hillary said she remembered one session in particular, in which Andrew asked her a question that really jarred her, likening the session to someone waking up from an anxiety-provoking dream, only to question his or her subjective experience of reality.

Hillary said she remembered Andrew asking her if she felt like she deserved to be loved, a question that initially shocked and confused her, ultimately resulting in her thinking about and re-evaluating every relationship she had experienced in the past. Hillary reported that thought about her significant relationships, as Andrew’s question threw her into a historical examination of how she operated with significant others. She said that when she immediately knew the answer to his question was no, she started to ponder, for the first time, an alternative idea of what she really wanted or expected in a partner.

From that point on, she reported explicitly defining what she wanted in a partner, and began to think about her standards and expectations for that person. In the past, she said

181 she had been “walked all over,” unable to establish boundaries and articulate what she was willing to accept in an intimate relationship. For Hillary, she said it was a new experience for her to think about setting the tone in a relationship, asserting her needs and directly articulating her expectations. As she noted, she began to “demand respect from people,” including men she wanted to engage with, in addition to close friends she had.

Hillary said she started to feel more confident in her ability to pick and choose which relationships she wanted to maintain, and when to end relationships that were toxic and problematic. As she recalled, she developed “a better understanding of myself, period.” This newfound understanding, established throughout her treatment with Andrew, allowed her to not only improve her self-worth, but also it helped Hillary change what she came to expect from people, helping her understand her own role in perpetuating problematic relationship dynamics. Additionally, Hillary reported that she was able to redefine how she viewed herself, and what type of treatment she expected from others she allowed to get close to her. She said she was no longer willing to be “a doormat,” taking on people’s problems as her own while discounting what she needed in a partner. Had it not been for her treatment, Hillary wondered aloud what her relationships would look like today, a thought that made her shutter with anxiety.

A last component of therapeutic action that Hillary said she found helpful included Andrew’s reported ability to help her see what she wasn’t seeing, or, in other words, to illuminate what was outside her conscious awareness that she couldn’t or wouldn’t acknowledge. Hillary said this pattern was especially pointed out in the context of the men she was dating. For example, she reported one situation in particular where there were some signs that the man she was dating, at the time, was also dating another

182 woman, possibly in a significant relationship or married even. After discussing the details of this relationship over several sessions, Hillary said that Andrew asked her if she was certain that she was the only person this man was dating, a question that Hillary said initially angered her, but only because she then realized that she was missing some clear indications that something was amiss, and that she was actually in a problematic situation where she was being used.

Hillary said that Andrew also helped her see how she would accommodate to other people, and unconsciously take care of them at the expense of addressing her own needs. She remembered him telling her that she did this with him, in her sessions. She reported: I went in almost rehearsing the first lines of things. So it’s almost like the first quarter of the session was utter bullshit, until I kind of just like got into the flow of things…Where you know if I go in, I’m like, well I don’t have anything to talk about today, and then of course something always comes up, and you work through that, but I don’t feel the need to come in and serve that purpose. That reminds me. He pointed that out to me. Where he, and I think this really went into kind of like how I was with those roommates, where I would tend to them. And so he pointed out, and I don’t remember exactly how he put it, but it was like, it was almost like I was tailoring what I was saying to impress him or something.

According to Hillary, Andrew helped her see how she was tending to others, accommodating to them and their needs while discounting her own, implicitly conveying a sense that she didn’t need anything from her friends or partners. This pattern manifested first in her relationships with close girlfriends, where several of them would

183 come to Hillary to “unload,” discussing problems they were having with men while Hillary said she sat and listened, and attempted to make them feel better. In addition, Hillary said she would nurture them, taking steps to cook and clean up after them. She said this pattern eventually came out in treatment through her relationship with Andrew, where Hillary tried to accommodate to his needs, attempting to impress him initially in treatment with exciting material to discuss. For example, she said she brought up her dreams at one point, thinking that he would appreciate that given Andrew’s training in psychodynamic theory. For Hillary, she said it was extremely helpful for her to see how she took care of others, and how this relational pattern first experienced with her friends and boyfriends and later in treatment with Andrew resulted in her accommodating and tending to others, and feeling unsatisfied in her close relationships as a result. Becoming aware of this pattern, according to Hillary, helped her imagine a new way to operate in relationships, ultimately finding a means to assert her needs and directly articulate her expectations, without perpetuating one-sided relationships with others.

Hillary said she ended her yearlong psychoanalytic treatment with Andrew due to moving away from California. She described herself as a new person, one who operated completely different in her intimate relationships. When asked what seemed different about her today, as compared with before she started treatment, Hillary reported the following: Honestly, everything. Everything…I think I have much more of, a better understanding of myself, period. And what that means in the workplace, or in a relationship, or in any capacity. And I just kind of, I have a better understanding of, something that was really important coming out of that

184 treatment was this idea that like my parents’ past or my dad in particular, their past actions don’t predetermine how my life ends up. And that’s something that I constantly have to remind myself…I feel like I have a better tool kit to understand bouts of depression, or understand when I feel anxious, or whatever. I mean I was, God when I first started seeing him I had no, no understanding of how to be with myself. You know, and that’s actually a good comparison, right, when I first started, or when I first started seeing him, I would just busy myself to stay away from myself.

In the last interview, Hillary described how good it felt to reflect on her treatment with Andrew, and felt proud of how much progress she had made in her treatment.

Hillary said that while her treatment could be very emotionally draining, it was a “transformative” experience for her that she said changed her life. She reported that there was nothing extreme that stood out for her that was unhelpful in treatment. That being said, she described a few moments in psychotherapy that were really difficult for her, moments that centered on Andrew discussing an observation of his that related to his perception of Hillary’s functioning in relationships. For example, Hillary recalled “a lot of sessions when I walked out and I was pissed off” at Andrew. She said she remembered one session in particular where she felt so angry with Andrew that she thought about quitting treatment, even “hating” how she felt when she walked out of that particular session. After that session, Hillary recalled calling her sister, which helped her calm down. After speaking with her sister, Hillary said that she could take a step back, and realize that she wasn’t actually mad at Andrew, but frustrated that, as she reported, he “was pushing me in a really, really hard direction that I’d gone through some pretty

185 extensive efforts to ignore.” In other words, Andrew called attention to Hillary’s unconscious, problematic relational patterns that impacted all of her close relationships.

As she reported, that moment in treatment forced her to take a hard look at how she was operating in her relationships, something she said she had worked hard to avoid, and didn’t even acknowledge until her treatment with Andrew.

Psychodynamic assessment and interpretation of Hillary.

So far, I’ve shared Hillary’s reported narrative in relation to her childhood and development, in addition to discussing her experience in adolescence and emerging adulthood. From there, I provided details related to Hillary’s subjective report of treatment with Andrew during emerging adulthood, including her thoughts related to therapeutic action and what she found helpful in psychotherapy. Now, like I’ve done in past cases, I offer a psychodynamic assessment and interpretation of Hillary, one created from her narrative, in addition to my countertransference feelings and reactions experienced throughout the interviewing process. From a relational perspective, countertransference feelings are just as important to understand as the transference (Maroda, 1991), so attention was given to re-current feelings and reactions I noted while engaging with Hillary.

Childhood and development.

It seems likely that Hillary has an anxious temperament, which, if it has been lifelong, may have contributed to her experiencing her father as neglectful, critical, and unavailable to her in many ways she felt she needed over the years. For example, many

186 of Hillary’s earliest memories included her reportedly having a constant preoccupation with death and dying, in addition to feeling anxious and frequently worrying that some disaster would happen to her parents, like a fatal car crash. Moreover, I imagine that situational problems contributed to her anxiety as a child. For example, Hillary’s home, in addition to their family cars, were vandalized on more than one occasion during her childhood, resulting in the entire family believing that they needed to remain hyper-aware of their surroundings. It seems plausible that these events, combined with Hillary’s anxious temperament, contributed to her feeling unsafe, and consequently requiring more attention and reassurance from her parents, and in particular her father. It’s possible that had Hillary felt more emotionally safe and secure with her parents, and especially her father, then the environment might have seemed less scary. In other words, her relationship with her father intensified her possibly inborn high anxiety and its further intensification by the neighborhood.

In a discussion of the patient’s wishes, needs, and desires, and how they manifest in the context of a psychoanalytic treatment, Mitchell (1993) argued that the relational or temperamental fit between a child and her parent plays a significant role in the child’s sense of feeling soothed, recognized, and responded to in a helpful way by her caretaker.

He contended that a given level of responsiveness might work for one child, and might fall short for another, particularly if that individual has an anxious or aggressive temperament, resulting in one desiring “something particular from someone particular” (p. 196). From this perspective, it seems possible that Hillary and her father had a problematic temperamental fit, a mismatch where her anxious self needed more recognition and reassurance than he was probably able to provide, contributing to her

187 sense that he was emotionally cold and neglectful throughout her development. An example of this temperamental mismatch includes a salient memory Hillary associated to in high school, where she said she tried to walk with her father at school to speak with him, but that “he wouldn’t walk with me.” Instead, she reported that he walked “two paces in front” of her, and if she tried to catch up with him, “he’d walk faster.” While this is only one instance, it possibly symbolizes the difficulties Hillary experienced as she attempted to connect with her father, only to reportedly feel frequently rebuffed by him.

Additionally, I imagine that her preoccupation with anxious thoughts and feelings precluded her from recognizing situations in which her father was available, contributing to what Stern (2010) calls “unconsciously selected perceptions” that make one turn away from possibilities of relating that could make possible a different experience of the other (p. 7). Instead of providing the emotional availability and recognition Hillary said she wanted and needed from her father to calm down, he alternatively taught her how to journal on her own. While it’s plausible that a different child may have found this intervention a helpful way to manage anxiety, Hillary experienced it as a way for her father to remove himself from helping her deal with her feelings, contributing to Hillary’s sense that her father was neglectful, unavailable, and cold, unable to provide her with the comfort she said she needed and craved at a young age.

Hillary’s report was that her father wanted her to manage her anxiety entirely on her own, and taught her how to journal in an attempt for her to accomplish that goal, allowing him then to remove himself from assisting her with managing distressing feelings in the future. Following Stern’s (2010) idea, it’s entirely possible that Hillary’s father felt he was actually empowering his daughter, rather than washing his hands of

188 her—after all, he stays in contact with her despite her lack of responsiveness. He just didn’t provide exactly what she felt she needed from him, and she noted these moments of misattunement. In Mitchell’s (1993) model, it’s possible that Hillary desired to be soothed by her father’s consistent attention and responsiveness, yet, from her perspective, was met with a journaling “intervention,” one that made her feel as though he was withholding care. Mitchell (1993) described how both firmness and flexibility are important aspects of both parenting and being a psychotherapist. In a dyad, if one feels as though the other is frequently standing firm and withholding gratification or responsiveness, it’s plausible that the individual can feel abandoned or betrayed (Mitchell, 1993). From this viewpoint, it’s probable that Hillary experienced her father as firm and withholding, possibly capable, yet unwilling, to respond to her in ways in which she felt she needed.

It seems plausible that Hillary’s anxious temperament, coupled with her sense that her father couldn’t or wouldn’t recognize and attend to her needs in ways in which she wanted, manifested in specific relational patterns that she adopted when interacting with others. It’s possible that Hillary’s sense of paternal neglect played a role in her reported need to seek attention and recognition from men in particular, either in the context of dating, or, in rebellious, acting-out behavior in high school aimed at getting attention from her father. Mitchell (1993) argued how a child’s longings for attention and recognition, chronically felt over time, can be unconsciously transformed into magical fantasies of being rescued by a significant other, a dynamic that can manifest in one seeking attention and responsiveness at all costs. As Hillary recalled, she wanted any attention from her father, something she felt she never received, even reporting with what

189 seemed to me as an embarrassed expression a particular situation in high school, one where she said she had a “tantrum” and threw herself on the floor to elicit a reaction from her father. Instead of him reacting, Hillary said he responded to her “tantrum” by walking away, and not saying a word to her. It’s possible that her failed attempts at pulling him into the type of relationship and recognition she craved contributed to intense disappointment, and her reported feelings of severe depression. This dynamic seems like a possible set-up for Andrew, in both positive and negative ways: there’s both the transferential assumption that older men may let her down, yet also the hope for rescue.

This also seemed to operate in her illusion in college that her boyfriend John would come back, and they’d reconnect. Here is may have served as a bridge between Hillary and the good therapeutic experience she had with Andrew.

It’s also possible that Hillary’s anxious temperament, combined with her sense of paternal neglect, resulted in her struggling to be alone, and consequently dating others to keep her anxious feelings at bay. This was something she described in the interviews, experiencing feelings of anxiety and worry that her current boyfriend would potentially leave her at some point in the future, despite in reality having no evidence that he was unhappy, at all, in the relationship. If fact, she reported that he had recently reassured her that he was extremely content with the relationship. It seems that Hillary’s anxiety can cloud her ability to interpret other’s actions in a realistic manner, contributing to her need to seek reassurance and approval from her boyfriend, something I imagine also played out in the context of her relationship with her father (Stern, 2010). However, it’s possible that instead of her father feeling inclined to reassure or comfort her, he taught her skills to

190 self-regulate, something Hillary experienced as abandoning and neglectful, withholding the gratification and care she desired (Mitchell, 1993).

It’s plausible that Hillary concluded, based on her repeated interactions with her father, that she was the cause of his neglect and coldness, that there was something wrong or defective with her that led him to abandon or reject her, especially because she had no evidence that her parents had been unhappy together. For example, Hillary recalled a particularly insightful experience in her treatment during emerging adulthood where she realized that she didn’t feel as though she deserved to be loved, and that she had never felt that way, specifically reporting that she has never “done” anything to deserve love from an important other. In hindsight, she believed that this contributed to her staying in a problematic relationship for several years during college, despite her report that her boyfriend at that time treated her poorly, and just “strung” her along for several years.

Consequently, it’s possible that she operated within a self-state where the self was viewed as bad or damaged, needing to earn the love and appreciation of others. McWilliams (1994) argues that when one has a sense of self as being bad or defective, and consequently believes that she has driven away the needed object, that she must work extremely hard to prevent one’s badness from provoking future loss and rejection. This internal experience possibly contributed to a relational dynamic where Hillary reportedly became a caretaker when dating men and in her close friendships, unconsciously believing that she needed to earn their love and appreciation. Bollas (1987) argues that people unconsciously play out their early life, or internal object relations, with significant others, contributing to the possibility of several different identifications, like identifying with the self, the other, or part of the self or other. It seems plausible that Hillary’s

191 identification as a caretaker resulted, in part, from her sense that her own defectiveness or badness drove others away, contributing to her discounting her own relationship needs while she tended to others, unconsciously hoping to earn their love and recognition as someone “good,” as someone worthy of their love and recognition.

Benjamin (1990) argued how, from the perspective of intersubjective theory, managing a healthy need for recognition in any relationship calls for “a constant tension between recognizing the other and asserting the self” (p. 39). It seems that Hillary stopped asserting her needs and became preoccupied with recognizing and attending to the other, possibly convinced that the dynamic with her father would play out in subsequent relationships (Mitchell, 1988). In effect, it’s possible she unconsciously attempted to avoid re-experiencing the neglect she felt with her father, while simultaneously perpetuating that very dynamic by not asserting her needs and taking care of others, due to an underlying assumption that her badness drove away significant others. It seems that these factors, combined with Hillary’s anxious temperament, have resulted in relationship problems throughout her development, something she said she finally addressed in her treatment during emerging adulthood.

Personality patterns and characteristic defenses.

As previously mentioned in other cases, relational theorists like Mitchell view personality patterns through predominant self-states that emerged in past significant relationships (Mitchell, 1988). What struck me about Hillary’s presentation was that, despite seeming articulate, intelligent, likable, and successful professionally, she also seemed to me as though she felt significantly insecure about herself. This became

192 evident to me on several occasions throughout the interviews, when Hillary would answer a question in an articulate, thoughtful way, and then ask me if she answered the question properly, making sure I got what I needed from her in each question. If this behavior happened once or twice, I’m not sure I would have paid much attention, as my first reaction was that her gesture was kind and thoughtful, making sure she wasn’t offbase with her responses. However, this dynamic seemed to happen frequently, creating the impression that Hillary needed constant reassurance and approval from me. In fact, I noted in my field notes that this behavior happened at least three times in each interview.

From Mitchell’s (1988) perspective, it’s likely that Hillary re-creates this need in her relationships, unconsciously nudging others into an enactment where they provide the reassurance she feels she needs. In the interviews, she seemed apprehensive at times, and worried that she wasn’t responding to the questions in a correct or appropriate manner.

In other words, this dynamic made me wonder about Hillary’s insecure self-state, and her probable view of herself as flawed and defective on some level, consequently needing reassurance, approval, and comfort from others.

A way to interpret the dynamic mentioned above includes the idea that Hillary operates predominantly within an anxious, dependent self-state, one contingent on reassurance from others. What contributes to her need for approval and reassurance externally? It seems possible that Hillary has an internal object of an unavailable and critical father, an experience that manifests in her seeking responsiveness and recognition externally, a pattern that possibly mitigates her need for reassurance and bolsters her selfesteem, albeit in a transitory manner. Additionally, it seems that Hillary has an internal representation of herself as bad or defective, as someone who drives away important

193 others. As a result, both her internal object of her father, and her internal representation of herself in relation to this object, contribute to what I’ve described as Hillary operating predominantly within an anxious self-state, and seem to manifest in two predominant relational patterns.

One, it’s likely that Hillary needs reassurance from others, and possibly uses professional achievement and success to alleviate her sense of being defective and consequently in need of an approving, comforting other. If she can continue to experience professional success and advancement, she can temporarily feel better about herself. Second, it’s probable that, due to her reported experience with an unavailable father and her resulting conclusion that her badness possibly drove him away, and therefore she must earn the love of others, Hillary took on a caretaking role in her important relationships. This dynamic led her to discount her own needs, and attend to the needs of others in an attempt to earn their responsiveness and so to feel more secure in her relationships. This pattern became evident right from the first interview, where Hillary asked me on more than one occasion if I needed anything from her, like providing more details related to a given question, or making coffee for me. In addition, it became clear from her reported interactions with her long-time boyfriend that she identified as the caretaker and constantly attended to his needs, even stating that she felt most comfortable when caring for him. For example, when Hillary felt as though she was “doing” something for him, like cooking or baking for him, she felt important to him and consequently more secure in the relationship. Additionally, she reported experiencing fewer anxious thoughts in those moments, less preoccupied with the potential of her boyfriend ending their relationship at some point in the future.

194 In terms of defenses, it’s plausible that Hillary used identification as a way to deal with and manage her experience in relationships. Specifically, it seems probable that Hillary identified with her mother, a person who Hillary described as also taking on the caretaker role in her own marriage, constantly attending to the needs of Hillary’s father.

Hillary’s experience of her mother was that she was attentive and available to everyone in the family, and pushed her needs aside in an attempt to ensure that Hillary’s father was happy. In indentifying with her mother, it seems plausible that Hillary unconsciously attempted to get her needs met through taking care of others. If, on some level, Hillary assumed that close others in relationships aren’t available to attend and respond to her needs, like her reported experience of her father, it seems possible that she identified with her mother’s caretaking role, an unconscious attempt to keep unavailable others close to her, and potentially mitigate any sense of her feeling bad or defective. In other words, it’s possible that Hillary assumed that the only way to get others, particularly men, to feel close to her, or to not neglect or reject her like her experience of her father, included becoming a caretaker and creating some type of dependence on her. It’s plausible that while this relational pattern made Hillary feel more secure, it also perpetuated her tendency to experience others as unavailable. Specifically, it’s possible that while this identification created dependence on her and the illusion of closeness, it seems that it also re-created a type of unavailability she experienced with her father, while simultaneously reinforcing her possible assumption that through caretaking, she must earn the love and appreciation she long for and desired from her father. It seems that Hillary had no other relationship models to follow, and so out of her anxiety relied more heavily on the model she had seen throughout childhood, that of her mother’s.

195 It also seems plausible that Hillary employed the use of projection throughout her development. I accept that there were several instances in which Hillary felt that her father didn’t do enough, and that his response to her anxiety and distress fell short of what she felt she needed. From Mitchell’s (1993) perspective, it’s possible that Hillary and her father had significantly different personalities, a temperamental mismatch that contributed to her experiencing him as cold and rejecting. From these repeated experiences, it seems possible that Hillary has an internal object of an unavailable and critical father, something that is easily evoked and projected onto others, especially men.

From this viewpoint, it’s likely then that Hillary unconsciously expected others to be unavailable and critical, manifesting in her reported experience of frequently feeling anxious in relationships, even ones where the other is available, attentive, and consistent, like her reported experience with her current boyfriend. It’s probable that Hillary’s use of projection contributed to her operating in specific ways when engaging with others, from taking care of them by closely attending to their needs, to using her professional success and constant drive to get the recognition she craved, yet assumed would not be provided. Freud (1914) argued that people unconsciously repeat certain dynamics that originated in past interactions with significant others, instead of consciously remembering those experiences. It’s possible that Hillary unconsciously repeated her subjective experience with her father in her other relationships, resulting in an underlying assumption that others will be unable to recognize her and respond to her emotional needs. Hillary hinted at this idea when discussing several relationships in college after a painful break-up, reporting that she’d end the relationship at the first sign of emotional attachment.

196

Fantasies/experiences of relationships.

As previously mentioned in other cases, Mitchell (1993) was interested in how people actually operate in relationships, and the learned strategies and assumptions for engaging with close others. A predominant underlying assumption that I believe emerged from Hillary’s interactions with her father include that idea that men are unavailable, preoccupied with their own needs, something that seems to contribute to Hillary feeling anxious in relationships, and reportedly expecting something bad to happen. For example, Hillary discussed in one interview how she, at one point, was convinced that her current boyfriend was going to abruptly leave her, despite having no evidence to support her conviction. It’s possible that this idea emerged as a result of her belief that men will put their needs first and do whatever is best for them, something she felt her father did when he decided to divorce her mother.

It seems plausible that Hillary’s experience of having a distant and unavailable father contributed to a strong craving for recognition. Benjamin (1990) argues that in a healthy relationship, an individual must feel recognized by a significant other, in addition to developing the capacity to recognize the other in return, a process that establishes mutual recognition. If a person feels that a significant other consistently deprives one of recognition, the healthy tension between recognizing the other and asserting the self disappears, contributing to a one-sided relationship devoid of mutual responsiveness and recognition. In Hillary’s case, it’s possible that she operates with an unconscious belief that the stability of the self is heavily contingent on recognition from the other. While Benjamin (1990) showed that it’s normal to need recognition in any healthy relationship,

197 it seems that Hillary’s sense of feeling deprived of attention and responsiveness from her father contributed to an intense craving for recognition, a dynamic that makes her sense of self easily influenced by her perception of others. From this viewpoint, it’s possible that her sense of feeling secure and content in a given relationship is greatly swayed by her perception of the other’s availability, contributing to Hillary’s need for consistent reassurance in her close relationships, something I experienced with her multiple times in the interviews. It’s possible that Hillary’s poor self-esteem left her unconsciously believing that she is primarily constituted by what others feel about her, rather than having a primary and enduring sense of self that is separate from, and not dependent on, how others perceive her.

Last, it seems likely that Hillary’s internal world was filled with anxiety, feelings that led her to unconsciously adopt specific strategies when engaging with close others, ones utilized to mitigate her anxious thoughts and feelings that emerged in relationships (Mitchell, 1993). First, as previously mentioned, it seems that Hillary identified with her mother, becoming a caretaker with important others. Second, it’s possible that Hillary learned that she could get the recognition she felt deprived of through professional success, something that has contributed to her strong professional drive and incessant focus on professional advancement. Third, it seems that Hillary learned to seek approval and reassurance from others, a pattern of relating that calmed her anxiety, albeit in a transitory way, yet perpetuated her need to seek comfort outside the self. I will say more about how I think these experiences shaped her treatment in a later section, particularly her sense of paternal deprivation and neglect, and how I believe it impacted her relationship with her psychotherapist.

198

How I understand what brought Hillary to treatment.

Hillary reported that she sought treatment due to feeling immensely depressed and anxious. She said that before starting treatment, she was working long hours at an unpaid internship, and believed that her job was “masking” the intense depression and pain she reported feeling, yet attempted to ignore, unsuccessfully, by throwing herself into long hours at work. After realizing that her internship was not what she originally thought, she said she quit, and found herself without a “purpose” in her life. From my perspective, I imagine that this was particularly difficult for Hillary, due to her reported tendency to need a plan and some sense of direction in her life, in addition to her need to earn affirming responses from others. Up until that time, Hillary always had a plan: she would do well in high school, get into a good college, and ultimately graduate and find a job. It’s possible that when Hillary found herself without a job and unsure of what direction to take professionally, she felt particularly stuck and lost and missed what she needed from others to maintain even a shaky self-esteem, contributing to an intensification of her anxiety and depression. From a developmental perspective, it’s possible that when Hillary found herself without a job and a plan for the future, her identity and sense of self felt particularly unstable and uncertain, contributing to an increase in her depression (Escoll, 1987; Erikson, 1959). In her words, she needed help pulling herself “out of this dark place,” not expecting her treatment to lead to a focus on her relationship with her father, and the ways in which her past experiences with him impacted her life and functioning.

199 Countertransference.

My first impression of Hillary was that she was likable, someone who was easy to speak with that seemed very articulate and intelligent. We developed a rapport immediately, a dynamic that I think was facilitated by her thoughtful, detailed responses to my questions. In addition, Hillary seemed insightful and psychologically-minded, answering questions about her subjective experience in a detailed, nuanced manner that made it easy for me to stay attentive and engaged with her. Moreover, she had a warm, inviting presence, one that made me feel comfortable speaking with her.

A salient reaction I had in meeting with Hillary included my sense that she often took care of others. This feeling originally emerged after I noticed that Hillary immediately asked me, before the start of each interview, if I needed anything from her, like coffee or food. It seemed as though she expected or assumed that she should provide something, outside of her participation in my research. While this was a very nice gesture, and one that I appreciated, I noticed that it seemed second nature to her, and it made me wonder if she had a tendency to take on a caretaking role with others. I remember wondering how this behavior played out in the context of her relationships, and thought about what may have happened in Hillary’s life that contributed to my perception that she often tended to others.

A related reaction to my impression that Hillary often operated as the caretaker in her relationships included my sense that she needed approval and reassurance from important others. For example, in every interview, Hillary would provide an articulate, detailed response to a question, and then end with asking me if she answered the question properly, or inquiring to see if I needed her to elaborate more on a given question. As

200 previously mentioned, I noted in my field notes that this happened at least three times in all five interviews. My initial response to this behavior was that Hillary was being nice and thoughtful, and I didn’t think much of her inquiry. However, as it happened more and more over time, I started to feel as though Hillary had a need to please me and seek approval from me, wanting reassurance that she was doing what I wanted or needed, that she was being “good.” This dynamic didn’t frustrate or annoy me. However, I took note of it, and found that as I got to know Hillary more, I sensed that she felt insecure about herself, needing external approval and reassurance, despite on the surface being successful both personally and professionally.

I soon learned that Hillary’s experience growing up was that her father was critical and unavailable, something that seemed to contribute to her insecurity and need to seek validation from others. One interpretation of this relational pattern includes Hillary’s tendency to project her internal object of an unavailable and critical father onto real people, an experience that contributes to her assuming that others, too, will be unavailable and critical (Mitchell, 1988). From this interpretation, it’s likely that Hillary unconsciously behaved in a particular way with me in the interviews, taking extra measures to ensure that she was responding to the questions properly, enacting a dynamic where I then felt pressure to reassure her. I found myself operating in this enactment with her, providing reassurance that she was, in fact, giving me what I needed in the interviews. From a different perspective previously discussed, it’s possible that Hillary’s internal sense of being bad or defective contributed to an unconscious assumption that she had to earn my appreciation, manifesting in her taking extra steps to ensure that she was providing me with what I needed.

201 I strongly sensed that Hillary has struggled immensely with her feeling that her father was distant and unavailable throughout her life, and thought about the implications of that experience for her. I felt this after she discussed her relationship with him in several interviews, and I saw how frustrated she appeared when discussing this relationship. I sensed a hunger, a craving to get her father’s attention, and a deep desire for recognition from him. After hearing more about Hillary’s story, it seemed that she was attempting, with each promotion and professional achievement, to prove to her father that she is worthy of his attention, worthy of the recognition she desperately wanted from him over the years. In the last interview, Hillary described how she had applied to a Master’s program in finance, and, after an infrequent visit with her father, decided to read him aloud her personal statement she wrote as part of the application process. She said she couldn’t even finish reading her essay before her father interjected, telling her that a word here or a word there was incorrect, and urging her to revise the essay. Once again, Hillary said she felt crushed and frustrated, wishing that her father would just offer his support and recognition of her achievement. However, she said he couldn’t do it, and she felt deprived of the response she wanted yet again. In hindsight, and during the interview, Hillary nervously laughed as she recalled this moment, berating herself for even thinking that her father could respond to her in the way in which she hoped.

However, from my perspective, this moment illuminated Hillary’s ongoing conflict with him, and her difficulty in coming to terms with her father’s unavailability.

Last, I had a sense that Hillary struggled with being alone, that she felt a strong urge to date to feel approval from a male figure, even if the relationship was devoid of a close, emotional attachment, as in her relationships in college after the end of a long-

202 standing relationship. This is speculation, as Hillary never explicitly discussed feelings of abandonment anxiety, or a fear of being alone that manifested in her dating others, despite wanting to keep emotional distance from some of them. However, I noticed that with each new transition in her life, for example, moving to a new city, she was dating someone new within weeks, a situation that made me wonder about Hillary’s experience of feeling neglect from her father, and possibly managing these feelings by seeking some connection and approval through dating men. I don’t know if this is necessarily true, but I have the sense that despite Hillary’s personal and professional achievements, internally she continues to struggle with her self-worth, hoping to fill a void left by the man she attempted to access throughout her life, without much success.

In summary, it seems imperative to highlight what I believe my countertransference feelings and reactions say about Hillary’s core issue, as these feelings are imperative data that I think shed light on her functioning, as well as what possibly manifested in her experience in treatment. It’s plausible that Hillary’s felt sense that her father was emotionally distant and unavailable resulted in a craving for recognition as described by Benjamin (1990), a need of hers to prove, through her personal and professional success, that she’s finally worthy of his attention, adequate enough for his recognition and responsiveness. It’s plausible that this pattern established in relation to her father contributes to her enacting constricted relational patterns in which her sense of security, and sense of self, become contingent on the desired response of the other, particularly with men. These patterns seem like unconscious attempts to defend against already existing, relationally developed anxiety resulting in part from her unconscious assumption that important others will be unavailable. Moreover, it’s plausible that she

203 believes, on some level, that her defectiveness contributed to her experience of paternal neglect, resulting in a pattern where she takes care of others to earn their love, to feel worthy and lovable. I will say more about how I believe this core issue shaped her treatment experience with Andrew, and how this possible need manifested in her psychotherapy.

