Defining a clearer contract in the contest of a shared case formulation
As we just described, Mark is both depressed and disconnected with his vital drives. He is unable to set a direction and, consequently form a reasonable plan. Once ruptures in the therapy relationship has been repaired (Muran et al., 2021), I give him reasons for why we need to set together goals that make sense to him, and then devise strategies suited at achieving them. I also made clear that we needed to make sure he would explicitly commit himself to tasks, otherwise we would end up again in a cycle where I push him and he discounts my proposals. This time Mark accepts to explore new avenues. He tries taking time in-between sessions exploring his inner world: “What do I want in this situation? What is my own perspective? I feel … how? ”. He understands that every time he gives up on doing things it’s because he foresees that his sister will suffer and he sees himself as bad. He notices more and more often that the emotion he feels is guilt and also sees more and more clearly the envy towards others.
A necessary step now, is helping Mark figure out that is negative ideas about himself and the others are just perspective, and are not necessarily true. He now reports more episodes and these helps observing recurring patterns in his interpersonal relationships. As a first step I offer him a summary of what occurs to me as being the structure of his narratives:
T: “Mark, it seems that things tend to go in similar ways in the different encounters you have. You told me that earlier you arranged a dinner with your colleague but then you didn’t show. Thursday, you planned to go to the cinema alone and then you changed your mind and ordered pizza and eat it home. In both cases it seems that you are driven by curiosity, but suddenly either you start focusing on Sandra home without you or on your aunt who will be overburden by caregiving, At that point you see yourself as mean and selfish and feel guilty. Then you give up with your plans and resort to be the caregiver, which alleviates guilt but deprives you of vital experiences. Mostly you are blocked by the idea you will make the other suffer if your give room to curiosity and exploration… is that correct?
M: “Exactly, it’s true!
T: “You believe so much in the idea: you are the villain who hurts others, so you have no right to do things you like ”.
M: “Things would really go like this, so it’s better that I don’t do anything anymore ”.
T:You often give up. You only find kind of a solution, that is lying in order to prevent blame or facing disappointment in the face of people you love. I remember that time you went out but only after having said something unexpected at work happened and you would have just be back home later than usual.
M: “I said half the truth ”.
T: “Yes, but basically you didn’t allow yourself to say: I will be out because I need, you were justifying yourself! But that time I noticed you felt free, at least for once. It means that you have the capacity to experience freedom and curiosity, it just lasts so shortly in your mind, sudden over-run by guilt. But it’s there, it’s a part of you ”.
M: “I was a little happy but then I felt guilt as usual. No no, better not doing anything… it’s less risky ”.
T: “For you acting is a risk! You can do protect yourself from guilt and idea of being mean and selfish but… can you see now it comes to a cost. That is devitalization, anger and ultimately depression? Is it correct?
M: “It’s me! I always mock the others for the things they do, trips, going out to the restaurant, but fact is that at least they give it a chance… I was thinking about it last night on the bed… and I told myself that mine life is miserable, that I’m miserable compared to others (slumping on the chair)
T: “This is important! So would we agree that not acting shield you from guilt but then paves the road to unhappiness? And moreover, if you give up with your autonomy, you don’t feel good. You spend countless hours ruminating about it, filled with anger and frustration and a sense of failure. At the end you just feel sadder and miserable. You measure yourself against others, you consider them better than you and you see yourself even more as a failure …”
M: “The others… and their bloody lives… ”.
T: “… what are you feeling right now when you say ‘their bloody lives?’
M: “Envy. I envy everyone. Now I see it clearly. Like it happened with you, remember? I don’t want to… but it’s beyond my control ”.
Now that we agree on this reconstruction, the next step is helping Mark realizes that these ideas are not necessarily true, but are learnt. Put it simply, I tell him that on the one hand it is human he cares for his sister and aunt. But on the other hand he made the hypothesis that his tendencies to give up with autonomy in order to prevent moral criticism and to not experience guilt were more than a normal human reaction, but a learnt pattern. Therefore I ask him if he can recover autobiographical memories which could help understand where this pattern stem from. Mark recalls his mother’s harsh face when she ordered him not to go out and stay with his sister. He also recalls his mother’s indignation when she made normal adolescent requests, such as playing soccer, participating in board game sessions or staying in the village square on Sunday mornings.
The result was that any enthusiasm vanished he felt guilty and gave up. Consequently, Mark never gave himself a chance to act autonomously and live social experiences that usually adolescents live. Now, as an adult, he feels powerless and paralyzed, and everything looks to him beyond his reaches. The roots for his current sense of stillness and boredom, and for his anger and envy is now clear to the both of us.
Once a pattern is understood, time is ripe to try and break it and this happens with specific work, which includes a behavioral component (Lewinsohn, 1974). Does Mark want to commit himself acting in order to fulfill his wishes? Will he accept to expose himself to feeling guilty and face the idea of being mean and selfish but then access a different idea of self as being as motivated by a normal, human drive for new experiences and a richer sociality? This is time to redraft the contract in order to see whether we agree on behavioral experiments aimed at breaking the patterns and exploring new and healthier directions. Also in this case I have to seek an explicit agreement because patients with NPD, as mentioned previously, have the tendency to act little, to remain in their situations even if they generate pain, and they cultivate the expectation that change is impossible or that it is generated by others. Mark, as a victim of these beliefs, had to grasp the disadvantage of this position and take responsibility for his well-being and life-changing. Let’s see if he agrees otherwise I would have had to remain in a position of closeness and listening but which would not have favored any change in his life.