Many years ago I conducted classes in collective psychoanalysis. The meetings took place in the building of the Moscow State University, in one of the classrooms of the Faculty of Philosophy. One day a young man approached me and said: "I need your help. I'm studying here in graduate school. But I do not have money for therapeutic work. " I allowed the young man to go to the group without payment. He was a tall, well-built young man. Hair, cropped "under the hedgehog," gave him a special attraction. At the meetings that took place at the Moscow State University, Volodya often spoke of his loneliness, his lack of repose, and told how difficult it is to build communication. However, I was not particularly remembered, because there were other subjects in the group that aroused general interest.
The following year I headed the Faculty of Psychology at the Institute of Public Administration. Volodya came to where the classes were going, and was very upset that they had stopped. Then he began to look for me, and, of course, he found. Now he went to classes with students who studied psychoanalysis. In the group, he began to enjoy appreciation and even tenderness.
I also had the opportunity to look at it more closely. Soon I had an assumption that he is an anal carrier. I wanted him to ask me for therapy and during the lecture I made him understand that I have an approximate idea of his problem and invite him to a more open confession. We once said during a lecture that a psychoanalyst has no right to show his disgust when it comes to some not very noble diseases. If, say, a patient talks about constipation, then the therapist does not come to mind:
- What are you telling me about all the shit ...
It seemed to me that Volodya understood the essence of my reasoning, but was still waiting. And then came the holidays. Classes stopped, and Volodya ran to my office and told me that since childhood he suffers from constipation, that his torment has brought him just on the operating table. He had a crack on the anus, and it was patched. Doctors, having fulfilled their mission, gave general recommendations: to change the diet, carefully choose food ... In short, not about the graduate student, Volodya said that he had long been with me in conditional communication, but the circumstances of life accelerated recognition.>
I instructed to conduct this patient to my student Tatiana Anatolyevna Knysheva. When the classes were going on, and they were often conducted in the form of laboratory meetings, I was constantly nervous, it seemed to me that the work was slow and not always effective. However, when Tanya presented her graduation essay with an analysis of this clinical history, I gave her the floor that I would someday tell this brilliant work to readers.
Then follow the records of my student. "The patient underwent psychoanalytic therapy for a year, once a week, with a break of three months. The therapeutic interaction took place mainly in the form of a conversation. The patient also was engaged in auto-training, worked under the individual program, receiving at the moment of the greatest relaxation the images that Pavel Semenovich offered him. There were attempts to work out some problems in psychodrama. Since all the work was done in the group, it was necessary to take into account the group impact on the patient .
Patient Volodya, 28 years old, higher education, pleasant appearance, accurate, reserved. Behavior calm, melancholic. Speech is quiet, without emotion, carefully selects words.
Physical structure: high, proportionally folded, flat stomach, muscular tension in the back, legs feel weak. Breathing is superficial (the diaphragm is clamped). The patient complains of the state of health: intestinal problems, there was an operation on the rectum (crack), hypertension, insomnia. The patient also experiences anxiety, fear of "being raped by a man", which manifests itself quite often, especially in crowded places. He also has a fear of women as sexual objects. Hence the fear of leaving the house. According to the patient, the anal problem for him is the main one. He says that he "constantly thinks about this problem, no matter what he does, he is afraid that he will lose a lot of blood after going to the toilet."
The patient treats his health with care and attention: periodically undergoes medical examinations.
The patient, he said, is very lonely, he has no friends, spends his free time in the library, likes to listen to pessimistic music ("Agatha Christie"), read philosophical literature. It turned out that he has his own archive, which he carefully watches.
Volodya was brought up in a full family. He graduated from school, served in the army. The army recalls as "the best time in his life". In the service of the patient there were two mentors - "real Communists", who, he said, gave him "the perspective of the development of life". On their recommendation, he came to Moscow, entered the school, then - to the university.
Volodya reluctantly told about his family. Parents visited once a year out of a sense of duty, most recently - two years ago. According to the patient, he grew up in an authoritarian family. My father was strict, he demanded that his son help with the housework (they lived in their own house with a vegetable garden). As he himself said: "I did not want to work on the site, but fulfilled all the demands of my father, and my thoughts were in another space." Father psychologically pressed on him, did not let him do what he wanted, it constantly evoked an internal protest. The image of the father often haunts the patient in a dream: "He goes to the toilet, opens the door and sees his father there." This causes panic and fear.
The exact psychological portrait of the mother could not be created, since the patient constantly contradicted himself, speaking of his mother. At first he told me that he and his mother had complete mutual understanding, "she was affectionate and kind, loved him more than the rest of the children in the family", which caused her father's anger (in relation to the "pet"). Volodya also said that his mother was always sad, cried a lot, treated him strictly, for him the opinion of other people was very important. The patient can not practically recall any joyful feelings connected with the mother. And the most sad childhood event he recalled is associated with the mother's "betrayal": "he trusted his mother very much, but one day the secret given to the mother became known to the father." It's interesting that the most joyful feeling is also connected with the family: the patient is 3-4 years old, parents hold his hands, and he jumps over puddles, kicking.