Psychodynamic understanding of therapeutic action.

It’s plausible that early in treatment, Hillary formed a paternal transference to Andrew, initially expecting him to be cold, rejecting, and unavailable to her, similar to her reported experience of her father. From this perspective, it’s likely that Hillary’s internal object of a critical, unavailable father was evoked and projected onto Andrew, as evidenced in her report that she was initially extremely anxious about engaging in treatment with him, and that she specifically worried about seeming too emotional or too needy and demanding. Additionally, if Hillary viewed herself as bad or defective on some level and consequently needing to earn the love or appreciation of others, as I’ve argued in the previous section, it seems likely that she was particularly preoccupied with Andrew’s impression of her. It’s possible that these feelings were intensified by Hillary’s perception of having unavailable providers in her past, individuals who made Hillary feel like a burden to them, ones who reportedly rushed her in and out of appointments, or repeatedly checked their watches during sessions. From these experiences, it’s possible that Hillary unconsciously projected and attempted to re-create familiar, constricted relational patterns in treatment with Andrew, old patterns and ways of functioning that emerged over the years from her relationship with her father (Mitchell, 1988).

204 Instead of corroborating her unconscious assumption, Hillary found Andrew to be very available, responsive, and attuned to her emotional state, contributing to her sense that she felt “important” to him. From a psychodynamic perspective, it’s possible that Hillary’s sense of Andrew’s consistent availability and responsiveness led her to experience him as a new, good paternal object, a dynamic that contributed to the internalization of a new relational pattern with a male figure, one that allowed for new experiences of self and other, particularly one where the other can be available and attentive to the self (Mitchell, 1988). In other words, it seems likely that Hillary’s experience with Andrew eventually contributed to the establishment of an alternative model for engaging with men, one different from the predominant pattern established with her father (Mitchell, 1988). From a developmental perspective, Escoll (1987) argues that young adults need to see their analyst, in part, as a new object, a process facilitated by the developmental movement in young adulthood toward new objects. It’s possible that Hillary experienced Andrew through the transference as a father-figure who could actually provide the type of emotional availability and recognition she felt she needed, yet missed, from her own father, contributing to the establishment of “changefacilitating new experience” (Hoffman, 2009, p. 627).

It’s possible that Hillary unconsciously nudged Andrew into engaging in a very specific enactment early in treatment, one that I believe impacted Hillary’s report of feeling cared for and important to Andrew, and seeing him as available and responsive, in addition to greatly impacting her self-esteem. For example, Hillary remembered what she described as a “defining” moment in treatment, one where she had printed off and handed Andrew an email exchange, a conversation between two “friends” about Hillary

205 that made her feel betrayed and extremely distressed, and feeling unable to function. She said she asked Andrew to read the exchange, reporting that he read the email and responded to her by showing sympathy and compassion for her. Why do I think this was particularly important for Hillary? While I think it’s obvious that Hillary needed recognition and approval from Andrew given her narrative—and that this need is possibly conscious to her—I believe that Hillary unconsciously nudged Andrew into providing (by printing off and thereby “forcing” him to read this exchange) this specific response from him early in treatment, due to my sense that her poor self-esteem left her with an unconscious belief that she is primarily constituted by what others feel about her, rather than having an enduring sense of self that is separate from, and not dependent on, how others see her. When she found out that her closest “friends” reportedly “disliked” her, it’s likely that she felt even worse about herself, and unconsciously evoked a specific caring response from Andrew in an attempt to “prop” up her shaky self-esteem. It seems that this response helped to contain Hillary’s fragile sense of self during a particularly distressing time for her, and contributed to her and Andrew forming a positive therapeutic relationship.

Additionally, in the previous section, I described how I think Hillary believes, on some level, that her badness or defectiveness contributed to her father’s neglect, manifesting in her operating within an anxious, dependent self-state where she must earn the love and appreciation of others. I believe that this dynamic, combined with her poor self-esteem, contributes to her feeling insecure about herself, and unconsciously nudging others into repeatedly providing the reassurance and approval she needs to feel better. I experienced this pattern through my countertransference feelings in our interviews, where

206 I found myself uncharacteristically providing Hillary with reassurance multiple times in every interview. This seems to fit with the idea that Hillary unconsciously believes that she is primarily constituted by what others feel about her. As a result, when she felt distressed from the incident with her friends, it’s likely that she felt particularly bad about herself, and needed Andrew to provide a positive response to potentially prove otherwise.

It’s possible that Hillary’s report of feeling significant to Andrew, as evidence by his ability to “remember very small details” about what she told him in session, contributed to Hillary feeling recognized for the first time in her life, especially by a paternal figure. As briefly mentioned, Benjamin (1990) argues that the “ideal resolution of the paradox of recognition is for it to continue as a constant tension between recognizing the other and asserting the self” (p. 39). As previously mentioned, Hillary identified as the caretaker in her relationships, tending to others while discounting her own needs. This eventually contributed to a one-sided dynamic, what Benjamin (2004) refers to as a doer/done-to dynamic where Hillary historically locked herself into a rigid, singular position as the caretaker when interacting with close others (Aron, 2006). In Benjamin’s (1990) model, if the tension between asserting the self and recognizing the other breaks down, as I believe it did in Hillary’s past relationships, dyads get stuck in one-sided, complementary relations. I posit that this pattern of interacting created an illusion of closeness in Hillary’s relationships, while also unconsciously perpetuating the very feelings of emotional unavailability and neglect she reported experiencing with her father, as this dynamic manifested in a preoccupation with recognizing the other’s needs (Mitchell, 1988). When Hillary felt recognized, and when Andrew remembered what she said to him in her sessions, it’s plausible that Hillary had a new relational experience, one

207 where she can assert and articulate her feelings and needs in the presence of a responsive other, instead of ignoring her needs through identifying as the caretaker (Mitchell, 1988).

Another aspect of treatment Hillary found especially helpful included Andrew’s assistance in helping her develop self-understanding and self-worth, particularly as they impacted her functioning in relationships. Before treatment, Hillary reported that she always accommodated to others, becoming a caretaker who eventually felt as though she was “walked all over” by friends and past boyfriends. Freud (1914) argued that an individual, instead of remembering past significant interactions, can act out by unconsciously repeating these patterns, especially through the transference between patient and therapist, leading to the unconscious re-creation of constricted relational patterns in the present (Mitchell, 1988). Hillary’s tendency to accommodate to others eventually became evident through the transference, where Andrew reportedly called attention to his sense that she needed to impress him and accommodate to what she felt he needed from her. Specifically, Hillary reported that she discussed some dreams in a few sessions, due to her sense that Andrew would appreciate her gesture, given his psychoanalytic training. Additionally, she said that early in her treatment, she’d anxiously rehearse what she wanted to discuss, preoccupied with having material to talk about with Andrew, and concerned about how he would perceive her. It seems plausible that Hillary unconsciously accommodates to others due to her strong craving for recognition, a need of hers to prove, by attending to others and giving them what she thinks they need, that she is worthy of their attention and love. This tendency not only contributes to Hillary discounting her own needs, but also it leaves her operating within an anxious, dependent self-state, one where her sense of self is easily swayed by her

208 sense of how she is perceived by the other, manifesting in a pattern where she seeks reassurance and approval externally, something I experienced with her in the interviews.

From Mitchell’s (1988) perspective, treatment should illuminate one’s predominant, constricted relational patterns as they emerge in the context of the therapeutic relationship, or through the transference and countertransference. After Andrew called attention to this pattern, Hillary said she pondered, for the first time, about how she was actually operating in relationships, and thought about her tendency to repeatedly accommodate to others, realizing that this pattern hadn’t helped her, particularly in past relationships with friends and ex-boyfriends. Davies (1999) understands transference as organizing schemas, not resolvable, but “perhaps expandable, perhaps malleable to a certain extent, renegotiable in new contexts, but at the same time, entrenched in their devotion to old object ties and familiar outcomes” (p. 184). It seems that Andrew calling attention to this unconscious pattern as it emerged through the transference helped Hillary first become aware of this tendency, and then think about if she wanted to alter or expand her typical, familiar ways of functioning with important others.

Another defining moment in treatment included Andrew asking Hillary a simple question, wondering aloud whether or not she felt as though she deserved to be loved.

From a psychodynamic perspective, it’s possible that this question was particularly meaningful to Hillary’s treatment as a result of it calling attention to what I believe to be one aspect of Hillary’s core issue, her internal sense that her own badness or inadequacy contributed to her father’s rejection and neglect of her. In other words, Andrew offered a question that led to a remarkably powerful insight for Hillary, one that helped her

209 suddenly realize how her poor self-esteem and feelings of low self-worth directly impacted how she operated with others, realizing in that moment that her past relationships were filled with situations in which she was, in her words, “walked all over.” In the past, it’s possible that due to her own internal sense of defectiveness, Hillary unconsciously took on a caretaking role to earn the love and appreciation from others, a pattern of relating that contributed to her sense of security being contingent on the response and reassurance of those close to her. From Mitchell’s (1993) perspective, psychopathology in a very broad sense can be seen as a failure of imagination, what Stern (2010) considers a type of “rigidity that characterizes a person’s approach to experience” (p. 8). From these perspectives, it’s plausible that Andrew’s question helped Hillary imagine a relationship where she experienced feelings of love, without having to take measures to earn one’s love, or prove she is worthy of their attention and recognition.

It seems likely that Andrew’s ability to call attention to unconscious processes, or, in other words, identify problematic relational patterns outside of Hillary’s conscious awareness, contributed to her developing an understanding of how she was being used by others. While Hillary reported feeling initially frustrated and even extremely angry after a particular session where Andrew called attention to certain aspects of her functioning that she employed “extensive efforts to ignore,” his ability to do so ultimately resulted in Hillary examining all of her past significant relationships, and specifically looking at her own role in re-creating the same relational patterns (Mitchell, 1988). It’s possible that her sense of paternal neglect that manifested in a strong craving for recognition from others contributed to her neglecting her own needs and feeling used, reportedly realizing through her treatment that she was no longer willing to be “a doormat,” resulting in

210 Hillary ending relationships that were one-sided, or that didn’t benefit her. While she reported still wanting to take care of her boyfriend and close others in many ways, she said she stopped pleasing everyone, and instead “demanded respect from people.” It seems, based on Hillary’s report, that gaining insight into her problematic relational patterns, coupled with her sense of how she perpetuated them, led to the eventual establishment of alternative interactional models, ones less tied to the unconscious recreation of early family dynamics (Mitchell, 1988).

Last, it’s possible that Andrew’s recommendation of increasing the frequency of Hillary’s sessions contributed greatly to her having a new relational experience with a paternal object. For example, Hillary reported that early in her treatment, Andrew recommended that they meet multiple times a week, instead of meeting weekly. This recommendation seems crucial to her treatment: Hillary felt that her father wasn’t attuned to her, was emotionally absent and abandoning and that he withheld approval—all of that is in the object relationship to project onto Andrew. However, instead of acting in the way she assumed, instead Andrew not only understands her, but also he wants to see her more: a paternal object the polar opposite of her perceived experience of her father. So, just from a behavioral perspective, he challenges one of her predominant unconscious assumptions related to the availability of others, especially paternal objects.

Additionally, it’s possible that his actual attunement and consistent responsiveness may have altered Hillary’s unconscious understanding of what she deserved in a close relationship. Specifically, Andrew asked for nothing from her (except paying a sliding fee), yet he understood her. This may have helped undo the assumed connection she’d developed between being responded to only when she operated as a

211 caretaker. This then, lays the groundwork for his insightful question to Hillary: what does she think she deserves?

This experience seems powerful because it’s not what she understood to be her predominant relational model from her father. She believed that she was expected to make do with what little she received from her father, from lack of attunement to aloofness and perceived abandonment. Her needs did not seem to matter, as she understood it, so she came to assume they didn’t matter to anyone. Here, though, Andrew puts Hillary’s needs front and center, suggesting that, whatever she conceives them to be, they have their own inherent importance. This seems particularly significant—an older man, a paternal object or paternal stand-in—putting Hillary’s needs first. Altogether, these experiences may have helped Hillary to develop an entirely new set of relational assumptions, expectations, and relationship models, including both internal objects and object relationships within those models.

Current functioning.

Currently, Hillary reports doing well both personally and professionally. She works in finance, and has been promoted several times. She said she works long hours, and stays busy at her job. Additionally, she said she is pursuing a Master’s degree in finance, hoping that the completion of that degree will lead to greater professional success and career advancement. Personally, Hillary said she has been in a healthy relationship with her boyfriend for almost 4 years, and hopes to marry him in the future and start a family. While Hillary reports feeling content in her relationship, it seems that she continues to struggle at times with her anxiety, specifically feeling worried that

212 something bad could happen in her relationship, despite her boyfriend ostensibly reporting that he is very happy, and that he foresees a future with her. From her report, it’s possible that she continues to need some sense of approval and reassurance from him, especially to mitigate her relational anxiety. Moreover, it seems that while Hillary reported that treatment helped her considerably with her sense of self-worth and selfesteem, it’s possible—from her reported “irrational” worries related to her relationship possibly ending—that she continues to struggle with a self-esteem primarily constituted by her perception of how close others, especially her boyfriend, feel about her. However, it seems that she has developed and cultivated other sources of self-esteem and personal meaning, including a successful career and a healthy relationship with someone who is available to her, both physically and emotionally.

In terms of her family, Hillary reported having a healthy relationship with her older sister. In addition, she said she continues to have a close relationship with her mother, though she said she realizes, more and more, that they have different views on life and religion, something she said she has accepted. Regarding her father, Hillary said she continues to struggle with him. She reported dealing with his behavior by lowering her expectations for him to almost nothing, hoping that if she doesn’t expect anything from him, she won’t feel disappointed and hurt. However, she implied that she secretly seeks his attention and recognition still, and continues to connect with him sparingly via email or an occasional phone call. It seems that she continues to seek her father’s love and approval, despite consciously reporting that he’s unable to provide what she needs.

In summary, Hillary’s story is one characterized by a felt sense of paternal neglect and depression, and the ways in which she has attempted to deal with her father’s

213 unavailability. Hillary said she has improved considerably since struggling for years with depression, anxiety, and relationship problems, and attributes her success to the “transformative experience” she had in her treatment during emerging adulthood. She reported finding a psychotherapist who helped her understand and begin to address longstanding issues from her past experiences with her father. Specifically, Hillary said that she discovered how her relationship with him impacted all subsequent relationships, and manifested in one-sided relational patterns that left her taking care of others.

Participant D: Jasmine Jasmine is a 23-year-old African-American female living in the Midwest with her boyfriend of 2 years. She has dark skin, is of average height and weight, and has a bright smile. Jasmine seemed fashionable to me, and in a few interviews dressed in clothes with vibrant colors, wearing bright yellow and orange. She has short hair; however, at times, she wears a hairpiece, making her appear to have long, black hair that she occasionally wraps in a colorful headscarf. Jasmine said she works part-time at a clothing store, in addition to having a full-time class schedule. In the initial interview, Jasmine had a warm, inviting presence, and seemed eager to share her experience in treatment with me, one that ended within a month of her participation in this study.

In the interviews with Jasmine, she said she was anticipating graduating from college, something she said engendered anxiety for her as she started to think about, in her words, “being an adult.” She described having ambivalent feelings related to graduation. On the one hand, she said she felt excited for the future. On the other hand, she reported feeling anxious, uncertain about what the future entailed for her and nervous

214 about securing a full-time job, something that could support her financially as she currently relied on financial aid and student loans. She discussed having many interests that she wanted to pursue after graduation, though she wasn’t sure how they would come to fruition. She described herself as an idealistic person, wanting to have a positive impact on others, though she said she’s not exactly sure what that would look like for her.

Childhood and adolescence.

Jasmine described her experience in childhood as “painful.” She said she lived for the first few years of her life with her parents at her maternal grandparents’ home in an impoverished area in a large city. After 2 years, she said her parents bought a house down the street, and soon after that her mother had another girl, Jasmine’s only sibling.

Jasmine said her memories of living in the city included her parents constantly arguing, something that eventually contributed to their divorce when Jasmine was in the third grade. When Jasmine was five, she said that she and her family moved to a suburb that consisted primarily of White, middle-class families, and Jasmine was, as she put it, “the only dark-skinned girl in my class.” Though they ostensibly moved to a safer place with better schools, Jasmine said she didn’t fit in, and often felt alone and isolated from her White peers, who she said looked at her with suspicion. According to Jasmine, it was during that transition to the suburbs when the marriage of her parents started to really fall apart, an experience she reported being anxiety-provoking and confusing to her. As she reported: I feel like in the first and third grade is when things started to shift, in how I felt; and then, because my parents got a divorce when I was in the third grade. Well

215 they filed for the divorce; I didn’t understand as a kid, it took years for it to finalize. By the third grade things definitely shifted, things just plummeted. I started to feel insecure; I started to feel scared; I didn’t even know what divorce really meant. Like I don’t get to see my dad, what’s going on? And I just remember being in class, and this was my favorite teacher, and it was so crazy because my parents were so distracted by their relationship, I would go to school without my hair being done. And, I would do it, and don’t leave a third grader to do her own hair!

Jasmine said she felt as though both of her parents were preoccupied with problems in their marriage, leaving her feeling neglected at home and lost at school, where she said she struggled to fit in and establish friendships. She said that her younger sister was extremely quiet and didn’t talk much at all growing up, making her parents worried about her sister, and consequently assuming that Jasmine was adjusting well given her reported ability to pretend to be happy. However, she said she was anything but happy, and felt anxious every morning before school. Luckily, she said her favorite teacher took her under her wing, and cared for Jasmine on days when she showed up to school disheveled or unprepared for class.

Growing up, Jasmine said she didn’t feel as though she had close friends that truly cared about her, and recalled being bullied by her peers. When asked to recall salient moments from childhood, Jasmine associated to a particular memory that still, to this day, reportedly engenders feelings of shame, anxiety, and anger. She said she was 7 years old, and told a friend of hers that her parents were getting a divorce. The friend then threatened to tell everyone in her class about her parents. Jasmine reported the following:

216 I do remember that happening in the third grade, and that was the first point I think I started to feel shame in my life, and just carried it throughout my entire life because she made me feel like I said something wrong, I said something that I shouldn’t have said. And now she’s going to retaliate against me because I told her that information. And I always felt like that with people; that they’re going to tell my business or people will look at me weird, or you’re different, and we don’t like you. And so around that time girls just started being mean, and catty, because I was the dark-skinned girl. I was the ugly one; I was really constantly bullied because I was dark-skinned.

Jasmine said that in the third grade, girls who she thought were her friends would call her on the phone after school, calling her a “bitch” and “ugly” before hanging up the phone laughing. She said she felt sad and angry, but didn’t tell her parents about the phone calls because, despite being treated poorly, she said she still wanted to be friends with those girls, the only friends she said she had. Jasmine said, at that time, she started to dislike herself, and remembered asking to play with dolls that were light-skinned, instead of dark-skinned dolls that looked more like herself.

Jasmine reported that her relationship with her father growing up was complicated. On the one hand, she recalled positive memories with him, memories in which he would play games with her, and encourage her to pursue her interests. She said she remembered him making a conscious effort to help her be positive about herself, telling her that she could accomplish anything, even realizing her childhood dream of becoming a famous actress. She described both herself and her father as “dreamers,” often spending time together where they’d discuss Jasmine’s dreams, and talk about their

217 collective excitement for her to become an actress. In addition, Jasmine said that her father was aware of Jasmine being the only Black girl in her class, and made a point to remind her of how beautiful she was, reportedly telling her that her dark skin was “beautiful.” Jasmine called herself a “daddy’s girl” before the divorce, something that changed after her parents experienced more and more conflict at home, resulting in her father responding to her mother by spending hours, or even days, away from the home and Jasmine’s mother.

On the other hand, Jasmine said her father could be impulsive, unpredictable, and unavailable, leaving the home on occasion without notice, making Jasmine wonder when, or if, her father was coming home at night. She recalled a salient memory in third grade, where she said her father “was just flipping out,” screaming at Jasmine’s mother and threatening to hurt her, eventually culminating in grabbing her mother and pinning her to the ground, until Jasmine rushed downstairs and yelled at them, causing her father to get up and abruptly leave the home. However, Jasmine recalled the most painful memory of her father occurring when she was in fifth grade, after her father had moved out of their home, but before the divorce of her parents was finalized. She said her father took her to a BBQ with some of his friends, something she said he had done in the past with her.

She said that they were having a great time, until the end of the party when her father’s friend turned on the microphone, told everyone to be quiet, and announced that the entire restaurant and bar would greatly miss Jasmine’s father, wishing him the best of luck on his new journey. Jasmine said she was shocked and puzzled, and looked at her father with a quizzical expression. He turned to Jasmine, and, at that moment, told her that he was leaving the next day, moving to South Carolina permanently. Jasmine said she felt

218 shocked, devastated, and completely lost, not sure how to comprehend the news. The next day, she said her father moved, and she didn’t hear from him for almost a decade.

She said he never called, never sent a card, and never came to visit her for years.

During her childhood, Jasmine said she also had a conflicted relationship with her mother. On the one hand, she said her mother was “very loving” and that she tried her best, always ready to, in her words, “put her best foot forward” for Jasmine and her younger sister. She remembered her mother providing for them financially, working long hours to ensure that Jasmine and her sister had whatever school supplies and clothes they needed. On the other hand, she described her as “a tough nut to crack,” “stern,” and “realistic,” someone who Jasmine said didn’t have time or the patience for discussions about Jasmine becoming an actress, or to entertain her fantasies of being on stage performing someday. Jasmine said her mother wouldn’t allow her to participate in theatre, and encouraged her to develop “realistic” interests that would result in her finding a job and financial security. She said her mother would often tell her she’s “too sensitive,” resulting in Jasmine reportedly feeling reluctant to open up and talk to her mother about her struggles in school and at home with the divorce.

Jasmine described a particularly painful memory when, in junior high, she said she felt suicidal for the first time, and disclosed these feelings to her mother. She said her mother, in her words, “didn’t even care,” and felt that she was more preoccupied with someone at school finding out about Jasmine feeling suicidal, potentially taking Jasmine away from her. After that incident, Jasmine said she decided not to open up to her mother at all, and said she maintained distance between them, not sharing any experience that could make her seem weak or vulnerable. In addition, Jasmine described her mother

219 as “uncommunicative,” something she said made it easy for her to hide how she was feeling from her mother. For example, she said that both of her parents never talked about their emotions, and would never inquire about Jasmine’s own feelings and psychological health. This resulted, according to Jasmine, with her feeling unprepared to manage her emotions, particularly negative ones she experienced in grade school and junior high. She said her mother was too preoccupied with the divorce, one that became official when Jasmine was in sixth grade, after her father moved to South Carolina. After her father moved, coupled with Jasmine’s sense that her mother was emotionally unavailable, she said she pretended that everything was fine, and put on, in her words, “a happy face at home.” She said that her mother didn’t talk about her father’s absence much at all, and they tried to start over, without him in their lives.

Jasmine said she thought high school would be a fresh start, a time for her to figure herself out and finally connect with other people. She said she found herself with one close friend, but kept others at a distance, particularly those that had bullied her throughout grade school. Despite reporting that she felt disconnected from the majority of her peers, she recalled some fond memories of her first year in high school, due to getting involved in speech and theatre, two extracurricular activities that allowed her to meet a few peers with similar interests. While she reported enjoying these activities, Jasmine said she continued to feel alone, different, and skeptical of her peers, saying that her fellow classmates “really put me down, and really didn’t have their best interests in friendship with me.” Instead of cultivating friendships, Jasmine said she focused on academics, and also began dating for the first time.

220 Academically, Jasmine said she did well, and experienced academic success for the first time in high school. She said she finally felt motivated to study, and started to make the Dean’s list every semester. In addition, she became a familiar face around teachers and her principals, connecting with them more than her peers. For example, Jasmine said she was, in her words, “best friends” with her principal, and that her role as president of student council allowed her to interact with both students and administration, something she felt happy about doing. However, she said her relationships with peers continued to be problematic. Specifically, she said that after puberty started, she reported increased attention from boys, a new experience for her as she said that previous attention from boys centered on her being called “ugly” and “different.” She began dating, but soon thereafter learned that her boyfriend was cheating on her, an experience Jasmine called “traumatizing” that led to what she reported as her first anxiety attack in high school. She said she felt rejected and ugly once again, and ended the relationship, telling herself that she didn’t need to interact with boys in her class.

Jasmine said her father re-entered her life briefly when she was in high school after experiencing what she referred to as a “traumatic” event. At 15, she said she was riding home in a friend’s car, when the car was struck by another vehicle, causing Jasmine to suffer multiple fractures to her body, knocking her unconscious until she woke up in the hospital later that night. Jasmine said that “somehow” her father found out about her accident, and he drove to the hospital from South Carolina. She remembered feeling angry due to her sense that it took something as drastic as a car accident that could’ve been fatal, for her father to re-emerge in her life. She said he came to the hospital with his new wife and step-children, something she said felt shocking and

221 frustrating to her as she had no idea that he had remarried and started a new family. She said she felt as though her father started a new life, and, in her words, “forgot about me.”

Despite feeling angry, she recalled having mixed feelings related to whether or not she wanted to see him in the hospital, ultimately deciding that she wanted to talk to him and try to let him back into her life, “little by little.” Even though she reported feeling angry and confused, she said she wanted to give her father another chance. As a result, she said that she and her father exchanged phone numbers at the hospital, and agreed to start talking on the phone weekly. However, Jasmine said her father didn’t stick to their plan after a few weeks, and she stopped calling him, ending their communication.

Jasmine said she continued to feel isolated throughout high school and her adolescence. She said she attempted to fit in with her peers but couldn’t, due to her sense that she was different from them, in addition to her belief that her peers judged her, and that they were critical of her. However, she said she did connect superficially with two other girls, and spent the majority of her time with one in particular, someone she called her best friend. Despite having a few friends and staying busy in school activities, Jasmine said she felt depressed, isolated, and anxious throughout high school. While she said she never attempted suicide or cut herself, she reported constantly thinking about hurting herself. She said she got through high school by focusing on the future, thinking about one day having friends and not being the only Black girl in her classes. Jasmine said she was eager to graduate from high school and leave her hometown, tired of being one of the only minority students in her class. She said she “finally” graduated and felt excited about leaving for college, hopeful for, yet again, a new start.

222 Emerging adulthood.

Jasmine said she went out of state for college, mainly due to her reported wish to get away from the peers she had been in class with throughout her schooling. When asked about her experience in emerging adulthood, Jasmine said she remembered that she “always wanted a boy’s attention,” due to feeling as though she never received enough attention from males, particularly her father, throughout her development. What’s interesting is that Jasmine reported experiencing increased attention from boys during high school after she went through puberty. However, from her report here, it seems that she felt she needed more attention, or that she didn’t receive the type of attention she wanted in high school. Or, it’s possible that she may have been conflicted about receiving increased attention from boys—it may have been what she thought she always wanted, particularly given her report that she didn’t get enough attention from her father—however, after the increased attention ultimately led to her dating and then being cheated on in high school, it’s possible that she experienced ambivalent feelings related to this need. That being said, it seems that her need for attention outweighed any concerns she had after leaving for college, as Jasmine reported that she started dating someone right away during her freshman year, but that something, in her words, “felt off.” Specifically, she said she didn’t know how to be herself in a relationship, and reported that she didn’t feel comfortable with herself, let alone comfortable when engaging with a man. She reported that her new college relationship was problematic, and that her boyfriend became verbally and physically abusive to her within a few months of dating.

223 Jasmine said that multiple reasons contributed to problems in her college relationship. First, she said she was unsure about her sexuality, later realizing that she is, in her report, “bisexual.” She said she wasn’t really attracted to her boyfriend at the time, but that she engaged with him due to desperately wanting attention from a male figure.

Second, Jasmine said her boyfriend had a temper, and that she believed he wanted a relationship with her solely to have sex, something that Jasmine said was anxietyprovoking to her, particularly after finding out that her boyfriend in high school was having sex with other girls while they were dating. Last, Jasmine said she later realized she was “traumatized” from her first relationship with her boyfriend in high school.

Specifically, she was referring to her experience of finding out that she was being cheated on, something she said made her constantly feel anxious when dating, though she said she could never pinpoint exactly why she felt that way until she was out of her college relationship. She said she decided to end the relationship, and made an attempt to focus on her academics.

Jasmine said that during her freshman year of college, she wanted to study fashion. However, she said she soon found herself spending more time with friends she had made, instead of going to class and studying. She reported doing poorly academically, and, through her mother’s advice and recommendation, moved back closer to home, transferring to a new school. When describing her relationship with her mother during emerging adulthood, Jasmine smiled and said they developed a much closer bond since she entered treatment, reporting that their relationship “blossomed into something I never would have thought.” Jasmine attributed her newfound closeness with her mother in the last few months to her sharing her psychological difficulties with her, and in turn,

224 her mother finally discussing her own problems, specifically her long-standing struggles with depression, in addition to how difficult the divorce was for her. While Jasmine felt frustrated that her mother never inquired about her struggles with depression, or, never shared her own experience with mental health problems until recently, she said she felt closer to her after sharing their collective difficulties, and wanted to work on having a closer relationship moving forward.

Jasmine said her father re-emerged in her life, yet again, after her freshman year of college. She said that after she transferred schools and was attending college closer to where she grew up, her father “randomly” moved back, finding a place not too far from where Jasmine lived. She said that she didn’t know why her father moved back, reporting that he evaded answering the question when she asked about his move. Even though she hadn’t seen him since her car accident, Jasmine said they decided to meet weekly for dinner, something she was initially skeptical of given her father’s reported tendency to disappear without any forewarning. In addition, she said she felt anxious about reconnecting with him, but decided that she, in her words, “didn’t want him to be alone,” as her younger sister refused to have any contact with him whatsoever.

According to Jasmine, weekly dinners with her father engendered mixed feelings. On the one hand, she said that she felt happy that her father was attempting to have a relationship with her, reporting that she had always wanted his attention and recognition. On the other hand, she said she often felt frustrated, due to his reported tendency to dominate their discussions by talking about himself, or, at times, bring a random woman with him, preoccupied with her and acting as though Jasmine was not even at the dinner table.

225 Jasmine recalled one particularly upsetting memory that she said epitomized their weekly interactions. She said she and her friends made a video highlighting their college memories and experience. She felt excited to show him the video, hoping that by seeing it, he could have a better understanding of the person Jasmine said she had become.

When she eagerly showed him the video at dinner, Jasmine said he seemed disinterested, telling her that the video was too long for him to watch. Jasmine said she felt disappointed, and said she remembered, once again, that she needed to temper her expectations for what her father was able to provide. She said she thought about ending the weekly dinners, but didn’t as a result of deciding that she wanted some connection with him, even if it wasn’t the relationship she hoped for and imagined.

