CHI CHI SUMMARY Age: 47 Gender: Female Race/ethnicity: Caucasian, Italian, and Mexican descent. Her father ‘was an Italian American and her mother is from Mexico. Chi Chi was bilingual, English and Spanish, asa child, but she identifies more strongly with her lalian descent. She also speaks Iajian. “Marital status: Single Education: Some college Occupation: Unidentified professional office work; part-time bar- tender Current status and presenting issues: Chi Chi describes herself as ‘a very good writer, a good actress, and a good talker. She has a small circle of good friends; she is generally outgoing and social. Her hob- bies include gardening, reading, writing, and playing board games. She enjoys drinking alcohol, but she does not drink to excess, although she reports that she has in the past. While she has tried many illegal drugs, she never “got into them.” Chi Chi has previously been in individual and group therapy in which she was working on anger management and processing her sad- ness over the loss of a 6-year relationship. She feels that the therapy helped her greatly with her anger. In her previous therapy, she felt that having directed behavioral interventions was most helpful, whereas she did not feel that talking about her emotional state was productive. She reports that she became “too upset and could not go on with it” Chi Chi would like to work with the three therapists on her me vation and self-direction. She feels that she continually starts activities but is unable to bring them to a successful conclusion. She would like to be able to set goals and follow through with them, from career plans, to exercise and weight management, and to writing, She feels that her life is adrift, and she wants to gain control and establish clear direction. Parents: Chi Chi’s parents were married for 35 years, Her méther is living, and Chi Chi describes her as “very dramatic." Her mother was both verbally and physically abusive to her children, with Chi Chi “get- ting the worst of it.” Her father has been dead for 10 years. He died at 65 from a heart attack. Chi Chi describes her father as “the calm type.” Chi Chi’s father worked for the U.S. State Department, and the family lived outside of the United States for the majority of her life ina variety of countries: the Dominican Republic, Hong Kong, and Italy. Siblings: Chi Chi has one sister who is 10 months older than her ands mildly developmentally disabled. Her sister lives with her mother. Chi Chi describes her sister as being just like her father, calm and quiet, whereas she describes herself as being much more like her mother. She has a brother who is 2 years younger than her. She says her brother “has issues” and has had some difficult times. He is divorced and has two children.Nowa Meudil wns ud 100 | EXPLORING THREE APPROACHES TO PSYCHOTHERAPY EMBODYING A PSYCHOANALYTIC SENSIBILITY Thope my behavior in the videos exemplifies a psychoanalytic sensibil- ity. [liked Chi Chi and was genuinely trying to understand her, Because it is a background auitude more than a set of procedures, I leave it 10 viewers to assess the degree to which I embodied the analytic values 1 have mentioned. L was acutely aware during the filming, and later in watching the DVD, that itis impossible to demonstrate a psychoanalytic process under the circumstances in which we were filmed. I think I communicated some psychoanalytic content, but the general sense of an ongoing safe relationship in which the patient finds within herseif the sources of healing cannot really come through in a short, videotaped encounter. Although I was very much my professional self in the role of Chi Chi’s temporary therapist, I talked more than T ordinarily talk in sessions, ‘made more connections than | would in an ongoing therapy, and found ‘myself in teaching mode more than is typical. USING THE THERAPIST'S SELF-KNOWLEDGE In the APA filming, I was trying to stay aware of several potentially interfering dynamics in myself. For example, I am a pretty competitive person,and despite the fact that APA carefully framed the project as comparison of three good treatments rather than a competition for which approach is best in some overall way~a construction with which Tam intellectually in strong agreement—I felt a subtle internal pres- sure to "be the best.” Because I was consciously in syne with the official attitude, I was not entirely aware of this drive in myself until I noticed that I was more anxious than I had felt before doing a prior APA video that had involved only me as an individual therapist. When I associ- ated 10 the anxious feeling, what came to mind was the pep talk "Go out and win one for the [psychoanalytic] team.” I hope my being aware Of this competitive agenda reduced my tendency to act it out in ways that would undermine wiat my better self saw as a legitimate clfort to | compare and contrast, without better-and-worse rankings. Twas also in touch with a sense of tension between attempting to be of