Summary of Psychotherapy Session: 7/21/09 (Gary Freedman and Abbas Jama, M.D., D.C. Department of Mental Health)
1. Pt. reports he is unhappy with his antidepressant because it causes ejaculatory delay. Pt. reports that he masturbates about once a day, but is only able to achieve orgasm about twice a week. Doctor notes that the ability to achieve orgasm lessens with age. Doctor implicitly reinforces the usefulness of Effexor and seems to imply that the pt. needs to accept the sexual side effects of the medication. Doctor is a black Muslim from the African country of Somalia. Pt. reports a problem with alcohol abuse in the mid-1990s.
2. Pt. states: "I am not sexually attracted to you, but if you offered to have sex with me, I would not say no." Doctor appears irritated and fails to see pt.'s statement as the pt.'s (analyzable) fantasy. Doctor states that his role as a physician precludes his having sex with the pt. Doctor asks: "Aren't you able to find women to have sex with?" (In fact, the pt. has, in the past, had the same thought, or fantasy, in relation to Barack Obama.)
3. Patient reports that he learned, via the internet, that an "Abbas Jama" was a research fellow at the University of Maryland Medical School doing research in the genetics of schizophrenia. Pt. says he feels drawn to doctor because of the doctor's research orientation. Pt. says he believes doctor possesses qualities pt. values, and notes that he thinks the psychoanalytic concept of a "need for merger with an idealized self representation" applies to pt.'s desire for merger with the doctor. Doctor launches into a lecture on the two-way nature of friendship.
Doctor suggests that pt. do volunteer work. Pt. says he believes this action is impossible. (Doctor immediately looks up at the clock on the wall of the office.) Pt. says he fears anything he does will "come to nothing;" says he feels hopeless, that life is futile and meaningless. Pt. says that he feels he is in hiding. "I am in hiding from my destiny," he says. Pt. offers examples that support his feelings of futility and fear that only bad things will happen if he acts in the real world (outside his world of fantasy.) Pt. says he introduced himself to his neighbor, but subsequently, when pt. said hello, neighbor did not respond and turned away. Doctor says maybe the neighbor had other things on his mind and was distracted. Pt. says he identifies with "black hopelessness." He compares his own feelings of hopelessness in the face of repeated frustration in his past life to the despair of black Americans in response to generations of white racism. Doctor points out that Barack Obama is now President of the United States despite his race.
1. Pt. begins session with discussion of sexuality. He feels his orgasmic potency is frustrated by the antidepressant medication he is taking. Perhaps the issue is not specifically sexual, but relates to generalized feelings of frustration, powerlessness, and sexual (and social) impotency. Pt. reports that he tries to achieve orgasm every day but on most days he fails. Perhaps pt. is expressing concerns about futility and wasted effort, generally, and not just sexually. Implicitly, pt. is saying that things used to be better for him (sexually), but now he has reached a nadir. Maybe the pt.'s fears about doing volunteer work -- that it would be futile and just wasted effort -- is related to his feelings about lack of orgasmic potency (his act of masturbating without achieving orgasm). Is it possible that the pt. is struggling with an oral regression of phallic narcissism? See Wilhelm Reich, "Character Analysis," Third Enlarged Ed. at 217-224 (New York: Farrar, Straus and Giroux, 1972). Pt. reports a problem with alcohol abuse in the mid-1990s. Note that phallic narcissists typically turn to drugs or alcohol in states of oral regression, according to Reich. Doctor notes that orgasmic potency lessens with age. The issue of "limits" arises three times during the session:
a.) pt. must accept the limits imposed by aging; pt. needs to accept the limits imposed by the Rx;
b.) pt. needs to respect the limits imposed by the doctor/pt. relationship--doctor may not have sex with a pt.;
c.) but doctor totally disregards the limits imposed by pt.'s schizoid disorder and suggests that pt. deny his schizoidal despair and seek out volunteer work.
The doctor has a double standard with regard to the issue of limitations.
2. Pt.'s sexuality. Pt. states a fantasy about sexual relations with the doctor. Doctor asks why pt. brings up the issue. Note how the doctor fails to think about the context of the pt.'s statements and associations. The pt. started the session by talking about orgasmic potency (and, symbolically, about generalized feelings of frustration) . There is probably a relationship in the pt.'s mind between the issue of sexual frustration and orgasmic potency and the topic that follows, namely, his discussion about his fantasy about sexual relations with the doctor.
Doctor emphasizes the sexual nature of the pt.'s fantasy, but perhaps pt. is expressing his feelings of closeness to and identification with the doctor and his desire for a nonsexual relationship. The fact that the pt. has, in the past, had the same fantasy of sexual relations in connection with a successful black man, Barack Obama, suggests that the fantasy is related to pt.'s feelings of despair, prevalent, as pt. says, in black Americans. Pt.'s sexual fantasy may suggest that successful blacks symbolize sexual potency (an erection) for him, while black despair symbolizes sexual impotency (a flaccid penis).
