Psychologist Nancy Shaffer, Ph.D. -- D.C. Dept. Mental Health -- Clinical Notes December 1999

session Wed. 12/8/99


I open: you tend attribute to me narcissistic vulnerability anytime there's a conflict between me and an external objkect. I cited examples--

I and coworkers -- hypersensitivity

I criticizr you -- I read too much into things (exaggeration)

I and secret service -- you wanted attention (that itself was in ref: to "getting burned" fear of punishment observation .

I get attacxhed at staff meeting -- You were underwmployed

[also previou seesion: need to devalue. I analyze mother. Does this help you to forgive your mother? Later I respond, "That syrijes me as ridiculous." (i.e., because of my persbality disposition --not intent to devalue. Like saying, Do you forgive Anna Kerenina for commiting suicide.) NOTE: 2d session -- child abuse can be good NS response-- That's ridiculous.

at this point NS breaks in - "I'not remembering any of this?

agitated response -- self-jsutifications rartionalizations

Well, you're diagnosis is Nacr pers dis. Is it not appropriate that I attribute your poeblsm to the symptoms of that disorder (fallsback on fact that Lisa Osborne gave same diagnosis; but I didntt have the same feeling with her; at GW different diagnoisis. )

other response of NS at session: "How is this looking at both sides of the issue?".

--irony at this session she is simple reacting consistent with what I said -- name;y, resolving prblems by attrbiution of narcissitci vulberabnility, here citing diagnoiss itself.

Other responses by NS: at previous sessions "How does this help you?" or "I thought this was supposed to be about you, not me." possibel interpretations -- lonks up with superego functioning centering on fear of pishment - here I assume the role of superego figure who criticises and you get a lot of defensiveness and rationlizations -- possibly the way she routinely responds to authority

Berberich article/Nobick and Kelly -- presense of nars Dis doesnt obviate effects of aggression or that interpersonal diffculties in osme enviromnet were result of aggression or innate vulnerability -- narcs vulnerability can be consequence of aggression in some envirbment. Protects parents

Yalom -- memory -- diagnoiss "Love's Executioner"

group therapy "NS--other people comment on self -- (depicted as good thing) but patient not permitted to comment on therapist. conceals sadistic view of commenting on others -- and means of control.

later in session: starts asking about whether I had friedn in childhood -- what did we tal about -- what happens with my relationships. possible defensive maneuvering into safe area -- possibly shame-endowed response to earlier part of sessionss

session 12/15/99

anecdoes about autonomy.

NS reaction: emphasizes kindergarten anecdote and the fact that acting out may be a problem in my relations

MacCrory episode: emhasizes question of hwther I intentionally sought out obscure statute to make myself look different. (this is after hearing all the other anecdoes)

suggests that I might want to "pay lip service" to observing other peoples values; and avoid a hostile confrontational response to people to avoid arousing hostility in others. Sure, indepednece, creativity and originalthinking is good--but you need to considerthe consequences of certain behaviors. Need to at least try to act like others.

Emphasizes nehaviors over ego-functionib.

Bill Clinton -- could acvt like a saint -- repiblicans would still crirtcize him Clinton impeached because he's a dem not because he had sex with Monica

double binds -- racism -- black person is lazy and shiftless -- modifies behavior -- goes to college and becomes sucess --racists resp«ond: He's uppity. Thinks he can become as good as a whitea man by simply doing what the white folks do. A black man will never be as good as a white man no matter what he does!

overlooks superego functioning -- narcisstically regressd grousps

Ftitz sertern material

Where narc regressed groups are the issue -- its not behaviors -- these will be criticized no matter what you do if your'e outsider.

Sister -- just act like other people. then people will accept you.

Mythical constrcut -- ther's this thing out there. you need it you need to please it if your not accepted you have to modify self to be accpeted. rejevctio is punishment -- acceptance is reward. rejection means there's something abd about you (Rubin book) acceptance means youre good (Good moher will natutaly accept person who is good,.)