maximal help to the client, as I would try to be in any session, and recognizing that this was an inevitably contrived situation, a meeting for demonstration purposes in which both parties were keenly aware of | being filmed and also knew they would not be working together after their two scheduled meetings—hardly the usual clinical state of affairs. | Although Dr. Carlson’s intake conversation was intended to enable us to “do therapy” rather than to spend time on intake and formulation, this was my first day with Chi Chi, and one cannot simply dive into a stranger’s mental life as if one already has a therapeutic alliance.Paychodynamic Therapy Finally, 1 was alert to the fact that there was a present and future audience and that the point of the meeting was to demonstrate how analytic ideas translate into a therapeutic process. There were moments when I completely lost the sense of there being onlookers and immersed ‘myself in the interaction with Chi Chi, but there were other moments when I found myself feeling that “Id better try to make something hap: pen here that I can talk about intelligently later.” My own narcissism, hitching a ride with my more acceptable wish to teach something of value, was a constant complicating factor ESTABLISHING AND MAINTAINING THE THERAPEUTIC ALLIANCE Because of the delimited nature of the Tiree Approaches video sessions, I was more self-disclosing than [ would ordinarily be in an initial meeting with someone who had come to me for open-ended therapy. When I had asked Chi Chi (in the session not used for the final DVD) why she had volunteered for the project, she mentioned liking to act, and then she looked at me in a way that hinted at a worry that I would be critical of that motive. So I commented that I enjoy acting, too, and that I get how satisfying it can be. Such disclosures devolved from the artificial ity of the demonstration situation. 1 was trying to foster a therapeutic alliance by conveying that I had vivid personal reasons for appreciating her experience. In ordinary practice, Iwould not have volunteered this; biographical self-revelation, before one knows the client well enough to have a sense of how it will be taken in, can have problematic effects on a psychoanalytic process, In this situation, however, I saw no reason to preserve my ano- nymity. I did not have to worry about “contaminating” a tiansference that would not have any time to be elaborated. If [had been working long term with Chi Chi, 1 would have inquired about the look on her face, inviting expression of any worries that I was critical, and urging her to explore such perceptions so that she might become aware of the depth of her fear that other people will see her badness and reject her for it. I suspect that when she was expressive as a child and rebellious a8 a teenager, her rather stoic parents viewed her as overly dramatic Ifso, any worries that I saw her as unacceptably exhibitionistic would have eventually arisen in her transference experience of me. Ifshe had been a regular patient, my letting her know that I have an exhibition- Istic streak and like to perform could have shut down this important opportunity for increased self-knowledge. But my main goal under the circumstances was to be of some therapeutic value in a single day. Other ways in which I was trying to establish an alliance are prob- ably obvious. My tone was conversational. I tried to express ideas ten- tatively, inviting a collaborative conversation. 1 sometimes explained 101102 | EXPLORING THREE APPROACHES TO PSYCHOTHERAPY why [asked about something, as in my letting Chi Chi know that I was throwing something out to see if It would strike @ chord in her. Tindi- cated verbally and nonverbally that I did not want to push her too far beyond her comfort zone. I tried to welcome any negative reactions to me or the situation. I think I did not do this last part enough with Chi Chi, but more on that later. ENCOURAGING FREE ASSOCIATION Chi Chi was articulate and forthright. 1 did not feel I had to make.the point that she should be as open as possible with me; she was savvy ‘about therapy and knew that it depends on uncensored self-disclosure, But I saw her as having significant resistances to sharing her pain in all its emotional intensity. She was notably reluctant to talk about the Jost relationship that had most devastatingly affected her adult life; she seemed to be afraid that she would go into a bottomless abyss of pain or be exposed humiliatingly as a failure in relationships. Because what happened in that love affair seemed so critical to the unhappiness that she was trying to address, I did press her to try to talk about it. LISTENING RESPECTFULLY, OPEN-MINDEDLY, AND OPENHEARTEDLY ‘Again, I hope the video speaks for itself in this area. I was interested in Chi Chi, was touched by her story, and looked forward to learning from her, Because of the stresses of the one-shot, filmed situation, I was not able to relax into the state of reverie that would have evolved naturally if [had been working with her under normal clinical circumstances, But Ltried to be as receptive to, and as viscerally affected by, her words and their background music as I could in the face of those contingencies. INFERRING MEANING [Although I saw her as struggling with important, repetitive psychologi- ‘al issues, themes that ran through her history and suffused her per- sonality, I did not see Chi Chi as having personality “disorder.” She Seemed to me to operate predominantly in what many analysts com sire as the “neutotic range” of personality organization (MeWilliams. 