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.