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What Happens in Psychotherapy? Four Case Studies
One of the best ways to understand what psychotherapy involves is to read accounts of what happened to people when they went: the problems they came in with, the discussions that were had, and how things changed as a result. What follow are four representative case studies of the therapeutic process:
Underachievement
It ought to be a source of immense satisfaction for a parent to see their child secure success and esteem in their chosen career. But in reality, this is only possible if the parent has learnt to be comfortable with being superseded by their child, if they have the inner resources not to mind surrendering leadership, if their own sense of self is robust. It is not enough to know how to feel tender around the helplessness of an infant; an equally crucial, though less recognised, challenge is to cope with their eventual strength as an adult.
Twenty-seven year old Nathan [not his real name] arrives in therapy complaining of a sense of listlessness and despair. He had always seemed marked out for a special destiny. His father is one of the city’s most powerful bankers, a self-made man who overcame a deprived childhood to achieve extraordinary wealth and renown.
His mother, a former beauty queen, is on the board of the opera, the museum and several children’s charities. Nathan is their only son. There has long been a feeling that he would achieve something commensurate with the status of his parents. At a young age, his mother called him ‘little genius’. Family friends would joke to his father that his son looked exactly like him (the resemblance is striking, even though the son retains a handsome head of hair) and would soon be one to watch in the trading world.
But none of the early promise has born fruit. Nathan did not feel his grades in maths were good enough to follow his father into business. He was more naturally drawn to the arts and, after graduating, tried to write a novel. He kept at it for three years, but after yet another rejection letter, put the manuscript aside. He also started and abandoned three film scripts.
He complains of his love life. He is often in the role of pursuing women who want to be his friend but not lover. Sex can be awkward.
Nathan is currently working in a basic administrative role in an art gallery in a run-down part of the city. His salary doesn’t start to cover his rent, which is taken care of by his father. Payment involves a complex administrative rigmarole, in which Nathan is required to show up at his father’s office every month with a receipt from the landlord and is asked by the PA to wait outside for up to an hour while his father finishes apparently urgent business inside.
Nathan is, he says in a dry sardonic voice, with shoulders stooped, the ultimate loser.
On the surface, parents invariably speak of wanting the best for their child. But if they are nursing, somewhere within, a wound of neglect and humiliation, it may be intolerably envy-inducing to see a child succeed against odds smaller than those they had to endure.
The adult will feel compelled to keep winning, even against the child they ostensibly love: it might be at table tennis or Monopoly, in exam grades or political arguments. Or at life more generally. But there is a basic sense that there cannot be two winners in the same household and that in the choice, it is the senior party who has to triumph.
Nathan has always admired but been intimidated by his father. He mentions in an early therapy session trying (he would have been no more than seven) to identify something to buy his father for his birthday but realising that he would never be in a position to afford anything this potentate of finance actually needed.
He also remembers a time, the first and only time, he beat him at tennis. They were at their house in the Bahamas. Nathan was fifteen. The father was proud of his game. But this time, Nathan won. Clearly and unambiguously. Yet the father accused Nathan of being a ‘cheat’ and stormed off the court in fury. They didn’t speak all day – and never played again.
In the unconscious mind, a child facing parental competitiveness understands that they are being offered a deal: a choice between love and early retirement; or success and possible expulsion. Unfortunately, it mostly doesn’t feel like a choice. The capacity to stand up for oneself requires enough of an experience of unconditional love at the outset for the threat of its loss to seem endurable down the line. But without inner ballast, the child has no realistic way forward other than to put aside their ambitions and submit to (imperceptible and never-quite-stated) parental edicts.
For Nathan the work of therapy involves seeing that his father’s seeming support is really an expression of rivalry. His father is generous with money, but the way it is distributed serves to reinforce the idea of Nathan’s dependent, inferior position.
At the same time as bringing the father’s competitiveness to consciousness, therapy helps Nathan appreciate its origins. The father is not so much vindictive as fragile. His power in the world is almost inversely proportionate to his feeling of inner security. The more he dwells on his father’s past, the more Nathan starts to feel sorry for, and almost protective of, him. It cannot be much fun to be an adult threatened by an adolescent’s growing skill at backhand.
