THERAPY SESSION: FEBRUARY 12, 2018
I arrived at the session with computer disk. I explained that the disk contained several documents including results of psychological testing I had taken in February 2014 which I had previously provided to the therapist. I explained that the disk also contained a 30-page personality profile I had prepared about myself years earlier.
The computer disk’s contents – results of psychological testing and a self-created personality profile – suggest my preoccupation with issues of identity and self-definition. According to Sidney Blatt a patient’s preoccupation with issues of identity and self-definition is indicative of introjective character pathology.
THERAPIST: Our old computers might not be able to handle disks.
PATIENT: Could you hold onto the disk? Could you put the disk in a file for future reference?
THERAPIST: So you’ve been talking about me to other clinics.
[The therapist was referring to my email I sent to the ABC Clinic on December 18, 2017.]
PATIENT: Yes, I sent out therapy inquiries.
THERAPIST: We got a communication from the ABC Clinic.
[The therapist stated that the email message contained a threat. “If you don’t do such and such I will do such and such.” The therapist’s comments were vague. At another point the therapist referred to the email message as my act of “bad mouthing” her.
In fact, the therapist never read the message. She condemned the message on the basis of word of mouth without having the facts or inquiring into the facts. The therapist seemed anxious about the email. One wonders whether the therapist felt that my email message to the ABC Clinic posed a threat to her job at the clinic. Unconsciously, did the therapist feel that I was threatening her access to the nurturing breast (i.e., her valued connection with her employer)?
In fact the email read:
To the ABC Clinic:
I am forwarding in the attachment a document that summarizes some of my recent therapy sessions. The document illustrates my special needs in therapy.
I receive out-patient psychotherapy at the ———- Center. Unfortunately, my problems exceed my therapist’s abilities. I request a referral to a therapist who can work with a client who has serious character pathology and who is intellectually-gifted. My IQ is in excess of 130. I have Medicare and DC Medicaid.
I sensed intuitively that the therapist was experiencing emotional distress and exhibited a regression to a primitive ego state. I sensed that she proceeded to use projective identification in an attempt to force her mental contents into me relating to issues of rejection and abandonment (loss of access to the “nurturing breast,” to use Kleinian terminology).
The therapist embarked on a series of revealing associations relating to issues of outsider status (or castration), exile and confinement. Cf. Rubin, T. Anti-Semitism: A Disease of the Mind. A Psychiatrist Explores the Psychodynamics of a Symbol Sickness at 99 (New York: Continuum, 1990) (exile, imposed restrictions, ghettoization (confinement) and disenfranchisement on any level are symbolic castrative acts). She seemed determined to force these disturbing contents into me.
In a rambling chain of associations the therapist referred to “queers” (i.e, castrates or outsiders); “involuntary commitment” (i.e., confinement or ghettoization), “termination of my therapy” by the clinic because of my act of “wrongdoing” (contacting another clinic) (her reference to “therapy termination” being suggestive psychoanalytically of abandonment or a symbolic loss of the nurturing breast). The therapist referred to past terminations I had experienced, namely, Dr. Acharya’s termination of my therapy by DBH in February 2016 as well as my former primary care doctor’s action in terminating my treatment and taking out a protection order against me (July 2016).
All of the therapist’s associations seemed to relate to her own psychological concerns about issues of exile, abandonment, and other symbolic castrative acts. The therapist’s associations, in my opinion, were an attempt to force her own anxieties about abandonment (i.e., loss of access to the nurturing breast symbolizing her employment with DBH). I sensed intuitively that the therapist felt that her own employment relationship with the clinic was threatened and that she was discharging her distress through projective identification. The therapist’s use of projective identification to defend against her anxieties would evidence her regression to a primitive ego state.]
PATIENT: My primary care doctor filed a perjured affidavit, in my opinion. He claimed I was stalking him. He said it was Internet stalking – I posted things on social media about him. It was totally ridiculous. I had posted imaginary conversations on Twitter between him and me. He said he felt threatened by my references to him. What he complained about were my references to things like “eggs and sausages,” “baby aspirin,” “poker games,” and “kosher Vietnamese restaurants.” The whole thing was totally ridiculous. I think his lawyer put him up to it. He claimed that he first learned about my Twitter on June 16, 2016. But he didn’t file an affidavit for a protection order till a month later, on July 14, 2016. The interesting thing is that something important happened in the interim. I had sent an email to his clinic’s lawyer during the weekend of July 4, 2016 and I said that there was evidence that I was engaged in health care fraud. I think that email to the lawyer had a lot to do with the doctor filing the affidavit. I don’t think the doctor actually felt threatened by me. I think the clinic’s lawyer had the doctor file a perjured affidavit with the court.]