The doctor appears to be personally threatened and responds with the questions "Why are you talking about this?" and "Can't you find women to have sex with?" Note the pt.'s reference to the concept of a "need for merger with an idealized self-representation." The pt.'s fantasy about sex with the doctor may suggest pt.'s need to merge or identify with a successful black man, symbolically speaking, a phallic (sexually potent) male.
Keep in mind that a conscious homosexual fantasy and a need to merge with an idealized self-representation can be derivatives of fundamentally nonsexual core ego defects. Cowan, J. C. "Blutbrüderschaft and Self Psychology in D. H. Lawrence's Women in Love." Annual of Psychoanalysis, volume 20: 191-214 (1972) (relying on the work of the object relations theorist, Heinz Kohut). (Dr. Abraha was supplied a copy of this paper.)
Note that the doctor uses the same defense in two different contexts:
a.) Doctor is personally threatened by the pt.'s sexual fantasy, so he suggests that the pt. go out and have sex with women. Doctor is relying on objects outside the therapeutic relationship to rescue the pt. (and ultimately remedy the doctor's perceived threat to his masculinity [castration anxiety]).
b.) Doctor may be threatened by the refractory nature of the pt.'s disorder and recommends that the pt. do volunteer work. Doctor is again relying on objects outside the therapeutic environment to rescue the pt. (and ultimately remedy the doctor's perceived threat of professional impotence [and castration anxiety]).
3. Pt. researched "Abbas Jama" and learned that the doctor is himself a researcher. Doctor ignores, again, the pt.'s associations. Pt. started the session talking about sexual impotence, and then talks about a sexual fantasy concerning the doctor. Isn't it possible that the act of "research" is sexually cathected by the pt.? Freud viewed intellectual curiosity in the adult as a sublimation of the sexual researches of the child. For the pt. intellectual productions and research may be sublimations of pt.'s sexuality. Is such a sublimation related to phallic narcissism?
Doctor's lecture on the two-way nature of friendship is largely irrelevant. Doctor ignores the pt.'s specific pathological needs and social limitations, and focuses on the mechanics of normal social adjustment. By analogy, it's as if a doctor presented with a case of cirrhosis of the liver (pathology), launches into a lecture on the anatomy and physiology of the liver (how normal things work). The doctor is denying that the pt. has a specific pathology with recognized features:
a.) need for merger with idealized self-representations;
b.) schizoidal fear of harming the external object;
c.) schizoidal fear of future loss ("everything I do comes to nothing");
d.) severe identity disturbance (sexual and otherwise). Note the strong split between the experiencing ego and the observing ego as evidenced by this very writing; and
e.) tendency to retreat into fantasy when social needs are thwarted in the real world.
Doctor needs to acknowledge the deep existential nature of pt.'s despair, hopelessness, and feelings of futility. Doctor denies this and points out that Barack Obama, a black man, is successful. The fact is that President Obama is not struggling with black despair and does not have a psychiatric disorder. Doctor's use of Barack Obama as an example of anything pertinent to the pt.'s disorder is totally irrelevant. Doctor's comments that pt.’s neighbor may have been distracted, accounting for the neighbor's failure to greet pt., is also irrelevant. The fact is that the pt. is, in fact, struggling with deep existential despair, hopelessness, and futility and social (and sexual) impotence, regardless of the value of his comments about his neighbor. (Note that the pt.'s neighbor is a young man who is sexually active (potent); he has (noisy) sex with women and also masturbates (noisily)).
Pt.'s concerns about repeating the same failures and difficulties in his past life are a legitimate recognition by the pt. of the possible role of the repetition compulsion in causing his interpersonal problems. "Early internal objects of a harsh and phantastic nature are constantly being projected onto the external world. Perceptions of real objects in the external world blend with projected images. In subsequent reinternalization the resulting internal objects are partially transformed by the perceptions of real objects. Klein suggests that the early establishment of harsh superego figures actually stimulates object relations in the real world, as the child seeks out allies and sources of reassurance which in turn transform his internal objects. This process is also the basis for the repetition compulsion, which involves a constant attempt to establish external danger situations to represent internal anxieties. . . . To the extent to which one finds confirmation in reality for internally derived anticipations, or is able to induce others to play the anticipated roles, the bad internal objects are reinforced, and the cycle has a negative, regressive direction." Greenberg, J.R. and Mitchell, S.A. "Object Relations in Psychoanalytic Theory" at 132 (Cambridge: Harvard University Press, 1983). See also Fernando, J. "The Exceptions: Dynamic and Structural Features." The Psychoanalytic Study of the Child (1997).