clinical example--5

I have had one more couple and individual session.

Couple session: The wife was not as angry. She explained that her
anger level was decreasing. At the same time she was saying
"vicious" things to him but did not feel she wanted to stop at
this point. Much of the session involved discussing his parents.
She is thinking of him as an abused child and this thought seems
to help her forgive him somewhat. She is still vascillating
between being angry and wanting him out and forgiving him and
working on the relationship. We discussed their different
reactions to an incident before they were married. His father
asked if he wanted some money for the date. Before given the
money, he had to screw in a light bulb. She regarded this as
degrading and embarassing. He claims he did not. It was typical
of the kind of thing his father would do.

One interesting thought: she married someone like her mother who
she has many negative reactions to and he married someone like
his father who he has many negative reactions to. Her mother was
very demanding, sucked up everything from her but didn't give
much back. He has described his wife as demanding, bossy and

In the couples session, each described the incident which I
referred to as "a turning point." This incident meant to her that
he really regretted, felt sorry for his actions. This incident
meant to him that he realized how sad and lonely and empty he
would be if he lost his wife and children.

Individual session: He was feeling sad and depressed. Much of the
session was spent talking about his wife's negative descriptions
of members of his family. This lead to mostly talking about his
father. He has learned how to handle his father. The picture of
his father was: a big, tall man compared to the patient with a
bad temper. The father was very anxious, showed many obsessive-
compulsive traits, was very impulsive, and very controlling of
others. He was physically abusive when angry. An incident was
recalled when he was about 11 or 12: he father told him to go to
the store and buy cigarettes. He told his father "no", he
shouldn't smoke. His father chased him into the bathroom where
the man locked the door. He remembers his father's fist coming
through the door and unlocking it. Then he doesn't remember what
happened except he was beaten up.

We also talked about his mother. The picture of the mother was:
overly involved with her son with sexual overtones, was phycially
abusive of him at times. There was an incident in which his
mother threw a hammer at him which hit him in the head. There was
an incident in which his mother smoked pot with him.
The patient has learned how to handle his father through talking
and actions. When his father becomes abusive verbally, he hangs
up the telephone or leaves his presence. The patient has
distanced himself from his mother.

We went over the history of his relationship with his wife. At
one point they had broken up and then later went back together.
Each were very sexaully active with many different partners
during the breakup.

He will not allow himself to think any positive thoughts about
himself. He said he did find comfort in an idea I presented to
him: Normal people have multiple self-images which are separately
controlled for. This means that he is not all bad. We also
examined in further detail the experience of lying on the bed,
curled up in a fetal position and crying very hard and long. He
had a sense of being alone, sad, in the dark, empty, not alive. I
asked him who was making these observations. I suggested that
this was an observer self which is above the various self-images.

I also suggested that his actions on this night might have been
to relieve his depressed state which he had been in all winter.
The fact that he was angry at his wife this particular night is
also important I think. When this man was a teenager, he used to
flagrantly do things in the house such as have sex, smoke pot,
and drink even with his parents in the apartment. He would do it
to defy his parents.

From all the discussion of his family, this man grew up in an

emmeshed family in which the individual boundaries were violated
often and he became used to it. I think this is why he did not
become overtly upset during the lightbulb incident. This is a man
who has a hard time recognizing when he is crossing boundaries.
His wife's intuitions that his actions are somehow connected with
his experience withing his family makes sense. He allows people
to violate his boundaries, for example, this woman, the
babysitter, violated his family boundaries in the beginning and
even though he sensed it, sat back passively and allowed it to
happen. Another example, there is an incident in which the
bahysitter quieted the crying of their firstborn by putting the
baby to her breast and allowing him to suck. The wife was shocked
and horrified by this but he didn't support her that something
was wrong about this picture.

This man has a hard time recognizing and dealing with negative
emotional states. When he is depressed, he ignores it and eats,
runs, has sex, or works hard to deal with it. When he is angry,
he ignores it, withdraws from the person, and then acts out
impulsively against the person. He has to learn other ways of
dealing with his feelings and moods.

In summary, my thinking of this case so far is that this man has
to learn to: (a) not allow other people to violate his boudaries
with impunity and to learn when he is violating other people's
boundaries. In HPCT terms, he has to become more sensitive when
he is having error signals in his self-image systems., (b) sense
and take actions when he is feeling sad and angry which are
consistent with all his self-image systems., (c) develop an
understanding of his different self-image systems all at once,
from the observer self point of view which will serve the
function of integrating the different self-images., (d) not treat
his wife like her mother treated her which is a big disturbance.

I have been really impressed with his wife. She is intelligent,
attractive, and is usually on target with her descriptions of his
faimily. His wife has to learn to: (a) not treat him the way his
father treated him which is a big disturbance; this will require
her to learn some things about herself., (b) make him aware of
when he is violating boundaries, (c) make him aware of when he
seems sad or angry, (d) be more self-disclosing about herself,
for example, her hobbies., (e) deal with the big internal
conflict about staying or leaving this marriage; I think she has
decided to stay. She would really benefit from seeing someone
herself but refuses. I can use the couples session to address
some of her individual issues. I can also give her Ed Ford's book
to read.

I think that this is a workable marriage. I think they still love
each other. They are both committed to the family they have
created together. Together, they have to work on the kinds of
things I talked about when I wrote about HPCT applied to group
therapy. Spending quality time together is the basic means to
achieve these goals.

This will be the next to my last post on this clinical example.
Hope you have enjoyed it. It is hard to apply HPCT to clinical
cases but I think it is doable. In my last post, I will answer
any questions which you may have about the case and will give my
own reactions to the application I have made of HPCT to the case.


To: interested CSGnet members
From: David Goldstein
Subject: clinical example--5
Date: 5/16/92