[Note my concern about the issue of professional performance, the reference to the lawyer suborning an act of perjury.]
[Incidentally, I saw meaning in the doctor’s body language at the court hearing on July 28, 2016. Throughout, he assiduously avoided eye contact with me. He sat across from me in the courtroom; I glanced at him from time to time and he never returned the gaze. Did he have feelings of shame? When the court mediator advised the doctor that I had agreed to accept the proposed protection order without admissions, he smiled broadly. Did the doctor feel relieved that he would not have to testify under oath that he felt threatened by me? Then, at the end, when the doctor stood to leave the court room, I noticed through a corner of my eye that he turned back to look at me — as if he wanted to get one last glimpse of me, perhaps thinking that he would never see me again. I interpreted his backward glance as a friendly gesture.
By the way, I note the following point. Typical for me is the fantasy that another person likes me despite all the evidence to the contrary. Here, I believed that my primary care doctor liked me despite the fact that in reality he had taken out a protection order against me alleging that he felt threatened by me. This fantasy recurs in my life history. Whereas the therapist filters evidence about me in such a way that satisfies her apparent fantasy that I am attacking her.]
Later in the session the therapist said . . .
THERAPIST: You are feeling rejected.
[Let us return for a moment to the events of the session on January 29, 2018:
I had not seen the therapist for the previous six weeks. My last session with the therapist was December 18, 2017. I said that I didn’t miss therapy. I said I didn’t miss the therapist during the six week break. I stated that, to the contrary, I felt good not seeing the therapist. I said it was like a vacation for me. My statements to the therapist about my therapy work represented a repudiation of her as a person and her work as a therapist. In effect, I was expressing my “rejection” of the therapist.
One wonders just who was feeling rejected: the therapist or I?
I sensed intuitively that the therapist herself on February 12, 2017 was experiencing anxieties about her job at the clinic and that she was attempting to force anxieties about rejection into me. She wanted me to talk about how I was feeling rejected. This would be typical projective identification: make the other person feel your own unwanted feelings and get the other person to talk about those discarded feelings. The therapist attempted to force feelings of rejection into me and then wanted me to talk about how I was feeling rejected.
At another point in the session the therapist referred to my anger and apparently wanted me to talk about my feelings of anger. I stated that I didn’t feel particularly angry with her, but rather with her supervisor for recommending that the therapist terminate her work with me.
In fact, what I was feeling was not rejection at all. I was feeling I was at the mercy of paranoid forces: namely, (1) the therapist’s false accusation of my having defamed the therapist (the therapist had said “you bad-mouthed me to another clinic”), and (2) the contemplated drastic remediation of terminating my therapy. In fact, I saw parallels with my job termination by the law firm where I worked until 1991. The employer made false accusations against me and thereupon undertook the drastic remediation of terminating my employment. The employer thereafter filed a perjured sworn statement with the D.C. Department of Human Rights rationalizing the termination. I saw a pattern: false accusations followed by drastic remediation. To me the sequence was suggestive of the other party’s paranoia. The other party felt threatened by me, then undertook drastic remediation using false accusations as an excuse. I wasn’t feeling rejected. I felt I was a victim of another person’s paranoia.]
PATIENT: Why would you terminate me?
THERAPIST: You “bad mouthed” me to another clinic. [Note the unintended, ironic reference to the Kleinian “bad mouth.”] That could be seen as a boundary breach.
PATIENT: Why is that a boundary breach?
THERAPIST: (no answer).
PATIENT: I said in the email (to the ABC Clinic), I believe my problems exceed your abilities. I fail to see how that is bad mouthing.