Jasmine said she continued to experience difficulties in connecting with peers during emerging adulthood. She reported having a few close friends, and said she spent the majority of her free time with her boyfriend and best-friend. However, she said she encountered conflict with her close peers. Specifically, Jasmine reported that her friends told her that she was difficult to be around due to their sense that she didn’t trust them, something they said manifested in her appearing cold and guarded, unable to be open and discuss her feelings with them. She said her friends pointed out that she seemed disinterested or annoyed with them at times, and that they didn’t know how to read or understand her in those moments. Jasmine, in discussing this pattern, said she found it “really, really hard” to let people in, pointing to her experience in grade school when she told a friend about the impending divorce of her parents, and that friend reportedly using that information to blackmail her. Additionally, she said she felt a sense of shame for feeling different from her peers, and, in being closed off and guarded to most people, said

226 she tried to protect herself from further criticism. Jasmine said she always felt judged, and tried to ignore those feelings by pretending to be happy, or, by not sharing her feelings with others, a pattern that emerged and created conflict with her close friends.

Treatment in emerging adulthood.

Jasmine said she had just finished her junior year of college, and felt depressed, anxious, and had suicidal thoughts occasionally. Additionally, she said she felt stuck, uncertain about what she wanted to do professionally when she anticipated graduating from college the following year. Furthermore, she said her cousin had recently committed suicide, something she said shocked her entire family, and played a major role in her seeking treatment. When recalling what led her to seek treatment in emerging adulthood, Jasmine reported the following: When I went to my cousin’s funeral, it just really dawned on me like, this could have been me. This was going to be me! On several different occasions, and seeing my family so distraught, and it really sucked because I don’t want to put my family through something like this; and I just wish I was there, I wish I was there for him because I’ve had those feelings…I have to do something, I can’t, I don’t want to end up like that. I don’t want my family to be in this church all over again. So, I’m going to do it, and just not sit on it anymore. And that was the day I found treatment...I always knew something was up with myself. When I kept thinking, why do I always end up alone? Or, why do I always lose friends? And I’m like, well maybe it’s me? So, I have to look into myself.

227 While she was grieving her cousin’s death, Jasmine said she found a blog post that discussed a young woman’s battle with mental illness, and her perpetual struggle to maintain lasting relationships as a result. She said the article spoke to her, and she remembered feeling as though she could end up like her cousin, and decided to seek help.

Jasmine said she hoped that treatment would help her understand herself better, and particularly shed light on her long-standing difficulties in connecting with others. In addition, she said she wanted a specific diagnosis, not to “label” herself, but to help her understand why she always felt as though she was “missing something.” For example, Jasmine said she had a sense, for many years, that something was wrong, but that she couldn’t pinpoint exactly what plagued her. This is somewhat baffling, as she’s discussed experiencing severe depression, suicidal thoughts, being victimized by racist bullying, and being abandoned by her father. From my perspective, Jasmine had plenty of reasons to talk with a therapist, though it seems as though she believed there was something else “wrong” with her, something I’ll take up in a later section. Regardless, she said the blog post she read included references to dialectical-behavioral therapy (DBT), and how it helped improve that particular woman’s relationships. After searching online for treatment centers that offered DBT, Jasmine said she found one close to her college. She called and spoke with an intake worker, and had an initial appointment the following day.

Jasmine said her treatment lasted roughly eleven months, and included both group and individual therapy in an intensive outpatient program. She said that, due to her depressive symptoms and past suicidal thoughts, the treatment center determined that they thought she would benefit from intensive outpatient psychotherapy, and

228 consequently started her in both group and individual treatment. For the first half of her treatment, Jasmine said she had three weekly group sessions, in addition to an individual session with her psychotherapist, Jennifer. For the latter half of her treatment, she said she had only one weekly group session, in addition to her weekly individual therapy.

Jasmine said she began treatment feeling anxious, unsure of what to expect. She said she felt worried because, in her words, her “entire” emotional development was not fostered in her childhood, making her feel as though she lacked any “emotional awareness,” worrying that others in the group would notice this about her. When asked to elaborate on this concern in the interview, Jasmine said that thinking about engaging with others in group therapy made her associate to the aforementioned memory she reported in grade school, one where she said she told a friend about the impeding divorce of her parents, and felt betrayed and judged by that person. She said she worried that group therapy would be a similar experience for her.

Jasmine said her treatment started with group therapy, with two of her three weekly group sessions focused on first learning, and then practicing, DBT skills. She said they first learned affect regulation skills, specifically identifying situations and behaviors that resulted in problematic interactions with others, in addition to identifying idiosyncratic behaviors that resulted in one feeling anxious or depressed. Once they could identify those situations, Jasmine said they learned concrete strategies to calm down, following a structured workbook on DBT skills given to each group member.

Jasmine said that in the very first group therapy session, the group therapists trained them in mindfulness meditation, teaching members how to breathe deeply and focus on the present moment. The third weekly group therapy session, according to Jasmine, was

229 more open-ended, providing any group member with time to process an issue he or she experienced during the week. Jasmine said she was initially skeptical of both group therapy and learning mindfulness meditation, not knowing what meditation or talking in a group setting could offer her in feeling better. She said she entered treatment expecting to have a psychological assessment and evaluation, get a diagnosis, and find a “solution” to her issue. However, she said that didn’t happen, resulting in her reporting feelings of frustration that almost led her to leave the treatment center within the first month.

In hindsight, Jasmine said she felt uncomfortable initially at the treatment center due to feeling worried that other group members would criticize her, and also anxious that they would think she didn’t need to be in treatment, as she said she saw people who ostensibly appeared to be struggling much worse than her. However, Jasmine said that several events made her change her perspective after the first three weeks of treatment, resulting in her deciding to stay. First, she said she called her mother, and her mother discussed how expensive treatment was, encouraging her to take it seriously and try her best, a conversation that Jasmine said helped her think about being more engaged in her treatment. Second, Jasmine said she wanted to show improvement to the people in her life, particularly her friends, parents, and boyfriend. Specifically, she said she wanted to show them that she could be a healthier person who could be more open and trusting.

Last, Jasmine said another group member she connected with in the first week of treatment left the center, deciding that she didn’t need help. After a few weeks, this friend had a relapse where she attempted suicide, and was back in treatment after her hospitalization. Jasmine said she identified with this friend’s tendency to pretend that everything was fine, and could see herself struggling like her if she left treatment.

230 Additionally, she said her friend shared with her that she didn’t take her treatment seriously, and “tricked” herself into believing that she didn’t need help. After these experiences, Jasmine said she felt determined to change her perspective on treatment, deciding that she needed to be more open in group therapy and with her individual psychotherapist.

Therapeutic action: what Jasmine reported.

Group therapy.

When thinking about what was helpful in her group therapy, Jasmine reported that the sessions eventually made her feel like she wasn’t, in her words, “crazy.” She recalled that, despite having a difficult time initially opening up in the group, she eventually participated more and ultimately felt supported by other group members, in that, by sharing their own struggles, Jasmine said she felt as though she wasn’t “crazy” or too different from them, something that resulted in her feeling comfortable enough to begin sharing her own difficulties. Additionally, Jasmine said that as more and more group members discussed their long-standing struggles with mental health, she felt less isolated, an experience that allowed her to begin taking risks. Specifically, she meant that she not only started sharing her own problems with depression and establishing relationships with others, but also she said she began providing support and advice to others, something she said made her feel empowered.

Another aspect of group therapy that Jasmine said was helpful included her sense that she was perceived as a positive influence by other group members, specifically describing herself as a “role-model” to fellow members. She reported:

231 I liked that people looked at me as a role-model. That felt really good, because I don’t know, we all survived, I think. And they just look at me as like no, but you do it differently. I’m like, no, I’m just literally surviving like you guys are surviving. And, it’s just, they were just so nice; they were just so nice and so helpful, and I just wish they knew how much of an impact they made on me.

Jasmine said she felt, for the first time in her life, that she made a positive impact on another person, an experience she said directly impacted her self-worth and selfesteem, two issues she said she struggled with in the past. For example, she said that through supporting and encouraging other group members, and ultimately being seen as a role-model, she began to see herself as someone who could have better relationships, someone who could have positive interactions with her own family and friends. In addition, she said her friends noticed this behavior as well, reporting that they commented on Jasmine seeming more positive around them, as well as reportedly noticing that she offered helpful advice and support related to their own problems.

Another experience in group therapy that Jasmine found helpful included the selfunderstanding she developed in one particular session, what she called her one “aha” moment in her treatment. She said she was discussing in one specific session how she felt when she thought about interacting with friends in the immediate future, and the subsequent feelings of anxiety and worry she experienced as she anticipated attending a social event. Jasmine said that she described in the group how, when she felt that way, she wanted to stay at her apartment alone, away from any social interaction. As she discussed these feelings in the group, Jasmine said that one of the group therapists interjected, and told her that what she was describing was Social Anxiety Disorder, and

232 reportedly provided a detailed description of the condition. Jasmine said she felt shocked, and said she had never, in her words, “put two and two together.” She said this realization jarred her, and she recalled stepping away from the group, taking a walk around the facility by herself. After she thought about what happened, she said she felt relieved, and described feeling like she could finally understand one aspect of why she felt so uncomfortable in social situations, and anxious interacting with family and friends.

The last aspect of group therapy that Jasmine said she found helpful included the mindfulness meditation skills she learned in the structured DBT group sessions. She said the mindfulness techniques included various strategies that all included some form of deep breathing. According to Jasmine, the skills she learned helped her better manage her emotions, in that when she was able to meditate daily, she said she found herself less stressed, as well as better able to manage her “mood swings,” times when she instantly felt sad, anxious, or depressed. In addition, Jasmine said the mindfulness strategies she learned helped her focus more on the present, instead of being preoccupied with the past or future. For example, Jasmine said that she continued to feel “shame” from being the only Black girl growing up, in addition to being called “different” and “ugly” by her peers. This manifested, she said, in an inability to trust others, maintaining a guarded presentation around people. Through the mindfulness strategies she learned, Jasmine said she was better able to focus on what was happening in the present in her relationships, instead of worrying about what happened to her in the past. In other words, she said she learned to focus less on her tendency to distrust others, instead attempting to be open and connect with her peers. She reported noticing this pattern, both with her two

233 closest friends, and with her boyfriend, who all commented that Jasmine seemed happier overall, and less inclined to shut down and appear guarded when engaging with them.

Individual therapy.

Jasmine said she felt relieved in treatment when she was assigned to an individual therapist named Jennifer. When discussing what she found helpful in her individual treatment, Jasmine reported that Jennifer was, in her words, “really resourceful.”

Specifically, she said that Jennifer “always had resources for me anytime I needed them,” providing Jasmine with articles on anxiety, relationships, and other issues germane to her life. For example, she said Jennifer would provide her with a “really cool article” that she thought Jasmine would like, one that highlighted a particular issue that she had recently discussed in treatment. As Jasmine reported, Jennifer “never left me emptyhanded.” Additionally, Jasmine said that Jennifer was very goal-driven, providing worksheets for her to explore and complete on the weekends. She recalled finding one worksheet especially helpful, what she called a “value sheet” that listed several different personal values she could explore. She said she felt as though the worksheet helped her think about what values were most important to her at that specific time in her life, in addition to seeing how she had changed as a person, tracking how the most important values to her had shifted in importance since the beginning of treatment. Jasmine said this helped her see how she had changed as a person, and made her feel as though she was making progress in therapy.

A second aspect of treatment that Jasmine said she found helpful included her feeling that Jennifer was always available to her. Initially in treatment, Jasmine reported

234 that she was skeptical of Jennifer’s ability to help her, something that contributed to her being reserved and guarded, in addition to feeling reluctant to share details about her life, reporting that she initially withheld information from Jennifer. After Jasmine decided to remain at the treatment center, she said she felt determined to engage more in psychotherapy, and to be more open and vulnerable in her individual treatment. After deciding to become, in her words, “all in,” Jasmine said she started telling Jennifer everything, opening up to her about her current issues in connecting with her peers, as well as her long-term problems in managing her shifting mood states. Additionally, she said she discussed her long-standing sense that she felt different from others, particularly due to her reported experience of being bullied and teased because of being Black, an experience she said she had only shared with her boyfriend and a close friend. Jasmine said that Jennifer was “available” to her throughout these discussions. When asked to clarify exactly what she meant by Jennifer being “available” to her, she reported that she felt deeply listened to, as well as felt as though Jennifer provided validation and affirmation of her feelings. Simply put, she said she felt deeply listened to and understood, and not dismissed or ignored, for the first time in her life when engaging with another woman. Jasmine said that experience with Jennifer changed the dynamics of their relationship, in that she said she felt closer and more connected to her.

Another example of Jasmine finding Jennifer available involved something Jennifer reportedly told her one session, and continued to reiterate throughout her individual treatment. Jasmine said she remembered Jennifer telling her that she wanted her to call her or email her if needed in-between sessions. Specifically, she recalled that Jennifer said she even “wanted” Jasmine to contact her if she needed to talk, or if she was

235 feeling sad or depressed and needed support outside of their appointment time. Jasmine recalled that this offer was a significant moment in her treatment, specifically reporting that it made her feel cared for and important to Jennifer. While Jasmine said she only took Jennifer up on her offer once, she said that Jennifer being available to her outside of their normal session time made her feel like she could depend on her. Additionally, from Jasmine’s perspective, this offer made her feel that Jennifer honestly cared about her as a person, and not simply because of her prescribed role as her psychotherapist. As she stated, Jennifer wasn’t “just doing this for your check,” something she said she felt with authority figures in the past. Moreover, she said that not only was Jennifer consistently available to her, but also that she was always positive in their sessions. For example, Jasmine recalled one particular week where she said she struggled immensely, unable to complete both her assignment for group therapy as well as one given to her by Jennifer.

Instead of discussing what she didn’t do, Jasmine said that Jennifer focused on what she was able to finish, and told her that she appreciated what she did complete, despite feeling particularly sad and depressed that week. Jasmine said she felt “appreciated and validated” in that moment, and after that specific session, left her office feeling more motivated to make changes.

A concluding aspect of treatment that Jasmine said she found helpful included moments when Jennifer would self-disclose, telling Jasmine about her own personal experiences. Jasmine said Jennifer would, at times, discuss her own family issues, particularly revealing funny yet “ridiculous” remarks her mother made over the years, something that Jasmine said made her laugh and feel more comfortable with her. She said that it was nice, in her words, to connect “like two girlfriends having a chat.” She

236 said she “loved” that about Jennifer; that she could be open, personable, and vulnerable, a way of being with Jasmine that she said made her feel comfortable and closer to her, as though they were sisters or girlfriends informally discussing how to make changes for the better.

Impediments to therapeutic action: what Jasmine reported.

Group therapy.

While Jasmine said that overall, her experience in group therapy was helpful, she also discussed aspects of her experience that she found challenging. Initially in the group setting, Jasmine reported that it was particularly difficult for her to open up in the group, manifesting in a specific pattern where Jasmine said she offered support and advice to others, yet felt reluctant to reveal her own personal struggles, something that maintained distance from her and other group members. She said she initially maintained distance from others due to having trust issues from past interactions with peers, particularly those in which she felt betrayed. Additionally, Jasmine said that her tendency to remain guarded was intensified due to her fear that she could be hospitalized if she disclosed the true severity of her depressive symptoms, something she said she saw happen to another group member. For example, Jasmine said that, in her words, “any crack” from her could result in a group therapist hospitalizing her, something she felt prevented her from completely letting her guard down, as she said she worried about being seen as too unstable to leave the center. As a result, she said she held back in group therapy on several occasions, pretending she felt better than she really did. In hindsight, she said she

237 wished she didn’t have to hide her feelings and “walk on eggshells” on certain days, particularly ones when she said she felt especially depressed.

Another aspect of group therapy that Jasmine said she found challenging included her feeling that she and other group members were constantly “looked at objectively,” a sense she had that made her feel, at times, as though the group therapists were “looking down” at her. When asked to elaborate on this point, Jasmine said she felt, on occasion, that the group therapists focused too much on group members and analyzing every behavior and interaction among them, making her feel suffocated and objectified. In other words, she said that there were times when she felt judged by the therapists, and had a sense that she thought they believed they were superior to her. Jasmine reported that none of the group therapists ever said anything explicitly to make her feel that way; rather, she said it was a feeling she had as she watched them interact with group members. However, she said that as she felt more comfortable with both the group members and group therapists, she worried less about the potential of being judged.

Individual therapy.

Jasmine said she felt that, overall, her individual treatment with Jennifer was really helpful to her. However, she did report aspects of her treatment that she found disappointing. When thinking about what was not helpful or missing in her treatment, Jasmine said that she completed treatment without ever receiving a diagnosis, something she said she needed and wanted. Initially in treatment, Jasmine said she felt worried after being assigned to Jennifer, specifically due to her sense that Jennifer was not much older than her, something that made her assume that she must be a new clinician who wouldn’t

238 be able to provide her with the answers she wanted. Jasmine said that her sense was that Jennifer “never really wanted to label” her, instead focusing on helping her deal with her problems in living, as well as managing her mood. Despite wanting a diagnosis from her, Jasmine said she never explicitly asked Jennifer for one, reporting that she “didn’t want to make her feel uncomfortable,” and didn’t want to put pressure on her to provide something that Jasmine thought Jennifer was uncomfortable providing. It seems, from my perspective, that Jasmine didn’t want to potentially create conflict and tension between her and Jennifer, contributing to her leaving treatment without an important answer she felt she needed. I will discuss this dynamic more in an upcoming section that provides a psychodynamic understanding of her treatment experience.

A final thought Jasmine had about what was not helpful or what felt missing in her treatment included her feeling that, at times, she wished that Jennifer would have pushed her more, specifically asking questions outside of her normal inquiry into how things were going for Jasmine in school, with her family and friends, and with her boyfriend. While Jasmine said it was helpful to discuss those topics, she said that she felt as though they would constantly talk about those three issues, creating what she referred to as a sense of repetitiveness in her psychotherapy that could make her feel frustrated.

In other words, Jasmine said her treatment could be, occasionally, too focused on her current life events, and feel more like a weekly report, instead of what she described as potentially delving into deeper issues from her past. That being said, Jasmine said she never addressed this with Jennifer, and couldn’t articulate exactly why she didn’t.

239 Psychodynamic assessment and interpretation of Jasmine.

Thus far, I’ve discussed Jasmine’s reported experience in childhood and emerging adulthood, as well as her subjective experience in treatment, including what she found helpful and not helpful in both group and individual psychotherapy. Now I will offer a psychodynamic assessment and interpretation of her, one based on data gathered from her reported experience growing up, in addition to my countertransference feelings and reactions throughout the interviews with her. Then, I’ll use this assessment to inform my psychodynamic understanding of her treatment experience, which will be discussed in a later section.

Childhood and development.

It seems plausible that multiple factors, both genetic and environmental, may have contributed to Jasmine struggling with severe depression, anxiety, and relationship problems throughout her childhood and development. Regarding genetic factors, Jasmine said she learned in recent months that both of her parents struggle with mental illness.

Specifically, she said her mother recently disclosed to her that she has struggled with depression for years. In addition, Jasmine said she recently learned that her father struggles with Bipolar Disorder and alcohol addiction, two issues that she said helped her understand her father’s behavior, which she felt was erratic and unpredictable. She reported feeling like her father was happy and attentive to her one minute, and angry and upset the next, leaving their home seemingly without any warning or provocation.

Regarding her own difficulties with managing her mood, Jasmine said she remembered historically struggling with severe depression and suicidal thoughts, intense anxiety, and

240 frequently feeling “alone” and “different” from others. Additionally, she said she always felt as though she was being “watched” and “judged” by her peers, what Jasmine attributed to her past experience of encountering racist bullying combined with her report of having Social Anxiety Disorder.

It seems plausible that several environmental factors contributed to Jasmine reportedly feeling unable to trust others, and often feeling suspicious of their intentions, a way of being that has contributed to relationship problems with peers in particular.

Jasmine remembered feeling “different” and being teased and bullied often in grade school and high school, due to her being the only “dark-skinned girl in her class.” She said she often felt alone and isolated, unable to relate to and connect with her White peers. Leary (1997) argued how, in a discussion of racial tension, “most blacks and whites construct and are constructed by vastly different social worlds,” a difference that often results in opposing realities that can clash and generate some type of violence (p.

164). While Jasmine said she never encountered physical violence in her childhood, she did experience racist bullying, and remembered feeling “different” and “inferior” to other children as a result. Despite encountering racist bullying, Jasmine said she attempted to make friends and fit in by “pretending” to be happy, yet reported that she never felt truly comfortable with her peers.

It seems highly likely that Jasmine’s experience with racist bullying in grade school and junior high contributed to her reported sense of frequently experiencing some level of anxiety when interacting with others, something that made it difficult for her to be open and let her guard down, instead maintaining distance from her peers. While this relational stance was used to possibly protect Jasmine from future bullying and

241 harassment, it seems that it also contributed to the sense of isolation she said she often felt as a child. Based on Jasmine’s report, it seems that she was bullied for what may have been primarily racist reasons, as her highly visible difference set her apart from her peers. Also, what made her different from peers in a way that triggered bullying was something she shared with her parents—until her father left Jasmine for good. Jasmine had seemed close to him, but he abandoned her, leaving her with fewer people she was similar to, one of whom didn’t seem to listen much to her feelings.

It’s possible that Jasmine’s father’s abrupt move and subsequent absence from her life not only intensified her difficulties in trusting others and feeling suspicious of their intentions, but also it’s possible that it created abandonment anxiety for Jasmine, feelings that she said she couldn’t discuss with her mother, who she said didn’t talk about emotions, and who also was struggling herself with Jasmine’s father’s absence. In a discussion of depressive character organizations, McWilliams (1994) argues that, from a psychodynamic perspective, a circumstance that encourages depressive tendencies includes a family atmosphere where mourning is discouraged. From this viewpoint, when mourning is discouraged and unprocessed, it often takes the form of a child’s belief that there is something wrong in the self (McWilliams, 1994). In addition, McWilliams (1994) contends that emotional or actual abandonment from a parent often contributes to depressive dynamics in the child. Following these contentions, it’s possible that Jasmine attributed the loss of her father (particularly in the absence of mourning and without being given an explanation by either parent for his departure) to some problem with herself, worsening her depression.

242 It’s also possible that Jasmine’s abandonment anxiety, depressive symptoms, and feelings of rejection from her father manifested in specific relational patterns, from being reserved and closed off with peers in an attempt to protect herself, to believing that others will abandon her in some way, like her father. It’s possible she re-created this familial dynamic with her peers and expected them to leave her, contributing to a guardedness Jasmine said she often felt (Mitchell, 1988). However, it’s also plausible that, unconsciously, her father’s absence created a craving for attention and recognition from others, particularly men, a feeling Jasmine corroborated by recalling her need for attention from male figures, especially in high school and college. That being said, it seems possible that Jasmine experienced conflicting feelings related to this need, as it also led to her engaging in relationships in which she was cheated on, or reportedly jumping into relationships when she wasn’t ready to date, as in college.

It’s my speculation that Jasmine’s experience in childhood with peers and with her parents left her with an underlying assumption that people, particularly those who are supposed to be available and attentive to her needs, will fail her or disappoint her in some way. This was true in grade school from Jasmine’s perspective, as her visible difference as a result of being Black made her feel like an outcast, like a pariah who attempted to let others in, only to feel betrayed by them, teased and bullied by girls she thought were her friends. This was also true, according to Jasmine, in regards to her parents, as she felt that her father abandoned her and her mother’s tough love mentality made it difficult to express her feelings, contributing to her believing that she couldn’t fully depend on anyone. It seems possible that these experiences created havoc in her relationships, and made it difficult for her to feel comfortable and safe enough to establish and maintain

243 emotional intimacy. This may have led to Jasmine unconsciously developing a model of relationships in which she assumed that significant others would fail her, contributing to her tendency to maintain distance from others, expecting them to let her down.

Last, it seems plausible that Jasmine’s experience in childhood contributed to unconscious conflict related to her willingness to establish close relationships, particularly due to experiencing ambivalent feelings and competing desires of the self, possibly wanting both closeness and separation in the same relationship, but unsure of how to reconcile those feelings in the presence of real abandonment by her father (Mitchell, 1993). From a psychoanalytic perspective, it seems that her conflict about closeness is over-determined, resulting from both being abandoned by a parental figure, in addition to experiencing racist bullying in her past. On the one hand, it seemed that she craved attention from others, particularly due to her sense that she missed the responsiveness she felt she needed from both parents, but especially her father. This could have manifested in Jasmine wanting connection from others, even if that very desire engendered feelings of anxiety and worry about the other’s availability. On the other hand, it seemed that Jasmine’s sense of being bullied and teased as a result of her difference contributed to her keeping others at a distance, a guarded presentation that I imagine made it difficult for others to get close to her, and unconsciously perpetuated the very rejection she hoped to avoid.

Personality patterns and characteristic defenses.

As briefly mentioned in previous cases, Mitchell (1988, 1993) argued that one’s personality, or the self-other configurations that constitute an individual’s predominant

244 self-states, are understood and defined through one’s relations with important others, especially those that emerged in the context of significant past relationships. It seems plausible that Jasmine operates primarily within an anxious, sensitive self-state, one hyperaware of perceived rejection from others. Given Jasmine’s report of experiencing repeated bullying from her peers throughout grade school and junior high, and being abandoned by her father, and cheated on by successive boyfriends, it makes sense to me why she might worry excessively about being rejected by others, and have concerns about fitting in and connecting with peers. It seems likely that Jasmine attempted to protect herself from anticipated future bullying and rejection through a variety of measures: keeping distance from peers, at times appearing guarded and reserved; “pretending” to be happy, ignoring the hurt and pain she might have felt in the hope of finding connection; and isolating herself from others, clinging to her belief, deriving from how she experienced childhood relationships, that people misunderstand and reject her because of her race.

Following these reactions to perceived rejection, it seems possible that Jasmine’s attempt to protect herself unconsciously contributed to the very rejection she feared, as her need to maintain distance potentially made it difficult for others to feel close to her, contributing to conflict and the possible end of a relationship. Jasmine corroborated this idea in one interview, describing how her closest friends told her that she could be difficult to engage with, particularly when she’s guarded and reserved, keeping others at a protective distance.

When examining characteristic defenses, it seems plausible that Jasmine employed the use of projection. Before discussing this process in greater detail, it’s

245 necessary to describe what gets projected outside the self and onto others, and how this process is first established. It’s my speculation that Jasmine has an internal persecutory object, what Tsigounis and Scharff (2003) describe as an internal self representation permeated with harassment, suppression, torture, and self-hatred, among other possible negative thoughts and feelings. The persecutory internal object forms when a person who is the object of a child’s desire and dependency for relationship is oppressive or unavailable to her, resulting in the child’s taking in of the experience in an attempt to control it inside the self (Tsigounis & Scharff, 2003). This idea is built upon Fairbairn’s discussion of how internal objects are developed as a means for an infant to manage anxiety resulting from caregiving failures (Fairbairn, 1943).

In Jasmine’s case, it’s possible that multiple experiences contributed to her perceived feelings of abandonment and rejection from significant others. First, it’s possible that she felt that her father failed her even before he moved away, reporting that he suffered from Bipolar Disorder, and that she felt his behavior could be erratic and unpredictable, often offering no explanation as to why he’d leave their home without any apparent warning or provocation. She reported coming home from school on some days wanting to talk to her father about her day, and feeling disappointed when he wouldn’t come home for dinner, or feeling frustrated when he’d be home for a short period of time before leaving for the evening. Second, Jasmine reported feeling as though her father rejected and abandoned her after he permanently left the home, and said she felt even worse after he moved away and stopped calling her, and also stopped answering her phone calls, an experience that made her feel as though he was completely unavailable to her, and that he didn’t want her in his life. After he left, coupled with Jasmine’s report

246 that she wasn’t given an explanation by either parent for his departure, it’s possible that she attempted to explain the situation to herself, resulting in her “taking in” the experience to control it inside the self, and consequently placed the blame on herself (Fairbairn, 1943; Tsigounis & Scharff, 2003). Moreover, Jasmine reported feeling taunted, frequently bullied, and overall rejected by her peers, seemingly because she was Black. However, it seems likely that her sense of rejection was, by this point, already heightened, and plausibly had led to the establishment of an internal persecutory object that was available for projection.

It seems that Jasmine’s persecutory object that possibly formed in relation to all of these experiences was then, at times, projected outside the self onto others, what Tsigounis and Scharff (2003) describe as an individual identifying with the victim position and projecting aggression and a sense of feeling hated and oppressed externally.

I found myself wondering often in the interviews where Jasmine’s anger was, as she had multiple reasons for her to feel completely furious, both at her peers for the racist bullying she encountered, and at her parents for her reported experience of their physical and emotional abandonment of her. From this perspective, it’s possible that she projected her anger onto others, contributing to her report that she felt she needed to be on “guard” and “watch” others, as she possibly worried about being verbally attacked by them.

However, this process is more complicated than Jasmine simply using projection to manage her internal persecutory object. In fact, from Jasmine’s report of her development, it seems that she had very realistic and well-earned wariness about being verbally attacked, rejected, or bullied by others. She could indeed have experienced massive racist bullying from her White peers, and possibly drew the conclusion that

247 everyone was against her. She bolstered this idea in one interview, reporting that in grade school and junior high, she felt that “no one cared enough” about her. As a result, it seems that her realistic concerns of potentially being bullied and rejected by others combined with her possible reliance on the projection of bad internal objects were both in operation, something that made establishing close, intimate connections with others seem impossible.

In summary, it seems possible that Jasmine’s past experience with racist bullying and her possible use of projection contributed to her feeling reluctant to be open and vulnerable with others, instead appearing guarded, withdrawn, and suspicious of their intentions. If this is true, then her presentation possibly nudges others into experiencing the projected feelings, something that then confirms her fears about peers rejecting her.

In other words, her own behavior, shaped by internal forces and her realistic wariness of others, contributes to the very experience that she potentially dreads and yet unconsciously anticipates. Relational writers would describe this process as an enactment, something I will take up in a later section on my assessment of her treatment experience. For the time being, what’s important is that these powerful intrapsychic and interpersonal processes possibly shaped her capacity to connect deeply with others, creating feelings of isolation and rejection that contributed to Jasmine feeling depressed and suicidal throughout her development.

Fantasies/experiences of relationships.

As mentioned in previous cases, Mitchell (1988, 1993) was interested in examining what people actually do in relationships, and the strategies learned from

248 engaging with significant others, strategies that contributed to the formation of specific relational models, and the predominant self-other configurations embedded within those models. It’s possible that as a result of Jasmine’s experience with her father, there’s an established relationship pattern where a man who becomes important to her may become unpredictable and abandon her, something that manifested in Jasmine reportedly wanting recognition from male figures, yet simultaneously experiencing feelings of abandonment anxiety resulting from her father’s abrupt departure. Moreover, Jasmine seems already to have projected her internal paternal object onto the external world. Her father abandoned her and her mother, emotionally “cheated” on her by starting another family; and then she found successive boyfriends who cheated on her. It’s possible that this relationship pattern contributed to Jasmine experiencing unconscious conflict related to establishing connections, possibly needing attention and closeness from others, yet, simultaneously, needing distance to protect herself (Mitchell, 1993).

