PRL5ENTAT<0N Of TH€ PSVCtiOTHERAPEUTIC TREATMENT^_81
PRESENTATION OF THE PSYCHOTHERAPEUTIC TREATMENT OF PSYCHOSOMATIC PROBLEMS OR IN PURSUIT OF WOAAANHOOD?
__Janez Rojsek_
KEYWORDS: psychotherapy, psychosomatics, symptom change process, formation of the self
KLJUČNE BESEDE: psihoterapija, psihosomatika, proces spremembe simptoma, oblil<ovanje seifa
ABSTRAa
The case study of a younger woman who had no menstruation for more than three years is presented. Introductory psychodiagnostic treatment revealed extensive restraints on the oral possessive and aggressive field accompanied by stressed symbiotic ties and identity problems.
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The application of AT was first indicated by somatic symptoms and the patient's interest. Her feeUngs and visualisation enabled a fast move to causal, analytical psychotherapy.
Psychotherapeutic process is clearly shown in developmental phases which led, through somatisation, to psychogenic problems, narcissistic feeling of shame, clearer formation of self, and finally to pregnancy and conception respectively at the time of reporting.
PRIKAZ PSIHOTERAPEVTSKE OBRAVNAVE PSIHOSOMATICNIH TEŽAV - ALI ISKANJE ŽENSKOSTI?
POVZETEK
Prikazan je primer psihoterapije mlajše ženske, ki več kot tri leta ni imela menstruacije. Uvodna psihodiagnostična obravnava je pokazala obsežna zadržanja na oralno posesivnem in agresivnem področju ob poudarjeni simbiotični vezanosti in identitetnih težavah.
Telesna simptomatika in pacientkin interes sta najprej indicirala uporabo ATja. Doživljanje in vizualizacije pa so omogočale hiter prehod na vzorčno-analitično psihoterapijo. Psihoterapevtski proces se nazorno kaže v razvojnih fazah, ki so prek somatizacije pripeljale do psihogene problematike, narcističnega občutka sramu, jasnejšega oblikovanja selfa, do nosečnosti oziroma zanositve v času referiranja.
PRESENTATION OF THE PSYCHOTHERAPEUTIC TREATMENT... 83
A 27-year-old woman is presented in the casuistic presentation of the psychotherapeutic treatment. The patient, who finished the College of Administration, has been more than 3 years without menstruation. Although she was given a thorough diagnostic and therapeutically hormonal treatment by her gynaecologist, there was no change. All organic reasons proved to be Bp.
SUMA/W\RY OF THE DIREaED ANAMNESIS SYMPTOMS
The patient reports to treatment upon the recommendation of her brother. She reports that her problems began some three years ago, when she started working as a secretary of self-management bodies in the bank. She also tells that she had studied law and due to the lack of persistence and her great wish to reach a profession, she then finished the College od Administration. She had never had any problems regarding her education: she was an excellent pupil in primary school and a good student in high school as well. The abundance of material she was confronted with when she began studying law was such a problem that she did not satisfactorily complete the first year of her studies. She did not give up but tried again next year. After the third year, she did not manage to pass all her exams so she became depressed and decided to continue her studies at the College of Administration. In addition to that, she split up with her steady boyfriend she had been dating for 10 years, a month ago. It was a hard blow for her which ultimately depressed her.
She believes an adult persons should be firm, withheld and always without problems. If any problems occur an adult should try to solve them within his/her own family. The marriage of her parents represents an ideal to her especially when she tries to view it in the light of other marriages. She doesn't feel too well at work although she is communicative and always ready to offer help. In her opinion that is because she only tries to cover her real problems. It seems to her that she is unable to defend herself. She feels rather shocked when she finds out that some people at work had tried to do her harm but she found it out after having been warned by some co-workers.
She let her boyfriend live according to his notion of free life. They split up because of her groundless jealousy. She comments: "That's not nice, I know." They started dating at the age of seventeen. He was a sportsman who was
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away from home quite a lot and didn't have much time to spend with her. She didn't want to set any Umits or bind him with their relationship in any way. He reproaches her that she is too tightly attached to him and doesn't want to look for company of her own, although she sings in an academic choir. They were classmates and only after they had found jobs and she had started talking about their living together, he began avoiding their conversations which gradually became a real nuisance. Being still in love with him, she is engrossed in thinking about him.