Aunt -- brother-in-law -- reactions not based on objective factors, rather externalization aimed at preserving idealized self-image

kindergarten story -- igonores fact that teacher permitted behavior.

Complementary ideas: (1) failed to pay "lip service" to others ideals in kindergarten anecdote; (2) intentionally tried to stand out in law school by searching for an arcane solution to problem (no evidence for that-- it's her confabulation).

session 12/22/99

Begin bey telling about decision to stop taking antideprasset meds. But continue and incerase dose of Ativan.

Say that I think Dr. Taub is playng games with medication.

Repsonse: Is it I Taub who is playing games with meds pp or is it I. Shows me letter f

dated 10/29/99 about diagnoses. (Appears to be excuse to show me letters -- poor transition from what I was talkng abouyt, The letter was on NS's des, says she just receievd it--apparently looking for some excuse to introdeuce it.

NS asks: was it an issue of control that I stopeed taking meds. (note yjay I'm still taking ativan and even incerased dose. She herslef said she did not notice change.

Note that NS raused issue of contril when I sopke of anorexia in childhood. Was it an issue of contrl--that you refused to eat the food that your mother put in front of you. Issue of "control re: oral ingestion."

NS asks: What was I trying to prove with the letter. Associate this with previous week session. Maccrory anecdoet. "Did you intentialonlly go out and reserach some statute that was arnace. Note the element of paranoia. ¬Trying to proveb thinsg.:

NS asks: whether I am trying to dive a wedge between Taub and her; more paranoia. She knows I have never sponekn negatively about her to Taub in my four sessions with him (9, 10, 11, 12). Note paranoia and abandonment fears.

NS asks: true sto get at issue of what it was that I am concerned with about her Dx. Raises issue of my statement in past that I said I was concerne about SSA. Note the symmetry with her own abandonment fears. That is, her latching on to my fear of getting benefits cut off may be a projection of her own fears about vulnerabilities in her professsional relations.

when I ask tape recording sessions. She is more strongly hesitant than before. Originally was totally neutral; in later session, she stated possible negative asoects; now she is virtually close to prohibiting (suspect that she will not directly refuse, however; so that shem, in shalliow fashion, can maintain the pretense that she never directly refised to allow me to tape record sessions. States reason: I might tend to focus on details in obsessive fashion if I am allowed to tape.

NS refers to my imperviousness; expressly compares me to a wall. But see Shengold about delusional denial (end of book chapter)

NS -- I'm not buying into this victim business-- But see shengold -- patient's deluded notions of being victimized in the present may screen actual past victimization.

NS cites fact that I didn't give her a copy of the letter, as if I was trying to pull one over on her (You know that everything you give to me, I share with Dr. Taub; and everything you give to Dr. Taub I share with him).

NS -- actyally diagnosis falls out of the picture once the treatment begins; but note comment at previous session re: my complaint about her attributing my interpersonal problems to my narcisistic vulnerability: "Well, your dx is narcissistci disordr, so why woul I not attribute you rpoeblsm to narcisitci vulnerability.

Inner/Outer -- paranoia --

a.) talking aboyut psych testing I mentioned that test evaluator routinely attributed my actions in relation to internalized values to an attempt to impress external object -- hersledf. NS seemed unable to distinguish between inner/outer directd behavior and creative person's need for an audience. NS seemed to try to bolster the

b.) what about me(?) had complained about resdents at GW; I stated that perhaps part of the problem was that they were supervised residents and that they were under pressure from supervisor; NS says what about me? I'm not supervised; I'm indpeendent -- what would cause me (NS) regress -- note lack of any appreciation of nternl pressures -- sees only outside pressures

Overview of issues: control, paranoia (proving things, interfere with professional relations), abandonment fears,

Alternative view:

Shengold material -- patient who complains that health profesional has aggressed on her. Shengold deals with the issue analytically. Does not use this as opportunity to chastise patient about her characterflaws and opportunity to discharhe therapists own irrational concerns.