It also seems likely that Jasmine often operated within a self-other configuration where the self is felt as “ugly” and “different,” and others are perceived as rejecting and superior, an internal object relationship projected externally onto others, likely contributing to Jasmine experiencing difficulties in trusting others, as well as a recreation of constricted relational patterns from the past (Mitchell, 1988). In several interviews, Jasmine described feeling both “ugly” and “different” from her peers, an experience that seemed to engender painful feelings for her, and impact her ability to relate with others. For example, when Jasmine discussed her experience of feeling “different” and “ugly” in the interviews, her affect shifted from holding back tears on two separate occasions, to seeming really frustrated on a different occasion, her voice

249 becoming louder than usual. It seems possible that Jasmine’s early experience with her father’s absence, as well as her sense of being constantly bullied by her peers, contributed to an underlying assumption that others can’t be trusted, as they will fail or disappoint Jasmine in some significant way. Additionally, it seems plausible that if Jasmine’s assumption included a sense that others believe they are superior to her and perhaps also a corresponding anxiety that she herself is inferior, it’s likely that she reacted with suspicion and distrust, manifesting in a reluctance to allow allows access to her internal world, perpetuating distance between her and those attempting to engage with her.

Last, it seems possible that Jasmine’s experience with her parents throughout her childhood left her with a relational model where she unconsciously assumes that others will be self-serving and narcissistically preoccupied with their own needs. Jasmine experienced this pattern repeatedly with her father, from him abandoning her and starting his own family, to his reported inability to take interest in Jasmine’s life even after they re-connected, often using their weekly dinners to talk about himself, instead of focusing on Jasmine and her life. Additionally, Jasmine also felt this way with her mother, reporting that she felt as though her mother emotionally abandoned her, preoccupied with the divorce and unable to tolerate hearing about Jasmine’s feelings and subjective experience in school. All of Jasmine’s combined experiences in relationships with both her parents and with her peers have been overwhelmingly negative, something that seems to evoke real conflict around engaging with others. In other words, it seems highly likely that Jasmine’s past relational experiences contribute to feelings of severe anxiety around her taking the risk of making herself vulnerable enough to be known and intimately connected to another person.

250

How I understand what brought Jasmine to treatment.

Jasmine reported that she finally sought treatment after her cousin committed suicide, making her feel scared and anxious as she thought about the possibility of ending up like her cousin if her depression worsened. While I believe that this experience certainly played a role in Jasmine seeking treatment, from a psychodynamic perspective, there may have been other contributing factors that also impacted Jasmine’s decision to enter treatment. From my perspective, it seems possible that Jasmine had a jarring experience after wondering, ostensibly during one random day, if she was actually the problem, if she was a main contributor to the difficulties she was experiencing in her life, particularly in her relationships. While I believe Jasmine felt damaged and defective on an unconscious level, it’s possible that these feelings were previously outside of her awareness, instead unconsciously repeated in her relationships (Freud, 1914). In one of the interviews, Jasmine said, with a shocked expression on her face, that her thoughts one day shifted to why she continued to experience difficulties in relationships, and to why she always felt alone. While she didn’t report that this shocking and upsetting revelation played a significant role in her seeking treatment, it seems particularly salient to me, especially when considered in the context of her past relationship with both parents.

Specifically, Jasmine said that her mother never discussed her own emotions, and “never” inquired about how Jasmine was feeling, contributing to her perception that she never developed from an emotional standpoint. Additionally, Jasmine said her father couldn’t handle his feelings, running away and moving to a different state. In essence, it seems that Jasmine experienced both parents as prone to avoiding their feelings and

251 mental health problems, creating frustration and disappointment for her and making it difficult for Jasmine to master affect regulation. She discussed on more than one occasion her feelings of frustration with her parents and extended family for never discussing their psychological problems, and believed that their collective silence on mental health issues perpetuated a culture of avoidance in their family, one that she believed contributed to her cousin’s suicide. One interpretation is that when Jasmine became aware of the idea that she might be the problem, it seems possible that she wanted to differentiate herself from her parents by facing her difficulties, instead of avoiding them like she felt her parents and extended family did over the years. Another interpretation is that Jasmine was accustomed to hearing that there was something wrong with her. In other words, her internal persecutory object could have been active, blaming her for the relationship issues she continued to experience throughout her development.

Another salient aspect of why I think Jasmine sought treatment included the fact that she desperately wanted, in her words, “a diagnosis,” one that she thought would explain her difficulties in childhood. Jasmine bolstered this idea in the initial interviews, stating that she struggled to manage her severe depression and anxiety, contributing to a sense of feeling out of control. Additionally, while she said she knew that she repeatedly encountered relationship problems, she said she didn’t know how to operate differently with others, repeatedly feeling some level of anxiety when relating to most people. In going to treatment, she wanted a diagnosis that she thought would help her understand these difficulties.

From my perspective, it seems possible that, on an unconscious level, Jasmine desperately wanted a diagnosis to help her understand why her father left her.

252 McWilliams (1994) argues that individuals with depressive characters often make sense of unmourned losses by converting the loss into an unconscious conviction that there was something about them that drove the object to leave. In other words, it seems to me that from a psychodynamic perspective, Jasmine needed an answer to what was so unlovable and flawed about her that someone as important as her father would abruptly leave, choosing to move away and break ties with her. Additionally, if we apply the concept of an “internal persecutory object,” it seems plausible that Jasmine took in her father’s badness in an attempt to control it (Fairbairn, 1943; Tsigounis & Scharff, 2003). That would leave her with both a conviction that others will reject or leave her, just like her father did, as well as an explanation for this, which is the sense that she is defective and unlovable. From my viewpoint, it’s possible that Jasmine needed a diagnosis to help explain why her father left, as he failed to provide any explanation related to his sudden move, leaving her to come up with her own conclusion related to his unexpected departure.

Countertransference.

I had two different experiences when interviewing Jasmine. In the initial interview, she seemed excited about participating in my research. She was very personable and quite talkative, discussing her childhood and past experience in great detail, ostensibly with few, if any, reservations. She was very articulate and didn’t seem to have any issues feeling comfortable speaking to me. In addition, I sensed a positive presence to her, noting that she smiled and laughed often. I wrote down that even her clothing seemed to reflect a positivity about her, wearing bright colors of orange, yellow,

253 and pink. She didn’t seem too excited or happy; rather, it seemed to me that she was outgoing and had an easy time connecting to me, and felt confident and comfortable enough with herself to open up and share her story with me.

The second interview with Jasmine was a different story. Immediately as I sat down to interview her, I sensed something different about her mood and affect. The positive presence I felt in the initial interview was no longer there, and she seemed guarded and withdrawn, and somewhat depressed. In addition, she wasn’t as articulate and talkative, and it took several attempts on my part of asking the same question in different ways to get her to provide details about her experience. Her responses to my questions were short, very different from how she responded in the initial interview, and I remembered feeling disconcerted with the change in her disposition. When I asked how she was feeling after noticing her change in affect, she discussed how she was dealing with some financial concerns in regards to paying for college, a recent development that was extremely upsetting to her. However, she didn’t want to delve into the issue, and we proceeded with the interview.

What struck me most about this interview session with Jasmine included her different presentation, no longer seeming like the positive, excited emerging adult I experienced in the first interview. I could understand how a recent financial stressor impacted her mood, but her presentation seemed so different to me than before that it seemed significant, yet, at that point in the interviewing process, I didn’t have enough data about Jasmine to understand what I was sensing about her. However, after the last interview, I could understand my initial feelings better, particularly after I experienced, in the two intervening interviews, a similar shift, from appearing happy and more talkative

254 in the third interview to seeming more withdrawn and guarded the following interview.

Her presentations were noteworthy to me, and something I started to think about more as I spent time with her in the interviews, examining how her presentation impacted the way in which we related, and shaped how she responded to my questions.

I believe that the way Jasmine presented to me on these different occasions reflected her typical variations in mood, and the possible impact her mood had on her functioning with others. I imagine I experienced, albeit in a condensed form, what it might be like to engage with Jasmine when she’s feeling happy and excited, as in the first and third interview, and what it’s like to interact with her when she’s feeling sad and depressed, as in the second and fourth interviews. While she was still pleasant to me in the second and fourth interviews, and continued to answer all of my questions, albeit in a cursory manner, I believe that my countertransference feelings during these interviews reflected an important aspect of how Jasmine functions in relation to others, depending on how she feels in a given moment.

Specifically, Jasmine seems engaging, dynamic, outgoing, and articulate when she’s happy. She seems reserved, shy, and withdrawn when she’s depressed. Moreover, what also struck me included how my own behavior changed depending on Jasmine’s affect. For example, when she appeared happy and outgoing, I noticed that I felt happier, felt inclined to ask more questions in the interviews, and in return, received lengthy, articulate responses from Jasmine. In these moments, she had no issues whatsoever elaborating on her subjective experience, and didn’t seem to omit details, offering whatever thoughts and feelings came to mind. Conversely, when she seemed depressed and withdrawn, I noticed that I felt more uncomfortable, and felt less inclined to ask lots

255 of questions. It was as though we both wanted the interview to end. Additionally, when Jasmine’s affect seemed depressed to me, she didn’t elaborate on her experience, often providing shorter responses to my questions that were devoid of the details she provided in past interviews. I noticed that this made me feel somewhat frustrated with her, a feeling I imagine her peers may experience when they interact with a depressed, withdrawn Jasmine. She supported this idea in a later interview, describing how her closest friends told her that it could be really hard to get to know her and feel close to Jasmine, given her difficulties in trusting peers that manifests in a guarded presentation.

It’s understandable that Jasmine had a difficult time trusting others and letting her guard down, particularly given her past reported experience being the victim of racist bullying.

However, I imagine that when she’s feeling depressed and withdrawn, friends find it difficult to engage her, potentially contributing to maintaining a level of distance not helpful in fostering trust and emotional intimacy with others.

In summarizing my countertransference feelings and reactions to interviewing Jasmine, a concluding thought comes to mind that sheds light on what I think could be her core issue, what seems to me as feelings of abandonment anxiety she experiences when dependency longings and the possibility for emotional intimacy emerge in her close relationships, resulting in conflicting feelings about whether or not she should be vulnerable with others. In other words, it’s possible that Jasmine seeks connections with others, yet unconsciously expects them to be rejecting, abandoning, or otherwise unavailable to her in some way, a dynamic that manifests in her seeming withdrawn and reserved (Mitchell, 1988). Additionally, it seems that Jasmine developed a model of

256 relating to others where she unconsciously assumes that they will be self-serving and preoccupied with their own needs, unable to take interest in her life and feelings.

In thinking about my countertransference and how it might infer something important about her functioning in relationships, two main thoughts come to mind. There is an interpersonal part where Jasmine has variations in her mood and can appear guarded and withdrawn, which influence others’ reactions to her. Additionally, there is an intrapsychic part, where she possibly projects specific judging, rejecting, abandoning roles on others, then behaviorally nudges them into experiencing those feelings. As a result, she unconsciously re-creates the scenario, or enactment, that she ostensibly hopes to avoid. I will say more in an upcoming section about how I believe my countertransference feelings relate to Jasmine’s experience in treatment, and how her core issue possibly shaped her experience in psychotherapy.

Psychodynamic understanding of therapeutic action.

Group therapy.

It seems plausible, from Jasmine’s reported experience in significant relationships since childhood, both with her parents and her peers since grade school, that she entered group therapy operating within an anxious self-state, one unconsciously expecting others to reject or bully her, corroborating her long-standing sense of feeling different from her peers. This seems particularly fitting, especially as Jasmine found herself in a group setting attempting to relate to mostly White peers, a dynamic that could have unconsciously re-created her experience in grade school, one where she reported feeling like the “ugly” Black girl. From the perspective of Jasmine’s characteristic defenses, it

257 seems possible that her internal persecutory object was easily evoked and initially projected onto other group members, resulting in her expecting them to be critical, rejecting, and oppressive towards her. It’s possible that these dynamics manifested in Jasmine appearing guarded and withdrawn from the group, maintaining a protective distance to fend off the potential judgment and criticism she expected from others. This pattern also seemed to play out in the context of Jasmine’s perception of the group therapists, reporting that she initially believed they thought they were superior to her, what seems like an unconscious repetition of her past experience where she attempted to relate to her White peers in school, only to report feeling inferior and different. On the surface, it seems plausible that these unconscious dynamics created immense levels of anxiety for Jasmine at the start of group therapy, and a reported skepticism related to how engaging in group therapy could possibly benefit her.

Instead of feeling criticized, judged, and different from other group members, Jasmine eventually felt accepted, valued, and even seen as, in her words, “a role-model” in the group. It seems plausible that Jasmine’s experience in group therapy was particularly helpful to her due to her experiencing a new, different type of interaction when relating to her White peers, a novel experience that eventually provided an alternative relational model for her to draw upon when engaging with others (Mitchell, 1988). From Mitchell’s (1988) perspective, treatment must help an individual relinquish ties to old, constricted relational patterns that prevent one from having novel interpersonal relations. Along those same lines, Hoffman (2006) argues that treatment should contribute to “relatively new, growth-promoting experience” (p. 723). For Jasmine, it seems possible that her experience in group therapy eventually provided a

258 novel relational experience for her, one where being open and vulnerable with peers led not to racist bullying and being seen as different, but led to closeness and trust among group members. Additionally, it seems possible that this experience helped to somewhat detoxify her internal persecutory object, making her less inclined to unconsciously anticipate criticism and harassment from others (Tsigounis & Scharff, 2003).

In the previous section, I described how I believe Jasmine operated within a selfother configuration where the self is perceived as ugly and different, and others are experienced as rejecting and superior, an internal object relationship projected externally, likely contributing to Jasmine having difficulties in trusting others, and manifesting in her appearing withdrawn and reserved (Mitchell, 1988). I imagine that Jasmine initially presented this way in a group of mainly White peers, revealing very little about her own subjectivity, and contributing to her initial skepticism of how group therapy could help her. By not sharing her own personal struggles, or by providing advice and support to other members and thereby maintaining a focus on their difficulties instead of her own, it seems possible that Jasmine was unconsciously attempting to avoid being more open and personally vulnerable with the group members—as doing just that could potentially leave her open to rejection and criticism—evoking an aspect of what I’ve described as her core issue. Additionally, it’s possible that Jasmine unconsciously assumed that group members would be self-serving and preoccupied with their own needs, unable to be available to her and take interest in her life and her feelings, something she experienced repeatedly in the past with her parents. Instead, Jasmine felt warmth and acceptance from the group members when she eventually shared her personal struggles, a new experience for her where being open and vulnerable in a relationship didn’t result in Jasmine being

259 bullied or abandoned (Mitchell, 1988). Moreover, she eventually felt safe and comfortable in the group, something that possibly mitigated her feelings of abandonment anxiety experienced from her relationship with her father.

Jasmine reported that she found her group treatment particularly helpful due to, in her words, “seeing” people like her, an experience that she said made her feel as though she “wasn’t crazy.” Moreover, she described other group members viewing her as a rolemodel, an experience that she said “felt really good.” It seems plausible that Jasmine becoming a role-model in her group treatment allowed her to experience an identification with the other, an unconscious process that provided a novel relational experience for her, particularly in a group setting with mainly White peers, a dynamic that in the past made Jasmine feel different and inferior. Theorists have discussed the possibility for a patient to inhabit different identifications in a given treatment, from identifying with the self, to identifying with the other or parts of the other, and unconsciously play out or enact that identification in the context of treatment (see Bollas, 1987; Davies, 2004).

It’s possible that Jasmine feeling like a role-model provided an encounter where she was able to experience an identification with a superior other, and relate to the group members without feeling inferior to them, a relational pattern she reported never experiencing in the past when engaging with her White peers. While it’s impossible to know the White group members’ thoughts and feelings about Jasmine, it’s possible that as a Black woman in a primarily White group, all her remembered experiences might have led her to expect rejection; but perhaps a developed sense of shared psychological pain allowed for a sense of connection and affective resonance among group members.

When Jasmine reported that this dynamic “felt really good,” I imagine that her past sense

260 of “shame” she reportedly felt from being different from her White peers was momentarily out of her conscious awareness. In other words, this experience possibly provided a novel self-other configuration where the self is no longer inferior, and others view Jasmine as different because of her ability as a role-model, and not because of her race (Mitchell, 1988).

Individual therapy.

It seems possible that Jasmine entered individual treatment also operating within an anxious self-state, particularly due to Jennifer being White, a dynamic that possibly evoked past experiences in which she felt criticized, bullied, different, and rejected by her White peers. In other words, it’s plausible that Jasmine attempted to unconsciously repeat relational dynamics from early interactions with peers in the context of her individual therapy, manifesting in her report of initially being guarded with Jennifer in treatment (Freud, 1914). Consciously, Jasmine reported that she initially worried about engaging in treatment with Jennifer due to her belief that Jennifer was not much older than her, something that reportedly made Jasmine think about her as a new, young clinician, worried that she had little experience in providing treatment, and skeptical of Jennifer’s ability to help her.

From an unconscious perspective, it’s plausible that Jennifer being both young and White evoked Jasmine’s persecutory object, initially projecting it onto Jennifer and consequently expecting her to be critical and rejecting, similar to her reported experience engaging with White females in particular (Tsigounis & Scharff, 2003). In Mitchell’s (1988) model, Jasmine connected with Jennifer early in treatment by projecting and re-

261 creating familiar constricted relational patterns, unconsciously placing Jennifer in a predesigned category based on her past experience with White females, irrespective of how Jennifer actually acted and related to her in treatment. As a result, it’s possible that Jasmine’s initial concerns about Jennifer’s ability to treat her were imbued with unconscious meaning from the past, resulting in Jasmine’s assumption that Jennifer didn’t have the treatment experience to help her.

Instead of experiencing criticism and judgment from Jennifer, Jasmine said she found her warm, inviting, and always available to her, both in her scheduled appointments and outside of her sessions, providing resources that Jasmine could read and use outside of her appointments. It’s plausible that Jasmine’s initial transference to Jennifer not only included expectations of her potentially being critical and feeling superior, but also contributed to a sense that Jennifer would be unavailable to her in some way, a transference assumption based on her report that her mother was emotionally unavailable throughout her development, and that her father was physically unavailable and abandoning. In the previous section, I described how I believe Jasmine likely experienced unconscious conflict related to establishing close relationships, wanting both closeness and separation from others, but unsure of how to reconcile those feelings in the reported presence of physical abandonment from her father, and emotional abandonment from her mother. I imagine that this possible conflict created anxiety and conflicted feelings for Jasmine as she attempted to connect with Jennifer, yet found herself having a transference reaction where she expected her to be unavailable in some way.

It’s possible that a specific enactment early in treatment helped challenge one of Jasmine’s unconscious expectations related to the availability of important others. In the

262 previous section, I described how it’s plausible that Jasmine projects specific judging, unavailable, abandoning roles onto others, then behaviorally nudges them into experiencing those feelings, re-creating the very enactment she ostensibly hopes to avoid.

This can manifest in Jasmine appearing guarded, withdrawn, and suspicious of others, making it difficult for others to connect with her. Early in her treatment, it seems possible that Jasmine unconsciously attempted to re-create this enactment with Jennifer, reporting that she was not only skeptical of Jennifer’s ability to help her, but also that she was withdrawn and guarded, withholding details about her subjective experience that made it difficult for Jennifer to get to know her. It’s possible that Jasmine was unconsciously nudging Jennifer into experiencing the projected feelings, and, through her withdrawn, guarded, and skeptical presentation, attempting to evoke a negative reaction from Jennifer. However, instead of taking on the projected roles and being critical or unavailable to her, Jennifer reportedly became more available, even explicitly telling Jasmine that she “wanted” her to call or email her if needed. This seems especially important because it broke from her transferential expectation that important others will fail her by being physically or emotionally unavailable, preoccupied with their own needs. Jennifer resisted taking on the projected roles, instead responding by becoming more available, and more interested and focused on attending to Jasmine’s needs.

When describing her report of both parents being unavailable on several occasions in her past, Jasmine recalled two particularly painful memories, one where she said her mother responded to her disclosing suicidal thoughts by scolding her, unable to accept and tolerate her feelings. The other memory included her father’s abrupt departure from her life, and her subsequent sense that he rejected and abandoned her. From these

263 experiences, Jasmine’s reported sense of Jennifer being consistently available to her eventually provided a new, alternative model of interacting with a close other, one different from her primary model of engaging with unavailable others who couldn’t tolerate her feelings, or who couldn’t respond to her emotional needs (Mitchell, 1988).

As a result, I imagine that as Jasmine continued to experience Jennifer as consistently available to her, she felt less conflicted about establishing closeness with her, loosening the grip of her transference expectation that she would be unavailable and consequently fail or disappoint her in some way.

It seems possible that Jennifer’s availability was also particularly helpful to Jasmine due to her consistent responsiveness possibly mitigating her feelings of abandonment anxiety. In addition to being abandoned by her father, Jasmine knew her mother was emotionally unavailable. While Jasmine never explicitly reported feelings of abandonment anxiety, she said that after her father left, she found herself frequently wanting attention and recognition from others, particularly men, but experienced what she called “social anxiety,” specifically struggling with not trusting others and worrying about their intentions with her, finding them unpredictable. Following these thoughts, it’s plausible that Jasmine’s experience with her father left her with an unconscious assumption that others are abandoning and unpredictable, manifesting in what Jasmine consciously called “social anxiety” when attempting to establish close connections. In the previous section, I described how I believe Jasmine’s core conflict includes feelings of abandonment anxiety she experiences when dependency longings and the possibility for emotional intimacy emerge in a relationship, generating conflict about whether or not she can be vulnerable with, and depend on, an other who could be unavailable or

264 rejecting. From Jasmine’s report, there is no evidence to suggest that her possible feelings of abandonment anxiety were directly addressed in treatment. However, it seems possible that Jennifer’s consistent availability in treatment indirectly mitigated these feelings, and contributed to the eventual establishment of an alternative model of interacting with a close other, one that helped Jasmine be more vulnerable, and trust that Jennifer would not leave her abruptly (Mitchell, 1988).

It’s plausible that Jennifer’s reported tendency to occasionally self-disclose about her own family dynamics and issues with her mother contributed to Jasmine being more open and vulnerable in treatment. Several writers have discussed how self-disclosure on the part of the psychotherapist is quite common in some form, though the type of disclosure depends on many complex factors (see Ehrenberg, 1995; Greenberg, 1995).

It’s possible that Jennifer self-disclosing around some of her own issues contributed to Jasmine seeing her as vulnerable and similar to herself in some ways, an experience that possibly challenged her assumption that others, especially White others, believe they are superior to her. As Jasmine was able to see Jennifer as vulnerable like herself, it’s plausible that her reported experience of always feeling, in her words, “different” from her White peers was challenged as she recognized Jennifer’s own vulnerability. This would connect with the possible mutative factor in group therapy, where it seems that the group members developed a sense of shared psychological pain. Leary (1997) argues that race operates as a powerful and pervasive influence on treatment, though it is often overlooked and underappreciated, casted aside unless a patient specifically brings race into the treatment room. While Jasmine didn’t explicitly bring race into the treatment, it seems possible that seeing a White woman as vulnerable like herself contributed to her

265 feeling less “different” from Jennifer, potentially resulting in her feeling more comfortable with being open and vulnerable with Jennifer about her struggles. In other words, it’s possible that Jasmine had a new relational experience with Jennifer where vulnerability and intimacy eventually felt safe and even secure, instead of leaving Jasmine open and vulnerable to potential hurt from others’ actions (Mitchell, 1988).

From a developmental perspective, it’s plausible that Jasmine was struggling with identity formation (Erikson, 1959), a process that can make one’s sense of self feel unstable, and contribute to vulnerable feelings, like self-doubt and depression, or feelings of being lost and confused. Additionally, a young adult can shift between different emerging identities, a process that can be painful and confusing, yet also potentially exciting (Gould, 1978). For example, Jasmine discussed feeling both extremely excited and immensely anxious about graduating from college and establishing a professional identity, feeling uncertain about what that would even look like or represent to her, especially as she reportedly had just started to understand herself, and her characteristic ways of functioning. From this perspective, it’s possible that as Jasmine struggled with her own vulnerable feelings of self-doubt related to constructing her identity, and what that meant to her, it could’ve been helpful for her to see that someone like Jennifer, someone who Jasmine possibly viewed as “superior” to her, could also be vulnerable and struggle, too. In other words, this experience could have helped Jasmine feel less different from others, and also potentially mitigated her feelings of self-doubt related to her struggle with establishing her identity.

266 Psychodynamic understanding of impediments to therapeutic action.

Group therapy.

In the previous section, I discussed my ideas related to why Jasmine might have been initially skeptical of group therapy, until she felt more comfortable and was seen as a role-model, a novel experience for her when engaging with others that possibly contributed to her being more open in the group. Other than seeming initially skeptical of group treatment, Jasmine reported two aspects of her group therapy experience that she found problematic, or unhelpful to her.

Jasmine reported feeling anxious about sharing something that could result in her being hospitalized by one of the group therapists, making her feel as though she had to, in her words, “walk on eggshells” at times. It’s plausible that Jasmine found this unhelpful due to the potential of this experience unconsciously evoking past distressing feelings related to a particularly upsetting memory she recalled from childhood, one where she told her “friend” about the impending divorce of her parents, only to have that friend threaten to tell her entire class, resulting in Jasmine reportedly feeling a sense of shame and betrayal. After that experience, she said that she refused to trust peers in her class, and tried to “pretend” that she was always happy. I noted in my field notes that Jasmine discussed this same memory on four separate occasions throughout the interviewing process, and each time appeared upset and still frustrated with this individual, even pointing to that memory as one reason she said she would never go back and visit the town she grew up and lived in for several years. It seems possible that this memory contributed to an unconscious assumption that if Jasmine said the wrong thing in group therapy, a disastrous outcome could result, manifesting in her initial reluctance to open

267 up to fellow group members, in addition to her conscious experience of feeling anxious and concerned about the potential of being hospitalized if she said the wrong thing.

While these two experiences are obviously unrelated, it’s plausible that from a psychodynamic perspective, they both stem from the same unconscious assumption, specifically that others can be unpredictable and betray her like her father and her “friend,” and consequently shouldn’t be trusted. It seems that the unconscious reactivation of this experience in school contributed to an anxious, guarded presentation she said she initially exhibited in group therapy, one that helped her protect herself from the unpredictable response of an other, while also perpetuating a distance between her and other group members that guaranteed that she would feel disconnected from them.

Jasmine’s sense in group therapy was that she was constantly “looked at objectively” by the group therapists, in addition to her perception that they were, at times, “looking down” at her and “judging” her. From my perspective, it seems possible that the group therapists were simply observing her and the other group members, something that may have felt to Jasmine as though they were “judging” her, given her past experiences with bullying. It seems plausible that Jasmine experienced this dynamic for two main reasons. First, it’s possible that her internal persecutory object was evoked and projected onto the group therapists, something that contributed to her feeling as though they were examining her with a critical eye, and expecting them to be judgmental of her.

Second, it’s plausible that the group therapists noticed that Jasmine reportedly appeared guarded and withdrawn on some days, and were curious about her mood and presentation, particularly on days when she reported feeling especially depressed, and consequently more withdrawn from the group, disinclined to participate at all. I noted in

268 my field notes experiencing this pattern during two specific interviews when Jasmine seemed more depressed, manifesting in her seeming not only guarded and withdrawn from me, but also less talkative, responding to my questions with short answers devoid of the level of detail she provided in a past interview. In one interview in particular, this presentation made me feel frustrated, and I noted that I responded by asking the same question in different ways in an attempt to elicit more details from Jasmine, something that I imagine could have felt to her as though I was “judging” her responses.

From the perspective of my countertransference, it’s possible that the group therapists also noticed this change in Jasmine’s presentation at certain times in group therapy, and became curious about her mood. In other words, it seems possible that when they noticed her seeming more guarded and withdrawn, they attempted to understand it, and possibly asked her more questions, or tried to analyze Jasmine’s behavior and her interactions with other group members. She reported one particular session in which she said she felt severely depressed, resulting in her feeling as though the group therapists focused too much on her, asking her multiple questions about her feelings and behavior.

It’s possible that they attempted to draw Jasmine out of her guardedness in an attempt to understand her subjective experience—however, it seems possible that she felt she was placed under a microscope and was wary about the motives behind the extra questions.

Specifically, what I mean is that it’s possible Jasmine interpreted the extra questions as the group therapists “looking” for ways to potentially bully her or criticize her, evoking early memories of feeling judged and criticized by her peers in school.

269 Individual therapy.

Overall, Jasmine reported a positive experience in treatment with Jennifer, and generally found her helpful. However, she also reported a few aspects of her experience that were not so helpful, or parts of her treatment that felt missing. It seems possible, from Jasmine’s report of treatment, that the therapeutic dyad found themselves at one point in an unconscious collusion, one that was never explored or understood, contributing to Jasmine’s report that something was missing in her treatment.

Specifically, while Jasmine said it was helpful that she and Jennifer occasionally operated like two “girlfriends” chatting about their collective issues, it seems possible that this dynamic eventually contributed to establishing a relational pattern where they, at times, unconsciously colluded in avoiding an exploration into Jasmine’s more upsetting feelings and problematic relationship patterns, including ones Jasmine experienced in the past when engaging with significant others. For example, I found myself frequently wondering about Jasmine’s lack of anger, or lack of rage, from being the victim of racist bullying. It’s possible that avoiding a discussion of her anger or rage is one example of what could have felt missing in her treatment, a collusion between the therapeutic dyad where Jasmine’s feelings of anger or rage weren’t discussed or explored. While it’s impossible to say, perhaps discussing those feelings felt too scary to both of them.

Jasmine also said she wanted a diagnosis from Jennifer, though she never explicitly articulated that to her, reporting that she didn’t want to make Jennifer feel uncomfortable, or put her “on the spot.” It’s obviously unclear why Jennifer might not have wanted to give Jasmine a specific diagnosis. However, for Jasmine, it’s plausible that in her treatment with Jennifer, she had her first experience establishing a deep,

270 emotional connection with an available woman she had grown to depend on and trust.

Consequently, it’s possible that she didn’t feel comfortable pushing Jennifer into providing what Jasmine thought could make her feel uncomfortable, not wanting to potentially create conflict and possibly re-create past problematic interactions, particularly those that could evoke painful memories of engaging with White females.

While the previously mentioned possible collusion was never explored or understood, and while Jasmine was never given a diagnosis—two things that potentially contributed to her sense that something was missing in her treatment—it seems to me that, developmentally speaking, what was more important for Jasmine was her having a new, different type of relationship when engaging with an intimate other, one where she felt that the other was available, responsive, accepting, and similar to her in some ways.

Based on Jasmine’s narrative, it seems that her treatment experience provided her with one of her first emotionally intimate relationships where she was open and vulnerable with a woman, especially one who on the surface was seemingly very different from her.

It seems that this provided a new model of interacting with others, one that in some ways impacted what I’ve described as Jasmine’s core issue, in that she experienced a relationship with someone who would not abandon or reject her, or fail to be available to her in significant ways.