The patient has an older sister and a brother (seven years older). Relations with his brother were not pleasant, he never took it with him and, to get rid of, frightened him, tightly squeezing. In addition, his father demanded from Volodya that he tell him about what is happening in his brother's life (where and with whom he walks, what he says). About the sister, the patient did not disclose any information. According to Volodya, he had no special problems with his parents, he was an obedient child, but at the age of 12-14 he suddenly stopped talking with peers, and he began to like solitude.
By interpreting the patient's dreams, you can see that almost all the dreams, somehow related to the parental figures, show the ambivalence of the patient's feelings towards them.
For example, a dream (4.03.98): A dark room. In bed lay a naked woman. The patient is standing next to the tin soldier in the counter and looks into her eyes. The woman answers him with a look. Next to the woman is a man, he folded his hands and feet on her. A man starts to molest a woman, she resists. The patient is offended, he feels guilty that he can not protect the woman. On the other hand, he wants a man to punish her. The woman breaks and sits on the edge of the bed. The patient looks at her naked body ... A woman in strict clothing, she leaves.
Another dream (15.04.98) also manifests the feelings characteristic of the Oedipus complex: the ambivalence of feelings towards parents, the desire for their death and, sexual desires, while experiencing feelings of fear and guilt for such inclinations.
The content of the dream (15.04.98): A flock of sparrows flies, and the patient himself in this flock. It's easy and good for him. The flock reaches the shed, and all the sparrows fall into a small hole under the canopy, and he falls into the courtyard, into the darkness. Goes in the darkness around the yard, overcoming obstacles - a heap of manure. The dogs barked. He comes to the gate - they are closed. He is afraid that neighbors will come out and think that he is a thief. This dream evoked memories of two childhood events. First: the patient slept in the garden. In the morning, sparrows twittered in the village and prevented sleep. He took a slingshot, shot at random and killed a sparrow. He was tormented for a long time with a sense of guilt. Volodya did not tell anyone about this. After this incident, he slept in the house.
The second event: the patient was 9-10 years old. One night some robbers entered the courtyard. Shots were heard, mothers screamed, dogs barked. Everything ended well, but the patient for a long time felt a painful sense of guilt for not going out into the yard, defending his mother, and, moreover, at that moment he wished his parents to die. After this incident, a big dog began to run in the yard, which he was afraid of. And at night the patient went into the yard to the toilet, experiencing an unbearable sense of fear.
Analyzing these memories, it can be noted that in both cases images of animals appear: "sparrow, which the patient accidentally killed" and the "dog he was very afraid of". Here you can talk about protection from unconscious fear and guilt, generated by the oedipal situation. This protection is manifested in the displacement and displacement of unconscious fear, ambivalent feelings, aggressiveness and hostility toward parents on animals.
The patient's words, "it's terrible that neighbors will come out and think he's a thief", point to a strict moralistic Super Ego, for fear of not meeting public moral standards, which, most likely, with through the process of introjection, have become the internal standards of the patient himself.
Although the patient does not speak of "severe education" in the family, it can be assumed that strict requirements, authoritarian and overly principled behavior of parents are factors contributing to the development of the same authoritarian character as a patient who is in constant fear of punishment, tries to please the authority and at the same time experiences an internal protest, revolt.
As a result of education, the patient has formed a very strong system of prohibitions on the manifestation of aggression, on sexual life, on a free, spontaneous manifestation of feelings and any independent actions.
Noting the patient's qualities such as thrift, stubbornness, punctuality, one can talk about an anal character that is associated with fear of losing control over oneself or the situation (thus, the child's fear of losing control over the sphincters is transformed). This is evidenced by the psychosomatics of the patient. As mentioned earlier, these qualities arose from the patient as a result of excessively strict parental requirements as a protective process called the formation of a reaction.
Working with fear being raped by a man found that the patient experiences this fear quite often, especially in crowded places, when he "sees a woman, but represents next to her a man - in this situation, the patient experiences aggression towards the man (wants to protect the woman)." Inside the patient there is a feeling of a "compressed spring", he experiences a strong internal stress.
According to V. Reich, this feeling characterizes the chronic state of fear, prolonged stay of the organism in such a state leads to physical contraction of all blood vessels: the sphincter, the vessels of the brain. From here are possible and hypertension, and problems with defecation, and problems with the intestines.
We can assume that for fear of "being raped by a man" The fear of women as sexual objects is hidden, which speaks, on the one hand, of the unconscious desire for an incestuous connection with the mother and the fear of punishment on the part of the father (since fear arises from competition). On the other hand, it can be assumed that the patient experiences unconscious fear of the "castrating mother", and as a consequence of the defense against this fear, unconscious acceptance of the homosexual attitude takes place.
In order to understand the patient's early relationship with the mother, it is necessary to have more information. However, it can be assumed that the patient did have a close relationship with his mother. Perhaps in the early stages of the development of Volodya on the part of the mother, seduction occurred unconsciously, and to avoid punishment for incest, the patient was forced to suppress sexual desires.