NS Ignores other issues -- such as

Refusla to take meds as revellion -- Fernando

assuming conyrol of therapy -- actig as own doctor -- perhaps related to assuming parental t]role. (Friedman, Beren)

what about issue raused by therapust herself implicitly--namely, concerns (including guilt) relating to oral ingestion.

seems to view narcissistic distruance as cliche (bad child imago) rather than as distinct clinical entity. Note major issue re: dx is confiusion about images (psyhotic versus nonpsychotic). Novick and Kelly. Therapists possible rartinalization of simply saying: You're a bad child and I and going to hold you responsible. None of this "insnaity defesene" crap (paranoid schizohrenia. You are bad amd will be held accoujtavble. Narcissitic dx. (from this irrational prespecftive) allows the therapist to discharge her own shame Re; issues of control, abandonment, etc. in a way that she could not if she viewed me as pscyhotic.

session 1/5/00:

discuss ethical precept requiring that psychologist refuse to work with client who she cannot benefit.

cites issue of the fact that psychotherapy can be expensve; and, that as a general matter, not all acilities are as affordable as this clinic. But that if it got to a point that it was clear that I could not benefit here, she would make referrals.

ISSUE OF MORAL REASONING: What about following respone-- My ultimate loyalty is to my requirements as a professional, not to this clinic which is my employer. If I felt that I could not hel you, I would recuse myself from your case, and tell Dr. Taub or the Commsision that it had to find alternatie treatment for you. It would be then up to the Commission to resolve the issue. The money issue is irrelevant. The sole concern is whether I can help you. If not, I would recuse myself. And not simply see you week after week and bill SSA.

Later in session, in response to my analysis of my family background. "Does this help you (this analyzing of your self") -- Does it help you -- I don;t ant to say get over -- Does t help you (resolve? I say) -- no, not resolve. Same respone again. Utilitarianism wheneber I start to analyze others or therapist -- Almost like I am doing forbiden thing, but if I get help she will excuse it. Analogous to medical matijuana/ "I can't condone smoking marijuana, but if you need it, I will permit it -- you have my dispensation." Therapist does this wit analysis. or another analogy -- raduation is dangerous -- you can use it for specific medical/dx purposes but its not a toy you dont play with it. (intellect something very dangerous, that is to be used for specific purposes only)

Also: Issue of "Does this help you (to think about and analyze these issues)?:

a. Authoritarian state: (Big brother)-- what Big brother would tell someone who analyzed the regime. "This doesn;t help you. We run this country with an iron fist. Things will not chnage here--you will not bring about reform of the regime. This is a waste of time for you. It does not help you to analyze us.

b. Brother-in-law -- would brother-in-law be better off if he had analyzed his situation. Note how therapist rewards the deceptive appearance of adjustment. Self and brother-in-law both victims of overstimulation. I react with intellectyualization and analyzis. (this arouses hostile reaction). Brotehr-in-law reacted with socially acceptable means of confrpamce, denial and projection -- society rewards these solutions. Society (particlarly authoritarian personalities) do not reward the person who attempts to resolve his distress by intellectual means.

c. note the different standard for utility of analysis versus meds: NS chastised me for not continuing t otake meds, despite fact that she would acknowledge that meds are simply maintenance therapy--they do not cure problem. Yet as far as y attempts to analyse, she seem sto hold me up to a higher standard of utility--dos this help you [get over] your problems. Does this help you forgive your mothers. Implicitly syaing, if this doesnt cure the problem (and is simply a form of malingerinfg). This may simply reflect the overdteermined antipathy of the authoritarian personality toward questining or analyzing parents & the use of the intellect, analysis, and indepednent thinking, and the failure to confform to a convetinal set of values and percpetions of family. Part of the appeal of medication to the authoriatarian therapist may be that it is non-intellectual and involves the patient deferring to the control and authority of an authority figure. (cf. when I stopped taking meds, NS expressly raised the issue of control - "Was this a dispute over control. Were you trying to exert control.