In this situation she feels humiliated and hurt. Because she has given so much and received so little, she has the feeling that she has been double-crossed. By putting so much in the relationship with her boyfriend and literally living for it, she was practically infatuated with him. They even told her she had no other aim in life besides him. She is easily huffed and could even revenge although so far she has managed to withdraw. As she says : "I'm so sick because I'm not able to get things straight into other people's heads." Sex hasn't played an important role and she has never had orgasm. In addition to that, she has no sexual experiences with other men. Sexual relationships were mild even though she often encouraged them. The reason for this situation was supposed to be another woman.
Her ideal is an extrovert, sociable man, who is important and who is willing to discuss various things. He shouldn't be anonymous. That probably misled her since she new the boy's father, her professor, who is a very kind man. His son is just the opposite. She is jealous "as hell" which she thinks is a very bad emotion. She has always felt that she has a rival and so she tries to analyse how much better other women are. Although she is aware that her boyfriend had other women, she is ashamed to ask whether it was true or not. Her anger and rage are hidden inside her. Her state of mind reflects at work where she is able to express her resolute "no" which wasn't the case some time ago. She used to be ready for everybody, willing to listen to problems, helping people, giving professional advise, organising meetings etc. People were never grateful and hence she was never adequately "rewarded." Although she is very thrifty, she used to lend money to her colleagues when they were in need. Her parents taught her how to deal with money and how to be financially inventive.
Her parents are 61 years old. Her mother is a retired bank employee and her father a retired professor. The only thing that is of any value to them is the grade excellent; they feel only adequate school and titles are of any importance. Her mother is hard-working; a good person one can easily rely on,
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but she suffers too much if everything doesn't wori< out for her children. It happens so often that she even interferes in their personal matters. In order to avoid arguments, the patient and her brother always have to report where they go. When confronted with problems at school, the patient could more easily complain to her mother, but she looks for advice with her father which her mother does not approve of. The patient takes shelter with her mother, but the solutions to problems are the father's domain since he was brought up to defend and to feed. It was his wife who introduced him to social life. The father's attitude towards young people is full of understanding; the patient concludes this on the basis of his father's attitude toward students he is tutoring. There were no conflicts between the patient's mother and father and even if there were some, the patient and her brother have not noticed any. Sexuality was no taboo so she was given answers to all her questions; getting dressed or undressed presented no problem although they appreciated intimacy. Her father showed considerable jealousy when the patient decided to visit her boyfriend at the time when he was in the army. In spite of his father's feelings, she decided to carry out her plan. Her father is much more withdrawn in his relationships, whereas her mother tends to be critical. The patient's grandmother, who is 83 years old, is in command of everything, being very authoritative, domineering and manipulative. The patient first severed her relations with her after their conflict.
The patient is afraid of failure although she has always considered herself as a successful student. She has always had what she wanted and then after the third year at the university, she decided to give in too quickly. It seems to her that success is something too highly stressed in their family. The words like " the doctor's son or the professor's wife" make her angry. Her weak point is that she is not persistent enough in her work. In case of a failure, she takes the line of least resistance. She thinks she is not ambitious enough, she gets bored too quickly, but in fact she is, by nature, somebody who does not take risks. It bothers her that she cannot sign things she prepares and that other people take advantage of her work. She is sent to different seminars. To her that is a proof that they really trust her but at the same time she feels that her manageress feels jealous about it. It seems to her that she always tells too directly what she has in mind so her colleagues often say " mind your own business and let others alone". Her manageress often wanted her to work overtime and even to do some work at home. It was all this because she has got no family and no obligations connected with it. Since her work does not satisfy her anymore, she started rejecting the requirements of her manageress. The patient is a pessimist by nature; she is afraid of future because she is no more certain who will be her partner and how her future life will look like. It
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is true that she considers a family, children and a partner to be her sense of life. After so many years she spent together with her boyfriend, she feels there is a dark hole in his place. She often wonders if she is able to bring up children, since she lacks independence regarding housework; she cannot cook or wash clothes because this all is her mother's domain. "I'm a spoilt thing", she remarks. That is why she has considered to hire an apartment in order to prove and show herself that she is capable of living on her own, without her parents. All her colleagues are married and the patient thinks she wouldn't be able to cope with the style of life they lead. She is surprised that all these women, who have to deal with their work as well as take care of their families, have no problems.
