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.