Note the Orwellian Double-Think:

a. continuing self-analysis = self-empowerment = noncurative maintenance = possible malingering = bad or questionable: Efficacy standard - Does it cure problem. No? Then stop it. But will never say "Do more of it -- you should spend more time thinking about you problems (yet that's exactly what Freud did in his own Self-analysis).

b. medication = control by external authority (doctor) = noncurative maintenance = good: Efficacy standard - Does it cure problem - No? GIve it time to work/ do more of it (incerase dose).

mendacity issues: initially states, at beginning of session "If you feel this therapy isn't helping you, I could help you with referrals. Of course, not all facilities are as economical as this one." I.e., economic-financial issue is the first thing that came to her mind.

Later in session, when I report that mother wallpaperd rooms in sisters house -- and that this saved sister a lot of money. therapist says: "That's not the first thing that came to mind for me. What came to mind first was the amount of time that must have taken. Here therapist denies money issue.

Later in session when I mention that I purchased theater tickets for parents, her comment was: "That must have cost a lot of money" --(referring to the tickets, pots and pans and the gift for aunt.)

other contradictions and mendacity issues:

1. questions "how does it help me" to analyze my family nackground. Yet, how does my interaction with her help me? She's billing SSA $10,000 for what, basically crap--but that doesn;t bother he. But questions how my analyzing myself helps me. Analysis: she's doing everthing required of her--whether I response or not is not her problem.

2. When I complain about conditions in my family askes whether I talked to my parents about this. Did I ever gave discussions with parents about what bother med in family. Note that when I criqtique or question her she responds defensively or becomes angry. (Note here the double standard or splitting)

3. NOte possible symmetry between issue of futility or utility -- "How does it help you to analyze" possible relation with other superego sanction "Impossibility" "other clinics are not as economical as this one. Here my financial limitations are a source of control of limitation, which she points out.

I suspsecrt that these two issues, what might be termed "imposibility" and "utility/futility" are two interrelated superego values. She will either point out how something desired is impossible or how the puruit of something that she disapproves of dioes not meet utility value. "You want other therapist" - but you don't have money to pay (thus, invokes impossibility sanction). You try to analyze yourself, but what good is that (utility issue). Note how this is done mendaciously. Supportive psycotherapy of me is really an "impossibilty" yet she pursues this without any problem despite the fact that she could --and has the right top refise to terat me (under APA rues). She pursues therapy with me despite the fact it has no value (she violates her own utiliy sanction, but that poses no problem for her).

impossibility and futility ultimately relate to the mother the "idealized primary object" and to superego functioning. For NS the inability to attain the mother are encapsulated in imposibility and futility -- they are both shame endowed states that are associated with separation from mother and the inability to attain mother or re-unite with her. One needs to avoid the shame associated with impossibility and futility to avoid injury to self-esteem. These states are therefore impulse control mechanisms that relate to all desired objects (derivatives of the good mother). If something is futile it must be avoided, and th person must go on to what has utility; if something is unattainable (impossible) one needs to avoid that to avoid threats to self-esteem. This form of impulse control would tend to arise in a person who had a poor imaginative capacity, and who no ability to fall back on an ability to imagine and derive a sense of narcisistic integrity from the act of imagining the idealized primary object. Cf. Solnit/Ritvo. Also, what seems to be a positive form of superego functioning carries a heavy dose of mendacity with this therapist. You can see that in her therapy with me, its really futile, but she will rely on rationalization to fulfill (in decpetive fashion) her superego sanction to avoid the futile. If her superego vales were genuine, she would find her work with me to be an intolerale strain. But she avoids the strain of coping with the futile by the rationzalision that she is doing sometjomh useful.

Probaly as an infant she relied on "out of sight out of mind" If mamma leaves room, I will just put her out of my mind. Self, when mama left room I would hypercathect my imagined recollection of mamma.
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Therapist tends to rely on irrelvancies in support of her reasoning -- or her rationalizations. Upon close inspection you begin to see that some of the thinsg she says just don't make much sense.