She would say she sees no sense or aim in her life; she lacks self-confidence. Whenever she thinks of something or starts doing it, the following thought appears : "1 won't succeed anyway".
She wants to complete her studies, have a family, two children and find somebody she could trust. To be successful at work is also one of her wishes. She has been dreaming about her boyfriend lately. These are pleasant dreams and when she wakes up she feels excited. In her dreams she went swimming with him and talked to him a lot.
She dreams about a new job and new colleagues with whom she would be able to get along well.
What are her problems that she would like to solve :
• She is too sensitive; she should not get involved so much.
• She tends to draw back instead of trying to socialise a bit more; she would like to discuss only serious matters.
• to have more optimism, a stronger will, because she now lives only from memories.
• to go in for things with hope and not burdened with complexes.
When our anamnesis sessions are rounded up, she feels astonished because she thinks she does not know herself. These areas are: her studies, job, parents. Once these problems are expressed aloud they sound quite differently. She discusses a number of dilemmas which come to the surface when, on the basis of our treatment, she tries to find her identity by moving into a new apartment, finding a new job, and reaching a decision regarding the choice between her professional career and family life. She expects a crisis
PRESENTATION Of THE PSYCHOTHERAPEUTIC TREATMENT... 87
sometime around the New Year, because she will then have her birthday when everybody talks about family life etc.
PROGNOSTIC ASSESSMENT
The prognostic assessment contained a number of factors which enabled psychoanalitically directed treatment. Social adaptability and involvement, sociability, adequately high intelligence and a sense for organisation and languages were favourable prognostic features. She was also capable to reflect her own experiences and emotional responses. Her physical, somatic status is good and she is well equipped with energy; her figure is short and plump, and she is likeable.
From the prognostic point of view, her lasting symptoms are less favourable.
Prior to this state, she used to have headaches in spite of her successful professional life, which is not accompanied by satisfaction and as such resembles workacholism which, together with the symptoms, serves as a defence against the usual requirements and demands life sets up in front of a person of her age. That is why the pressure of her illness was estimated as functional.
From the diagnostic point of view, we can see there are extensive inhibitions on the oral possessive and aggressive expansive area together with a stressed symbiotic link and identity problems (insufficiently developed self).
THE PROCEDURE OF THE THERAPY
In the pact for the analytically directed psychotherapy ( sessions twice a week) the patients accepts the offered conditions. She reaches the point where she states that "one has to do something for him/herself in life". In order to decide what this is, one should give this matter a thorough consideration. She wants to achieve "inner stability" so she would like some assistance with AT.
Regarding her psychosomatic picture, it is agreed to dedicate the introductory sessions to AT. A special attention is paid to her feelings, thoughts, images which appear during the training. They are obsessively connected with her ex-
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boyfriend as well as with her job. After the introductory sessions she keeps asking herself why she is so inclined to do this and how she would like to get most with as little effort as possible. And then she so easily gives in. The association technique was applied. She comments that men have more rights and possibilities. Namely, she spent most of her childhood surrounded by boys and played their role. "Is it possible to preserve one's own sex and do what the people of the opposite sex do^"
Regular training and "orders" as well as the possibility to become the president of the choir are connected with disappointments, because she is "a good for nothing" at work, and the performer of her mother's orders at home. "I'm not meant for this world; I needed and expected support, protection and acceptance".
She is thinking about self-confidence and independence; the news about her own apartment come as a blow from the blue. After realising that her "body does not respond as she expected" she first mentions the feeling of shame together with feeling of failure and humiliation.
After the 11th session, we do not deal with training but concentrate on the analytical work. The patient talks about her bad conscience and about herself as being only her mother's shadow without individuality. I add that she has also given up her menstruation. Her dependence from her mother is expressed by "she was moving me around as if I were a cat". She connects this to her relationship with the boyfriend. She was her boyfriend's friend and not a woman in their relationship, and hence her sexual problems (frigidity). He still belongs to her.
