Therapist: “Could it be that by holding yourself to high
standards you remind yourself of having actually high self-esteem?”
Alec: “I guess so – you are right! By setting unrealistic standards of
getting all my work done in one day I tell myself that I can do it. It
reassures me in the moment, but only makes me feel more panicky later
because I don’t get any work done.”
Confronting cycles of self-criticism and paradoxical efforts of
regulating self-esteem through self-attacks allowed Alec to see how his
efforts to regulate self-esteem pulled him further and further away from
writing. Realizing that pattern, he hired a tutor who suggested how to
organize his multiple disjointed paragraphs. Initially, these
recommendations challenged his expectations and he considered hiring a
different tutor. Gradually though, he was able to reconsider his
reactions in light of his perfectionism, accepted the recommendations,
completed the thesis, and graduated.
Graduation brought a short-lived sense of accomplishment. Alec was
facing a new chapter in his life: becoming a young professional and
launching his own life. On a practical level, he knew that if he wanted
to go forward with his independent life he needed to look for a job.
However, he took a different approach. He moved back into his parents’
home. Initially, he thought of it as some well-deserved time to
recuperate and put his thoughts together about his future. However, soon
it looked as if he was living his life as a perpetual adolescent on a
permanent summer break. He slept late, fed the cat, read books on
history, and occasionally got together with old friends from high
school. Underneath a care-free façade, he was plagued by self-doubt,
pessimism, and avoidance.
The possibility of applying for jobs terrified him. Hopeless and
fearful, he was hiding behind walls of negativity and futility,
portraying his future as bleak and full of failures. He imagined that he
had no control or power and that I had no ability to help him either. My
repeated reflections on his very real capabilities, as well as his prior
academic achievements, were invariably rebuffed by his arguments that
everything was futile, hopeless, and pointless. His capabilities were
skillfully recruited to prove his point: everything was hopeless,
including efforts to help him. He imagined that even if he found a job
he would find himself paralyzed again, the same way he was paralyzed
writing his thesis. Hence, he thought, there was no need to apply for
jobs.
At times he felt increasingly desperate, and yet unmovable about his
career. The occasional get-together with friends provoked mixed feelings
in him. He enjoyed spending time with them, though each time he felt
trepidatious, comparing himself to their careers. Feeling panicky and
hopeless, he would try to justify the delays and find reasonable excuses
for the growing gap in his resume: “I think it is not unreasonable to
take time off after graduation. I also think I can explain during
interviews that the pandemic froze the hiring process for many jobs.”
Once he felt comfortable with his justifications, he would fall back
into familiar avoidance. A few adjunct treatments followed. Those
included medication changes, a day treatment, TMS and ketamine
infusions. His depression did not change very much, and Alec started to
recognize that “maybe this is not a biological condition,” but part of
his personality.
His romantic life fueled an equal measure of rejection and defeat.
Contemplating dating, he initially worried about a repetition of the
relationship with Mary: falling in love and not being able to accept a
partner’s “imperfections.” After talking about it in therapy helped
him assuage his worries, he joined a couple of dating sites. He started
talking to a few women, but soon faced a lack of progression: sometimes
women did not want to talk again after what he thought were good
conversations, and sometimes they did not want to go out on second or
third dates. Sure, sometimes a lack of chemistry was mutual, but many
times he felt rejected after feeling excited and liking the women he
went out with. He started to consider the possibility – a very real one
– that these rejections had something to do with his life situation. He
realized that he was approaching dating without consideration of
developmental context and life stage: many women wanted to get married
and were looking for a partner to build a family with. However, he was
unmovable.
Both he and I were defeated: he felt that his chances of having a
successful job were next to none, I felt my efforts were falling flat. I
worried that the time was passing by and that eventually not only would
Alec have an unexplainable gap on his resume, but also that he would
miss out on developmental milestones, such as an independent life, a
career, and romantic relationships. I felt that I needed to do something
and, in line with Good Psychiatric Management (Gunderson, 2014) and
Transference Focused Psychotherapy (Yeomans et al., 2015), discussed
with him the recommendation of taking a job. The rationale for such a
recommendation was to help him engage in “real life” to address
avoidance, start confronting his well-defended grandiosity, learn to
deal with disappointments, and start accepting himself and others with
all the complexities of strengths and limitations. I also hoped that by
doing so he would start moving forward with his life plans. However,
Alec avoided following through on the recommendation. Consequently, I
faced the dilemma of whether to stop treatment or not. In thinking about
this further, I decided to continue treatment because I realized that
stopping treatment would convey my collusion with his futility and
hopelessness and repeat the abandonment by his parents. I hoped that I
could help him address avoidance through greater engagement in treatment
and exploration of his emotional avoidance and his preservation of
grandiosity through avoidance of life, pervasive futility and pessimism,
and disconnect from his internal world.
This brought him to talk about his earlier times when such experiences
of futility, entrapment, and self-doubt dominated his life, bringing up
vivid and palpably anguished memories from his teenage years. He talked
about his dilemmas growing up with real feelings of rage, abandonment,
neglect, loneliness and despair. He felt unseen and abandoned by his
parents in the middle of his own identity crisis during his adolescence.
He had nobody to turn to, except fantasy novels. He spoke with
hopelessness about his fears of growing up: Would he become like his
work-obsessed father, his disengaged mother or his paralyzed brother?
None of that was appealing, though he was starting to recognize that he
was effectively becoming all of them at once. He was struck by the
parallels between their ways of being and his own ways of dealing with
emotional pain: to escape his feelings through work, to disengage from
others and reality, or becoming paralyzed and unable to move forward.
These realizations were scary and uncanny. Our relationship became even
more important as he relied on me to understand his feelings, his
avoidance, and the “damned if you do, damned if you don’t” dilemma. He
felt he was destined to fail either way, whether he was trying to get a
job or a personal life.
During that time his interest in my background became of greater
significance. Initially, I thought of his questions, such as “do you
have any plans for this weekend?” or “what was it like to come to the
U.S.?” as being either defensive or a projection of his own feelings. I
thought that he was avoiding his feelings about himself by being
preoccupied with me. I also thought that these questions might reflect
his feelings of not belonging and disconnection, or maybe he worried
that I could not understand him fully because I did not grow up in this
country. I thought this also could reflect feelings of superiority over
his “foreigner therapist,” though I could also see how he might have
been idealizing my multicultural background and devaluing his own. As I
entertained different possibilities, my thoughts on the matter started
to shift. I started to consider that my initial interpretations of his
questions as being defensive were partially correct at best if not
simply wrong.
As I became more curious about our exchanges, I started listening to
them from a different vantage point. Gradually, Alec brought up a
totally new area into treatment. He grew up with a younger brother who
became paralyzed and parents who became unavailable. What he always
wanted was to have an older brother. He wanted this brother to keep him
company in his difficult family – misery loves company, as they say. He
also wanted to have an older brother who could teach him things. Life
stuff – how things work in life. Alec felt that he was finally having
these experiences in therapy with me. I was there for him through these
changes and transitions, and I had not abandoned him even though there
were multiple periods that felt stagnant, futile, and hopeless. I also
never bought into the idea that therapy was futile and continued to help
him understand himself better.
He agreed to take a job at the family company as an administrative
assistant. He was horrified that the job would become his actual career
and that his career would follow the same trajectory as his father’s. He
did not want to give up his dream of pursuing his own career, which led
him to apply for a job in one of the research institutes where his
historical background and interests were of interest. After a series of
interviews, a job offer was extended. On a month’s notice, he moved out
of his parents’ home and relocated closer to the job. Initially, he was
obsessed with the possibility of failure and considered starting
ketamine infusions.