Current functioning.

Currently, Jasmine describes herself as, in her words, “a changed person,” someone now capable of managing what she calls her “mental health issues.” She said she continues to struggle with depression and anxiety, but that she can better manage her

271 emotions, able to utilize skills she learned in treatment to prevent herself from feeling really depressed. She reported that she is more aware of her feelings and understands herself better, two skills she said she developed in treatment that allow her to recognize when she might be feeling too distressed, and find a way to cope with her feelings in a healthy manner, like talking with her boyfriend, or using mindfulness meditation to calm down. As she said, “a bad day is just another day,” and she doesn’t allow one bad day to make her feel depressed or anxious for several days, like she reported in the past.

Regarding her peer relationships, Jasmine reported feeling more connected to her best-friends, more open and vulnerable with them, and less preoccupied with thoughts that they may do something to compromise her trust. She felt proud in the last interview when she reported that some of her closest friends asked her for advice on how to handle distressing situations, something that Jasmine said made her feel happy and grateful that she went to treatment. Moreover, Jasmine said she experiences fewer symptoms of social anxiety, and reported that she is able to, for the first time in her life, not take interactions with friends so personally, a change that she said makes her feel more comfortable when interacting with them.

Jasmine said she has dated the same man for almost 2 years, and they currently live together. She described their relationship as “healthy,” and said that they talk openly with one another about their feelings. She said that her boyfriend is the only person she’s ever envisioned being together with long-term, something she said makes her happy and feel excited for the future with him. She described him as a “supportive person,” someone who was instrumental in encouraging her to attend treatment, reportedly telling

272 Jasmine that he would support whatever decision she made to feel better. She said he is a stable person in her life, someone who brings comfort to her when she feels upset.

Regarding her parents, Jasmine said she now feels as close as ever to her mother.

Since finishing treatment, she reported that her mother has been more open with her about her own feelings, in addition to supporting Jasmine and her efforts to feel better.

She said she was able to have an honest discussion with her mother about the sense of neglect and isolation she felt during her childhood, particularly when her parents were going through their divorce. She reported that her mother apologized profusely, something that contributed to them becoming closer. Regarding her father, Jasmine said she continues to experience conflicted feelings related to their relationship. However, she said that learning about her father’s struggles with mental illness has allowed her to empathize with him, and work to forgive him for his absence in her life. She said she has, in her words, “mourned” the father she always wanted, and “accepted” the father she has. In the last interview, Jasmine reported with both anxiety and excitement that her father plans to attend her college graduation, and that they are going to attempt to have a relationship yet again, though she worries about his ability to follow through with his reported wish to have a relationship with her.

In summary, Jasmine said that her treatment was not what she originally hoped for and expected, but that she ultimately learned much about herself, in addition to findings ways to effectively cope with her feelings. While she said that certain things in her treatment felt missing, like a specific diagnosis, she said she learned, in her words, “how to deal with everyday life.” She reported feeling excited for the future, yet she wants to be more mindful in the present. In the last interview, Jasmine said that she

273 wants “to be happy, today, in this hour.” Her treatment seemed to provide a starting point for her to accomplish this, something that seems contingent on her continued willingness to be open and vulnerable in her important relationships.

Participant E: Tonya Tonya is a 26-year-old Caucasian female who lives with her boyfriend. She is of average height and weight, has pale skin, has curly, black hair pulled back in a pony-tail, and wears black-rimmed glasses. Tonya looks to me like an artist, wearing stylish, vintage clothing combined with lots of jewelry. In fact, she is a musician, and in addition to teaching children how to play the piano, she manages a small, family-owned business that teaches people how to play a variety of instruments. She seemed somewhat quiet and reserved after meeting her, and what struck me most during the first interview is that she didn’t ask any questions about the study, something all other participants did. In addition, she appeared somewhat preoccupied and distracted to me, and I noticed myself feeling somewhat disorganized as a result. My initial impression was that Tonya could be, at times, aloof, though she seemed somewhat more present in subsequent interviews.

I will share more of my feelings and reactions throughout the interviews with Tonya in a later section on my countertransference.

In the first interview, Tonya said that she wanted to participate in my research as a result of her being in psychotherapy with several different therapists since high school, and having only one positive treatment experience when she was in college. She said that she is “so on and off” in terms of questioning whether or not therapy was helpful to her, or could be helpful in the future, and thought participating in my study could help her

274 better understand her seemingly conflicted thoughts related to her treatment experiences.

It seemed to me as though she couldn’t make sense of her experiences in psychotherapy, and hoped that participating in my study would clarify some thoughts for her. I wondered about her ambivalence, and imagined there were several reasons for her to feel conflicted about treatment. What’s striking about this case is that Tonya provided few substantive details related to her early experience in childhood, and how it felt to her, something I’ll discuss more in a later section.

Childhood and adolescence.

Tonya said she grew up in the middle of a large city in the Midwest with her parents and older sister, who is 2 years older than she. When discussing what she remembered about her childhood, Tonya associated to memories of her babysitter, someone who would take her all over the city, from going to the zoo, to spending time at the museum or shopping district. Tonya said that she saw this particular babysitter until she was 14 years old, and while she felt embarrassed to have a babysitter in her adolescent years, she said she didn’t want to end the relationship, even having “nightmares” for a period of time related to thoughts about the day her parents would decide that she no longer needed a babysitter. She said her babysitter had three kids that Tonya felt comfortable with, describing them as her “older siblings.” Tonya recalled that her babysitter was “never mean” to her, was always positive and excited to spend time with her, and “spoiled” her and her sister.

Tonya described herself as an “anxious kid,” someone who was often worried about something “bad” happening to her and her family, for example, her parents’ dying,

275 or being told she could no longer see her babysitter. She said she was “sensitive” to her surroundings, and often hyperaware of what other people around her were doing. She recalled a particularly distressing memory when a girl at her babysitter’s house told her that the world was ending, something that “freaked” Tonya out, reporting that she cried herself to sleep every night for almost a year. She said she was very private, and that she was “never really good at telling people things,” keeping her anxious thoughts and feelings to herself. She said she “didn’t like to bring things up that were bad,” and consequently avoided sharing her concerns with her parents, instead acting as though she was fine. She said she frequently took what other children told her literally, and often ruminated about what people said, especially if what she heard created anxiety for her.

She reported crying often as a child, at times not even knowing why she was emotional, though she believed she frequently experienced what she called an “existential crisis,” worrying about the death of her parents or thinking they would get a divorce. To deal with her constant worrying, Tonya said she always wanted to have fun, and remembered frequently asking her parents and older sister to engage in different activities with her, feeling sad and disappointed if no one wanted to play with her.

Tonya said the majority of her childhood memories, outside of engaging in activities with her babysitter, included her spending time at her parents’ storefront, a small, family-owned business that teaches individuals how to play various instruments.

Tonya’s father is a musician, and he taught Tonya and her sister how to play instruments as well. She recalled spending much of her childhood at the store, playing with her older sister while her father taught music and ran the daily operations of the business. Tonya recalled positive memories with her sister there, creating new games to play together that

276 kept them occupied while their father worked. While the vast majority of her memories at the store were positive, Tonya said she remembered one particularly distressing memory involving an older man. She said one man who would visit the store would occasionally ask Tonya and her sister to sit on his lap, something she said that “creeped” her out, and also negatively “shaped” her feelings towards men. She said she was “suspicious” of men after that incident, and felt uncomfortable around them, though she couldn’t articulate exactly why those memories made her suspicious of all men.

When discussing her relationship with her mother during childhood, Tonya described her as “a really nice lady,” someone who’s very maternal. Specifically, Tonya said her mother was supportive in tolerating her many hobbies and interests, and overall thought she was someone she could rely on when she needed her. However, Tonya said she had conflicting thoughts and feelings related to her mother, as she also described her as “anxious” and “overprotective.” For example, Tonya said that her mother worried constantly anytime Tonya and her sister left their home, telling them both that she’d call the police if they didn’t return home right away, in addition to telling them that “a rapist” lived in the area, to ostensibly scare them into not veering far from their destination. She said her mother “doesn’t trust the world,” and is “anxious and suspicious” of other people, making Tonya feel anxious and distrustful of others too, particularly strangers.

While Tonya described her mother as “well-meaning and loyal,” she said her mother’s constant worry and anxiety around Tonya and her sister being safe made it difficult to leave the home, something she said she dealt with by spending time at the family business, or with cousins and other family members her mother trusted who happened to live in the same city.

277 When describing her relationship with her father growing up, Tonya said he was the “fun dad,” someone she was closer to as a child than her mother. Tonya described how she was her father’s “buddy,” and that she would often spend time with him on the weekends, heading to the local market or playing and talking about music. She said she bonded with her father over music, whereas her sister bonded more with her mother.

Despite feeling close to him, Tonya said she didn’t trust her father growing up, and was suspicious of him, at one point believing that he was having an affair, without having any evidence to support this belief. Tonya couldn’t recall exactly why she thought that, other than she had some sense as a child that her father “was bad,” a feeling that manifested in her thinking that her father was doing something inappropriate behind her mother’s back.

Tonya said her father seemed clueless about how to be a parent at times, and would often rely on her mother telling him what to do, something that could create tension and conflict between them. She described her parents as having very different parenting styles: her mother overprotective and anxious; her father laid-back and calm, letting Tonya and her sister do things her mother wouldn’t approve of or allow, like going to the local grocery store unsupervised.

Tonya said she remembered her parents arguing often in her childhood, an experience that she described as “tumultuous” for her, particularly when they would argue in front of her. Tonya said their disagreements made her feel distressed and anxious, often making her cry as she said she then thought about worst-case scenarios in her head, like her parents getting a divorce. Tonya said her mother would scream at her father when they argued. For example, she remembered a particularly upsetting memory when her mother found cigarettes in her father’s coat, and completely lost her temper,

278 screaming and verbally attacking her father in what Tonya reported as a fury of emotion.

She said these moments in her childhood made her conclude that her mother didn’t trust her father’s ability as a caretaker, something that then also made Tonya doubtful of his ability as a father. She said these arguments continued throughout grade school and junior high, making her feel convinced that her parents would eventually get a divorce.

Despite Tonya’s sense that her mother was overprotective and always anxious, she said that her home environment was very unstructured. For example, Tonya said her parents “didn’t really expect the things that a lot of parents expect,” reporting that they didn’t require her to keep her room clean, to complete chores, to eat together for dinner, or to contribute to the housework in any way whatsoever. In addition, Tonya said her parents had no expectation that she get good grades and work hard in school, and described how they would have the same response to her if she received a good grade, or if she received an average or below-average grade. Tonya said they wouldn’t even ask her about her homework, or help her complete an assignment. She said her parents let her do whatever she wanted, and maintained a “nonjudgmental” stance about whatever she decided to engage in or pursue. She said they never put pressure on her to push herself, something she now resents as she said she wished she would have been more focused and disciplined during her schooling, and really figured out what she was interested in and liked. She reported currently feeling frustrated with her parents for not helping her find out what she’s really good at, and said she feels as though she’s “all over the place,” feeling stuck in her professional life. She said that as a result of her parenting, she now leads a very structured life, and described her need to be organized and on time, something she never experienced with her parents throughout her development.

279 In her adolescence and in high school, Tonya described herself as more social, spending time with “the stoner kids.” She said her high school experience was highly influenced by drugs and alcohol, and that she partied frequently. She felt that her parents turned a blind eye to her substance use, recalling how she’d even smoke marijuana in the basement of her home while her parents were upstairs. She remembered the transition to high school being easy for her, particularly due to her older sister attending the same school, and Tonya and her sister sharing the same friends and social group. While Tonya said she went to an academically rigorous high school, she said she managed to pass all of her classes without any problems, due to her grade school and junior high experience where she said she learned how to perform well on standardized tests. As a result, Tonya said she was never worried about academics, but that she often had concerns and issues around dating, something that created tension in her relationship with her mother.

Tonya said she sensed, particularly in high school, that her mother didn’t want her to have a boyfriend, a feeling Tonya said she had due to her mother being overprotective and suspicious of other people. She said she felt afraid to tell her mother about boys, due in part to her belief that her mother would be “mad” at her. When she was a freshman in high school, Tonya said she started to date an upperclassman, an experience that “freaked” her mother out and made her constantly worry. Tonya remembered wanting more independence from her mother, and consequently staying in the relationship, despite being treated poorly by her boyfriend. Eventually, Tonya said she figured out that her boyfriend just wanted to have sex with her, something that caused her to end the relationship. Tonya remembered that relationship, in particular, causing her to think about what she wanted in her life during high school. On the one hand, she said she

280 wanted more independence and wanted to be an adult. On the other hand, she said she wanted to be a kid still, two conflicting thoughts that produced anxiety and angst for her.

Eventually, she said she decided she needed independence from her mother, manifesting in her, one day, telling her mother what she’d be doing during the day and on the weekends, instead of asking her permission to do so. Additionally, she said she stopped telling her mother about her daily experience in high school, deciding that her mother didn’t need to know what she was going through, a decision that Tonya said produced immense levels of anxiety in her mother.

In terms of her mental health, Tonya said she remembered friends and family members telling her she was depressed and anxious throughout high school, but said she didn’t remember feeling that way, and said she couldn’t recall why others said that about her. What she could say was that she was “very emotional,” but couldn’t recall why that was the case, and couldn’t articulate in the interview what she meant by feeling “emotional.” This is just one example of how interviews would often go with Tonya: I’d ask a specific question, and she would divert her eyes and anxiously look at the floor before attempting to recall a “fact” about the past, like others describing her as “very emotional.” However, when I asked for clarification, or asked her to elaborate more on her feelings during a particular time, she’d pause, and report that she couldn’t remember any other details, especially if those details included any reference to her feelings or emotional life. She’d sheepishly laugh, and report that she just “wasn’t good at communicating” and discussing her feelings. During these moments, she’d appear anxious and uncomfortable to me, often reaching for a drink of water, or picking up her phone to ostensibly check her text messages or email. Occasionally, her face would

281 become flushed with red. I attributed this to Tonya’s tendency to easily feel anxious and overwhelmed with her emotions, and then struggle with what to do with her feelings, needing to distract herself from her anxiety by doing something, like drinking water, or checking her phone.

What Tonya did remember was her long-time babysitter moving out of state, an experience that she said made her have another “existential crisis,” worrying about her babysitter dying, or worried about her never coming back to visit. Additionally, Tonya said she believed that dating in high school made her feel depressed, as everyone just wanted to have sex with her, something she said she didn’t want. She remembered seeing a therapist in high school for her depression and anxiety, though she couldn’t remember anything about her treatment, other than she stopped attending her sessions after a short period of time. After a few failed dating experiences, Tonya said she decided she didn’t want to date anymore, and focused on spending time with her friends and her older sister.

As high school graduation approached, Tonya said she wanted to get away from her family. She remembered wanting to be an adult and move away from home, something her sister hadn’t done in college. She reported that she thought she had become an “independent person,” and felt ready to be on her own for the first time.

Tonya said that her parents were completely uninvolved during her college application process. She remembered that despite their expecting her to attend college, they didn’t help her with the application process, and didn’t influence her at all in terms of what college she decided to attend. Despite wanting more freedom and independence from them, particularly her mother, Tonya said she later resented the fact that her parents

282 didn’t help her in the application process. She said she ultimately picked a school out of state that was “easy” to get into, and moved away to start college.

Emerging adulthood.

Tonya said her feelings of wanting to be away from her family and enjoying more independence quickly faded as she settled into college. She said she felt “really homesick,” something that made her first year of college particularly difficult for her.

She remembered realizing, after she moved away, that she was more attached and dependent on her parents than she originally had thought, and missed them greatly, especially as she transitioned to living in a different state for the first time. She reported feeling very depressed, and was scared of being alone, inevitably finding herself feeling upset and crying profusely. To manage her loneliness, Tonya said she started dating a man, a relationship with someone she described as “horrible,” though she said she continued to date him to manage her feelings of isolation. Despite coming to “hate” her boyfriend, Tonya said it was better than being isolated, and temporarily served as a distraction from her thoughts and feelings related to wanting to be back home. When she wasn’t spending time with her boyfriend, Tonya said she partied frequently, especially with one friend she grew close to and spent time with often.

Tonya recalled relying more on her mother during college, especially as she continued to battle depression, anxiety, and feelings of isolation. She tried antidepressants, but said they didn’t help her, only making her experience the side effects of the medication. She said she called her mother often, and felt comforted after speaking with her. For example, whenever she felt so depressed that she couldn’t stop crying or

283 leave her bedroom, Tonya said she’d call her mother and just vent to her about her feelings. She remembered her mother not saying much of anything, but simply listening to her for as long as she needed. At times, she’d also talk with her father, something Tonya felt was not helpful to her as he was less inclined to listen, and more likely to offer advice. However, Tonya said his advice was “really off the wall,” and she found herself more frustrated than anything with him. In general, Tonya said that as she entered emerging adulthood, she found it difficult to connect with her father. She reported struggling to be affectionate with him, and felt unable to be open and honest with him about anything other than their joint interests, like music. She couldn’t say exactly why she felt a disconnect with her father, though she reported that something felt “off.”

Tonya continued to struggle in college, though she said her situation felt more manageable after meeting her current boyfriend, Tim. Tonya said she continued to feel homesick, and remembered feeling as though “she was growing up too fast.” However, she said that Tim is the first boyfriend she’s had that has treated her well, something she said eased the burden of being away from home. She said she realized in college that she, historically, dated “assholes” who treated her poorly, reporting that she never felt as though she was good enough to date someone who treated her well. With Tim, she said she finally experienced what it was like to date someone who truly loved her and cared about her. After college, Tonya decided to move back home, closer to her parents and sister. Tim joined her, and they moved into an apartment, and have lived together since graduation.

Within the past year, Tonya said she is experiencing some form of an “identity crisis.” Regarding her parents and sister, Tonya said she finally feels as though she

284 doesn’t depend on them, and noticed that she has “detached” somewhat from them, and feels like being around them less. She said she recently took an online personality inventory, the results of which said that she is an “introvert” and a “thinker.” She said those terms describe her well, and said that while she has very little to say when relating to others, she is thinking constantly in her mind. Regarding her friendships, Tonya said she has little social interaction, and spends time with a few close friends on occasion.

Professionally, she said her biggest struggle is deciding whether or not she wants to continue managing the family business, and if she does, whether or not she should try to expand the business. She said she has several ideas she has been considering, but as she reported, she’s better at thinking of ideas rather than implementing them. Tonya said she has a good relationship with Tim and feels happy with him for the most part, though she said that they struggle mightily to communicate their feelings with one another.

Treatment in emerging adulthood.

Tonya’s first experience in psychotherapy during emerging adulthood with a male psychotherapist named Dan was the only treatment experience, to date, that she said has been helpful to her, reporting that she “just got lucky” in finding Dan, the only “good” therapist she’s ever had. Tonya recalled that she went to the college counseling center to seek treatment, only to be referred to Dan due to her long-standing concerns with depression and anxiety, something she said wasn’t a short-term issue treated by the counseling center. According to Tonya, Dan is the only male counselor she’s ever had, and pointed out to me that she sensed he was gay, something she said made her feel more comfortable, though she couldn’t exactly articulate why that was the case, other than

285 recalling a past memory in childhood of feeling “creeped” out by men, suspicious of their intentions with her and other women.

When asked about what led her to seek treatment with Dan, Tonya said that she felt like something was wrong with her. Specifically, she reported the following: I just felt really emotional a lot. I remember crying and I feel like it was about that. And I think that also triggered this thought that there was something wrong with me, because I was always crying, and upset about something, and I would act out on it. Like, in tears, you know? So, I think that is what made me feel like there’s something wrong. Why am I always crying? I don’t know. Just crying; I don’t think that I really understood what I was crying about at the time.

Tonya recalled that she felt very depressed and anxious throughout college, but particularly during her first 2 years living away from her family, something that contributed to her seeking help from Dan. Additionally, she said she continually found herself dating “assholes,” men who would treat her poorly and make her feel even worse about herself. At 19, she decided that she needed help, and was ultimately referred to Dan, someone she would meet with weekly for almost 2 years. In the next section, I will discuss Tonya’s subjective experience in treatment with Dan in detail, including her report of what she specifically found helpful in psychotherapy with him.

After having to end treatment with Dan due to his re-locating, Tonya said she set up a meeting with another provider, a female social worker whose contact information was one of many therapists listed on a referral sheet she obtained from Dan. Tonya couldn’t recall her name, and said she only saw this person for roughly two months, even missing a few sessions. When recalling what prompted her to start therapy again, Tonya

286 said she couldn’t remember, other than a feeling that she was “supposed” to continue in treatment. Since her two-year treatment with Dan, Tonya said she felt less depressed and anxious, though she never felt completely devoid of her depressive and anxious symptoms. Tonya reported that her therapist after Dan “was horrible,” attempting to act like her mother. She remembered that this woman was starting her private practice in a “homey, weird office” in the back of her house. Tonya said that she couldn’t imagine how anyone could trust her as a therapist, due to her tendency to “talk about herself a lot.” She said she was a bad listener, very reactive, and worse yet, would always make comments to Tonya about how her own son was experiencing the same problem as her, constantly bringing up her son’s issues. Tonya quickly concluded that her therapist wasn’t professional, and left treatment.

After Tonya graduated from college and moved back home, she entered treatment with another therapist for roughly six months. She couldn’t recall the provider’s name, but remembered that she said she specialized in hypnotism. However, Tonya said she was never able to hypnotize her, and described her experience with this woman as “terrible.” Specifically, Tonya recalled that this therapist would look at her phone during sessions, and text and email in the middle of their appointments. On a positive note, Tonya said she never charged her at all for her sessions, and she abruptly left treatment, convinced that there are, in her words, “more bad therapists out there than good ones.”

After her brief stint in treatment with a hypnotherapist, Tonya said she found herself living with her boyfriend, managing the family business, and working long hours.

After getting adjusted to living closer to her family, Tonya said she, once again, found herself looking for another therapist. According to Tonya, she’s not exactly sure what led

287 her to seek treatment again, and she couldn’t provide an explanation of what she was hoping to get out of another experience in psychotherapy. All she could say is that she felt some depressive symptoms, though it was not as nearly severe as the depression she said she felt in college. Tonya said she went online to find a therapist with her insurance who had an office close to where she lived. She found Julie, and soon thereafter started what would become her latest and last treatment experience to date, seeing Julie weekly for over a year, from the ages of 23 to 25. Overall, she said her treatment with Julie was very unhelpful, and in summarizing her experience with her, said that Julie attempted to be her “friend,” not her therapist. In hindsight, Tonya said she felt as though her treatment with Julie made her feel “worse,” and engendered feelings of doubt for her about the ability of “most” psychotherapists to be helpful to their patients. In an upcoming section, I’ll provide details related to Tonya’s reported experience in treatment with Julie, and highlight what she specifically found unhelpful. First, though, I’ll share more about Tonya’s treatment in college with Dan, the only therapist she’s found helpful.

Therapeutic action: what Tonya reported.

Tonya said she’s had six different therapists in her life, with Dan being the only one who was able to understand her and ultimately help her. When asked what was specifically helpful in her treatment, Tonya recalled that Dan asked several questions initially in treatment to get to know her, something that made her feel as though he was making a strong attempt to really understand her. As she reported: He was really good at just like asking questions, repeating what I was saying, and showing me that he knew me, and understood what was going on in my head.

288 And if he didn’t, he was good at sort of like, like finding that out for me. Am I right? And if I would say like no, you’re not, and then listening and finding out what was right. So he took the time to get to know me, which then built the relationship of trust.

According to Tonya, Dan’s asking several questions early in treatment made her feel as though he had a context to understand her life, something that made her feel heard, listened to, and understood. She remembered his not jumping to conclusions about what she was thinking or feeling, instead allowing her space to answer his questions in whatever way she wanted. Tonya recalled Dan repeating, at times, what he heard from her to ensure he understood her correctly, something that made her feel as though they were on the same page. Also, Tonya said that Dan’s probing questions helped her find answers to her questions on her own, instead of him giving her advice or telling her why she was feeling a particular way, or what she should do in a particular situation. She said she needed someone to “guide” her, and Dan provided the type of direction she said she needed. His guidance, she said, made her feel empowered and more in control of her life, especially due to her sense that Dan made her feel as though she was the one finding answers to her questions, and putting in the work to discover more and more about herself.

Tonya reported that Dan was organized, something she also found helpful in treatment. For example, Tonya recalled that, during her sessions, Dan would bring out his file of her, and have it on his desk. Additionally, she said he would consistently have his pad of paper and pen ready, jotting down notes as they discussed various aspects of Tonya’s life. According to Tonya, Dan’s keeping a file of her and actively writing notes

289 during her sessions made her feel as though they were making progress, in addition to making her feel that “we’re moving forward, you care about this.” Moreover, Tonya said that Dan’s note-taking worked well with her “Type A” personality, as it made her feel that they were accomplishing something each session, that “everyday I’m getting something done.” In other words, she felt that she had “gotten something” out of each session, and felt as though she was on the right path after leaving her appointments.

Another defining aspect of treatment Tonya found helpful included Dan’s tendency to provide affirmation to her each session, particularly around her dating experiences. For example, Tonya recalled a significant moment in treatment with Dan, in which she described her recent decision to start dating Tim, her current boyfriend. Tonya said that Dan “showed that he was really happy for me,” telling her that he thought it was a positive relationship for her, and conveyed his happiness about her making a healthy choice to date someone who ostensibly treated her well. She recalled his affirmation making her believe she made the right choice in dating Tim, and felt that his happiness for her was “genuine,” not fabricated. Moreover, Tonya recalled that Dan helped her question her relationship choices when she was dating men who treated her poorly. She said that he would never explicitly tell her that a particular man was bad for her, and that she should end the relationship. However, she said that through the questions he asked, she could begin to understand that a given relationship was toxic, something that she said she often sensed, even as she remained in negative relationships due to having low selfesteem and little self-worth. According to Tonya, she stopped dating those types of men during her treatment, eventually beginning her relationship with Tim.

290 The last salient aspect of treatment that Tonya found helpful included her feeling that the focus of her treatment was exclusively on her, that it was “very one-sided, very much like serving its purpose of being my therapist.” In fact, Tonya said that she knew nothing about Dan outside of her experience with him in treatment, reporting that he was “very good with boundaries.” Additionally, Tonya said that with Dan, she never experienced any “unnecessary talk,” an experience she said she felt with every other therapist she’s had. After having three subsequent therapists since Dan who all, according to Tonya, had poor or questionable boundaries, it was especially helpful to her that Dan maintained a degree of distance between them, and used treatment with Tonya to focus exclusively on her thoughts and feelings. She said he never shared anything about his private life, an omission that Tonya said made her experience with him feel more professional, contributing to her establishing trust in his ability to help her.

After almost 2 years of weekly treatment, Tonya said she had to end treatment with Dan, due to his accepting a position that required him to move to a different state.

Tonya remembered her last session with Dan, in which he made it “a little bit sentimental,” conveying his positive feelings about Tonya and their work together. She remembered feeling uncomfortable, as she said she doesn’t like good byes, and, in her words, will “avoid the goodbye” at all costs. Additionally, she remembered feeling really upset that she’d no longer be meeting with Dan, reporting that she wanted to “see him forever.” Despite the ending, Tonya said that overall, she had a great experience with Dan, especially considering her belief that he’s the only helpful therapist she’s had.

291 Impediments to therapeutic action: what Tonya reported.

Tonya said she had a negative experience in psychotherapy with Julie, finding the treatment unhelpful. A salient reason Tonya said treatment with Julie was not helpful included her sense that Julie wanted to be her “friend” and have a personal relationship, instead of a professional therapy relationship. For example, Tonya remembered telling Julie about the elementary school she went to as a child, and how she thought her experience there contributed to some difficulties she encountered in the past, and throughout her development. Instead of understanding her experience, and inquiring about what happened in elementary school that Tonya felt contributed to some of her problems, Tonya said that Julie instantly told her that she knew about the school, and responded with excitement that her children would be enrolling there in the upcoming academic year. Tonya reported that although she initially humored Julie, she said she felt upset and ultimately shut down, switching subjects to avoid a discussion of her elementary school experience. She said she felt uncomfortable sharing her negative experience about a school Julie was clearly excited about, and wanted to discuss. Tonya said that Julie never caught on, and never addressed the original point she wanted to make. She reported that the elementary school example was just one of many incidents where she felt that Julie would take something she was discussing “into this personal realm,” and find a way to make whatever Tonya discussed somehow become instead about Julie. For example, Tonya remembered one session where Julie complimented her on her appearance, and then steered their session into a discussion of their personal styles, once even reportedly deciding to change her look and discuss her new change with

292 Tonya. As this happened repeatedly, Tonya said she began to wonder about why she came to treatment, and started to feel “worse” after each session.

Another notable aspect of her experience that Tonya found unhelpful included her sense that there was no direction to her treatment, and that Julie never asked questions to understand and begin to assess what Tonya wanted and needed from her in treatment.

Additionally, Tonya said she felt as though Julie jumped right into the present, without ever getting to know Tonya and her developmental history. Specifically, Tonya said that Julie asked few questions about her throughout her treatment, something that was particularly worrisome to Tonya initially in her sessions, as she felt as though Julie didn’t know much of anything about her, and consequently wouldn’t be able to offer anything of much value to her. Tonya said she needed more direction and a better focus to their meetings, and ultimately sent Julie an email outlining her concerns, specifically asking Julie for more thought-provoking questions, in addition to a greater focus on providing direction in their sessions. Tonya reported that while Julie acknowledged her email, she said she was unable to ask “thought-provoking questions.” She did, however, suggest to Tonya that she read a book about anxiety, something that Tonya said made her feel frustrated, as she said she didn’t have time outside of her treatment to read the book Julie suggested, instead wanting the sessions themselves to be more productive and structured.

Another salient aspect of treatment that Tonya found unhelpful included her perception that Julie never stopped talking during their sessions, filling any silence with “unnecessary talk.” For example, Tonya said that she often felt like Julie had a tendency to resort to “nervous talking,” as though she had “caffeine energy” and couldn’t control herself. According to Tonya, this would manifest in Julie constantly talking, often about

293 topics that didn’t have a purpose or were irrelevant to the treatment, causing Tonya to find herself “spacing out,” unable to listen to what Julie was saying. Worst of all, Tonya said Julie lacked any awareness, whatsoever, that Tonya wasn’t engaged with her, or that she was discussing something that had nothing to do with what Tonya was just talking about in a particular session. It got to the point, Tonya said, where it seemed to her that Julie completely dominated the sessions, unable to sit back and listen to what Tonya had to say.

The last part of treatment Tonya found unhelpful in psychotherapy included her feeling that Julie was off-base with her understanding or recommendations, unable to offer an intervention that Tonya found fitting or relevant. Tonya remembered Julie telling her about a specific book on anxiety that she thought Tonya would find helpful.

