JAKE'S EXPERIENCE WITH A PSYCHOANALYTIC THERAPIST
JAKE'S EXPERIENCE WITH A PSYCHOANALYTIC THERAPIST
Dr. Eckman, a short, white-haired man in his early seventies, motions Jake toward a squat, squarish, earth-colored couch perched behind a deeply stained oak coffee table. The corner desk is piled with folders and old books and an array of mismatched coffee mugs. As he takes in the figurines and artwork in the office, Jake notices the surreal quality of the moment, unsure exactly how things had gotten bad enough that he needed therapy. Dr. Eckman has a surprisingly warm and welcoming look as he gestures to Jake to sit in on the couch. "I thought I was supposed to lie down on the couch," Jake says in a half-joking voice. Dr. Eckman looks at Jake and, with a soft, trusting voice, says, "You can if you like, but I usually don't work that way. Mostly, I just want you to feel comfortable so we can take a look at what's going on with you. Based on our brief phone conversation, it sounds like you're a bit discouraged, Jake. Can you tell me a little about what has brought you to therapy?" "I was just wondering about that myself." Jake smiles slightly before continuing. "I guess I've always been a bit of a worrier, but things are much worse now.
As I mentioned on the phone, I recently had a panic attack. I'm almost more worried about having another one than I am about something happening to the kids-well, almost. I'm completely powerless when it happens," Jake begins. Jake explains the circumstances around his last panic attack, when Luke and Celia knocked the family car out of gear and were sitting inside as it rolled into the street in front of their house. "When my sister and I were their age, we were messing around in my dad's car and my sister was nearly killed," Jake shakes his head as if to erase the thought from his mind. "I think seeing those kids in the street like that just flipped me out." Dr. Eckman continues to listen as Jake shares, "I know I have been unreasonable at home, but I can't seem to control my fear that something horrible might happen to Angela or the kids. A part of me wishes that Angela and the kids would just stay home, never leave.... I asked Angela to home-school Celia and we had a big fight about it. Part of me knows how unrealistic and unfair that sounds, but the other part really wants it. It just seems like all this anxiety is getting in the way of our relationship."
Despite developing some hypotheses about Jake's situation, initially, Dr. Eckman is concerned about building a relationship with Jake and helping Jake feel comfortable enough to share some of his deepest thoughts and feelings. At the same time, Dr. Eckman is already hypothesizing to himself about Jake's predicament. For instance, he wonders about the unconscious forces that he believes are feeding Jake's anxiety. He considers how Jake's early childhood development shapes the configuration of the structure of personality (the id, ego, and superego), which ends up creating a template for how he deals with relationships throughout his life. Dr. Eckman is particularly interested in how the ego fends off real and perceived anxiety motivated by urges from the id and the demands from the superego. At the opening of the second session, Dr. Eckman comments, "Jake, you seem to be favoring your right leg. What happened?
"Oh, that," Jake says, reddening a bit. "That happened in the accident I was in with my sister." Jake swallows and continues, "When the semi hit Dad's car, Justine went through the windshield. The front end of the car was smashed in, and there was some damage to my hip. I broke a couple of ribs, and I had a bad concussion."
"You hadn't mentioned that before. It sounds like it was pretty bad," Dr. Eckman prompts.
"Yeah, I guess, so. I don't ever really talk about what happened to me. It was Justine that really had it bad, you know. She has a brain injury and well, it was just bad, that's all."
"You had quite a long recovery, and it sounds like you are lucky to be alive," Dr. Eckman probes. "How did you two end up in the car in the first place?"
"Wow, I haven't thought that far back in a long time." Jake's expression grows serious. "Well, you know, Justine was about the bravest girl I ever knew. There was never a challenge that she wasn't ready to tackle. She was incredible. And she was really, really smart, too." Jake's glance drifts to a cluttered corner of the room as he begins to share his memories, almost as if he is talking to himself. "Justine really wanted to play a trick on Dad and take the car and hide it in the woods. As usual, I was scared and tried to talk her out of it, but she was sure it would be really funny. So finally, I caved. I remember she is her but feet curled up under her in the front seat the seatbelt hanging loose at her side. I told her to buckle up, but she just laughed at me."