[In a previous letter I wrote the following about the therapist (session August 21, 2017):
The therapist repeats the same ideas about the mother-child relationship at almost every session as though it were an idee fixe. Is the therapist’s formulation an expression of the therapist’s oral fixation? Is the therapist’s depiction of the mother child relationship an expression of a Kleinian “bad mouth?” That is, the infant at the mother’s breast receives succor from the mother (the child sucks, he wants something from the mother) and the infant can bite the mother’s breast (he “acts out,” as it were). Is the therapist saying, “You wanted things from your mother (you wanted to suck), you perceived that you didn’t receive them and so you acted out (you bit her breast).” “You want things from me (you want to suck my breast) but you feel you don’t receive what you want, so you act out by writing letters (you bite your mother’s breast). Is the therapist’s explanation for my letter writing actually a projection of the therapist’s oral-fixation and her oral sadism (a preoccupation with oral aggression, i.e., biting)?
Significantly, at an earlier session, I had told the therapist that I felt like a patient with kidney disease and that the therapist was a cardiologist. “You may be the best cardiologist in the world but my problems exceed your competence.” My concerns center on lack of fit, and lack of identity match between the therapist and me (i.e., the lack of opportunity for twinship, idealization and mirroring). Whereas the therapist’s concerns centered on my devaluing her professional abilities (my biting her breast) and threats to her job (her “access to breast”). But my statements to the ABC Clinic were not “bad mouthing” or devaluation. The email alluded to the lack of fit or identity match between the therapist and me.
Let us recall what I earlier reported in this letter about my interaction with DBH attending psychiatrist Monica Acharya, M.D. in February 2016:
In February 2016 the attending psychiatrist at DBH undertook to contact therapists and clinics outside the DBH system to locate a new therapist for me. In fact, I sat in her office on one occasion when she telephoned the Psychiatric Institute of Washington on my behalf. In light of my experience with Dr. Acharya, my belief that a DBH clinic might help me to locate a therapist for me outside the DBH system was reasonable. Dr. Acharya had terminated my psychotherapy at DBH in February 2016 based on her conclusion that I could not work with a female therapist and that I needed psychodynamic therapy. Dr. Acharya said to me in February 2016: “We let you down. You’ve been with DBH for nearly 20 years. Our residents are trained in supportive psychotherapy not psychodynamic therapy. You need psychodynamic therapy. We don’t provide psychodynamic therapy. I talked to some of your previous therapists. They all said they liked working with you. They all mentioned that they learned a lot from working with you.”
Dr. Acharya acknowledged that there was a lack of fit or identity match between my psychological needs and what DBH had to offer. She undertook to find alternative therapy for me at a clinic outside the DBH system. The current therapist transformed my legitimate and reasonable behavior – i.e., sending a therapy inquiry to another clinic — into a “bad act” (“bad mouthing”) that warranted the termination of my treatment.]
PATIENT: I blame you for this. I had asked you to help me find a therapist. You refused and told me to find another therapist on my own. You told me on December 18, 2017: “You’re a big strong lawyer. Why can’t you find another therapist on your own?”
THERAPIST (laughs): I would never have said something like that to you.
[I won’t belabor the point of what the therapist actually said on December 18. I will note a curious fact, however. At my first consult with her in April 2017 I told the therapist that I had two law degrees and that I was licensed to practice in Pennsylvania. The therapist proceeded to ask me a number of questions about why I didn’t practice law. The exchange lasted several minutes. I remember saying that I was a perfectionist and that I couldn’t do the quality of work I (irrationally) required of myself given the time constraints of law practice. At one point in that first session the therapist gave me her views on the workings of the U.S. Supreme Court; my recollection at this time is that the therapist had said that Supreme Court opinions were more political now than in the past. In my twenty five years of psychotherapy with about 16 therapists, this was the only occasion on which a therapist inquired about why I was not practicing law; it was the only occasion on which a therapist volunteered her views about the U.S. Supreme Court! No previous therapist cared about these issues. Did the therapist in fact say to me on December 18, 2017: “You’re a big strong lawyer?” I can’t prove that she did.]
PATIENT (continuing): My own chart says I have “grossly impaired judgment.”
You’re holding me to a standard of behavior that might be reasonable for a normal person but the Clinic’s own chart says I have “grossly-impaired judgment.” I don’t think you have a sense of my vulnerabilities.