She said she “literally brought that up to me like ten times,” with each time Tonya showing no interest in reading the book, even telling Julie she didn’t have time outside of her sessions to read. However, she said that Julie continued to mention the book, even discussing a workbook Tonya could complete alongside reading the chapters. These experiences, according to Tonya, made her feel completely misunderstood, and ready to leave treatment. Moreover, she said that Julie would attempt to understand an experience Tonya was sharing, but that “she never got it right.” She decided to leave treatment, and has never returned to another therapist since that experience.

Psychodynamic assessment and interpretation of Tonya.

The case so far highlighted Tonya’s reported experience in her childhood and adolescence, as well as what she recalled during emerging adulthood. From there, I

294 discussed her various treatment experiences during emerging adulthood, exploring in detail what Tonya reported finding helpful in treatment with Dan, as well as what she found problematic related to her experience in treatment with Julie. Now I’ll offer a psychodynamic assessment and interpretation of Tonya, and later use the assessment to inform my psychodynamic understanding of therapeutic action with Dan, in addition to the impediments to therapeutic action in her treatment with Julie. This provides the opportunity to interpret and understand both of Tonya’s treatment experiences in the context of her reported developmental history.

Childhood and development.

From her report of being an “anxious kid,” it’s possible that Tonya has an anxious and sensitive temperament, and that, if this has been lifelong, it possibly contributed to establishing an internal world in which the world became a fearful place, full of people and experiences that could potentially harm her, what she described as constantly worrying about something “bad” happening to her or her family, something that caused what she reported to be several “existential crises” in childhood. For example, Tonya recalled several memories in childhood where she’d hear something anxiety-provoking from a peer at her babysitter’s house or in grade school, like the idea that one’s parents do not live forever, and “freak out,” reporting that she’d then ruminate about losing her parents, something that made her feel so anxious that she’d retreat into her bedroom and cry herself to sleep.

Tonya said she wouldn’t tell her parents about her anxious thoughts and feelings, though she couldn’t articulate why she felt reluctant to talk to them. What she could say

295 is that those moments made her feel so anxious that she tried to distract herself from her own thoughts, often by engaging in some activity with her sister. If playing with her sister didn’t help with her anxiety, Tonya reported that she’d ask her parents to go to her babysitter’s home, someone who would take Tonya to do something “new” and “fun” that would often make her feel better. What’s interesting to me here is that when Tonya felt extremely anxious and couldn’t calm down by playing with her sister, she’d ask to spend time with her babysitter, instead of one or both parents. From my perspective, it’s possible that Tonya’s reported anxiety was linked to what she reported also about her mother’s anxiety about the world.

It seems plausible that Tonya’s mother’s reported anxiety and suspicious demeanor intensified Tonya’s own anxious, fearful temperament. Tonya reported that her mother was overprotective, always anxious, and that she didn’t trust other people, often threatening to call the police on Tonya and her sister if they didn’t come home right away from the store just down the road, or constantly worrying about what Tonya was doing if she wasn’t at home by her mother’s side. While one may interpret her mother’s behavior as being protective and cautious, it seems extreme, particularly when combined with Tonya’s own anxious temperament. It’s possible that another child may have simply ignored Tonya’s mother’s admonitions, or that another child less anxious wouldn’t have been affected by her anxious presentation. However, because of Tonya’s anxious personality, it seems highly plausible that her mother’s anxiety contributed to an intensification of Tonya’s own anxious, fearful thoughts. Moreover, it seems possible that Tonya’s tendency to retreat internally into her private thoughts was used, on some

296 level, to maintain distance from her mother’s anxiety, attempting to stymie or minimize the unconscious transfer of her mother’s anxiety to her.

Tonya’s anxious presentation possibly manifested in her attempting to avoid, or maintain distance from, her feelings and emotional life, contributing to a constricted, distant presentation I experienced in every interview with her, where it felt to me as though she was occasionally someplace else, not present in the moment, instead seemingly preoccupied with her own thoughts. I will say more about my feelings and how they unfolded throughout the interviewing process in a later section on countertransference. That being said, it seems that her anxiety contributed to her experiencing conflicting thoughts related to establishing and maintaining relationships with others, as engaging in close relationships could engender the very anxiety she hoped to avoid or suppress.

It’s also possible that Tonya’s anxious, constricted emotional life made it difficult for her to connect with others, particularly on a deep, emotional level. It seems plausible that this dynamic first emerged between her and her mother, where Tonya seemed to have ambivalent feelings related to connecting with, and depending on, her mother. On the one hand, she described her mother as nurturing, and always available to listen to her, willing to drop everything and be there for Tonya when she discussed her feelings of depression and anxiety in college. On the other hand, she said her mother was always anxious and worried, making Tonya and other family members anxious as well, in addition to making Tonya want distance from her, especially when she’d “put” her anxiety onto Tonya. It’s possible that when Tonya sensed her mother’s overwhelming anxiety, she retreated into her own internal world, wedded to not sharing the anxious

297 thoughts she often experienced throughout childhood. From this perspective, this dynamic contributed to Tonya not sharing her anxious thoughts, instead ruminating about them privately. She could have sensed that her mother couldn’t contain her own anxiety, and consequently avoided sharing her worries, in addition to attempting to distract herself through engaging in activities, a behavior that allowed Tonya the ability to contain her anxiety to the extent that she remained busy. This dynamic, combined with Tonya’s anxious temperament, possibly manifested in her attempting to ward off all emotions, something that worked in a transitory manner, until she found herself greatly depressed, most times without a clear understanding of why she felt so bad.

In summary, a combination of Tonya’s anxious temperament coupled with her mother’s intense anxiety seemed to contribute to Tonya struggling with how to handle her emotions. It’s plausible that a lesson Tonya may have learned, unconsciously, is that relationships are not helpful in mitigating difficult, or anxiety-provoking, circumstances.

In other words, she may have learned that intimate relationships might even intensify one’s own negative feelings. If this is true, it seems that Tonya unconsciously feared becoming close to her mother because doing so meant coming into contact with her mother’s overwhelming, existential anxiety. Perhaps Tonya developed a relational stance that protected her from her mother at the price of learning that vulnerability and intimacy can actually feel safe and secure.

Personality patterns and characteristic defenses.

Tonya described herself as an introvert, someone who is quiet, reserved, and a private person. At the time of the interviews, she had recently taken a personality

298 inventory, with the results identifying her as a “thinker,” and not a “feeler.” These descriptions are important in that Tonya saw them as accurate, and seemed to place significant value on them, discussing them on five separate occasions in the interviews.

For example, there were moments when I’d ask Tonya a question related to how she felt during a particular time in her life, and she’d appear anxious to me as she struggled to articulate anything related to her feelings, and then would refer to the description of her as a “thinker” as the reason why she couldn’t discuss her emotional life. It was as though she believed it was too overwhelming for her to “think” about her feelings, and so she used the findings of the personality inventory to support this belief. While I will say more about my countertransference feelings in a later section, feelings that I believe provide critical data into Tonya’s personality patterns and internal world, it seems necessary to briefly discuss some of my thoughts related to Tonya’s personality, particularly as it unfolded in the interviews.

What Tonya described as introverted, to me seemed more distracted, appearing preoccupied with her own thoughts, especially in the first three interviews when Tonya seemed more anxious to me, feelings I noticed after some of her anxiety seemed to transfer to me. Her presentation manifested in her seeming disinterested in my research, at least initially, and I noticed that she seemed to struggle with staying present in the moment, often needing me to repeat questions. Her distracted presentation also contributed to difficulties in Tonya articulating herself in the interviews, responding to questions in a manner that often lacked specific details and references to how she felt at particular moments in her life, a pattern of interacting that made it difficult to obtain a clear picture of Tonya’s developmental history. There seemed to be a confusing nature to

299 her communications: while she said she wanted to participate in my research, her manner of relating to me conveyed something much more ambivalent, and I imagined that if she repeated this pattern in other relationships, those engaging with her could feel confused, similar to how I felt as I attempted to manage the tension between her verbal and nonverbal communication.

Tonya’s distracted, preoccupied presentation also, from my perspective, made it difficult for her to connect with others, manifesting in her having few friends, and keeping distance from most people. She indirectly corroborated this idea in the interviews, and said that she is a very private person, and feels comfortable sharing her thoughts and feelings with only a few close others, though she continues to experience difficulties in expressing her feelings with her long-term boyfriend. Tonya’s way of relating, combined with her distracted presentation, contribute to her appearing to have an independent personality, at least on the surface. It seems plausible that her private, distracted disposition contributes to others experiencing her as self-sufficient, needing little social interaction. However, as I’ll discuss more in a later section on my understanding of her treatment experience, it seems possible that her distracted, seemingly independent personality pattern is used defensively to maintain distance from others, due to her need to keep her anxious thoughts and feelings out of her awareness.

In terms of defenses, it seems possible that Tonya’s anxious personality contributed to her relying on a manic defense throughout her development, in an attempt to ward off anxious thoughts and feelings related to perceived impending danger. For example, Tonya described being preoccupied as a child with anxious thoughts about her parents getting a divorce, the world ending, and her babysitter leaving her. In addition,

300 she occasionally felt suspicious of men, particularly after an experience where she felt “creeped” out by a man who occasionally wanted her to sit on his lap. Tonya reported engaging in what sounded like almost continual activities, constantly involved in whatever interest she could explore. It seems possible that Tonya unconsciously attempted to suppress her anxious thoughts by engaging in incessant activities as a child, stating that she always wanted “to be doing something.” From this perspective, Tonya may have needed to distract herself from her own anxious thoughts, using the manic defense in an attempt to keep herself from ruminating, preoccupied with thoughts of potential situations that could bring fear and loss to her or her family. Tonya said she was “hobby-centered,” always looking for something new to play. It’s possible that her investment in engaging in activities was an unconscious attempt to maintain distance from her anxiety, and her fearful thoughts that would make her feel terrified of the world and what could happen to her at some point in the future.

Fantasies/experiences of relationships.

As mentioned in previous cases, when examining one’s fantasies and experiences of relationships, Mitchell (1993) argued that one must look at what “people actually do with each other and the strategies they have learned for being a person with other persons” (p. 106). It seems plausible that one strategy Tonya learned early in childhood includes the idea that feelings are threatening, and that they should not be felt and communicated to others, as discussing them requires feeling them, which will only intensify her distress. In other words, this seemed to contribute to an unconscious fantasy where Tonya believed that thinking, and not feeling, should be the predominant mode of

301 relating to others, contributing to a rigid self-state based on the avoidance or suppression of emotion. Tonya discussed in several interviews how she kept her anxious thoughts and feelings to herself in childhood, at one point spending almost a year crying herself to sleep. It seems that Tonya’s parents didn’t recognize and respond to her anxiety at all, or at least enough for her to feel as though sharing her feelings with them could mitigate her distress. Instead, based on Tonya’s report of her mother’s overwhelming anxiety, it’s possible that she unconsciously assumed that any discussion with her mother would worsen her already difficult-to-manage feelings, contributing to her maintaining distance from her parents, and keeping her anxious thoughts and feelings to herself.

I experienced this pattern in the interviews with Tonya. For example, one specific moment comes to mind where she began discussing her wish to have a family in the near future with Tim, and then seemed to nervously laugh when she followed that comment by reporting that Tim doesn’t know if he wants children. When I asked her to tell me more about her conversations with Tim regarding this issue, she said she couldn’t talk to him about that now, since they were in a “good place.” During this moment, Tonya appeared more anxious to me, diverting her eyes and checking her phone. I then asked if she could talk about how this potential conflict with Tim felt to her, and she said she didn’t want to talk about it, and that she didn’t have anything more to say. We moved on to a different question, but I noted in my field notes that Tonya appeared anxious, and seemed to need to avoid her feelings related to this issue. This moment seemed to highlight her unconscious assumption that discussing feelings are threatening, and that they should be avoided or suppressed as a result.

302 It’s also possible that Tonya developed an underlying assumption that she can’t fully depend on people, an experience that possibly generates unconscious conflict related to establishing close relationships. Mitchell (1993) argued that the predominant strategies an individual learned included those experienced with parents in one’s development. As briefly mentioned, Tonya’s report of her mother is that her constant anxiety affected everyone in the family, and contributed to Tonya needing distance from her mother. From this perspective, it’s possible that Tonya developed an unconscious assumption that becoming emotionally close to another person results in the other’s narcissistic intrusion of his or her feeling states onto her—similar to Tonya’s reported experience of her mother, and specifically having to deal with her mother’s constant anxiety—what Tonya called her mother’s “distrust of the world.” This would fit with the idea that Tonya needs to maintain emotional distance from others in her relationships, as it’s possible that she unconsciously believes that establishing a relationship characterized by closeness and emotional intimacy would be too overwhelming. Specifically, she could find herself in a relationship where the other person intensifies her own anxious thoughts and feelings, or could find herself in a situation where a significant other’s narcissistic intrusion of his or her feeling states onto Tonya makes her shut down and need distance, similar to her reported experience with her mother.

Last, it seems that Tonya’s experience in childhood, particularly with her parents, left her with a predominant relational model in which she unconsciously assumes that others are certain to fail her, unable to attend to her needs. This seems to contribute to her maintaining emotional distance from others, in addition to being reluctant to discuss her feelings in the context of a close relationship. Not only does this seem to create

303 unconscious conflict for Tonya related to feeling close to, and depending on, intimate others, but also it contributes to her appearing mechanical, rigid, and emotionally constricted, a presentation I experienced with her in the interviews. Additionally, it’s possible that this relational model prevents Tonya from feeling close enough to a significant other to explicitly articulate what she needs or wants in a given relationship, fearful that others will somehow fail her and intensify her distress, or find a way to be intrusive and shift the focus away from Tonya and what she wants or needs. This seems to corroborate her unconscious assumption that others are destined to fail her, and also contributes to her feeling reluctant to directly ask for what she may want or need from someone, ultimately feeling disappointed in others and consequently re-creating the same cycle of feeling failed in familiar ways (Mitchell, 1988).

It’s not just that Tonya felt failed by her parents. She also said she felt disappointed by her school and teachers, as she said that she could perform well on standardized tests as a result of her schooling, but that she wasn’t provided with the necessary direction needed to figure out what specific area of study she should pursue, reporting that no one helped her identify her specific interests, something she said she wanted in school, yet never explicitly requested. From her report, it seems that she wants direction and guidance from others, particularly authority figures. However, instead of directly asking for what she needs or wants and potentially feeling failed or disappointed, it seems that Tonya maintains distance and keeps quiet, something that prevents others from providing direction while also bolstering her notion that she can’t fully depend on people for guidance and support. I will describe, in a later section on Tonya’s experience in psychotherapy, how I think this relational model impacted her treatment.

304

How I understand what brought Tonya to treatment.

Tonya reported that she sought treatment with Dan in college due to her sense that “something was wrong” with her. From Tonya’s perspective, this became evident after she found herself crying frequently, and felt depressed and anxious. Moreover, she said she felt isolated and alone, and didn’t have many friends. From a psychodynamic perspective, it seems possible that Tonya sought treatment in college for several reasons.

First, it’s plausible that her defenses stopped working like they had in the past, and Tonya’s propensity to employ the manic defense no longer provided the same level of protection and distance from her negative feelings. It’s possible that college may have represented a significantly new and more challenging social environment for Tonya, one in which there was nothing familiar to rely on to provide some sense of comfort. Second, and the most salient possibility from my perspective, includes the idea that Tonya couldn’t connect with her peers, and she found herself depressed as a result of feeling isolated and alone. I will say more about my countertransference in the next section, as I believe my feelings while interviewing Tonya provide some insight into the difficulties in relating with her. That being said, it seems possible that Tonya’s anxious personality, coupled with her difficulties in expressing her feelings, made it difficult for her to establish connections with her peers, retreating into the safety of her internal world from which she appeared reserved and disinterested in establishing friendships.

Additionally, it’s possible that Tonya seemed distant and preoccupied when engaging with her peers, resulting in her struggling to connect with others and make friends. It seems possible that her college environment evoked feelings related to her

305 unconscious conflict: she wanted to make friends and connect with others, yet simultaneously felt unable to allow herself to be more open and vulnerable, and establish close relationships characterized by emotional intimacy. It seems that this conflict left her wanting more friendships, yet feeling unable to actually go out and establish deep connections. She corroborated this idea in the interviews, describing how she struggled to make any close friends and consequently felt alone and “homesick” often in college. It seems likely to me that she felt completely alone, and sought treatment with the hope of connecting with someone to mitigate her feelings of isolation that seemed to contribute heavily to her depression.

In her latest treatment, Tonya reported that she didn’t know why she sought treatment with Julie. She said she was living with her boyfriend, managing the family business, and was able to visit her family whenever she wanted. However, soon after moving back to where she grew up, she said she found herself, once again, searching for another therapist. While Tonya said she’s unsure of why she began another treatment, from a psychodynamic perspective, her engaging with another therapist didn’t happen by chance.

From my perspective, it seems plausible that Tonya began her last treatment due to a nascent sense that something was missing in her life. It’s possible that she initially expected to feel differently after moving back home closer to her family, ostensibly relieving her feelings of being “homesick” and isolated. However, from Tonya’s report, it seems that she continued to feel distant and disconnected from her family members, despite being close to them geographically. It’s possible that Tonya’s predominant relational model that made it difficult to connect with others manifested in her feeling as

306 though something was off, that something was missing in her relationships, resulting in her seeking direction and guidance externally to understand her feelings. Moreover, Tonya said that when she moved back closer to home, she continued to struggle to communicate with her boyfriend, especially concerning their feelings toward one another.

It’s possible that she wanted to have a more intimate relationship with Tim, yet experienced unconscious conflict related to actually expressing her feelings and being vulnerable with him.

What’s puzzling is that, after having a good experience in treatment with Dan, Tonya reportedly found someone so bad in Julie, yet someone she stayed in treatment with for a significant amount of time. A possible explanation is that being failed by authority figures is familiar to Tonya, especially when being around her family. I will discuss Tonya’s treatments with both Dan and Julie from a psychodynamic perspective in an upcoming section, and specifically highlight the unconscious processes that I believe impacted both treatments.

Countertransference.

My initial impression of Tonya was that she was distant, and I remember wondering if she’d continue to participate in the study after the first interview. She was friendly to me, but she seemed distracted, creating the impression that she either wasn’t that interested in my research, or that she had something important on her mind that she needed to attend to, preoccupied with her own private thoughts. Because I relied on my field notes as a source of data to note my feelings and reactions to Tonya throughout the interviews, I was able to see, upon reviewing them, that I mentioned six times in the

307 initial interview that she seemed distracted. Over time, I learned that Tonya was, in fact, interested in the topic of my research, particularly due to her negative experiences in psychotherapy over the years. However, due to my sense that she seemed preoccupied and distracted, I noticed in the first two interviews that I felt somewhat distracted and disorganized myself, and initially struggled to follow along in the interview, noting that I had to put in additional effort to stay attentive to her. When reflecting on this impression of mine, I believe that I felt somewhat disorganized in the first few interviews due to sensing a mechanical rigidity in my initial interactions with Tonya, a dynamic I didn’t feel with any other participant. I remembered feeling surprised and somewhat disconcerted by how little she had to say at the beginning of the interviewing process, something I believe contributed to my own sense of disorganization.

I also felt that it took longer for me to feel connected to Tonya, specifically noticing that I developed a rapport more quickly with all other participants, something that was notable to me. I sensed this disconnect for two main reasons. First, it seemed to me that, at least initially in the interviewing process, Tonya struggled to articulate herself well, attributing her difficulties to her inability to “remember” certain details of her life.

For this reason, her case is noteworthy for its lack of substantive detail related to her early development and how it felt to her. This inability manifested in Tonya providing short answers to my questions, or, manifested in her exhibiting a somewhat puzzled look after a particular question, only to ask me to reiterate the question. It’s possible that she was anxious and distracted, preventing her from being entirely present in those interviews. I found myself repeating the question, or asking it in a different way, hoping to obtain additional details that would shed some light on her past experience. Tonya

308 would take some time to think, and could occasionally articulate herself better after I expanded on the question, though her responses lacked any mention of her feelings or emotional functioning.

I noticed that this dynamic between us created some distance, in that our conversations felt more mechanical, a back-and-forth question and answer session that seemed characteristic of someone who spoke with little emotion, her affect seeming flat and unchanging. It felt as though we quickly established a rigid pattern of relating, what Aron (2006) describes as a dyad getting stuck in complementary relations, one side taking a position the polar opposite of the other side, with little, if any, flexibility. What I mean specifically by this is that we, at least initially, seemed to fall immediately into rigid, formal roles that lacked any personal spontaneity, myself becoming strictly the interviewer and Tonya the respondent. While of course these roles are established and needed for the purposes of the study, what struck me particularly about this dynamic with Tonya is that her presentation made me operate in an overly formal manner, a way of engaging with others that is not typical for me. Additionally, I noted that Tonya spoke in a monotone manner, and rarely discussed her feelings. Later on in a following interview, Tonya would attribute this dynamic to her description of herself as a “thinker,” and not a “feeler.” To me, it felt like someone who struggled with emotions, resulting in a constricted emotional life. Interestingly enough, Tonya described how she had to “avoid the goodbye” with Dan, a pattern she also noticed with her friends, recalling a past memory where a close friend moved away, yet Tonya “pretended” that she would see her the following week, and as a result didn’t tell her goodbye. I noticed this as well in our last interview when I thanked Tonya for her participation in my study. After I expressed

309 my feelings of gratitude towards her for participating in my research, Tonya seemed uncomfortable and anxious in my presence, standing up right away to get a drink of water. I attributed this to her difficulties in expressing her feelings and becoming close to others, a dynamic that seems to make her need space and distance, especially when the possibility of establishing closeness emerges.

I also sensed Tonya’s anxiety when meeting with her. Initially, this manifested in her seeming somewhat reserved and guarded to me, as though she needed to spend time with me before she could open up more. It felt to me as though she needed to keep her distance, until she figured out if I could be trusted. Other times, this sense I had regarding her feeling anxious became evident when she would stop in the middle of answering a question, and wonder aloud if she remembered to complete something for work, checking her phone and then returning to the interview seconds later. In this particular interview, I noted in my field notes that this same behavior happened on three separate occasions. It seemed to me like she was distracted by a thought she had, and nervously checked her phone to assuage her anxiety. Additionally, I noticed feeling anxious myself in the first two interviews, and attributed these feelings to the unconscious transfer of some of Tonya’s anxiety to me, in addition to not feeling as though we developed a rapport immediately. While Tonya opened up and seemed slightly less guarded to me over time, even becoming somewhat more talkative in the latter interviews, it struck me that what I was sensing when engaging with her could be a representation of her struggles in connecting emotionally with others, due to her anxiety and tendency to be preoccupied and distracted with her thoughts, something I imagine perpetuates distance in her interactions. This dynamic certainly seemed to create distance

310 between us, contributing to a sense of disconnection I felt at several times throughout the interviews.

I also occasionally felt frustrated when interviewing Tonya. I noticed that some of this frustration resulted from hearing about her negative experiences in psychotherapy, particularly those in which she described her sense that her therapist “was unprofessional” and wanted some type of personal relationship with her, or when she described her experience in her last treatment where she felt that her therapist asked few questions and didn’t understand Tonya and her history, unable then to provide anything of use to her. On the other hand, I sometimes felt frustrated with Tonya, especially when she would seemingly avoid bringing up her concerns in treatment with her therapist, as though she was hoping or expecting that her experience in psychotherapy could change for the better, without articulating what she needed in treatment. While Tonya did eventually email her last therapist a list of concerns, for the most part, it seemed like she magically wanted her treatment experience to improve, without taking an active role in that process. It did seem that Tonya had some questionable treatments, based on her reporting. However, it also seemed like she didn’t take an active role in expressing what she needed from her therapists, contributing to her feeling disappointed during and after the vast majority of her experiences in psychotherapy. My sense was, due to her own anxiety and other unconscious reasons that will be discussed in a later section, Tonya felt disinclined to express her concerns and potentially create conflict between her and her therapist, instead feeling frustrated internally and ultimately leaving treatment.

In concluding this section, it seems necessary to end with a summarizing thought on what I believe these countertransference feelings and reactions mean or represent in

311 connection to Tonya, as these feelings are crucial data to help understand her internal world, and how her subjectivity plays out in the context of interacting with others (see Maroda, 1991). What do these feelings I experienced throughout the interviews with Tonya mean? It’s my contention that my countertransference sheds light on Tonya’s core issue, what seems to me as her ambivalent feelings of hope and terror she experiences when attempting to establish close relationships and connect deeply with others.

Following Mitchell’s (1993) idea that one can experience feelings of hope and dread when attempting to connect deeply with another person, it seems as though Tonya’s core issue revolves around her conflicting, competing thoughts and feelings related to getting close to others and establishing emotional intimacy. One the one hand, it seems as though she maintains a distance from others that affords her protection from her feelings and emotional life, what on the surface looks like a self-sufficient individual who needs little social interaction. This distance seems to help Tonya manage her unconscious assumption that others are not helpful in mitigating her distressing feelings, or that others will be intrusive and “force” their feeling states onto her, contributing to her need to operate in what seems like a rigid, mechanical manner. Additionally, it seems possible that this self-state helps Tonya manage her sense that others will fail or disappoint her, similar to her reported experience with her parents, her teachers, and almost all of her therapists. On the other hand, it seems as though she feels like something is missing in her life and in her relationships, a sense of disconnection that contributes to her seeking out therapist after therapist, despite consciously feeling dissatisfied with the vast majority of her treatment experiences. This conundrum, and how I believe it has shaped and impacted Tonya’s experiences in psychotherapy, will be

312 discussed in the following section. That being said, it seems plausible that this core issue has impacted every important relationship for Tonya, and has contributed to difficulties in relating to others since childhood.

Psychodynamic understanding of therapeutic action.

A salient aspect of treatment Tonya found helpful with Dan included her sense that he asked several questions in the early phases of treatment in an attempt to deeply understand her, questions she said that made her think about herself and ultimately begin to understand herself better. It seems that Dan engaged Tonya by asking about her, by being curious about her and thereby asking her to be curious about herself, something Tonya implied when she reported that Dan’s questions helped her begin to understand herself better. In Tonya’s words, Dan’s curious questions about her life and subjective experience helped her understand “what was going on” in her head, providing a structure for Tonya to think about, and potentially integrate, her anxious thoughts and feelings.

Additionally, it seems that Dan’s questions were not only helpful for Tonya in developing her own curiosity and self-understanding, but more importantly, they were focused exclusively on Tonya and her experience. This seems particularly powerful, as it suggests that Dan wasn’t intrusive like Tonya’s reported experience of her mother, that instead he anchored exchanges in Tonya’s experiences, feelings, thoughts, and needs.

This experience possibly provided an alternative relational model for engaging with close others, as her childhood experience could be reconceptualized as her mother’s narcissistic intrusion of her feeling states onto Tonya, who found adult anxiety utterly overwhelming and so responded by shutting down a kind of openness to others. While minimizing her

313 relational vulnerability protected her, it also left her isolated and unable to establish satisfying, reciprocal intimacy.

It’s plausible that Tonya’s sense that Dan was organized provided a sense of structure she felt her parents failed to provide her in childhood. Tonya reported that she would see her file on Dan’s desk at the beginning of her session, and immediately feel a sense of comfort, though she couldn’t say exactly why she felt that way. When discussing her past experience with both parents, Tonya reported that her childhood environment was unstructured, disorganized, and had few, if any, parental expectations.

Specifically, she said the lack of structure combined with few expectations made her feel resentful later in life towards her parents, as she felt as though she lacked any real direction and focus in her life. From this viewpoint, it’s possible that Dan’s perceived organization provided some sense of what Tonya felt she missed from her parents, and eventually contributed to her experiencing a new, growth-promoting experience with an authority figure, one where she could possibly feel more organized herself as a result of Dan’s reported organization and structure (Hoffman, 2006). Additionally, Dan was organized in the service of meeting Tonya’s needs; in contrast, her parents’ mismatch with her meant they were disorganized because of their own narcissistic preoccupations, ignoring Tonya’s needs. In other words, Dan seemed focused on tracking and meeting Tonya’s needs, unlike how she perceived her parents to be. It’s plausible that this experience eventually provided an alterative model of interacting, one where Tonya could manifest a self presentation less identified with the unstructured, disorganized past that was both familiar and familial, instead experiencing a novel relationship with an organized, structured other (Mitchell, 1988).

314 Tonya said that another defining aspect of her treatment that was helpful included Dan’s providing affirmation around her making positive choices for herself, especially related to dating men in college. It seems possible that Tonya unconsciously expected Dan to react to her dating experience with anxiety and suspicion, a maternal transference expectation she reported experiencing historically with her mother, particularly related to dating (see Freud, 1914). Instead of becoming anxious, suspicious, and consequently intensifying Tonya’s own anxiety about dating, Dan reportedly reacted with curiosity and happiness for her, a novel experience for Tonya where sharing her feelings with a close other resulted in a positive interaction, instead of the anxious questioning and “distrust of the world” she reported expecting from her mother (Mitchell, 1988).

It’s plausible that this interaction challenged Tonya’s unconscious fantasy that connecting with another person and sharing her private thoughts and feelings results in an anxious response from the other, a reaction that historically exacerbated her own feelings of anxiety. Hoffman (2009) argues that battling a patient’s bad objects, or battling the unconscious repetition of self-destructive tendencies, can require multiple approaches, one being the expression of feelings that emerge spontaneously in the context of treatment, feelings and attitudes that can potentially provide a different kind of presence in a patient’s life, one that can compete with destructive influences of the past. It’s possible that Tonya’s sense of Dan’s genuine happiness provided a different presence, one more positive and supportive of her dating experiences. Stern (2010) argues that psychopathology, in his model, is understood as the degree of freedom or rigidity that characterizes one’s approach to experience. From this viewpoint, it’s plausible that Tonya’s sense of Dan’s feeling happy for her provided the freedom she needed to

315 consider alternative meanings when interacting with others, one where the self can be more open, and less preoccupied with maintaining protective distance from the response of an anxious and highly anxiety-provoking other (Stern, 2010). It’s plausible that this experience with Dan challenged her predominant model of relating to authority figures, one where she maintains emotional distance by operating within a distracted, preoccupied self-state that contributes to Tonya seeming disinterested in establishing relationships and closeness.

It’s plausible that Dan’s ability to maintain professional distance and provide what Tonya described as a “one-sided” relationship was particularly helpful to her given her tendency to worry excessively about important others, in addition to her experience of interacting with an anxious, intrusive mother. As previously mentioned, Tonya reported historically experiencing anxious, fearful thoughts related to something “bad” happening to those close to her. However, if she knew nothing personal about Dan, someone she started to feel close to and depend on, it seems possible that Tonya could then feel less anxious about losing him, manifesting in her feeling a sense of comfort in her sessions with him, so long as she didn’t learn anything about him personally. From this perspective, it makes sense why Tonya felt uncomfortable when Dan announced they would have to end their treatment, even reporting that she needed to, in her words, “avoid his goodbye.” When Dan announced that he was re-locating, it seems possible that he became a real person to Tonya, someone with needs and desires of his own, possibly evoking the very feelings of anxiety and loss she experienced in relation to her family members. Before this moment in treatment, Tonya’s experience of Dan was that he was

316 someone who had focused exclusively on her needs, ostensibly needing nothing from Tonya in return, unlike how she perceived her relationship with her mother.

