Case 2: A lifetime of anger
Richard, age 51, is an optometrist referred to me by his internist, who described a patient who was “too influenced by anger from the past, had consistently unsatisfactory relationships with women, and generally needed to take control of his life.”
Richard spent the first four sessions with me relating the story of his life. He described a dominating mother, a passive father, and a successful older brother (attorney). He said he constantly felt discriminated against because of his obesity and religion (Judaism).
While attending a school of optometry in the Midwest, he had suffered a severe attack of ulcerative colitis that sent him home for a year to live within his “dysfunctional family.” He married 2 years later, initiating a stormy 10-year relationship that produced his two daughters. Divorce, from a woman he described as “critical and controlling like my mother,” resulted in a serious financial setback.
Fifteen years ago, his father died and Richard underwent intestinal surgery. Soon thereafter, his ex-wife insisted that he raise the two girls, which he was pleased to do. He has not remarried, and subsequent relationships with women have been consistently unsatisfying. He is unhappy at work, where he teaches students and sees some clients, receiving “little recognition for successes.”
Comment I was impatient with the lengthy 4-hour intake, but it became clear that Richard wanted to tell his story his way. My diagnosis was dysthymic disorder in a personality with narcissistic features.
I taught him the cognitive model for identifying key meanings and disputing them. We worked over two sessions separating the controllable aspects of this life from the uncontrollable. We discussed the implications of stage-of-life changes (his younger daughter was in the process of leaving home for college), as well as his views of women in general.
He identified a strong need for approval, as well as a tendency to discount positive feedback, especially in the workplace. We employed the framework of identifying choices and tracing likely consequences. When he focused on being overweight, I suggested that he keep a baseline food record from which we could together formulate a weight-loss plan. The major cognitive error we discussed was polarization—he thought categorically, with no grays.
By session nine, Richard reported his first “decent week,” noting especially a marked reduction in anger. He had twice failed to produce a food record, however, saying: “I resist the things I know I need to do.” We talked about identity: his idea of who he was and what was important to him.
He began session 10 by forcefully telling me that something had “clicked for him last hour.” He realized for the first time that he “could define himself;” he did not have to be a “prisoner of the past.” He brought in several typed pages of thoughts he had had about himself. We reviewed them in detail. “I have the power to re-create myself,” he said. He felt renewed energy, more interest in his work, more accepted by his friends. “It had been there all along,” he said, “I was just unable to see it.”
He now kept his office door open at work, questioned his previous “all-or-nothing” attitude, and vowed to “get out more and meet people.” He was markedly less often angry and was actively using cognitive techniques when he felt dissatisfied. “These changes,” he told me “are the mental equivalent of bypass surgery!”
Comment We met three more times over the next 6 weeks (13 sessions in all), and his gains were maintained. He felt that he could tackle the remaining issues on his own. He has called twice in the past year. The first time, he reported that he lost a substantial amount of weight. The second call described a gratifying relationship with a woman.
Discussion
Each of these patients was strongly motivated to do the work of therapy, both in the office and between sessions. They alluded to a degree of “rethinking of the past” as a by-product of psychotherapy, not as its focus. I believe the relevant changes preceded the rethinking rather than following it.
Cognitive changes are a component of most successful psychotherapies, brief or otherwise. The therapist-patient relationship, thought to be essential to how change occurs in psychodynamic psychotherapy, is a necessary ingredient in cognitive therapy as well. The first stage of any successful psychotherapeutic venture is, quite properly, called engagement. No engagement likely means little gain for the patient. I felt strongly connected to each of these patients.
My second patient’s 4-hour soliloquy notwithstanding, my interaction with my patients typically takes the form of a conversational dialogue. I use analogy, humor, and sometimes self-disclosure to focus attention on an aspect of a problem or an alternative.