[At this moment the therapist seemed stunned to hear that a previous assessing psychiatrist at the clinic (Didi Bailey, M.D.) (May 15, 2009) had said I had “grossly impaired judgment.” She remained silent. Speaking metaphorically – and only metaphorically – it was as if the therapist had viewed me as a “big strong lawyer” who had good judgment and that it was truly surprising to her to hear that another clinician had viewed my judgment as impaired. But, as I say, that is only a metaphor.
Also, note again, Dr. Acharya had recognized that I needed help in finding another therapist after she terminated my work with DBH in February 2016. This therapist will not lift a finger to help me. There is no evidence that the therapist even spoke to my case manager about my therapy needs. DBH (Dr. Acharya) determined that I needed to see a male therapist who is psychodynamic.]
THERAPIST: You want psychoanalysis. You’re not going to find that at DBH.
[Note how the therapist transforms my legitimate “needs” into arbitrary “wants.” In fact DBH (Dr. Acharya) determined that I need to see a male therapist and that I need psychodynamic treatment. The therapist’s reference to my arbitrary “wants” is a diversion. Clearly, my legitimate needs are not being met.]
PATIENT: I feel I need a therapist to talk to another therapist to determine if I am suitable for the therapist. No therapist will turn me down. That concerns me. Whatever therapist I talk to, he will say, “Yes, I can help you.” My experience is that therapists will not turn down patients. I need you to talk to a prospective therapist to determine if he is a good fit for me.
PATIENT: I got a communication from the Wendt Center. They said they were willing to take me on.
THERAPIST: It seems like you were intentionally withholding that information from me.
[Note the therapist’s imputation of wrongdoing to me. Once again, I was the client engaged in “bad acts.” I had “bad mouthed” her. I had “withheld” from her. Was the therapist’s use of the word “withholding” a reference to Kleinian breast issues and specifically an indication of the therapist’s envy of me? (Note that at the very first session, months earlier, the therapist had embarked on a lecture on the U.S. Supreme Court: possible evidence of her envious competition with me at the outset.) In effect, at the current session I had something of value (namely, information) and I was not sharing that information with the therapist. I had created a “deprivation” of some kind. I was “keeping the information for myself” like the mother pulling away her breast from the infant and “keeping the breast for herself.”
Melanie Klein saw envy as the fragile infant ego responding to a deprivation of some kind. This deprivation may even be minimal, or momentary (such as a momentary “pulling away” of the breast by the mother). The infant’s envious impulse is to attack, or to spoil the very source (i.e., the breast) that the infant originally relied upon for what was desired. In the infant, the feeling of failed gratification (such as a pulling away of the breast) is experienced as the breast withholding, or keeping for itself, the object of desire. Hiles, D. “Envy, Jealousy, Greed: A Kleinian approach.”
In Klein’s conceptualization of envy the infant has the notion that the mother has something valuable (the breast) and by “pulling back” (“withholding”) the mother is not sharing it. (See letter about session on November 13, 2017).]
PATIENT: What I’m looking for is a therapist who can assess me and say, ‘I recognize your problems. I know how to work with your problems. I’ve worked with people like you before.’
[I was expressing my need for identity recognition by another person that parallels my own preoccupation with identity and self-definition, that is, introjective concerns.]
The therapist and I engaged in our typical enactments throughout the session despite the detour in the work of therapy taken by the therapist at the outset in chastising me about my “bad acts” outside the therapy situation. The therapist’s concerns remained primitive throughout the session: she engaged in projective identification, expressed concerns about rejection, abandonment, and a pervasive concern that I was verbally aggressing on her (“biting behavior”) through acts of defamation and devaluation.
My own concerns seemed centered on identity (see disk documents), identity definition, mastery or perfectionism, quest for self-understanding paralleling my quest for the ideal therapist (note parallels to longing for narcissistic elation), need for identity recognition from therapist (a therapist who will recognize my problems), feelings of alienation (I had said I felt that I was not like the therapist’s other patients); concerns about professional performance (in therapists and ironically, in the primary care doctor’s lawyer who seemed to have suborned perjury).
Near the end of the session, the therapist said, “You didn’t get to talk about what you wanted to talk about.”
Ironically, I did get to talk about what I wanted to talk about. It is significant that the therapist’s projective identification did not derail my emblematic concerns for identity, self-definition, need for mastery, and quest for self-understanding and quest for the ideal therapist.