Looking up at Dr. Eckman, Jake pauses and says, somewhat taken aback, "Dr. Eckman, you look so sad."
"Jake, I'm just reflecting the sadness I feel from you." Jake swallows and feels the tears rising in his throat, breaking finally in sobs.
As their work continues, Dr. Eckman is able to identify a number of defense mechanisms that have served an important role in Jake's life by staving off anxious feelings emerging from his unconscious. His use of free association, dream analysis, exploration of memories and fantasies, and interpretation has exposed four primary defense mechanisms: repression, idealization, reaction formation, and denial. Sitting down with Jake's chart, Dr. Eckman begins to make sense of Jake's defensive response. After the session, he summarizes his understanding of Jake's defenses this way:
Repression: In his sessions, Jake is able to remember his sister's insistence that the two of them take their father's car, including a vivid memory of her sitting next to him moments before the accident. However, as he has been able to recall more of the incident, he has begun to remember that Justine had to bully him into doing the prank in the first place. Jake has gained access to the (id-based) anger and resentment he felt toward Justine directly after the accident for "making him" do the prank and has realized that he repressed this anger because it is in conflict with how he thought he "should" feel (superego: he should feel bad for his sister). Over the years, Jake's repression has not been entirely successful in containing the unacknowledged anger and resentment. It has seeped out in his anxiety and panic attacks, in his dreams, in periodic quips he aims at his sister, and in his sometimes obsessive-compulsive behavior toward making sure that his wife and children are "safe."
Idealization: Jake appears to have had a realistic relationship with his sister prior to the accident. However, since the accident, he has idealized her. He now always speaks highly of her and often refers to the bold and fearless behaviors that she had as a child. He can no longer see her as she was or as she is today. His idealization of her allows him to sidestep his full range of feelings, which include anger, guilt, sadness, and love.
Reaction formation: Jake unconsciously has anger toward his sister for "making" him drive the car. He also feels guilt for being the driver. The guilt is tremendous, given the severity of Justine's injuries and his parents' values for "always doing the right thing" that he has introjected. One way he appears to avoid these unacceptable feelings is by almost hurting his sister, although once in a while he quips at her (patapraxes!). His idealization of her makes it easier for him to maintain this mask of niceness.
Demiak: Although Jake was nearly killed when the semi slammed into his father's car, he has been unable to talk about this aspect of the accident, or even discuss his own extensive injuries. Until now, they have been denied altogether.
Coming so close to death himself, Jake is terrified of death. However, these thoughts, and their associated fears, are now slowly seeping into preconsciousness. His "edginess" toward his wife and his anger toward his "wild" and "impossible-to-control" son are indications that his denial is no longer working for him.
Dr. Eckman believes that all people with healthy egos use defense mechanisms at one time or another; however, he believes that psychopathology develops when defense mechanisms fail to contain anxiety or are used to avoid or distort reality, or when defensive attempts to contain anxiety become self-destructive. By Jake's own admission, his fears have become so exaggerated as to be out of sync with reality. As his defense mechanisms begin to falter, he has exhibited feelings and behaviors, like anger, edginess, and a need to control others, that have deleteriously affected his relationships with his family, particularly his wife and son.
As Dr. Eckman considers the sessions to follow, he will work to illuminate Jake's defense mechanisms and bring Jake's unconscious thoughts and feelings into his conscious awareness. He believes that he must help Jake learn new ways of understanding and containing his anxiety, as the old ways are not working. He and Jake will continue to spend a great deal of time exploring his past and making connections between these early experiences and the ways in which he responds to his family now. Although issues concerning the accident have been highlighted early in therapy, ultimately, Dr. Eckman hopes to uncover earlier relational issues with Jake's parents and others that have served to form the structure of Jake's personality. Dr.
Eckman hopes this process will put an end to Jake's demands that Angela stay near the house, his constant reprimanding of Luke, and his recent decision to ask Angela to home-school Celia.