Mantenimiento general

Despite encouraging aspects o the first meeting, I was not optimistic about psychotherapy with Ms A. Against the backdrop o longstanding physical complaints, Ms A’s ailing stance seemed to have become entrenched as a

CASE VIGNETTE 45

modus vivendi. Te ollow-up consultation indicated how one should expect relapses to the status quo, and how one would need to tackle deeply elt resent- ments and rustrations.

The early part of treatment

I was somewhat taken aback, thereore, when, even over the first two sessions, it proved possible to make quite a lot o headway. Critical to progress were qualities in Ms A that had emerged at the initial assessment consultation. From that time and then throughout treatment, and especially when chal- lenged, Ms A had the capacity to reflect on what she was doing in a way that was not  so helpless nor atalistic. Just as surprising and impressive, she could be generous in acknowledging my contribution to what was happening. For example, as she had stood up rom her chair at the end o the second session, Ms A remarked: “I know it’s short, but I eel a lot has happened in these two sessions, and I eel there is a chance o getting somewhere.”

In the early sessions, the principal ocus o the work was Ms A’s charac- teristic way o protecting hersel and nulliying the impact that anyone else might have on hersel. I have already described how it was possible to address such maneuvers in the assessment consultation, and it was not difficult to point out how, especially when she elt she was in danger o not being taken seriously, she would institute now-amiliar protective strategies. It was not merely that one could eel the abrupt shif in contact with Ms A as she lapsed into complaints or recriminations, but also that she hersel began to see what I meant when I commented on her choosing to take this path. She could also appreciate how there was something prooundly important in this. She said she knows she presents hersel as having these disorders, because it would be mean o anyone to question her reasons or being the way she is. I said she paralyzes people, in the nicest possible way.

Alongside this, o course, there was the task o examining anxieties and other difficult eelings Ms A was needing to avoid. In particular, we returned again and again to how sensitive she was to the way I treated her. Ms A could articulate this hersel, and could see that this act was deeply relevant or how she has elt or a long time. She described how she can easily eel that others do not appreciate all she does and has to put up with, or that others are try- ing to “put her into a box” in which they expect her to conorm to norms, or instance over the time she is expected to get up rom bed. How she resents that! Gradually she came to say how she knows she finds it very difficult to be open to other people. She can eel like she has been skinned, and her nerves raw.

I said how she and I do need to be aware just how hard it is or her to be open. She needs someone to be firm with her, i she is to ace things.

A FIRST CASE HISTORY 46

It was possible to explore some sources o Ms A’s eelings in her upbringing. In addition, it became more explicit how she could ashion her personal rela- tions so that others had to endure her  insensitivity and tendency to prejudice. I took up with her a very characteristic pattern in our exchanges, when she would begin with a “but …” and then talk as i to someone who is uncompre- hending and deserving a fight. Invariably, she would end up rustrated and not ully in contact. Tis meant that she became unreceptive and unavailable, and in this way similar to relatives whom she had described as insensitive to hersel. Te complication here was that ofen, I elt that Ms A’s very insights into hersel, or what she presented as her attempt to think through the causes o the way she is, were not enlisted in the service o change, but rather, to maintain the status quo. Even when she described parts o hersel quite accurately, it was not yet with a view to challenging her own habits and battling to be differ- ent. She would ofen spend time talking about her illnesses at some length, to plant her flag. Or she would keep wiping her nose like a chi ld, or speak o how she remains like a young bird in the nest. Such diversions would sap energy rom more productive lines o exploration. She would remain untroubled by hal-acknowledged, and potentially painul because unulfilled, wishes and desires or hersel and her own uture.

In addition, there was a fine line between my acknowledging Ms A’s struggles with her physical state, and being indulgent towards her. She elt she had to insist on describing her symptoms to a seemingly dismissive doctor, and it seemed that only intermittently could she recognize what she was doing. As her ambivalence over a variety o issues became more apparent, she was prone to switch to and ro among alternative stances in relation to hersel as well as mysel.

Tere were two times early in the treatment, when I had had to postpone ses- sions at short notice. Ms A told me, with striking directness, how she had elt and thought a lot about this. What is going on in his mind? What else might have come up that relegates her to second place? Afer all, she has made such an effort. Could it be I don’t want to see her? She was hurt, but also angry, and it was impressive that instead o mulling this over in a hurt, hard-done-by way, Ms A was direct in her criticisms and her mixed eelings. I took up the orthrightness with which she communicated all this, and said how her eelings are justified— and I apologized. I also took up how she was being direct, apparently expecting me to listen and hear her, and neither retaliate nor collapse. She nodded.