One way to meddle with the ambitions of a child is to imply the child cannot be a success; the other, equally harmful way, is to insist that he or she must be one.
Nathan’s mother’s greatest wish had once been to study literature and become a university professor. It didn’t happen.
She has always been extremely encouraging to Nathan – in a way. When he was little, he started reading extremely early, which began her habit of referring to him as a genius. When he turned thirteen she gave him the complete works of Nabokov. Now she sends him links to literary articles and talks about new novels he must read. She has taken the rejection of her son’s novel very badly – perhaps worse than Nathan himself did. She urges him to give things another go and to meet up with a creative writing teacher she met who has offered to help with plot structure. Nathan can’t bear to tell her that he’s thrown away his book and all its accompanying notes. He dreads that one day he will have to inform his mother of a greater truth: that he is not the genius she needed him to be.
It is as harmful to require a child to succeed as it is to require them to fail. In both cases, the child’s true developmental needs are sacrificed to the parent’s psychological requirements. Sincere love is in this area neutral; it doesn’t mean needing someone either to succeed or to fail, rather to grow on their own terms, which might be compatible with being either quite ordinary or, perhaps, even a bit exceptional.
In the course of a year of therapy, Nathan recognises that the world is broader and more robust than he had first imagined. A client of the gallery where he works offers him a new job in his architecture firm. Nathan accepts that he won’t ever write a novel, and perhaps never even wanted to. It’s an uncomfortable lunch with his mother, but it’s only one lunch.
Though it means tightening his expenditure dramatically, Nathan decides that he doesn’t need his father’s money for his rent. He tells him politely but firmly that he won’t come uptown for another cheque – which creates an unexpected response. His father immediately offers to give him a large upfront lump sum, no questions asked. Nathan is grateful but hasn’t touched the money yet.
At around the same time, he develops a new confidence around women – and meets a young German architect in the office. The sex is pretty good.
Nathan is, step by step, starting to discover something even more satisfying than knowing how to please his parents: leading his own life.
The Good Child
We tend to assume that all is well with good children. They don’t pose immediate problems, they keep their bedroom tidy, do their homework on time and are willing to help with the washing up. But the very real secret sorrows – and future difficulties – of the good child are tied to the fact that they behave this way not out of choice, but because they feel under irresistible pressure to do so. They are trying to cope with a legacy of caregivers who had no capacity to deal with their more complicated, and inevitably sometimes rather darker, reality.
Eva works in a top law firm. She is hugely coveted and has been made partner at the age of only thirty, an almost unparalleled achievement.
She comes to therapy because she recently collapsed on stage at a conference where she was delivering a keynote speech. It was hugely embarrassing but also deeply mysterious. The doctors could find nothing wrong. Eva interprets it as almost a deliberate act of self-sabotage. She registers an impulse in herself to let her firm down, to fail and mess up – like she has never done before.
She doesn’t know where the impulse is coming from but, after too long of being very good, there’s an occasional – but powerful – longing to try to be bad. ‘I wonder what it would be like to blow everything sky high,’ she tells her therapist, with a burst of almost childlike glee, which she then quickly checks, feeling a need to reassure the therapist of her fundamentally law-abiding nature.
On one occasion, she rather enjoyed taking a day off work, pretending she was ill in bed, and then spending many hours with a girlfriend at an upscale shopping mall instead. But she became terrified that wind of her ‘bad behaviour’ might reach her colleagues.
We imagine good children to be fine because they do everything that’s expected of them. But the good child isn’t good because, by a quirk of nature, they simply have no inclination to be anything else. They are good because they lack other options. Some good children are good out of love of a depressed harassed parent who makes it clear they just couldn’t cope with any more complications or difficulties. Others are good to soothe a violently angry parent who threatens to become catastrophically frightening at any sign of less than perfect conduct.
Eva’s parents were immigrants. From the first, they instilled in her a ferocious work ethic. When Eva’s father left the family, her mother had to support three children on her own. Eva was the eldest. She remembers hearing her mother wake up at 4 a.m. to start her first shift.
There was little room for laughter. Eve took school very seriously, desperate to get good grades, and pulled herself through university, working in the evenings and at weekends in a care home. There has been a lot of disappointment in Eva’s mother’s life. Eva always struggled hard to ensure she would not be another.