[General issue re: irrelevancies -- all concern the parental derivative and honoring their values, avoiding punishment, avoiding casting in negative light (2).

1. in case APA rules -- ptaient's ability to pay for other services -- isnt this irrelevant? If psychologist cvannot help patient, she should just recuse herself, let clinic worry about problem.

Aren;t patient's financial resources immaterial to the psychologist's need to discharge her dities under the rules.

2. when I talk about harassment (subtle harassment) -- what would their motive be? Why is my knowledge of motive relevant? Why would I necessarily knw the motice -- whether harassment is overt or covert. Even in case of overt harassment )say, e.g., not on desk admitting harassment), would I necessarily know the motive?

3. Kindergarten anecdote. -- Tell about my refusal to make costume. NS says couldnt I at least pay lip service (Note NS reaction to APA rules) to the other children by at least putting on a hat? Ireelevant -- I never said that other children cared, or that I had not gotten permission from teacher, or that there were any problems at all.
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When you go to school besure to play with all the ther boys and girls and be sure to play nice.

If you see the other girls and boys doing something, then you join in. And don;t quetsion what they are doing.

[But what if I don't want to play that game]

But you must. If you don't join in, they will reject you and not want to be your friemd. You will be alone and isolated. That's bad.

If eple don;t like you it means there's something wrong with you, you are doing something wrong. You need to look at yourself and see what you are doing wrong, and modify that. Then people will like you. I

[So, what you are saying, mommy is, if I am isolated that means there's something bad abot me that neds to be changed.

Yes. Because having friends means you are being accepted. You are only being accepted because others have judges you to be good, and they want you to be part of their group. But to be isolated means you are being rejcted, which means you are doing something bad.

[So what you are saying mommy is to be good means having frieds and being liked, and means I am a good person, and that conventionality is the ultimate ideal. And that there is nothing wrong and nothing needs to be changed. You xcan also look on accpetance as a form of reward for being good. (good, social acceptance, good person, reward, narcissistic integrity)

To be lonely is to be bad to be in need of changed. It is a shameful state, You can also look on loneliness as a form of punishment for being bad. (bad, isolation/rejection. bad person, punishment, shame, in need of change).

But what if the other boys and girls are doing something I don';t like. Can't I reject them and go my own way.

No! Never, child. Only monster children talk like that. You never question waht the social group is doing. The very fact that they form a group means they are good and approve of each other. Who are you to say they are wrong. You aer just one person. Remember, also, you are dependent on them for approval. Without them, you will feel bad

You mean, mamaa I can't just feeel good about myself, without other pepole saying I am good?

Thats right dear. Only monster children feel good about themselves without permission. When you grow up you'll learn that's called narcissism. That;s very bad. It means you are all alone and making your own rules.

SOmetimes I feel sad, moomy. SOmetimes I think about my life and I feel sad

Don;t talk like that. You need to get over that. When baby is sad, he cried. But he's a baby. You're not a baby, you are a big girl now. Thinking about how sad you are means you're not acting like an adult. You need to put those feelings behind you. The most important thing in life is to fit in. You ned to do practical things--thinking about making yourself a good person, so that others will like you Once you are acceored by others, you won;t feel bad anymore, because you will know by others' reactions that you are good. You will having nothing to feel sad about once you have a group of friends. Don;t think and analyse. That doesn' t help you. You need to be accepted by others. And thinking and analyzing doesn't help you make friends. It only alientaes you from others.

So, you're going to try to make friends, right? Yes mommy. Why? Because I live you mommy and I want to do what you tell me so that you will keep loving me. And If I don;t do what you, you won;t love me, that means I am being bad.

There's a boy in school. He's lonely. He doesn;t have any friends. Why mommy?

He must be doing something bad. Other children will naturally like and accept good children. They reject only bad chdilren. What motive would children have to reject a nice little boy? None. That's just silly.

SOmetimes I disagree with what the other kids in the "in group" do.