3011). This inference was based on her awareness of internal con- flies, ability 1o reflect on her own psychology and the psychologies of “others, and capacity to make a friendly, collaborative alliance. Diagnostic Formulation 1 saw Chi Chi as having a hypomanic defense against a basically depres” sive psychology (her hypomanic denial, a pattern of turning deadeningPaychodynamic Therapy negative affects into their opposites, is probably why she did not score high on the Beck Depression Inventory when Dr. Beck administered it), Although this personality type is no longer in the DSM because of a (scientifically questionable) decision to put all mood problems under ‘Axis I, there is a long-standing clinical literature (c.g., Akiskal, 1984; Kemberg, 1984; Lewin, 1941) on hypomanic and cyclochymic person- ality patterns. In the interview with Dr, Carlson, Chi Chi had mentioned struggles with anger outbursts, impulsive spending, hypersexuality, and excessive drinking—all characteristic of this kind of personality (Akhtar, 1992)—and I knew from conversations with others who knew her that she was unusually funny and lively. This animation coexisted with her crying uncontrollably with both Dr. Carlson and me when past losses came up. | inferred from her history and interpersonal manner that her attachment style was deeply ambivalent. Dynamic Formulation As the daughter of a diplomat, Chi Chi had moved from country to country throughout her childhood, and her father was frequently sep arated for long periods from his family. She tended to minimize the impact of these painful, involuntary losses, which I saw as intimately connected to her presenting problem of sell-sabotage. I had found Chi CChi’s description of her first memory striking: At age 4, she was put day care. She screamed and had tantrums but then made the best of it and had a good time with a new friend. 1 has been psychoanalytic experience that one’s earliest memory contains important data about recurring issues and patterns (a phenomenon that has inspired some interesting empirical work: e.g., Cogan, Stringer, Aldredge-Clanton, & Porcerelli, 2004). Chi Chis first memory contains both devastation about separation and a solution to the problem that emphasizes cut- ting off grief and throwing oneself into having fun without the primary attachment figure. Im her interview with Dr. Carlson, I had been struck by the tender- ness in Chi Chi's voice when she talked about her love for Dickens's novel Bleak House. Even the title is resonant of the emotional poverty of her upbringing. (looked up the plot and characters before I met with her and found that the hero of the story is considered one of the kindest characters in all of English literature. {felt that she was drawn to the compassion she had noted in describing the novel, but I suspected that unconsciously she felt she did not deserve such compassion and could not trust that it would last. My preliminary understanding of Chi Chi’s reported undermining of her own success, both in work and in love, was that it was a compul- sive repetition of the pattern of making attachments and traumatically losing them—unconsciously recreating trauma in the effort to master 103108 | EXPLORING THREE APPROACHES TO PSYCHOTHERAPY it by this time initiating it herself, I found myself thinking of Fairbairn’s (1952a) concept of the “internal saboteur.” I saw Chi Chi as having a depressive psychology of the introjective type (Blatt & Bers, 1993), in which there isa deep, powerful unconscious pathogenic belief by which she had made sense of her childhood experiences: [ suffered painful losses because I was wasn't good enough. People who get to know me deeply will see my badness, and 1 will lose them as [lost places and relationships that I loved as a child. So before this happens, [will precipitate these inevitable losses. In that way, I will atleast have some control over when, where, and how they happen. Tsay more about this shortly. ‘There is a vast clinical and research literature on attachment and separation, beginning with the studies by Dorothy Burlingham and ‘Anna Freud (1944) of British children who had been sent away from their parents to the countryside during World War IL. In spite of being physically safe, the evacuated children did not fare nearly as well psy- chologically as those who stayed with their families in London