Before turning to a discussion of Tonya’s treatment with Julie, it seems critical to end with a summarizing thought related to what I described as Tonya’s core issue, and how it may have manifested in her treatment with Dan. Based on her childhood and parental relationships over the years, it’s plausible that Tonya entered treatment with Dan and unconsciously attempted to re-create constricted relational patterns developed from the past, contributing to specific transference patterns described by Mitchell (1988) as the psychotherapist inevitably falling “into one of the patient’s predesigned categories” (p.

295), resulting in an unconscious expectation to experience new relationships in old, familiar ways. From this viewpoint, it’s possible that Tonya entered treatment with Dan expecting to find herself relating to an anxious other who, similar to her reported experience with her parents and particularly her mother, would fail to provide guidance and direction, or who could potentially intensify the anxious feelings she attempted to avoid or suppress. This would corroborate her unconscious assumption that relationships are not helpful in mitigating her difficult-to-manage feelings, and that others intrusively “force” their feeling states onto her, shifting the focus away from Tonya and what she may want or need in a relationship. Additionally, this would intensify her unconscious conflict related to getting close to others and establishing emotional intimacy.

Instead, it seems that Tonya experienced Dan as helpful and supportive, due in part to her sense that he was organized, he engaged her by asking curious questions that helped her understand herself better, he focused exclusively on her needs, and he maintained a professional distance from Tonya that seemed to mitigate her anxiety

317 related to engaging with an intrusive other. It seems that her treatment with Dan provided an alternative relational model of engaging with a close other, one that didn’t bolster Tonya’s unconscious fear that becoming closer to a significant other meant coming into contact with that person’s overwhelming, existential anxiety, something she experienced with her mother. With Dan, it seems that Tonya started to learn that being more open and vulnerable in a relationship could actually feel safe. While her treatment with Dan wasn’t psychoanalytic in the conventional sense, it seems that there was more of a need for Tonya to have an experience with a therapist who was engaged, curious, and supportive.

In summary, it seems that Dan provided solid supportive treatment that was focused on Tonya’s needs—but then he reasserted his own needs into the treatment by relocating and leaving: perhaps even felt as abandoning her. It’s possible that ending treatment with Dan was even more upsetting than Tonya reported in the interviews.

When I asked Tonya how she felt during her ending with Dan, she didn’t discuss her feelings much, though she did say that she felt “really upset,” and that she wanted to “see him forever.” It’s possible that her ending with Dan left her vulnerable to reverting to older patterns that emerged in the unhelpful, unsatisfying treatment with Julie, whom Tonya experienced as self-absorbed, like her own parents. It’s also possible that Tonya’s experience with Dan was a tantalizing hint of what therapy with a supportive other could be like, but not enough to considerably alter longstanding relational models, including the self and self-other configurations embedded within those models (Mitchell, 1988).

Discussion will now turn to Tonya’s treatment with Julie.

318 Psychodynamic understanding of impediments to therapeutic action.

While Tonya’s reported experience in psychotherapy with Dan was helpful, her experience after college with Julie was an entirely different story. As previously mentioned, not only did Tonya report that her treatment with Julie was more harmful than helpful, she also felt that Julie was “unprofessional,” sharing personal information with her. However, what seems puzzling is that Tonya continued to see Julie for a significant amount of time, over a year of weekly treatment. Based on Tonya’s re-telling of her experience in treatment, it seems possible that Julie used self-disclosure in a way that made Tonya feel uncomfortable, at times discussing her personal life in sessions. From a conscious perspective, it seems illogical that Tonya would remain in treatment with Julie for so long, even with her report that it took several months for her to understand that the treatment wasn’t working, and that it was possibly even making her feel “worse.” From an unconscious perspective, however, there are plausible reasons why Tonya remained in treatment, reasons that will now be explored.

It’s plausible that Tonya’s sense that her treatment with Julie lacked the direction and structure she said she needed was an unconscious repetition of her childhood experience with her parents, in which Tonya often felt her home environment was too unstructured and disorganized, lacking direction and support (Freud, 1914). From Mitchell’s (1988) perspective, a patient “seeks connections by projecting and re-creating familiar, constricted relational patterns,” something that prevents one from having novel interactions where different experiences of self and other become possible (p. 170).

From this viewpoint, it’s possible that Tonya unconsciously re-created a similar dynamic she experienced with her parents, one in which her child self looked for guidance and

319 direction from a disorganized, unstructured parental figure, only to feel failed and disappointed after she wasn’t provided with what she consciously desired, yet unconsciously played a role in re-creating (Mitchell, 1988). It’s plausible that this unconscious pattern contributed to Tonya’s remaining in treatment with Julie for so long, as being failed is familiar to her, especially when being around her family.

As briefly mentioned, Tonya reported that Julie never stopped talking, ostensibly unable to tolerate sitting in silence, something Tonya felt prevented Julie from focusing on what she needed in her sessions, and also from listening to her. In addition, Tonya reported that she felt that Julie wanted a personal relationship with her, one where Julie shared information about her children, often bringing the sessions into what Tonya called the “personal realm” that made her feel uncomfortable, and greatly contributed to her belief that treatment was unhelpful, and even made her feel “worse.” This seems particularly unhelpful because of Julie’s placing herself in the position of needing something from Tonya, of being narcissistic, and reversing the usual emphasis in treatment. In other words, Julie evoked something of how Tonya experienced her mother, as both Tonya’s mother and Julie used her to meet their own needs, as opposed to meeting Tonya’s needs. It’s possible that this experience with Julie bolstered Tonya’s unconscious assumption that others are not helpful in mitigating distressing feelings, and that others use her for their own intrusive, narcissistic needs. While this relational pattern is highly problematic, on an unconscious level, it serves to maintain ties to relational patterns both familiar and familial (Mitchell, 1988).

Related to the previous point, when interviewing Tonya, I occasionally felt some pressure to fill the silence by talking more. When reflecting on my countertransference

320 feelings, I went back to my field notes and saw that I noted this pressure to fill the silence when I felt particularly disconnected emotionally from Tonya. In other words, I noted that I felt confused and somewhat lost, unable to “read” what Tonya might be feeling or needing in a given moment, as her descriptions of her experience were often matter-offact, devoid of references to her emotional state. Additionally, Tonya seemed to operate in a rigid manner, seemingly lacking any personal spontaneity when responding to my questions. From Mitchell’s (1988) perspective, Tonya’s possible need to avoid experiencing unbearable anxiety manifested in her repeating “ritualized action” that resulted in predictable, mechanical patterns of relating, something I experienced when interviewing her (p. 290). From examining my own countertransference feelings and reactions, I imagine that Julie could have responded to the possible lack of affective engagement with Tonya by attempting to generate interest from her own life, resulting in her filling the silence by talking about personal matters in an attempt to establish some connection. Whereas it seems that Dan responded to the possible lack of emotional engagement with curiosity and probing questions, it seems that Julie responded by sharing experiences from her personal life, something that frustrated Tonya and made her feel as though Julie failed to provide her what she needed.

In a discussion of analytic impasse and the third, Aron (2006) discusses how dyads often get stuck in complementary relations “by a variety of splitting in which one side takes a position complementary to—the polar opposite of—the other side” (p. 352).

The challenge, he argues, is finding a way for the dyad to get beyond the complementary position toward opening up space, what he considers psychic or transitional space (Aron, 2006). From this perspective, it seems plausible that Tonya and Julie got stuck in a

321 complementary position where Julie talked to Tonya, instead of talking with her, or listening to her. If they were stuck in this position—and if Julie felt unconsciously “nudged” by Tonya’s silence to fill the space by talking about herself, resulting in Tonya’s responding by becoming even more distant—it’s possible they entered an enactment that created a therapeutic impasse. Additionally, it’s possible that this pattern of engaging with Julie was something of an unconscious re-creation of her relationship with her mother, a maternal transference enactment that was never explored. What I mean specifically by this is that both Tonya’s mother and Julie seemed to have something of a narcissistic preoccupation that left them unable to recognize and attend to Tonya’s needs, instead both forcing their own issues onto her. While this narcissistic preoccupation manifested in different ways for Tonya’s mother and Julie, it seemed to result in the same underlying conclusion—that both women seemed to need something from Tonya, shifting the focus away from what she wanted or needed in her relationships with them.

In concluding the section on Tonya’s treatment with Julie, I’d like to offer a summarizing thought related to what I’ve described as Tonya’s core issue. It seems that Tonya found someone onto whom she could project her object relationship of being failed, and found someone perfect to confirm that assumption. This seemed to intensify her predominant relational conflict, in that Tonya continues to yearn for the guidance and direction she felt she wasn’t provided by her parents, yet possibly feels even more reluctant to establish a new, close relationship. Tonya’s treatment with Dan didn’t seem long enough—it gave her just a hint of what was possible in treatment with someone curious, supportive, and focused exclusively on attending to her needs. However, it may

322 have been enough to create some hopefulness, and possibly contribute to Tonya seeking treatment with another therapist in the future.

Current functioning.

Currently, Tonya said she’s busy managing the family business. She lives with her boyfriend, and described their relationship as “good,” though she said she’s uncertain about whether or not he’s amenable to having a family, something she said she wants in the near future. In addition, she said they struggle to communicate well, and that they both are not “talkers that way.” Regarding her parents, Tonya said she feels closer to her mother, despite describing herself as more similar to her father. However, Tonya said she recently decided that she wants even more distance from them, and said that she feels more comfortable on her own. Socially, Tonya said she maintains a few friendships, something that provides her with “the minimum amount” of social interaction she needs.

In terms of her mental health, Tonya said she experiences fewer symptoms of depression and anxiety, and overall feels happier than she did in the past. In the last interview, she said that despite her last experience in psychotherapy making her “doubt” the ability of most therapists, she said she will, “probably,” return to treatment at some point in the future, because “that’s what I do.” From this statement, it seems that she continues to search for guidance and direction externally, though it appears that she remains conflicted about establishing and maintaining a new relationship.

323

Chapter Five

Discussion

I chose to do this study in part because of my interest in therapeutic action, and specifically on what individuals who engaged in psychotherapy during emerging adulthood found helpful or not helpful, in addition to exploring their overall subjective experiences in treatment. I found this area of study particularly interesting as a result of the dearth of psychoanalytic literature exploring the patient’s perspective on what is helpful or not in treatment, contributing to models of therapeutic action largely based on the therapist’s view of the therapeutic process (Bohart & Tallman, 2010; Duncan, Miller, & Sparks, 2007; Lilliengren & Werbart, 2005). While the therapist’s perspective is valuable as general background, I believe it is also crucial to inquire about the patient’s experience in treatment, and to use that data to look at whether and how existing theories usefully describe therapeutic action in specific cases, and what might need to be explored in subsequent research on treatment with this population.

I also wanted to go beyond the subjective report of my participants’ experiences in treatment by exploring their perspectives on therapeutic action in the context of their developmental histories, including their past significant relationships starting in childhood. My hope was to understand if, or how, the participants’ histories shaped their experiences in psychotherapy, and influenced what they found helpful or not in treatment.

324 I found evidence of what I had expected to find: each participant’s subjective experience in treatment, including what she found helpful or not helpful in psychotherapy, was shaped by each participant’s unique developmental history, and specifically by her past relationship with parents. In the previous chapter, I presented, case by case, how I interpreted the impact of each participant’s experience of parental relationships on her experience of treatment, and how I believe each participant’s childhood and development influenced what she wanted or needed from her therapist.

While each of the women in this study has a unique story, together their narratives of treatment suggest several overlapping themes, with uniquely specified applications for each participant. These findings, examined from a cross-case analysis, include the following: transference in the absence of conflict; enactments in treatment; the therapist as a good object; having a new relational experience; recognition’s effect: considering alternative identities; and evaluating treatment: defining therapeutic action. These themes will now be broadly explored.

Transference in the Absence of Conflict Transference has long been a central concept in psychoanalysis and psychodynamic psychotherapy for over a century (see Freud, 1912). From a relational perspective argued by Mitchell (1988), a patient’s transference to her therapist is shaped by her particular relational configurations, or the main relational patterns formed from early experiences with caretakers. Mitchell (1988) argued that these early relational patterns “seriously distort subsequent relatedness,” and result in an individual re-creating these patterns in the present, experiencing new relationships in ways dictated by the past

325 (p. 170). The five participants in this study all seemed to enter treatment having had experiences in which they felt that one, or both, of their parents were unavailable at significant moments in their lives, a theme that became a major part of their childhood narratives, and seemed to greatly impact their treatments during emerging adulthood.

It seems that transference played a factor in my participants’ early reactions in treatment to their therapists, reactions that often manifested in conscious feelings of anxiety or distress, in most cases without a clear understanding of why they felt that way.

However, despite what psychoanalytic theory would suggest would be common in treatment, a finding I had not expected was that every participant reported experiencing very little relational conflict with her therapist. This was true even for Tonya, who said that her treatment experience with Julie was so unhelpful that she felt “worse” after some of her sessions. Even so, her reported feelings of discontent did not result in conflict between the therapeutic dyad. I realize that transference, as a concept, does not demand conflict, and that participants might experience transference in widely varying ways, but I was surprised that no participant reported experiencing this with her therapist.

What I mean by being surprised at this finding includes the idea that often in treatment—as a result of the formation of transference and the corresponding development of countertransference in the therapist—one’s past relational patterns that contribute to the re-creation of problematic relationship dynamics emerge in the context of the therapeutic relationship (Mitchell, 1988). As the therapist struggles to understand and articulate a patient’s characteristic ways of functioning with others, ways dictated by the transference, conflict often ensues, particularly as a patient experiences the therapist as a “transferential, unsatisfying object,” or, in other words, as similar to parental figures

326 or past significant others (Mitchell, 1988, p. 305). In Maroda’s (1991) relational model, the objective of an analytic treatment is to go beyond the establishment of a positive working relationship to what she describes as a stage of dynamic conflict, where the patient’s conflicts and deficits are expressed directly in the therapeutic relationship. She argues that this stage even happens in analytic treatments of shorter duration, but without the depth or complexity characteristic of psychoanalysis and intensive psychoanalytic psychotherapy (Maroda, 1991).

Yet, as noted, all participants reported experiencing little relational conflict with their therapists. I do not mean to suggest that their treatments were devoid of internal conflict, or that there were not moments of great affective intensity between the therapeutic dyad, instances of brief conflict or what I have described as enactments.

However, I do mean that all of their treatments were reportedly characterized by little relational conflict. Why might this be the case? While I realize there could have been multiple reasons for the absence of reported conflict—for example a participant feeling reluctant to talk with me about any such conflict in the interviews, or the seemingly supportive therapeutic approaches of the participants’ therapists—this question led me to think about any relevant developmental factors that possibly contributed to this finding, and if, or how, the time period of emerging adulthood impacted this phenomenon.

It does seem possible that specific developmental factors played a role in each participant experiencing little conflict with her therapist. First, what struck me is that all participants continued to have some type of conflict, whether internal or relational or both, with one or both parents during their treatments. For Cathy, Jasmine, and Tonya, this conflict was more internal, as they all seemed to be attempting to understand how

327 their experience of being parented continued to impact their functioning in relationships, and also trying to determine what kind of relationship they wanted with their parents, or what type of relationship was feasible with them moving forward, especially in the context of past disappointment. For Amelia and Hillary, this conflict was both internal and relational. For example, they both reported experiencing some external conflict with a parent during their treatments that contributed to their contemplating what kind of relationship, if any, they could reasonably have with parents in the future.

It seems possible that for these five participants, their ongoing conflict with their parents contributed to their not experiencing what Maroda (1991) refers to as having dynamic conflict in treatment. In other words, I believe that my participants possibly needed a relationship with their therapists devoid of frequent conflict particularly because they all were already attempting to understand and reconcile ongoing internal or relational conflict with their parents. Instead of experiencing conflict with another parental figure in the transference, it seems that these participants needed more of a guide—someone who was available, warm, responsive, and provided some structure and stability during a time when they all seemed to be attempting to understand the impact of their parenting and childhood on their identity. In other words, it seems that for these emerging adults, having additional conflict with their therapists could have been too overwhelming, especially as they tried to make sense of the impact of their past on their current functioning. Perhaps my participants needed to work out relations with internal parental objects by using their therapists as new, good objects, as the “good” parents they needed to hold to in order to have useful conflict with their “bad” parents. Perhaps it was

328 safe to work out conflicts with their parents because they felt anchored in good therapeutic relationships.

A second developmental consideration that I believe contributed to, relatively speaking, a “conflict-free” space in their treatments includes these participants’ dealing with separation/individuation themes that seemed to result in, or intensify, issues related to identity exploration and formation. Arnett (2000), who first proposed a distinct developmental time period of emerging adulthood, argued that emerging adulthood is the time that offers the most opportunity for identity exploration, what Erikson (1959) previously discussed as the central crisis of adolescence. In Blos’ (1967) perspective, adolescence, or what most people in industrialized societies would now consider emerging adulthood or young adulthood (see Arnett, 2000), is the second individuation process, a time when one attempts to shed family dependencies and loosen infantile object ties, resulting in a pattern of finding love and hate objects outside of the family.

This process can create uncertainty and result in a young adult experiencing a temporary state of flux (see Escoll, 1987). Additionally, while this process can be exciting and liberating, it can also be terrifying, contributing to feelings of confusion and uncertainty, and a desire for guidance and support from parents and parental figures (Gould, 1978).

I believe that as each participant attempted to understand the exciting and potentially liberating, yet also anxiety-provoking process, of individuating from parents, they engaged in a process of identity exploration, and particularly the ways in which their childhood and reported experiences of being parented impacted the type of person each individual had become. Some participants explicitly reported experiencing “identity” issues, while others said they felt “stuck” and “unsure” of their personal and professional

329 future. It is possible that continued conflict with parents throughout treatment—coupled with the individuation process and attempting to establish a new identity outside of what was constructed in childhood—contributed to each participant’s reporting little conflict with their therapists. Instead, it seems they all, in their own idiosyncratic ways, experienced more of an available, supportive guide to help them manage the uncertainty and resulting distress characteristic of this developmental time period. In other words, it seems possible that treatment with these participants may have functioned more as a transitional space in which the perceived burdens and expectations of parents were lessened—while being explored and discussed in treatment—something that then allowed them to consider alternative ways of interacting with significant others. While transference was certainly evident in each treatment, dynamic relational conflict in the therapeutic relationship was not. That being said, these participants seemed to unconsciously evoke specific enactments in their treatments, a second finding that will now be explored.

Enactments in Treatment In relational psychoanalytic theory, enactments occur in every treatment, an unconscious mutual process that can be very subtle, and even go unnoticed and unspoken, or one that can manifest in more observable, even tense and uncertain exchanges that are only known and understood by the therapeutic dyad post-enactment (Aron, 2003; Mitchell, 1988, 1993). In the previous section, I described how each participant reported little conflict with her therapist. That being said, each one also seemed to unconsciously evoke what resulted in a specific enactment at different points

330 in treatment, something that seemed to elicit a specific, desired response from the therapist, or others that confirmed an existing, unconscious transferential expectation.

Specifically, it seems that each participant unconsciously nudged the dyad into an enactment resulting from one’s default model of relating, an unconscious attempt to repeat familiar, constricted relational patterns experienced with one or both parents (Mitchell, 1988).

For Hillary, this enactment included “forcing” Andrew into reading an email exchange she had printed and brought into session, a moment where she seemed to desire a specific response early in treatment from a paternal figure, one she seemed to need in order to avoid falling apart—a response she felt she missed, yet desperately desired, from her own father. For Amelia, this resulted in pushing Dr. Cohen into responding to her self-destructive behavior by implying that she was operating like a prostitute. While she initially felt angry, this enactment eventually broke with every transferential expectation, and seemed like a salient moment in Amelia’s having a new relational experience with a paternal object. For Jasmine, this resulted in feeling skeptical of, and initially guarded with and unavailable to, her therapist, with Jennifer responding by becoming more available and more responsive to her, a relational pattern that challenged Jasmine’s unconscious assumption that others are unavailable, or even abandoning. For Cathy, this possibly resulted in her leaving treatment for two months, perhaps unconsciously attempting to elicit criticism and generate conflict with her therapist, with Mary instead responding by asking Cathy to adhere to weekly treatment, and engage more in her psychotherapy. For Tonya, her possible enactment did not evoke a different type of responsiveness from her therapist, instead leading to an experience where Julie felt like a

331 maternal figure narcissistically preoccupied with her own needs, corroborating Tonya’s transferential assumption that parental figures inevitably fail her.

While the specific dynamics of each enactment were unique to the dyad and a specific moment in the treatment, and especially to the participant’s idiosyncratic history, it seems that they all unconsciously attempted to repeat problematic relational patterns with their therapists, moments that seemed to impact the ways in which the therapeutic dyad related. For some, like Amelia and Hillary, these moments were more clearly manifested interpersonally, involving an exchange of greater affective intensity. For others, like Cathy, Jasmine, and Tonya, these moments were subtle or even unspoken.

Instead, they seemed to be unconsciously communicated, slightly changing the way the therapeutic dyad operated. For example, according to Jasmine’s report, Jennifer never explicitly told Jasmine that she appeared guarded, suspicious, and unavailable to Jennifer initially in treatment. However, Jennifer seemed to pick this up from Jasmine’s nonverbal behavior, and responded by becoming more available and more attentive to her needs, a relational dynamic that contributed to Jasmine then responding to Jennifer’s gestures by being more open and available, changes that deepened the therapeutic relationship.

In conclusion, it seems that each participant, in a unique way, unconsciously attempted to re-create a type of unavailability historically experienced with one or both parents, something that seemed to evoke what resulted in transitory enactments between each participant and her therapist. For four of the five participants, the enactments led to a different experience with a significant other, something that broke with their transferential expectations. For one participant, this moment confirmed her transferential

332 assumption that parental figures fail her, contributing to her conscious belief that treatment was not helpful.

The Therapist as a Good Object Since Freud (1912) discussed the dynamics of transference over a century ago, psychoanalytic writers have written extensively about both positive and negative transference, and its impact on the therapeutic process. For example, Mitchell (1988), among many other theorists, took up the issue of negative transference and its relevance to treatment and therapeutic action. Specifically, he argued that if the most fundamental levels of a patient’s pathology are to be reached and addressed, the therapeutic relationship, in his words, “becomes the vehicle for the establishment and articulation of bad-object relations. The analyst cannot enter the analysand’s world in any form other than as a familiar (that is, “bad,” or less than gratifying, object)” (p. 305). In other words, Mitchell (1988) contended that a patient will inevitably experience the analyst in old ways, and even “insists” that the therapist becomes a “transferential, unsatisfying object” (p. 305). As a result, Mitchell (1988) argued that the analyst will discover himself as “a coactor” in the patient’s drama, falling into the patient’s “predesigned categories” and experienced by her in ways dictated by the past (p. 295). Consequently, he argued that a therapist must use one’s interpretive efforts to clarify and understand the unconscious recreation of these constricted relational patterns as they manifest in the therapeutic relationship (Mitchell, 1988).

It seems that every participant in my study, at least initially in treatment, had unconscious expectations related to experiencing her therapist in what Mitchell (1988)

333 referred to as a bad, or familiar, transferential object, expectations that seemed to manifest in feelings of conscious anxiety or distress early in treatment. However, instead of their therapists actually becoming (as opposed to being expected to become) the bad, familiar object, all of my participants experienced their therapists as good objects. The exception includes the case of Tonya, who experienced one therapist in emerging adulthood as a good object, while her other therapists were experienced as familiar, bad objects (Mitchell, 1988). Because Mitchell (1988) was writing about this idea in the context of psychoanalysis, it is possible that this could have played out differently with participants whose treatments consisted of psychoanalysis.

A somewhat similar study to this one conducted in Sweden that examined emerging adults’ perspectives on therapeutic action also reported a similar finding, specifically that participants reported that one curative factor in treatment included the experience of “being accepted, respected, supported, and seen by the therapist” (Lilliengren & Werbart, 2005, p. 330). This finding is similar to mine, in that experiencing the therapist as a good object involved my participants feeling as though they were taken seriously by their therapists, felt supported by them, and found them to be consistently available and responsive to their needs. This finding seems significant, and when coupled with a previous finding that my participants reported little relational conflict with their therapists, led me to think about the possible developmental reasons that these participants might have needed to experience their therapists as good objects.

It is possible that separation/individuation issues impacted my participants’ need to experience their therapists as good objects, in relationships devoid of frequent conflict.

Blos (1967) argued that the second individuation process resulted in one disengaging

334 from parental support, a regressive process not defensive in nature, but one that constitutes an essential developmental process, despite the intense anxiety that can result (Blos, 1967). In a slightly related discussion of psychoanalytic treatment specifically with young adults, Escoll (1987) argued that the analyst is seen as a new object, a process facilitated by the developmental movement away from old objects and toward new objects during this time. He posited that this process could be used to “defensively withdraw from the transference by attempting to focus on the analyst as a new object” (Escoll, 1987, p. 22).

While I do not believe that my participants defensively withdrew from the transference—as it seems that all of them had unconscious expectations related to experiencing some version of past, familiar objects—they all did experience their therapists as good objects. As briefly mentioned, the exception is Tonya, who experienced one therapist as a good object, while the others were primarily experienced as familiar, transferential objects that failed her (Mitchell, 1988). From a developmental perspective, it is plausible that as my participants attempted to manage separation/individuation issues and specifically become less dependent on parental support, they were forced to depend more on themselves, a process that seemed to create some feelings of anxiety, confusion, and uncertainty, particularly related to concerns about feeling stuck and unsure of the future. While this process was different for each participant, it seems possible that, as these women all individuated from parents, they felt some need to rely on an authority or parental figure, possibly their therapists.

From this viewpoint, it seems possible that for these participants, the anxiety and uncertainty related to the still-underway separation/individuation process and depending

335 more on themselves superseded the unconscious re-creation of bad object relations, except in the case of Tonya’s second treatment. Instead of finding a “transferential, unsatisfying object,” my participants discovered an attentive, available, and supportive good object (Mitchell, 1988, p. 305). While this dynamic was contingent on the responsiveness of the therapist, it seems that each participant was, developmentally speaking, “ready” for a supportive parental figure outside of the family.

For these participants, it seems that as they individuated from parents and depended less on familiar, past objects, they shifted their dependency needs to their therapist, someone eventually experienced as a good object. This process supported their developmental need to separate to some extent from parents, but did so in a way that engendered less anxiety about depending more on themselves and potentially feeling distressed, as they had a good object to “return home” to, a secure base to feel recognition and support in the midst of anxiety and uncertainty. It is possible that for my participants—individuals who all described one or both parents in some ways as bad, unavailable objects—that they especially needed to feel care from someone felt as a good object. While I believe that there were moments, or temporary enactments, where my participants expected and/or attempted to re-create past problematic relational patterns in treatment, it seems that they all needed to establish a supportive parental object relationship, one to help mitigate distressing feelings evoked by the separation/individuation process.

For Hillary, experiencing Andrew as a good object meant “feeling important and significant” to him, and believing that “he was genuinely concerned” about her. For Jasmine, she said she felt that Jennifer “really had my back,” and that Jennifer was

336 “always willing to listen to anything” she needed to talk about in session. For Amelia, experiencing Dr. Cohen as a good object included her belief that he truly “wanted the best” for her, reportedly telling her on multiple occasions that she was “a good person capable of anything.” For Tonya, this process meant that Dan, in her words, “knew me, and understood what was going on in my head,” in addition to her report of receiving what she referred to as “a lot of affirmation from him.” For Cathy, she recalled feeling that her therapists were “intuitive,” and that both Mary and Vanessa were “nurturing” and “guiding,” able to provide support and direction when she felt particularly distressed.

In summarizing this finding, it seems possible that there could have been more than one developmental process underway for these participants in their treatments.

Perhaps these emerging adults’ separation/individuation from parents required relating with the actual bad objects, making it easier to separate by emphasizing the bad objects’ badness. Perhaps, then, it was very helpful simultaneously to have had a supportive connection to a good parental figure, who might make it safer to work through the separation/individuation process. It seems possible that both were required for my participants in inverse processes: the separating/individuating may have occurred in inverse ratio to the developing of a good object, in the form of the internalized therapist.

In other words, it seems that the extent to which my participants experienced psychotherapy as helpful seemed, in part, to be related to these two inverse processes happening simultaneously. Following this argument, perhaps the reverse was true for Tonya, that she was unable to complete one process because the other failed her (i.e., the weak therapist).

337 Having a New Relational Experience A fourth, closely related finding includes the idea that all of my participants had a new relational experience with their therapists. Relational theorists all discuss the importance of a patient having a new relational experience in the context of treatment, and believe that therapeutic action is heavily contingent on this occurring. As previously mentioned, Mitchell (1988) argues that therapeutic action is dependent on one relinquishing ties to past, constricted relational patterns, resulting in an openness to new and richer interpersonal relations. Hoffman (2006) describes this process as a patient having “new, growth-promoting experience” in treatment, instead of the repetition of problematic relational scenarios of the past (p. 723). Stern (2010) describes this process as treatment helping a patient have more freedom when engaging with others, or helping a patient rely less on past, “unconsciously selected perceptions” that re-create the same relational patterns when engaging with others (p. 7). Consequently, all of these writers place special emphasis on one having a new relational experience in treatment, replacing the need to re-create the past in the present, something one constantly struggles to overcome.

A finding that emerged for all five participants included the importance of having a new relational experience with their therapists. In chapter two, I discussed a study somewhat similar to this one that followed emerging adults in treatment and elicited their ideas related to therapeutic action, and what specifically was helpful or hindering in treatment (Lilliengren & Werbart, 2005). In that study, one curative factor reported by the emerging adults included experiencing their therapists as attentive and supportive, something that provided the necessary conditions and feelings of safety needed for

338 “trying out new ways of being and relating to other people” (Lilliengren & Werbart, 2005, p. 331). For all of my participants, a significant component of finding treatment helpful included their report of having a new, different interpersonal experience with their therapists, something that then contributed to them operating in different ways outside of treatment, particularly in their close relationships with significant others.

What particularly struck me was the finding that all five participants, through the relationships established with their therapists, found ways to receive what they felt was missing, or what they felt was not provided, by their own parents at different times in childhood. Specifically, each participant reported feeling a type of responsiveness and availability from their therapists that they had not consistently experienced from one or both parents growing up, resulting in the provision of new relational experience within the context of the therapeutic relationship. Even Tonya experienced this in relation to Dan, though it should be noted that she did not have this experience with any other therapist. That being said, it is not just that the therapeutic relationship offered a new relational experience for each participant; additionally, my participants reported that the treatment relationship provided them with the foundation then to operate differently with important others outside of treatment, something that led to real changes in their external relationships. A somewhat similar finding was also seen in the Swedish study, with those emerging adults reporting that a supportive therapeutic relationship assisted them in trying out new ways of relating to others (Lilliengren & Werbart, 2005).