Now her mother, who lives very near her, expects to hear every detail of her daughter’s life and invariably has a lot of very firm advice about what Eva should do.
The repression of the good child’s share of challenging emotions, though it produces short-term pleasant obedience, stores up enormous difficulty. The good child becomes a keeper of too many secrets and a poor communicator of unpopular but important things.
In one session, Eva arrives having cut her hair short – and shows the therapist a small new tattoo she has on her wrist. She’s excited by these steps but nervous about the reaction her mother will probably have when she sees her at the weekend. The session focuses on how to understand the mother’s worries. Eva’s mother will think that it’s impossible for her be a partner in a law firm and have short hair or a discrete tattoo. The fears are exaggerated, of course, but her mother is trying to express as best she can her intense hopes for, and love of, her child. Her mother will be angry – but that’s because she’s frightened, she cares and she is sure that any indication of unorthodox behaviour will be catastrophically punished by the world. But with the therapist Eva can consider the evidence: the law firm is quite conservative but there’s no reason at all to think that her new hairstyle will damage her career.
The trouble of the good child is that they have no experience of other people being able to tolerate, or remain calm in front of, their badness. They have missed out a vital privilege accorded to the healthy child; that of being able to display confident or envious, greedy or aggressive sides and yet be met with toleration and love nevertheless. Perhaps a rebellion isn’t always easy for a resilient family, but – like a storm – everyone takes it in their stride.
The excessively good person typically has particular problems around sex. As a child, they may have been praised for being pure and innocent. As they become an adult however, like all of us, they discovered the ecstasies of sex, which can be beautifully perverse and excitingly disgusting – which may be radically at odds with what they believe is right.
They may in response disavow their desires, go cold and detached from their bodies – or perhaps give in to their longings only in a disproportionate way that is destructive to other bits of their lives and leaves them disgusted and frightened.
Eva hasn’t been in a sustained relationship; there have been people (both men and women) she’s really liked but when things got sexual it’s always become difficult. She would become very wary and unresponsive. At work she overheard some people talking about ‘the ice queen’ and she’s sure they were referring to her.
She has had some intense sexual encounters – once in the restroom of a restaurant – that she’s deeply embarrassed to mention and which she describes as ‘sordid’. They were with people she hardly knew and who she’d ‘never normally have anything to do with.’
It’s been difficult for Eva to discuss her sexual fantasies in sessions; she was sure the therapist would be appalled by some of her ‘perverted’ imaginings. It took many months to reassure her that there was no surprise or horror at her revelations – and that someone could entirely respect her and also properly understand her sexual character. It had seemed to her impossible that anyone competent and decent could do both. This wasn’t something she realised in one go; it took many re-encounters with the same anxiety for a degree of trust gradually to evolve.
Now Eva has become interested in finding someone ‘for love and sex’; she’s still looking but she has recently had dates with a couple of people she loves talking to and with whom she can imagine having the kind of sex she really wants. It’s still early days but it no longer feels impossible.
Maturity involves a frank, unfrightened relationship with one’s own darkness, complexity and ambition. It involves accepting that not everything that makes us happy will please others or be honoured as especially ‘nice’ by society – but that it can be important to explore and hold on to it nevertheless. The desire to be good is one of the loveliest things in the world, but in order to have a genuinely good life, we may sometimes need to be (by the standards of the good child) fruitfully and bravely bad.
After a year in therapy Eva has started to see less of her mother – she’s genuinely grateful and considerate but can politely but firmly push back on her excessive demands to be informed about everything. The phrases ‘I love you, but I can’t see you on Sunday’ and ‘I love you, but I’m going to keep that one to myself’ have been important to her because they put into words the idea that she can let her mother down in certain ways and still appreciate her mother’s past efforts.
At work, Eva has had a fruitful, though tricky, confrontation with a senior partner: when a number of impossibly tight deadlines were imposed on her team, she was able to explain that they couldn’t all be met; she couldn’t be a good colleague simply by pretending that everything could be done; she could only do her job well by making a bit of a fuss and making sure extra resources were assigned to the project, even though that wasn’t the answer her superiors wanted to hear.