Oh, child! Only monsters talk like that. If they're the in-gourp. It means they are good and wonderful. They approve of each other, and doing good things. You want their approval, you want to be a prt of them. Being with them will make you feel good abut yourself. You never criticize them. That's bad. It would be like criticixing mommy and Daddy. You never criticize your parents. We are good. You never criticizie the ingorp they are like mommy and daddy out there in the wider world. They dont like being criticise; you have no right to dricitze; and the fact that they are the in gorup means there's nothing to cicitice about them.

Sometimes I wonder about things mommy. Things in the wider world.

Is that part of a school project dear?

No. I just do it on my own. (adjustment, inhibition against thinking, preservation of good object)

What good does that do you? Does that really help you to think about things? No. Thinking is only for special purposes. It's to get good grades in your assignments, and then mocve on to the wider world and get a good job. Thinking is only good in so far as it helsp with adjustment. If you're not using thinking for adjustment it's npot good. You certainly don;t ever want to think differently from your teachers. You don;t ever want to have thoughts diffferent from other boys and girlsm because then they wont accept you and you wont have any friends. That' in itself means that you are bad. Its shameful. Thinking is like an x-ray machine. Do you know what that is? Yes mommy. Well, its a special tool that is very useful for specificthings in medicine. But that's all. It's not a toy. And if you plat with it like a toy, its very dangerous. Thinking is like that/ It's very useful for certain limited things, by pople who have permission to do it. But it is not to be used as a toy. It can be very dangerous to think on your own, as if it were yourtoy. Think about the things your teacher tells you. Think the same thoughts as the other boys and girsl. But dont ever disagree with the majority and don;t ever disagree with teacher. mommy or daddy. That's dab and sameful.

Other children naturally want to be in the in-group because it is good --their desirability tself indicates it is good. People naturally want and gravitate toward wat is good and gives them pleaseure and will avoid what gives pain --what is bad. If you see others avoid something it means it's Bd? Yes dear.

Will you do that dear?

Yes, mommy.

Why dear? Why are you an obedient child.

Because I live you mommy, Iwant you to continue to love me, and I want to do what you tell me to do, so that you will keep loving me. I fear you would abandon me if I didn;t do what you said.

Good dear. That's something you van trhink about and remember.

Kernberg -- authoritarian personality -- conventionlaity

Erikson, control -- shame.

pleasure - good - reward

pain - bad - punishment

adjustment - goodness - normality - virtue - strength

lack of adjustment - badness - illness (in narrow developmental sense) lack of virtue - weakness

[Sidney Phillips paper -- subtext -- possibel symmetry of folliowng issues

highly developed superego functioning -- will go beyond reqyuirements of pofession and follow his onw ideals eg -- resreached what patient said

able to deal with reactyive issues and not place them all within a dveleopmental framwwork. able to process aggression/overstimulation/ -- pare manifestly concerns Viet vet-- but concepts also apply to otherreactive phenomena such as child abuse.

conventional superego functioning (or poor superego functioning) will go along with system; poor ability to deal with reactive isues --

need to prtect arent is overdeterined -- turn away from bad thinggs done by mommy and daddy (turn away from reacrtive ussues) and in own professional work never go beyond expectations of mommy and daddy. i.e. superego functioning is reflected in both theoretical orientation and in his act of "research"

a. curiosity defensive attitude about research

b. able to deal with abuse defensively turns away from abuse isues

c. goes beyond requyirements by the book player.

of profession
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February 16, 2000

PATIENT"S REPORT: My father used to beat me when I was a boy.

THERAPIST'S REPONSE: What wias it that you used to do that caused him to beat you.

1. Therpist's formulation seems to focus on the "badness" or perecived badness of the child and the father's act of punishment.