as it was being bombed. Premature, nonvolitional separations from a home or froma parent can damage a child’s capacity for secure attachment, both directly and because of depressive reactions in a remaining parent who is coping alone (Massie, Bronstein, & Afterman, 1996). I thought I was seeing the effects on Chi Chi of multiple forced childhood moves and possible maternal depression. could identify with her hypomanic defenses. My own psychology includes depressive elements and defenses against them. For example, before my analysis, I was in the habit of saying 1 had had a “happy childhood” despite multiple serious losses and moves. In developing hypotheses about the meaning of Chi Chi’s experience, however, I was not self-consciously diagnosing or applying techniques or looking for similarities between us, Like most analysts, I experience my work as deeply organic, as the complex result of my identifications with my own analyst, my supervisors, my teachers, and the writers and theorists, whose metaphors and concepts have illuminated mysterious psycho- logical phenomena for me. I do not operate very intellectually when I ‘am sitting with a client; usually itis only after a session that I can articu: late relevant diagnostic concepts, dynamic formulations, and theoretical ‘models that the patient's story and personal presence have brought (0 mind. In the moment, I was simply opening myself to one after another point of identification with Chi Chi's pain and attempting to feel out what itis lke to live in her subjective world T tried to share my hypothesis about her presenting issue in a ten- tative, user-friendly way. I was hoping that Chi Chi would respond by feeling understood and would experience the gain in self-esteem thatPaychodynamic Therapy 105 can come from making sense of a problem in the self that otherwise can get attributed to weakness, stupidity, or perversity. If she had felt 1 was off base, I would have asked her to correct my misperceptions and. refine the process of trying to make sense of her suffering. Chi Chi mini: mized the impact of her childhood losses. Abandonment and imperma: nence were ego-syntonic to her—invisible, uninvestigated facts of life, like water to the proverbial fish. In the small amount of time she and Thad together, I tried to make such experiences more ego-alien to her (and when 1 did, she had a confirmatory association: her memory of how her British friends who had been sent away to boarding schools had never forgiven their parents). SPEAKING THE UNSPOKEN Jonathan Shedler once commented to me that he had not seen any therapist in the APA Psychotherapy Video Series ask the client why he or she had volunteered for the filming. His observation struck me as important, and I pursued the issue with Chi Chi. Like many responses to queries about the less-acknowledged conditions ofa relationship, her answers to my question (in the session not shown on the APA DVD) about why she had volunteered surprised mie and gave me important ‘clues about her psychology. She said that she had been the patient in several videos in the APA Psychotherapy Video Series: she liked to be con stage, and she felt she got something from the process. This response evoked my hypothesis that she had been trying to get help for her psy chological problems in brief, one-shot doses, perhaps to avoid becoming deeply attached to one practitioner and then facing what she uncon: sciously assumed to be the inevitability of losing that relationship trau ‘matically, as she had lost connection after connection in her childhood. That is, I understood Chi Chi’s therapy-in-bits-and-pieces pattern as related to her having been the daughter of a diplomat whose career had required her to give up her attachments again and again. {saw it as ‘an unconscious éffort to protect herself irom reexperiencing unbearable pain, an “Til leave you before you traumatize me by leaving me" solu tion to an old problem that no longer characterized hier life, I thought ‘that her habit of sabotaging relationships and jobs as they got increas- ingly satisfying was inadvertently recreating this traumatic history. This is a phenomenon that Freud (1909/1959c) termed the “return of the repressed” and Mowrer (1950) called the “neurotic paradox”: What we try to do to avoid childhood trauma tends to recreate that trauma. 