Splitting
The pioneering mid-20th century Viennese psychoanalyst Melanie Klein drew attention to something very dramatic that happens in the minds of babies during feeding sessions with their mothers. When feeding goes well, the baby is blissfully happy and sees mummy as ‘good’. But if, for whatever reason, the feeding process is difficult, the baby can’t grasp that it is dealing with the same person it liked a lot only a few hours ago.
So it splits off from the actual mother a second ‘bad’ version – whom it deems to be a separate, hateful individual, responsible for deliberately frustrating its wishes, and in the process, protecting the image of the good mother in its mind. In the baby’s world, there is a ‘good’ mother who is ideally lovely and perfect and another ‘bad’ mother who is entirely horrible. When there’s any difficulty, the baby feels, that the ‘bad’ mother has turned up, and that if she could just be made to go away – by being annihilated or banished – the ‘good’ mother would come back and everything would be fine. This process is known in therapy as ‘splitting’. It can cause us immense difficulties – and it doesn’t just happen in babies.
Miriam is strikingly beautiful; she has a very engaging personality: open, direct and friendly. She’s worked in various impressive roles around the media. She’s got an assured, cosmopolitan air. What’s brought her to therapy is that for years she’s been in a painful romantic cycle with men: she falls madly in love with someone wonderful; then after around three months, normally after a relatively small incident, she falls quite dramatically out of love with them again.
She’s savagely funny when she describes what turned out to be wrong with each of the men she’s been out with. There was the fantastically ‘anal’ graphic designer who was obsessed with ironing his socks and underpants and who would ‘practically froth at the mouth’ if he discovered a fork in the knife section of the cutlery drawer; there was a Finnish film maker with a habit of going into extended monologues about [here she copies his accent] ‘how he wanted to get back to the ways of the forest’; there was a banker who (she says) was in love with his sister.
But behind the wit, there’s a grim pattern: the people Miriam loves all turn out to be ‘buffoons, narcissists, lost-boys, scum-bags, weirdos or maniacs – or some novelty combination of them all.’
Ideally, over time the child manages to put together the two images of their carer. Painfully and with much constructive disappointment they see that there aren’t really two versions: there’s just one person who is a bearable combination of nice and frustrating – who is delightful in some ways and a bit disappointing in others. If things go well, the child comes, sadly but realistically, to grasp that there is no ideal, ‘perfect’ mummy – just one person who is usually lovely but can also be cross, busy, tired, who can make mistakes, and be very interested in other people. And they see – by extension – that this is how other people generally are and that what look like their failings are often tied to what is attractive about them: they are a bit fussy, because they are so caring; they are a touch boring at times, because they are rather serious about one or two things. The child (in the best possible scenario) comes to be reconciled to reality – and able to love people as they are.
Miriam lost her father when she was young. She cherishes memories of him. He was great fun, clever and kind. She loved it when he used to take her swimming; he often read to her at night and put on different voices for all the characters.
But she never discovered the full reality of who he was. She didn’t get to know directly the more complex sides of his character; she’s never really heard anything about his sexuality or what he was like in relationships. Her picture of her father is an idealised one. Which means that her frustration around the men in her life is built on a background accusation that they are not as good as someone whose true nature she never knew.
A central theme of therapy for Miriam has been realising that she could imagine ways in which her father was far from perfect – without feeling that this is being unfair to him or damaging to her deep loyalty to the good things she remembers. He could have been (and certainly was) both a very good father in some important ways and a very ordinarily flawed and muddled man. Had he lived, she would inevitably have clashed with him in lots of ways, found him annoying, embarrassing and disappointing – because these are standard parts of growing up. Miriam realises the cost of not having had an adolescence around her father.
Although childhood may be long over, the tendency to ‘split’ those close to us is always there. We can find it extremely hard to accept that the same person might be very nice and good in some ways and very disappointing in others. The bad version can appear to destroy the good one, though (of course) in fact these are really just different and connected aspects of one complex human being.
Across many therapy sessions, Miriam has been reconsidering her relationship history. The men she’s so good at mocking were indeed annoying in certain ways – but they were also (to varying degrees) kind, intelligent, generous, tender and hard working. And they were all fascinated by her. She was disturbed by flaws which needn’t necessarily have been fatal. She realises that there is unavoidably going to be something wrong with whomever she is with – not because she has ‘crazy taste in men’ but because everyone is revealed as rather odd and frustrating when we get to know them well.