I shall skip over the middle o treatment, much o which was spent address- ing the themes already outlined, which reappeared again and again in the exchanges between Ms A and mysel—although increasingly, in an atmos- phere o trust and a shared understanding that allowed much greater flexibil- ity o contact. Now I shall summarize the last two sessions.

CASE VIGNETTE ₄₇

The final sessions

Ms A arrived on time or the penultimate session. However, it took me three minutes to get through to reception to invite her to take the lif up to my floor. When she arrived in the lif—always a telling moment—Ms A gave an impres- sion o reshness.

Once in the consulting room, Ms A said I will notice she is wearing a new top—not exactly colored, but not the kind o thing she would usually wear (and in act, she was also wearing earrings which I had not noticed beore, and bright nail varnish). I said yes, I do notice, and also want to say (here Ms A looked slightly concerned) that it took me three minutes to get through to reception, so we can add three minutes to her session i she can stay or the longer time. She said yes.

Ms A returned to say how she has been looking out or colored clothes to look nice. At winter time it’s a problem, she has to wear high collars because otherwise she will catch a cold, other people can wear V-necks, she wears fleeces which she doesn’t mind or the material but doesn’t like the style; it’s difficult, but perhaps she will at least look out or things to buy. I said it’s nota- ble how actually it’s summer, when even she might wear a less high collar, but she immediately moves to talk about when it’s colder and more difficult or her to find clothes. It’s saer territory. She smiled in recognition, and contin- ued that at least she’s on the look out or things that might work or her, or possibilities.

In act, she said, with this being the last but one session, she’s been wonder- ing how she might continue on with the kind o thing we have been discuss- ing. She bought a book on Tai Chi, and one o the themes is being open to being open. She talked at some length about this. I said I think that one o the important things is that she needs me to appreciate she is pursuing such aims, not least so that in the uture she will know that I am aware o what she is doing.

She said how these are the kinds o things she could not have done three months ago. She has moved a long way coming here. I said that one o the striking things is how on the one hand this is true, yet on the other it has not been that hard or her to come to trust me. And this is despite the hiccoughs we had over the choppy session times. I linked this with her taking over her amily’s financial management, and how what might have proved a really big hurdle or her turned out to be something that was difficult, yes, but not so  very difficult. So, too, she finds she does not need to be a child and can be an

adult, open to relationships, even though this carries risks.

Ms A said how it surprised her over the changed session times t hat she had not needed to punish me. She said that yes, she had elt angry and upset, but

A FIRST CASE HISTORY 48

she orgave me. She also talked o how the most important thing coming here was that I was firm but air, and didn’t completely tell her she was wrong, she had to do it this other way—as she might tell hersel. I said yes. I also said that in what she says, she indicates she could value how I wouldn’t let her get away with things. At such times, she did not necessarily experience me as criticiz- ing her. I said I thought she had come with eelings o resentment, but to her surprise ound these were not so powerul. And in the case o the problems with sessions, she did express her negative eelings and actually elt I took them seriously. She said yes, definitely.

I said that, o course, this also presents her with a problem. She looked at me quizzically. I said that i it’s not such a big thing that she can do things she elt she couldn’t, then a whole world o possibilities opens up. I she can trust enough to have courage to wear different clothes and even be a bit sexy, then she can’t go back and think these things are just not or her. She said she thinks she may be giving up her perectionism, allowing things to be less controlled. Here the session ended.

Te final session was very moving. She came out o the lif wearing a pink/ purple top and smart jeans, and had had her hair cut attractively.

She talked o shifs in her vision o her parents, and how ragile and poten- tially explosive she eels her parents’ relationship and the home situation to be. She had been trying to persuade her mother to see a psychologist to allow hersel more space, but her mother does not eel able to be defiant or obstinate or whatever it takes to make a lie o her own.

At several points, Ms A was tearul about what the loss o the sessions, and what the relationship with mysel, meant to her. She thought she was probably  very angry about the brevity o the treatment, but sadness was her strongest eeling. I took up how I thought she was protecting me somewhat, by being sensible. Ms A nodded. She elt it was so important that she had elt heard without needing to batter away, and that I had witnessed her change. She said it’s not just talking about how things can be different, but actually experienc- ing them. As Ms A stood up to leave, and in tears, she said: “It’s been antastic, a dramatic voyage.”

In a client satisaction questionnaire completed at the end o treatment, Ms A wrote o improvements in a range o her difficulties (a matter also reflected in scores on standardized sel-report questionnaires), and described how she hersel was better at dealing with problems. “I think differently now about the problems—they don’t seem quite so big.” She wrote that she elt she had been treated with a lot o respect, and elt “very satisfied” with the way her treatment was managed. “I got off to a shaky start or various reasons but in a unny way even that in the end was helpul.”