What does this omit:

a. it omits a conisdertaion of that fact that the chiod may have done nothing, and the child was an innocent victim of the father's capricious rage. see Shengold. Tends to rationlize the parental object.

b. omits Oedipal issues: did the beatings occur ion an oedipal stage, and thereby heighten the meaning of the beatings in terms of castrartion fears of child? see Shengold (therapist does not ask what age the beatings occurred)

c. were there issues of the father's oedipal jealousy of the boy. See petere blos. Car crash--out of controld sexuality (1/21/00) Hulf war.

d. did beatings heighten sense of rebelliousness in child Eissler/Greenspan

e. did the beatings heighten the child's sense of masochism -- Freud.

f. what were effects on onsequent structuralization? Note how the therapist interprets the report as relating to the simple situation: act by child/response (punishmnet) by father. But there is no consieraion of the effects on the child. This may be consistent with a subtle type of role reversal in teh therapist. the therapist views the child as if her were an adult, with no special, or age-appropriate vulnerabilties, a person who is still at a developing stage. There is no difference between the way she views a child and an adult, where you might simply look at act by the adult and the response (punishment) by another, with no sequelae. She omits any consideration of sequelae, as you might with an adult, since an adult is fully developed. There is a striking symmetry with theway she views the adult who fails to comply with norms: he is depicted not as an adult adult who has a right to dissent or protest, but rather as a rebellopis child. Thus, the role reversal. For this therapist, the child will be viewed as a miniature adult with no age-appropriate vulnerabiliteis; and the adult who deviates from conventionality will be viewed as simply a "bad child." Probablty symptomatic of a narcissistic disturbance in the therapist. See Beren.

g. heightening of family romance fantasy -- child wishes to eliminate paremt in fantasy (auto crash -- 1991 and uncontrolled sexuality)

--also family romance fantasy is complement of beating fantasy in sister; both expressions of sibling jealousy. (In fact, at this session, pateinte, in dicussing the various persons in his matrix talked about fact that his siser was extremely jealous of him. Seen projectively, then (as an expression of pt's jealousy of sister) the reference to sisrer's jealousy of pat. is actiually related to pat's report about the car accident. (Yherapist misses these underlying dynamics because she doesn;t employ a psychoanalytic model). Intriguiig deep structural similatty between pt's statement "Mus sister was extrenmely jeaoul of me" and "Let me tell you about a car accident I had in 1991"

h. (Freud -- Three Essays on Sexuality) Beating can heighten the child's masochism -- fails to see connection with last remarks about therapist's remarks feeding sense of masochism.

PATIENT"S REPORT: I used to aggress on my mother because she offered no protection to me against the aggression by my aunt and brother--in-law.

THERAPIST: Wa your mother the weakest person in your matrix? as she the weakest link in the chain?

Here ther therapist depicts the patient as a bully who aggressed on the weakest person in his environment. In a sense the therapist is asking. "Was your mother the weakest person who you could aggress on and get away with it?

Parent aggresses on child -- what did child do wrong (not , perhaps father simply picked on the weakest person in matrix)? Child aggress on parent -- (not what did parent do wrong) but this is the weakest person in matrix

a. projective isue: therapist's relations with APA, commssion, and medicare?

b. fails to see mother's duty to protect child, and the natural psychological or almost biological reaction of the child to a mother, who fails to carry out her duty as mother--namely to protect child. Here, the mother's role as mother (and the specific role as maternal protector) is denied. And the mother is depicted as simple the "weakest person" in the matric. But see Spitzer.

c. denies aggression in the environment. Therer is a transmutation here. The child in reality has been a victim of aggression by persons in the matrix, but the sole recognition is the aggression of the child agaist the mother. In a sense the therapist has transmuted the aggreesion directed against the patient to aggression by the patient.

d. note the ptherapist's failure to recognize sequelae or of the abuse in terms of the child's inappropriate self-blame and shame in the face of the abuse, and depicts the patientimplictly as a shameful person wh aggresses on mother. See Spizetre.

The complex interaction is reduced from an abused child aggressing on a mother who fails to carry out her duty to one person aggressing on a weak person. This is more evidence of role reversal that rtakes the form of the therapist's failure to appreciate the specific ages and roles of the parties and alters therir identity so that they are simply two persons -- a person aggressing on a waek person.