Recently Miriam has become closer to her grandmother, her father’s mother. The grandmother has fleshed out the picture of her son – always in loving, but not always in flattering ways. She’s been able to accept that her father could be very moody; that he could be rather sly and underhand; and that at certain points he was quite irresponsible about money. He was far from perfect – and yet he was lovely.
Now Miriam has started going out with a man who – she admits – she really wasn’t mad about at first. His taste in clothes leaves something to be desired; he talks too much about his work; and she doesn’t like all his friends. But they’ve had some very interesting weekends together and she likes the way he warmly makes fun of her more eccentric sides. He’s also hit it off with her grandmother.
Anxious and Avoidant Attachment
Depending on what happened when we were growing up, many of us tend – as adults – to have a bias towards either an Anxious or an Avoidant way of behaving in relationships. With an Anxious pattern of being around our lovers, when there is difficulty, we may grow officious, procedural and controlling over small matters of domestic routine. We feel our partners are escaping us emotionally, but rather than admitting our sense of loss and our fear, we respond by trying to pin them down administratively. We get unduly cross that they are eight minutes late, we chastise them heavily for not having done certain chores, we ask them strictly if they’ve completed a task they had agreed vaguely to undertake. All this rather than admit the underlying, poignant emotional truth: ‘I’m worried that I don’t matter to you…’
Jayathri (a GP) and Arun (who works in IT) have been together for four years. Eighteen months ago, they bought a house together – with the idea that one day they might start a family. But increasingly they’ve been arguing a lot. The rancour can last for days. There are sulks, bitterness and a bad atmosphere that refuses to budge. They both regret it, but are at a loss as to what to do.
In the first session, Jayathri complains that Arun is appallingly unreliable: he says he’ll pick up the dry cleaning, and then not actually do so; or when they’ve arranged to go out to dinner, he’ll tell her at the last minute he’s going to be 15 minutes late. At home she finds it properly maddening when Arun checks his phone, just when she’s trying to tell him something important about a food delivery or his mother.
When she complains, to make matters worse, he doesn’t say anything. He just looks into the middle distance, then sneaks off to do some computer thing in the room upstairs. It seriously annoys her that he can’t even speak. Almost in tears, she describes how he ‘tunes-out’ and how she ends up having to take charge of everything herself.
Avoidant attachment is pattern of relating to lovers whereby, when there is difficulty, we grow unusually cold and distant – and deny our need for anyone. We may desperately want to communicate, to be reassured and to get our point across, but feel so unconfident that we may be unheard or unwanted, we disguise our need behind a facade of indifference. Rather than stay present and struggle towards closeness, we say we’re busy, we pretend our thoughts are elsewhere, we get sarcastic and dry; we imply that a need for reassurance would be the last thing on our minds.
Visibly agitated, Arun says he feels he’d often rather be on his own than have his girlfriend nagging him. Why can’t she just be kind? He resents the way she’s so bossy and tries to direct what he does with his phone. The worst thing is when Jayathri stands on the landing and shouts at him through the door of his computer room. She can go on and on. Half an hour or more. Arun is normally quite reserved during this tirade but it does eventually make him furious. Sometimes he’ll scream at her to ‘fucking leave me alone’ – and then return apparently calmly to Windows OS.
Patterns of attachment are not easy to budge of course, but it is hugely beneficial to understand which one we might have, so as better to warn those we love, and apologise after the storm.
Arun grew up in a lively, busy family; his parents (originally from India) were – and still are – both academics, often at conferences and preoccupied by work. When he was a child, they entertained a lot at home; no-one minded if he left the grown ups having long loud conversations round the dining table and went to watch television in his bedroom.
On one occasion he wasn’t feeling very well and went down to the kitchen to tell his mother. She gave him a hug, but didn’t stop talking to her friends. He felt his parents weren’t very bothered about what was happening at school. They were so taken up with teaching students it was as if they didn’t think anything really mattered ‘until you went to university’. When he was fourteen, he tentatively tried to tell his father there was a girl he was interested in and his father (Arun rolls his eyes as he says this) went off into a kind of lecture about ‘the Western Myth of Romantic Love.’ It was, in that kind of setting, pretty pointless trying to explain very much.