For Cathy, this meant trying to articulate and express her feelings in a relationship, instead of resorting to dramatic, attention-seeking behaviors. For Amelia, this included attempting to end relationships with “toxic” friends in her life, in addition to

339 trying out new ways of relating to her mother. For Hillary, this resulted in “demanding” more from people, and ending her tendency to be “a doormat” in relationships. For Jasmine, this included being more open and vulnerable with her peers, a change noticed by her close friends and boyfriend. For Tonya, this included ending a pattern of dating “assholes,” and finding someone who treated her better.

In summarizing this finding, it seems that the therapeutic relationship provided each participant with a type of responsiveness and availability they longed for and desired from one or both parents. This experience eventually contributed to the development of new, alternative relational models for participants to draw upon when engaging with intimate others (Mitchell, 1988). When this new experience was established and felt within the therapeutic relationship, it seems that each participant could then take risks to engage with close others in new ways, most notably peers and significant others. From a relational perspective, a new, different type of experience contributed to each participant trying out new patterns of interacting, ones less dictated by the predominant self-other configurations formed in childhood (Mitchell, 1988).

Recognition’s Effect: Considering Alternative Identities Related to the previous theme, another cross-case finding (the exception being Tonya’s treatment with Julie) included the effect of each participant feeling consistently recognized by her therapist, something that seemed to contribute to each woman considering an identity newly recognized as a full subjectivity (i.e. see Benjamin, 1990).

All my participants reported feeling as though one or both parents failed to recognize their emotional needs on several occasions in the past. Benjamin (1990) argues that the

340 achievement of mutual relationships, or the “ideal resolution of the paradox of recognition,” includes maintaining a tension between recognizing the other and asserting the self (p. 39). For these participants, the experience of feeling recognized and attended to by their therapists seemed to help them imagine becoming someone new, someone who operated differently in close relationships. Mitchell (1993) argued that in a broad sense, psychopathology could be seen as a failure of imagination, a sense of being stuck without being able to imagine the possibility for change, for operating differently in close relationships. It seems that feeling consistently recognized by a discerning, understanding other eventually helped these participants imagine a different identity, a new sense of self less dictated by and tied to past ways of relating.

For example, each participant seemed to “use” the experience of feeling recognized in subjective ways. For Amelia, this meant wondering about her professional identity, and actually imagining the possibility of working in a job that could challenge her. For Cathy, this resulted in thinking about what it would be like to be a person her parents depended on, instead of being the “sick child” they took care of and had to support. For Hillary, this experience made her think, for the first time, that her sense of her father’s neglect does not “pre-determine” every relationship going forward with a man, an idea that seemed comforting to her. For Tonya, she was able to think about her tendency to date unavailable men, and eventually found someone to treat her well. And last, for Jasmine, feeling consistently recognized seemed to result in her imagining that others “looked” at her and even stared at her because of “their issue,” and not because of her difference, or because of her “dark skin,” a new idea emerging from her treatment that mitigated some of her feelings of social anxiety. In short, feeling consistently

341 recognized seemed to impact the participants’ sense of self and identity, a developmental issue particularly relevant in emerging adulthood.

While Erikson (1959) argued that the central crisis of adolescence is that of identity versus role confusion, most identity exploration takes place in emerging adulthood, rather than adolescence (see Arnett, 2000). Arnett (2000) argues that research shows that identity achievement is rarely reached by the end of high school, leaving most individuals dealing with identity issues in emerging adulthood, specifically in the areas of love/relationships, work, and worldviews. This process is often exciting for emerging adults, yet it can also feel anxiety-provoking as they attempt to think about establishing more enduring personal and professional identities (Arnett, 2000). This can create uncertainty and self-doubt as individuals attempt to manage unstable identities. This description by Arnett (2000) seems particularly fitting for my participants, as each expressed anxiety and uncertainty about feeling stuck personally or professionally, or feeling worried anticipating the potential to feel stuck in the future.

For my participants, the identities they had created were powerfully shaped by their childhood experiences and past interactions with parents and significant others.

Moreover, these participants reported internalizing both explicit and implicit beliefs from parents related to how to become an adult, or what steps to take to achieve some type of adult identity. This manifested in most participants feeling as though they had some type of “plan� up until college, and then feeling lost after graduation. For Jasmine, who had not graduated yet at the time of the interviews, this process included feeling anxious and uncertain about finding a job after college, something she worried about, particularly due

342 to her mother’s admonishments about her needing to establish financial independence as soon as possible.

For these participants, feeling consistently recognized by their therapists seemed to mitigate some of their distressing feelings related to managing the process of identity exploration and formation. What I mean specifically is that through feeling consistently recognized by their therapists—an experience that provided a sense of feeling cared for and especially understood by a good object—these women seemed to become aware of their characteristic relational patterns that played out with others, and started to consider alternative identities, ones that included new ways of interacting with intimate others (Mitchell, 1988). In other words, it seems that the relationships established with their therapists facilitated multiple developmental processes: the separation/individuation process; attempting to relinquish archaic, unconscious relationship models; and the process of identity exploration and formation.

Evaluating Treatment: Defining Therapeutic Action All five of my participants discussed the relationship between having difficult-tomanage symptoms and ultimately seeking treatment, wanting assistance with symptom relief. For four participants, their presenting problems centered on feeling depressed, anxious, and experiencing relational conflict with peers and/or family members. For Amelia, symptoms related to the above conditions in addition to her report of the impact of experiencing trauma, and having intrusive thoughts and memories related to traumatic experiences from the past. Additionally, every participant reported some distressing aspect of their past relationship with one or both parents, an experience that ultimately

343 contributed to these participants, at different points in treatment, attempting to understand the lasting impact of their childhood, particularly as it related to their current functioning and important relationships.

While all participants discussed experiencing some symptom reduction as a result of engaging in psychotherapy, symptom relief was not a salient aspect of my participants’ conceptions of therapeutic action, nor what they reported finding particularly helpful in treatment. This is similar to a past study that examined significant moments or experiences individuals recalled about their treatments, and found that while symptom relief may be a positive result of therapy, it was not the primary benefit for many of the participants (see Levitt, Butler, & Hill, 2006). In my study, symptom reduction was generally talked about as an afterthought, and was not included in what my participants explicitly used to determine whether or not treatment was useful or not useful.

For all of my participants, what was far more salient than symptom relief was the importance of understanding how their past development and significant relationships with parents in childhood impacted the individuals they had become, especially in the context of two specific areas of functioning—how my participants felt about themselves, and how they operated in present relationships. Developmentally speaking, this finding makes sense, as Blos (1967) discussed how the individuation process inevitably leads one to seek extra-familial objects, what Arnett (2000) describes as the normative process whereby emerging adults engage in identity exploration in the context of love, exploring the potential for physical and emotional intimacy with others. However, it is not just that the participants achieved greater self-awareness and self-understanding; rather, after understanding themselves better in addition to feeling cared for in the therapeutic

344 relationship, they all made changes, outside of treatment, that felt positive. For most participants, this manifested in thinking about, and ultimately changing, how they functioned in close relationships, or for others, deciding to end problematic relationships altogether. In other words, each participant seemed to use changes in her external relationships as a barometer to measure the efficacy of treatment, instead of using symptom reduction to measure change. This finding is similar to one discussed in the Swedish study, in which researchers found that one curative factor reported by their emerging adults included the idea of how a new relational experience with their therapists helped them try out new ways of engaging with others (Lilliengren & Werbart, 2005).

Additionally, all participants reported that their experience of the therapeutic relationship was one of the most important aspects of treatment that contributed to therapeutic action, greatly influencing their ideas about the positive impact of psychotherapy. Tonya, the only participant to report that one of her treatments in emerging adulthood was not helpful, also discussed the impact of her experience of the therapeutic relationship on treatment, specifically reporting that how her therapist operated with her had an immediate effect on her sense of whether or not her therapist was capable of helping her.

Specifically, my participants reported that what was particularly important within the therapeutic relationship included their experience of feeling cared for, especially in ways in which they felt they were not cared for by one or both parents. For example, all participants reported, in subjective ways, that it was extremely helpful to feel that their therapists were available, supportive of their feelings, curious about their subjective experience and relationships outside of treatment, and could provide a type of recognition

345 and responsiveness they felt they needed, yet missed from parents in the past. Other studies have also reported a similar finding, both with emerging adults (see Lilliengren & Werbart, 2005) and with adults across the life span (see Levitt, Butler, & Hill, 2006).

For Cathy, she reported that her treatment helped her understand that “it’s normal to fall back into the same dynamics, but there’s things I can do to change that, and that involves becoming an adult.” For Amelia, her relationship with Dr. Cohen, in her words, “taught me to appreciate myself in a way that would never have been possible.” For Tonya, she said that her treatment with Dan “made me question my relationship choices,” something that contributed to her finding a significant other who would treat her well.

For Hillary, her treatment experience helped her “figure out how to redefine” herself, and develop “an understanding of my own value.” In her words, her experience in psychotherapy made her realize that “if other people’s trajectories are guiding your decisions, then it’s no longer your life.” For Jasmine, she recalled how her treatment experience contributed to her realizing that she needs “to be herself more” in her close relationships, and that once she felt comfortable opening up and expressing herself in treatment and with her close friends, “words just became easier for me.”

It seems, from my participants, that feeling cared for in the therapeutic relationship provided the necessary conditions to explore the impact of their pasts on their development as individuals, in addition to exploring the ways in which they operated with peers and significant others. However, from what I can conclude from the data with my participants, it seems that this exploration was more focused on each participant and her characteristic ways of functioning outside of psychotherapy, instead of a focus on transference and countertransference dynamics as they emerged in

346 treatment. It seems that transference and countertransference dynamics were certainly not dismissed in participants’ psychotherapy experiences. For example, I have discussed plausible enactments that emerged from each participant’s history. Additionally, in Hillary’s treatment in which she met with her therapist multiple times a week, she recalled certain moments in which the focus of treatment was directly related to what was happening in the therapeutic relationship. Still, for all participants, even Hillary, the therapeutic relationship seemed to be used more as a means to explore the impact of each participant’s childhood on her identity and characteristic ways of functioning in relationships outside of treatment, and how her past continued to influence how she felt about herself. In other words, the focus seemed to be more on what could be considered interpersonal or relational transferences to important others outside of treatment, instead of the traditional psychoanalytic examination of transference-countertransference dynamics as they emerged within the therapeutic dyad.

Last, it seems that most participants reported that they needed a type of structure in treatment to feel more at ease, and to especially experience their therapist as available.

By “structure” I specifically mean each participant’s knowing when her therapist would be available to meet in person, in addition to having some access to her therapist outside of scheduled appointments, like being able to call or email the therapist. For Hillary, this included seeing her therapist multiple times a week and having the opportunity to email or Skype with him if needed when he was out of town. For Cathy, this meant having homework assignments, specifically worksheets to fill out on the weekends when she felt especially distressed, something that indirectly provided some connection to her therapist.

For Amelia, this included seeing Dr. Cohen twice weekly, emailing and calling him if

347 needed, and also having literature to read outside of sessions. For Jasmine, this meant having weekly group and individual psychotherapy sessions, reading relevant literature outside of her sessions, and also having the opportunity to email her therapist, if needed.

Why did most participants seem to value this type of structure? It is possible that having had a predictable structure served an important developmental function for most participants. Specifically, what I mean is that as participants individuated from parents and looked externally for new objects (Blos, 1967; Escoll, 1987), while simultaneously attempted to manage identity issues during emerging adulthood—both understanding their childhood identities and trying to establish new ones in the context of relating differently with close others—it is possible they experienced a period of temporary flux, something that contributed to participants’ reports of feeling confused and anxious, uncertain about their personal and professional futures, and needing support and guidance from an available other. In addition, my participants may have valued structure from the therapists because so many reported either no structure, or inadequate structure, from their parents. It seems that this structure may have bolstered my participants’ sense that their therapists were good objects who were available to them, both physically and emotionally.

Limitations to Findings The main limitation of the findings reported here is that they are not generalizable beyond the experiences of the five women who participated in my study. Additionally, as discussed by Rose (2004), the qualitative nature of my study contains the potential for researcher bias, both in the interaction between me and the participants throughout the

348 interviewing process, and in subsequent analysis of data, by both me and the secondary reviewers, who are members of my dissertation committee.

Clinical Implications and Further Research While the findings of this study cannot be generalized, they do allow for speculating about potential contributions to theory related to emerging adults and their perspectives on therapeutic action, in addition to thinking about what could possibly unfold in treatment with this population. Hoffman (2009) argues that case studies, like empirical research, generate important possibilities for practicing clinicians to have in mind in their work with a particular patient population. As a result, while the results of this study cannot be generalized, my hope is that they can give therapists who treat emerging adults some important possibilities to consider in their clinical work with this population (Hoffman, 2009).

Against the background of the limited research that has been done with emerging adults—most of it quantitative in nature and most of it focused on eliciting the therapists’ point of view—my qualitative study focused specifically on the experiences in psychotherapy of a limited number of specific individuals at a particular time in their lives. As mentioned in chapter two, it is important to note the stark differences in underlying epistemological assumptions between these two research approaches, and the different goals that get assumed: researchers are looking for what is true for most people, and what techniques can be reliably tested and applied in standardized ways; therapists are looking for what is true for a specific individual, and often rely on case studies. That being said, psychotherapy outcome studies that are used to label treatments as “effective”

349 or “evidence-based” for a particular patient population often evaluate patient change and progress in treatment via self-report measures that assess changes in symptoms over time (Levitt, Butler, & Hill, 2006; Shedler, 2010).

As noted, none of my participants included symptom relief as a salient component of how they defined therapeutic action after treatment had ended, and it was not what they used to determine what they found helpful or not helpful in treatment. This is particularly important because—by using an open-ended qualitative model of reported outcomes that differs from the quantitative outcome model assessing “efficacy” of treatment via self-report measures tracking changes in symptoms over time—my study could conclude that my participants’ post therapy reports excluded symptom reduction as a salient factor in their therapy experiences. In other words, the “efficacy” model of evaluating outcome would have missed what my participants said was most important in their subjective reports of their treatment experiences, something that can be captured by using psychoanalytic case studies. A clinical implication of this finding is that therapists interested in working with emerging adults can make use of existing quantitative research as useful background information, but that therapists will also want to rely on case studies to help them think about plausible possibilities to consider in their actual clinical work with individual patients (see Hoffman, 2009).

Not only did my participants have a new relational experience in treatment with their therapists, but also they used the self-understanding they developed in treatment to make important changes outside of treatment, often within the context of relating to peers and significant others. Additionally, from what I could conclude from the data from participants, the therapeutic dyad seemed to focus heavily on what could be considered

350 the participants’ interpersonal or relational transferences to important others outside of treatment. A clinical implication of this finding is that, for therapists working with this population, it could be useful to discuss emerging adults’ interpersonal relationships for a few reasons: doing so may illuminate the full dimensionality of their relational dynamics (i.e., are their parents really critical, or do they often seem to feel criticized by others currently in their lives, as evidenced by what they report?); and doing so may also be a way to explore the transference in another expression of it. It may, then, also allow the therapist to observe changes in capacity for relating, over time.

More than any other factor in treatment, every participant in the study discussed the importance of her subjective experience within the therapeutic relationship in contributing to therapeutic action, and what she found helpful or not helpful in treatment.

This finding supports the conclusion that for each participant, her subjective experience of treatment was heavily contingent on how her therapist handled or mishandled the relationship. This finding, then, has important research implications: there is a need for future quantitative research that explores patients’ perceptions of the therapeutic relationship on the one hand, and a need for additional psychoanalytic case studies that explore in more depth patients’ experiences of the therapeutic relationship. In other words, there is a need for future researchers exploring patients’ perceptions of the therapeutic relationship to use a research strategy that includes both quantitative and qualitative approaches: quantitative measures that look globally at generalizable factors that impact patients’ experiences of the therapeutic relationship, and qualitative measures that offer a detailed, nuanced exploration of patients’ experiences of the treatment relationship.

351 Last, more research is needed on the emerging adult’s perspective on therapeutic action, including building on this study’s exploration of what individuals in this developmental time period find helpful and not helpful in treatment. Along those lines, because my sample happened to be exclusively female, it would be interesting to see in further psychoanalytic case studies what some male participants might say about their experiences of treatment while they were emerging adults. Professional research and practice continue to privilege the position and viewpoint of the therapist (see Bohart & Tallman, 2010; Duncan, Miller, & Sparks, 2007). As a result, it seems necessary to continue to explore the patient’s subjective experience in treatment, including the emerging adult’s perspective on therapeutic action. This seems particularly important now, as contemporary psychoanalysis has moved to a pluralistic viewpoint on therapeutic action, and what ultimately helps a given patient in treatment (Aron, 2000; Gabbard & Westen, 2003). In my perspective, this pluralistic viewpoint must include the emerging adult’s voice, one that has been neglected in past psychotherapy discourse.

Conclusion In this study, I wanted to explore the subjective experience of individuals who had treatment during emerging adulthood, and specifically examine their ideas related to therapeutic action, and what they found helpful or not in treatment. Overall, four of my participants found their treatments generally helpful, while the fifth participant found one treatment helpful and one that reportedly made her feel worse.

For my participants, they all seemed to experience some anxiety or distress as they entered treatment, what I have described as their unconscious expectation to find

352 some version of a transferential object, a familiar parental figure that felt unavailable to them in specific ways based on the participants’ past (Mitchell, 1988). Instead, these participants, with the exception of Tonya’s second treatment, experienced their therapists as good objects: as available, responsive, guiding others who made them feel cared for and recognized, ultimately providing a new relational experience for each participant (Mitchell, 1988). In addition, my participants seemed to need therapists to be good objects in order to support individuation from “bad” objects, or their parents. As they attempted to manage separation/individuation dynamics and identity issues—a process that contributed to these women examining the childhood identities they had constructed in relation to parents and past significant others, and how those particular identities continued to impact their current relationships—they were then able to use the therapeutic relationship as a means to experience the type of care they desired from one or both parents, something they felt was missing or was not adequately provided in the past. At times, this took the form of temporary enactments unconsciously evoked to recreate familiar relational patterns in treatment.

My participants’ experiences in treatment eventually helped them imagine different ways of functioning with close others, with the exception of Tonya’s second treatment. Additionally, their treatments contributed to them using their new relational experiences within the therapeutic relationship to operate differently with others outside of treatment, something these participants used to assess change.

While my participants reportedly entered treatment due to experiencing a host of symptoms and consequently wanting symptom relief, they ultimately found and experienced something very different from what they initially expected. Instead of

353 managing symptoms, they all seemed to focus on their experience of the therapeutic relationship, and used that experience as the most important factor in determining how they viewed therapeutic action, and what they ultimately found helpful or not helpful in treatment.

354

Appendix A Research Flyer

355

RESEARCH VOLUNTEERS NEEDED FOR A STUDY ON EMERGING ADULTHOOD Did you participate in psychotherapy for at least six months at any point between the ages of 18 and 25? If so, I’d like your help with my research study for a doctoral program in clinical social work.

The purpose of this qualitative study is to understand what was helpful or not helpful about your particular experience in psychotherapy, and what your thoughts are about this. Other factors for inclusion/exclusion include: • Being able to reflect on your treatment and attend a maximum of five one-hour interviews with the principal investigator • Your treatment consisted of weekly sessions that lasted at least 6 months • You ended your treatment within 5 years of this study There is a maximum stipend of $50 for participation in this research.

Participants will receive a $10 gift card (Starbucks, iTunes, Amazon, etc.) at the end of each one-hour interview, for a maximum of five interviews and a total of $50 for each participant. The anticipated risk for this study is above minimal; any risks will be discussed prior to the beginning of the study.

This research is being conducted for dissertation purposes by Damon Krohn under the supervision of The Institute for Clinical Social Work (ICSW) in Chicago, IL. If you are interested in participating in this study, please contact Damon Krohn at 312-622-1911 or damon.krohn@gmail.com

356

Appendix B Individual Consent for Participation in Research

357 Institute for Clinical Social Work Research Information and Consent for Participation in Social Behavioral Research Therapeutic Action: What Emerging Adults Found Helpful in Psychotherapy I, ___________________________,acting for myself, agree to take part in the research entitled: Therapeutic action: What emerging adults found helpful in psychotherapy.

This work will be carried out by the principal investigator, Damon Krohn, under the supervision of Scott Harms Rose, PhD, and is in the service of the principal investigator’s work toward earning a PhD in Clinical Social Work from the Institute for Clinical Social Work.

This work is conducted under the auspices of the Institute for Clinical Social Work (ICSW); at Robert Morris Center, 401 South State Street, Suite 822, Chicago, IL 60605.

Phone number: (312) 935-4232.

Purpose The primary purpose of this study is to build on existing general literature in the field by exploring in detail what a limited number of participants say was helpful or not helpful about their specific and unique experiences in psychotherapy between the ages of 18-25. While existing literature helps describe what may contribute to more successful psychotherapy outcomes for large populations, that information is highly general, and primarily discusses positive outcomes. This research aims to understand—within the reported lived experiences of a small number of participants—what specifically informed their particular, unique experiences of psychotherapy. This research is intended to be exploratory and to contribute toward filling the gap between the general and the specific.

A secondary purpose of this study is to understand the participants’ unique narratives about childhood and family experiences, and experiences with others during development, and how those specific narratives may contribute to how participants found their particular psychotherapy experience to be helpful or not helpful.

The results of this research will be published in a dissertation that will be available for viewing by the general public. Any identifying information will be modified and disguised before publication. In addition, the results may be published in other academic or non-academic venues, for example, in a professional journal, a book, or electronic or digital media, etc.

Procedures used in the study and the duration You will be asked to answer open-ended questions from a semi-structured interview designed to elicit your perspective on what was helpful and not helpful about your experience in psychotherapy. Follow-up questions may be used in the interview to encourage you to elaborate on stories and specific examples of times in treatment that were helpful, and times in treatment that were not so helpful. Also, questions will be asked to understand your past experiences starting in childhood, including your significant relationships growing up in your family, and how those particular experiences may or may not relate to how your specific experience of psychotherapy went. There

358 will be a maximum of five one-hour interviews that will be conducted at a private location that is convenient for each research participant.

Benefits There is a maximum stipend of $50 in the form of gift cards for participation in this study. Specifically, each research participant will receive one $10 gift card of his or her choice (Starbucks, iTunes, Amazon, etc.) at the conclusion of each one-hour interview, for a maximum of five interviews and total of $50 for each participant.

Costs There are no costs associated with participation in this study.

Possible Risks and/or Side Effects The risk for participation in this study is above minimal. There is the potential to experience a negative reaction when discussing aspects of your psychotherapy that were not helpful, as well as when discussing your past, your family, and your reasons for being in psychotherapy. In addition, there is the potential for the interviews to evoke emotional traumatic feelings that you may have experienced in the past. There may be a risk that being asked about your childhood and family experiences may evoke the experience of being in a psychotherapy session; to mitigate that risk, during the consent process and before the first interview the principal investigator will reiterate the purpose of the interviews as being solely for research purposes as well as have a list of questions to assess your understanding of the study as a research initiative and not psychotherapy.

There is also a potential to experience a positive reaction when discussing your past treatment. If you feel uncomfortable at any point during any interview, the principal investigator will offer immediate support. This means that you can take a break from the interview, you can skip and come back to a particular question, or you can choose to not answer the question at all. Also, you have the option of opting out of discussing past and present experiences in your life that you feel are too distressing. In addition, you may choose to leave the study entirely, at any time, without any consequences. Last, if you no longer want to be in the study for any reason or want to immediately end an interview, the principal investigator will ask you if you’d like a referral for debriefing at a later date with a qualified mental health professional. If so, the principal investigator will offer referrals to local community mental health clinics.

Privacy and Confidentiality Individual interviews will be digitally recorded and transcribed after each interview. Your name will be removed from the transcribed interviews and you will be assigned an identification number for the duration of the project, a number that is not personally identifiable. A master list connecting your name with your identification number will be kept separate from the transcribed data in a locked file cabinet in the principal investigator’s home. Consent forms with your name will be placed in a locked file cabinet separate from any other data. The principal investigator will be the only person who can view data with your identifying information. The raw data generated in the interviews (i.e., the transcripts of interviews) may be viewed by the principal investigator’s dissertation committee.

The digital recorder used for recording the interviews will be kept in a locked file

359 cabinet in the principal investigator’s home when the recorder is not being used. The master list connecting participant names with identification numbers, consent forms, and all raw data transcribed from the interviews will be kept in separate locked file cabinets in the principal investigator’s home for the period of five years following the principal investigator’s graduation, and then will be shredded and destroyed by the principal investigator. At that time, the digital recordings of the interviews will also be erased.

Additionally, all electronic forms of data kept in a password-protected file on a passwordprotected computer will be destroyed.

Subject Assurances By signing this consent form, I agree to take part in this study. I have not given up any of my rights or released this institution from responsibility for carelessness.

I may cancel my consent and refuse to continue in this study at any time without penalty or loss of benefits. My relationship with the staff of ICSW will not be affected in any way, now or in the future, if I refuse to take part, or if I begin the study and then withdraw.

If I have any questions about the research methods, I can contact Damon Krohn at 312-622-1911 or damon.krohn@gmail.com or Scott Harms Rose, PhD at 312-935-4240 or srose@icsw.edu.

If I have any questions about my rights as a research subject, I may contact John Ridings, PhD, Chair of the Institutional Review Board, ICSW, at Robert Morris Center, 401 South State Street, Suite 822, Chicago, IL 60605. Phone: (312) 935-4232.

Signatures I have read this consent form and I agree to take part (or, to have my child take part) in this study as it is explained in this consent form.

Signature of Participant

Date:

I certify that I have explained the research to and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward.

Signature of Researcher

Date:

360

Appendix C First and Second Interview Guides

361 Open-Ended Developmental History Questions How did you hear about this study?

What made you want to participate in this research?

Tell me what’s going on in your life right now? (Probes: Are you in college? Are you working full-time? Part-time? Are you looking for a job, traveling, thinking about what to do next?)

What kinds of things are you interested in?

What is your current living situation? Do you have family in the area? How did you end up in this area?

Please tell me about your childhood.

(Probes: Tell me about significant events you recall from your childhood) What kinds of memories come to mind related to childhood?

(Probes: What positive experiences do you remember? What negative experiences do you remember? What do you think you learned from those experiences?)

What was it like where you grew up?

(Probes: What did your parents do for a living? How did you spend time growing up?

Describe your town/city) Tell me about your mother. How did she seem to you when you were a child? How did she seem to you when you were between 18 and 25?

(Probes: What do you remember about her? What was your relationship like? How would you characterize her parenting style?)

What adjectives or words come to mind when you think of your mother?

Tell me about your father. How did he seem to you when you were a child? How did he seem to you when you were between 18 and 25?

(Probes: What do you remember about him? What was your relationship like? How would you characterize his parenting style?)

What adjectives or words come to mind when you think of your father?

Who took care of you when you were little? Tell me about him/her. (If parents are deceased or participant was raised by someone other than his or her parents) Do you have brothers and sisters? How many of each? What was your experience like with your siblings? (If applicable) How did you feel you were treated? Is that the same now, or different?

362 How was conflict handled in your family? What did your Mom and Dad do when they were upset or angry? What was that like for you? What do you think you learned from how they handled being upset or angry?

How did you spend your free time when you were a child? What about when you were between 18 and 25?

When you were growing up, what did you do when you felt upset?

How did your parents comfort you when you were growing up?

What helps comfort you now when you feel upset?

(Probes: What people do you turn to? What activities do you engage in?)

How has your relationship changed over time with your mother? Can you give me an example?

How has your relationship changed over time with your father? Can you give me an example?

How has your relationship changed over time with the person who took care of you when you were little? (If applicable) How would you describe your relationship now with your parents?

(Probes: Do you feel close to them? Do you go to them for guidance and support?

What’s the trust level like? Do they participate in major decisions of yours? How so?)

Which parent are you more alike? Why would you say that?

Which parent do you feel closest to, and why?

Were you ever scared of your parents? Why? Can you give me an example?

How do you think your overall experiences with your parents have affected your personality?

Did you lose any important people during your childhood or adult years?

What was your high school experience like?

(Probes: What memories come to mind? What do you remember about this time? What was your relationship like with your parents in high school?)

How would you describe your adolescent years?

What are you trying to achieve at this stage in your life?

363 Tell me about your peer relationships now.

Can you tell me about your history of romantic relationships?

What are your professional aspirations? Do you have a plan to accomplish those? How did those aspirations come about?

Who or what has influenced you the most in your life?

How do you describe yourself? How do you think your friends would describe you?

(Probes: Based on friends? Family? Sports? Relationships? Grades?)

What comes to mind when you think of your identity?

Has anyone in your family had experience with mental health issues? Things like being depressed, or being anxious, or worrying so much that it worries other people?

(Probes: Who? What problems?)

Psychotherapy Questions Private Theories Interview (adopted from Werbart and Levander, 2005, and modified to suit the needs of this particular study) What was it that led you to seek therapy?

What did you hope to get out of therapy?

What did you go in looking for in your therapy?

Tell me about some important experiences or events in your life that you associate with how your difficulties and problems began.

What do you think has been of help to you regarding the difficulties and problems you had?

(Probes: Can you give concrete examples?)

What have been the obstacles you’ve faced in addressing your problems?

What else has been of help to you? (Probes: In the therapy? What exactly in the therapy?

In what way did therapy help you?)

What in the therapy was not helpful? (Probes: What hindered progress in treatment? Can you give concrete examples?)

Did anything outside of the therapy help you with your problems?

364 Did anything outside of the therapy not help you with your problems?

If you compare today with when you began therapy what do you think is different? What remains unchanged with regard to your problems and difficulties? What has improved?

What has become worse?

My Own Questions How long were you in treatment for? How frequently did you attend sessions?

Describe your therapist.

What was your experience of psychotherapy?

How would you characterize your relationship with your therapist?

What did you imagine therapy would be like? What did you think it could help with?

Did it actually affect any of those things?

Did your therapist have a theoretical orientation, or a particular way of working with you that he or she discussed with you?

Did you set goals in your treatment? If so, can you describe them?

Who did most of the talking—you or your therapist?

What techniques did your therapist use? Were they helpful? (Probes: Was your therapist active and directive? Did you get homework assignments? If so, what were they?)

Was your therapist similar to or different from your parents? (Probes: In what ways?

Can you give concrete examples? Was it useful for you that your therapist was similar to or different from your parents?)

Who did your therapist remind you of?

Did your therapist use humor?

What did his or her office look like?

Can you describe a typical session?

What was it like to sit with this particular therapist?

What did you often feel when sitting with your therapist?

365 Overall, how satisfied are you with your treatment? What seems most significant? What did you think about it when you ended therapy? Do you feel the same way now?

Does being asked about your experience in therapy now change how you feel about it?

If I asked you to think about one thing you remember about your therapy, what comes to mind?

Why did you stop seeing your therapist?

366

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