During the 14th session she first mentions that she feels less hesitant, less afraid of the unknown. She is also more determined and firm. Her mother is excited and tries to evoke her daughter's feelings of guilt.
The patients is willing to meet her ex-boyfriend and find out the whole truth. In this way, she says, she would cover her real loneliness and dependence. It all reflects in her tendency to overeat as well as in her problems with menstruation. For the first time she faces her splitting into good-bad, white-black. Arguments which she has with her mother are settled with her manageress.
After coming back from abroad, she reports, during the 17th session, that she has managed to conquer the woman in herself, who is only trying to take
PRESENTATION Of THE PSYCHOTHERAPEUTIC TRLATMLNT^._Si
advantages by binding to her boyfriend which was only a child's fun. She realises she is capable of having a new relationship. There is an impulse to apply for an apartment, which she hires much later. During the next session she realises that she does not want a family, children and responsibilities connected with them. There are more frequent arguments within her family due to her attitude, behaviour and higher degree of independence. Her father's reactions are turbulent and mixed with jealousy towards the therapist. The parents declare that both their daughter and son are still children who are supposed to follow their orders. The patient experiences she is superfluous, useless: "I don't exist any more; I don't mean anything to anyone." She is extremely involved in her duties as the president of the choir. At the same time, she experiences rehearsals which guarantee success, as something humiliating because she cannot easily accept that people are not perfect. The meetings of the choir members are accompanied by diarrhoea.
During the 22nd session, she connects the menstruation with resistance and punishment : she hurts her father and rejects the mother. She has always been pushed aside because she is a woman. Her brother has always been their favourite. She trusted him, but he was humiliating her by : "Which school have you finished^" During the 23rd session she says she is "a flower without a blossom". The reason is a complete symbioses at home, without any autonomy and individuality concerning wishes, experiences and ways of dealing with life. She has been working and fighting for people but in fact she was losing them. She trembles with fear of failure. Only slowly does she realise that she sets her own limits as well as inappropriately replaces love with professional success etc.
In the 34th session she talks about her ideal "perfection of the superhuman" who works effortless. But at the same time she confronts her resistance : "I want no changes, I feel comfortable". Watching TV and daydreaming are two ways of dealing with loneliness and confrontation with herself. In this way she realises that she slowly begins to move away from her boyfriend who embodies independence, risk, ingenuity - everything that she lacks.
Her father's thoughts about his last will direct her to her fear of death and new responsibility. She is also thinking about infantile roles within her family. This leads up to her thinking about an ideal boyfriend and she is proud to find out that nobody is "good enough" for her.
The 48th and 49th sessions were completely dedicated to the investigation of the mother-daughter relationship. Through this relationship she identifies her
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role in the choir which is "a puppet who works for everybody". Nobody is there to defend her or show her any kind of gratitude. She helplessly states that they " treat me as if I were a piece of cloth".
During some last sessions she reports about a strange feeling she is not able to define.
In the 50th session she announces, that she has had her menstruation. At first she does not understand the mechanism but later she defines changes regarding her independence, maturity, activity; she points out her fear of loneliness as a current problem, which she reduces by escaping into work. And in the area of her professional work, she demands her immediate perfection and uniqueness.
During the following sessions she connects her overeating with love, loneliness and her mother's attitude towards her. Her colleague's death, due to cancer, is also the theme of her reflections. In the 59th session she tells that she was given notice and was supposed to move although it later turns out that she had rejected the offer to buy the apartment. She moves back home and because of her bad condition she even feels sick a few times and loses one menstruation. It is once more evident that she sees her father as a good person and her mother as bad one.
During the 61st session she realises that "I don't like myself". She continues in the next session by speaking how sorry she feels for herself, how unsatisfied she is with herself. She meditates over the sense of human existence, about the sense of living and life in general. She first mentions aimlessness etc. Since she has managed to solve the problems which were the reason for coming to treatment (menstruation), she thinks that all the above mentioned questions are something that have attracted her attention lately. This could be the starting point for further broadening of therapeutic objectives and for the continuation of the psychotherapeutic treatment.
230 sessions have been carried out so far. Narcissistic feelings of shame have become more evident. According to my experience, such feelings never completely disappear but they raise numerous questions regarding the length and the contents of the therapeutic process as well as concerning its procedure and termination.