The crucible of Avoidant attachment is the child’s sense that a parental figure is lacking concern. To seek closeness is to guarantee humiliation. The child gives up on hoping for warmth and closeness; they withdraw, and bury their longing for affection, so as to avoid any rebuff. They learn not to care whether anyone says anything sweet or tender; they close down any interest in gentle little signs of reassurance or playful gestures of affection. They feel cautious and uneasy around the expression of emotion, whether in themselves or by others. They may find this rather an advantage in a professional environment, but around relationships they can instinctively push away a partner who seeks deeper a deeper connection. They’re not – at the core of who they are – truly without emotional needs, but they have over the years committed a lot of resources to coming across this way.
For her part, Jayathri spent her childhood in Sri Lanka where her family were involved a number of businesses, mainly around textiles and construction. It was a volatile and rather chaotic upbringing; her parents could be very bountiful and warm one day and cold and quite frightening the next; there was a huge falling out across their extended family over an inheritance. Twice, when she was seven and then nine, she had to abruptly change schools for reasons that were never made clear to her. When she was fifteen, she was sent to a school in England where she was very lonely at first but later did well – getting prizes in Biology and Chemistry: ‘I had to pull myself together and just get on with it.’
Across sessions, without ever being direct, the therapist gets Arun and Jayathri to focus on the underlying concepts of ‘Anxious’ and ‘Avoidant’ relationship styles. As a child Arun had developed an avoidant strategy to cope with his parents lack of attention. When now he goes off to his room, it’s not actually because he doesn’t care but because he feels he’ll never be listened to and that he can’t explain anything to another person. Technology appeals to him so much because it’s automatically responsive; it won’t ask him to account for himself or shout when there’s a distracted look in his eyes.
Jayathri’s Anxious pattern of behaviour stems from her childhood way of coping with family relationships she felt were unstable and untrustworthy. She resorted to imposing external order as a way of coping with a sense of emotional flux. When she feels lonely or sad, her instinct is to try to micro-manage. It’s not that she’s essentially domineering: when she says ‘turn off your phone’ or ‘take the rubbish out now, how many times do I have to ask you?’ it’s a garbled way of trying to say ‘I need you and I want to be close to you.’
When we are Anxious in relationships, we can’t (we believe) force the partner to be generous and warm. We can’t force them to want us (even if we haven’t asked them to…). The goal isn’t really to be in charge all the time, it’s just that we can’t admit to our terror at how much we need them. A tragic cycle then unfolds. We become shrill and unpleasant. To the other person, it feels like we can’t possibly love them anymore. Yet the truth is we do: we just fear rather too much that they don’t love us. As a final recourse, we may ward off our vulnerability by denigrating the person who eludes us. We pick up on their weaknesses and complain about their extensive practical shortcomings. Anything rather than ask the question which so much disturbs us: does this person love me? And yet, if this harsh, graceless anxious behaviour could be truly understood for what it is, it would be revealed not as a rejection, but as a strangely distorted – yet very real and very touching – plea for tenderness.
Initially these interpretations of their own and each other’s behaviour felt very alien to Arun and Jayathri. But after several months of weekly sessions together, the true meaning of their rather behaviour to one another is starting to come into view.
Arun is learning to say ‘I feel you’re not listening and that makes me feel like running away from the terror of not being heard’ rather than retreat to his ‘cave’. Jayathri can sometimes say ‘I’m feeling overwhelmed and I’m worried you don’t love me’ rather than ‘we’re meeting Karen and David at 7.30 so you’ll need to be back by 6.50 at the latest; the taxi is at 7.15 and you should wear the dark blue shirt.’
They still squabble quite often and things are far from perfect; but the tensions tend to get resolved much more quickly; they can sometimes calm down after a vital few minutes. They’re more accepting of their needs. Jayathri can admit that Arun is a bit more solitary than she is – and it’s not a rejection of her; Arun can see that Jayathri likes to plan and organise and that this doesn’t have to be an attack on him. It’s not a perfect match – there are still tensions – but on the whole they are a great deal more comfortable with their life together.
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