Also, consistent with the issue of role reversal noted above, (f.) it may be that the child's specific age-appropriate need for maternal protection is denied; and the therapist transforms the situation in which a patient is simply expressing his (age-inappropriate) dependency on mother. It may be that ultimately the therapist views the patient's report as signifying his separation-individuation problems. "If the patient had had a well-deleoped sens of self, he wouldn;t have needed the mother's protection. The patient's need for protection is a symptom of ego weakness in the adult." Whereas the appropriate interpretation is that the child had age-appropriate need for protection, which was not met, and the patinet, now an adult, faces tye sequaele of that developmental deficit in the form of guilt. But in all likeloihood the therapsit naccnot process issues relating to guilt in the adult, since it requires an appreciation of internal object functioning. All guilt will be interpreted by this therapist in terms of eqo weakness and narcissitic vulnerability.

There is a process in the therapist's thinking.

1. a child has specific and age-appropriate limitations and vulnerabilities in addition to idiosynctaric limitations and vulnerabilities

2. a child can be subjected in his developmental environment to aggressions and deficits -- sometimes these specific aggressions and deficits can fall outside an average expectable environment

3. a child may develop specific and enduring sequelae that are a result of the interaction of a the child's personality (with its specific and age-apprriate limitations and vulnerabilities) with aggressions and deficits in the environment

What this therapist seems to do is

1. deny the age-appropriate aspect of the child's limitations and vulnerabilities, so that the patient is depcted as never having been a child, simply a "person" who at another time, in another environment (really the developmnetal environment) had certain narcissistci limitations and vulnerailities. This transforms normal age appropriate qualities into narcissistic vulnerabilities.

2. deny that the developmental environment exhibited inappropriate aggression or deficits or that the parents failed to fulfill their specific parental role. This preserves the parent and the developmental envroment as idealized.

3. deny that there are sequelae of aggressions and deficis in the develppmental envornment, that have affected the p«atient's ego strucyuralization. This reserves the image of the patient as simply a narcissistically disturbed and developmentally arrested individual with no unconscious unconflicts, wishes or prohobitions, and with no ego differentiation..

Ultimately, in her dealizings with he patients she can preserve the interaction as one between the Good Parent and Child. She preserves her role as the Good Parent whose role it is though encouragement and adminishment persuades the patient to be good by conforming to convent8ionlized social norms, who is no longer preoccupied with interactions in previous environments (including the devekipmental envioronment, which, after all, was an ideal environment in which the child, because of its own perversity and idiosyncratic limitations and vulnerabilities, failed to develop adequately).

g. what about role on adult peer relations and supereiors? this is totally ignored.

PATIENT REPORT: I was thinking of three different ways that a patient might respond to the interpretations of a therapist. Firts, the patient may be narcis impervious to interpretations and not accept anything the therapist says. Second. there may be an issue of ego strength [therapist sneers slightly]: the patient has the ability to withstand the therapist and hold his own opinion in the face of a contrary view. But another case is that the «atient, paradocially is accepting everything the therapist says--but that it satisfies the patient's inexhaustible sense of masochism and guilt.

Therapist response becomes tangential and focuses on how this patient changes -- something that she seem to do regularly.

Ultimate goal is adjustment -- social and occupational (basically, "fitting in")

equates adjustment with mental health

views the processs of therapy as a process of "change" specifically aimed at moving the patient from deficits in adjustment to a stage of adjustment

because the therapist is unable to accomplish change with the patient, and because this poses a strain for her (namely, because adjustment is a superego value--she has a narcisistic investment in adjustment), she needs to at least affirm "change" as a value.

At virtually every session, no matter what the content of the session, she will introduce the idea of "change" -- thereby at least affirming "change" as value.

This fits in with the idea of "lip service" -- at least she pays lip service to the idea of change. And this shallow affirmation of "change" will serve as an intellectualized substitute for change itself.
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