1 thought that Chi Chi’ affect in the conversation after this inquiry sup- ported that interpretation. In another instance of my trying to open up the possibility of talking about the unstated, L brought up another incident with Chi Chi, who 1 icici106 | expLORING THREE APPROACHES TO PSYCHOTHERAPY ‘think would have been too tactful to mention jt on camera without an jnvitation, Although I raised this in the hour that was not used for the final DVD, there is a reference to it in the session chosen for the final ‘raining video as “the makeup incident,” Thad had my makeup done for the filming by a professional, whose idca of making me “look natural” tured me into a person I did not recognize. When I saw myself in the mirror just before I was to do my first interview with the male patient, Twas horrified, and I went back, greatly upset, to the makeup artist, asking her to tone it down. . vas L was making this distraught plea to the cosmetician, I realized that the woman now in her makeup chair was the patient 1 would be interviewing in.an hour! (So much for APA's careful efforts to keep us apart until we would “meet” on camera.) Chi Chi, seeing my distress, immediately reached out sympathetically, saying, “Doesn't it feel ter ble when your makeup isn’t right?!” When we sat down together to be filmed, had no idea what she had made of seeing me in that ‘pabinged state of mind, or what that experience would have provoked in her, and so [raised it early in our first meeting. 1am not sure she told tne everything she thought and felt about the incident (if T had been the patient, I think T would have worried that the therapist was either @ snutease or a prima donna or both), but it did allow us to laugh over it, ‘ne woman to another, and my hope was that raising this issue would “underscore a general tone that I was trying to set that all topics were welcome, even those that embarrass the therapist WORKING WITH RESISTANCE It felt to me as if Chi Chi wanted to relate intimately and not 10 do so at the same time, as illustrated in the emotional quality of her relue- fant account of & significant personal Joss. I suspect that she uncon- sciously views motherly people with a lot of mixed feelings. She had Teported childhood attitudes of having idealized her father and found ther mother somewhat rigid and out of touch, and although she related to me cordially felt a subtle reserve from her. later learned from the woman who had recruited her to do the video that Chi Chi had come to the filming with negative feclings about intensive, long-term therapy. hhaving had a prior unsatisfactory experience with it. Some of the resis: tance I felt may have been related to that fact of her background, of which I was ignorant during the filmed sessions. ‘When I tried to interpret what I took to be Chi Chi’s transference fears that deep attachment would lead to inevitable traumatic loss, she vas outwardly accepting, but apparently inwardly skeptical, of what) aid. Tdid not sufficiently attend to my own sense that she was not fullyPsychodynamic Therapy on board with my advocating that she get “real” therapy (by which I ‘meant not necessarily analytic treatment but an ongoing, open-ended, devoted therapeutic relationship and not a one-shot exposure). In my eagerness to leave Chi Chi with what I saw as the main therapeutic message I could deliver in one afternoon, I missed a chance for us 10 look together at her negative reactions to what I was saying, Her com- ‘ment in the exit interview that she had not felt fully safe with me may reflect my not having given her enough space to express her skepti- ism and sense of threat when being urged to make a deep therapeutic attachment. WORKING WITH TRANSFERENCE AND COUNTERTRANSFERENCE Chi Chi's early attachment experiences seem to have been good enough to have laid the groundwork for her seeing the possibility that other people may be well-intentioned and helpful. From my own warm countertransference, I concluded that she had been loved enough to elicit loving responses from others. There was not sufficient time for other transference-countertransference experiences to emerge clearly in the natural and spontaneous way that they do in ordinary treatment, but there were elements of some other transference reactions that 1 thought I was seeing in her. I wondered, for example, how she had processed the makeup ind- dent. I also privately wondered throughout the filmed session if Chi Chi was “yessing" me as she had probably done many times with her ‘mother—being overtly compliant and covertly oppositional. Her pos- ture indicated a kind of casual avoidance of connection. Chi Chi’s mixed reviews of her session with me are a good example of how one cannot conclude from the fact that a client is compliant and deferential that what the therapist is saying is helpful, The more accurate indicators of. the rightness or wrongness of an intervention include, as Ihave noted, confirmatory associations, increased openness, changes in behavior, and general improvement in functioning, Another way of thinking about the down side of what happened between-us is that our session involved an unexplored enactment of what had been a familiar pattern for Chi Chi. In trying to persuade her to go into long-term treatment and hang in with one therapist, 1 was pushing an agenda that she did not experience as freely chosen. ‘This could be seen as emotionally comparable to what happened to her every time her mother tried to get her on board with a family reloca- on. Our interaction can be seen as a subtle replay of the dynamics that had fueled her enraged adolescent reactions, 107