The image of the "punishing mother" could result from strict training to the toilet, possibly even associated with some violent actions. Relations with the mother are very important for the child, because the mother creates a sense of security and the very existence of the child depends on her. The fear of losing the mother's love is tantamount to death, so the child supersedes the hatred of the mother associated with violence, and, perhaps, is identified with it.
Working with the individual program during the auto-training I conducted, the patient was offered a "boggy" image, which led him to a strong excitement and excitement: a whole body trembling, a drop of sweat on his face. According to Volodya, at first the image of the "quagmire" puzzled, and then he imagined the mire swallow the girl. This caused a strong sense of fear.
Analyzing the patient's feelings, one can speak, first, of the manifestation of unconscious aggressive and sexual impulses, and secondly, of hidden homosexuality, as "absorption" - a female symbol, and the realization of their homosexuality also causes fear.
Investigating Volodya's relationship with women, one can consider the unconscious refusal to perform a male sexual role, like fear of punishment for incest that speaks of an unreached Oedipus complex, and a possible violation of sexual identification as protection from an unconscious homosexual attitude. On the other hand, in real life, Volodya consciously seeks to create "normal relations" With a woman. This is also an intrapsychic conflict. Volodya is characterized by such a pattern of behavior: once the relationship requires closeness, both physical and spiritual, the patient is removed, isolated, i.e. there is a withdrawal from the situation. The patient's words that he was "the most confident he felt in the army and remembers the service as the best time in his life" can be explained by the fact that, firstly, an authoritative person gives instructions on how to live, takes responsibility for himself and, secondly, - an official ban on sexual life. Hence the lack of communication with women at this time, a sense of self-confidence (confirmation of their masculinity).
Analyzing the situations that cause a sense of fear, it can be noted that the patient constantly loses the situation of the Oedipus complex, seeking at the same time "to defeat his father and punish the betrayal of his mother." This also manifests itself in constantly recurring situations. For example, the patient constantly simulates the situation with the opponent. The patient initially attracts interest of married women. Repressed incestuous and aggressive desires periodically "burst from the unconscious to the surface" (the content of the patient's dreams, a chronic depressive state), causing painful feelings of guilt.
Thus, it is clear that the main psychological conflict that is the cause of the neurosis is the unresolved Oedipus complex, which resulted in a regression to the anal stage of development; the desire for incest and the aggressive impulses of eliminating the parents were probably very menacing to the child's "I".
While working with a patient, his monotonous voice, absence of affect, aggression, often a reluctance to talk about his family attracts attention. It can be concluded that aggression, anger, hostility the patient suppressed since childhood, as their manifestations, probably, entailed the punishment or deprivation of love. The external manifestation of the affect was a sign of debauchery, inability to behave in the hands, i.e. The behavior that seemed unworthy of his parents, especially his mother. Volodya remembers: when he was 13-14 years old, he witnessed an accident. This greatly shocked him. The girl was unconscious and lay in an indecent pose on the sidewalk. The patient's mother said that in all situations it is necessary to behave decently and be able to control yourself so that people are not ashamed.Thus, on the one hand, constant introspection and exaggerated control create conditions for hypochondriacal attitudes that can unconsciously be used as the equivalent of aggressiveness; on the other hand, aggressiveness directed at oneself causes strong depressions with suicidal tendencies. All this is exacerbated by suppressed sexual desires.
Each session began with complaints of health, according to the patient, he did not get better - psychoanalysis did not help. " He often experienced mood swings and talked about the meaninglessness of his existence, that periodically he had thoughts "step out of the window", as did Martin Eden. It is interesting to note that the hero of Jack London did not pace out the window, but, on the contrary, it was a life-affirming man: having overcome many obstacles in life, he achieved the love of a woman.
Thus, first, unconsciously, death for a patient is associated with an unmet need for love and recognition; secondly, death is perceived as a solution to all problems - no need to make any effort and take responsibility for one's own life; third, perhaps as a way to attract attention. This confirms the patient's passive life position.
Intellectualization on the topic of life and death was constantly present at the patient by the end of the first half of the year. In one of the last sessions, he said that "the drive to death in his case won the drive to life". When discussing what the patient feels when talking about death, his mother's image suddenly appeared. Probably, in the unconscious patient the image of mother and death is connected. The desire to die is the desire to go back to the sweet state of nonexistence, the unconscious memory of which devalues all the advantages and joys of real life. "
On the one hand, one can talk about the patient's unconscious communication with the mother so far, and the fear of breaking this relationship is tantamount to death; on the other hand, the patient's unconscious fear of the mother. There was an opportunity to work out the fear of death in psychodrama. Volodya proposed a plot that confirmed our assumption. According to the plot of psychodrama, the patient is in the hospital after the operation, as a result of which serious complications are possible. The doctor offers to discuss this situation with relatives. During the psychodrama, Volodya experienced strong excitement with which he tried to cope: the tension of the whole body, some numbness, his hands were locked into a lock, his eyes scattered, sweat appeared on his forehead; behaved alienated, did not want to discuss his problems with his relatives. The appearance of his mother's figure was unbearable for him: he jumped up, eyes were filled with tears and fear, the patient leaned back, put his hand in front of him (defensive or repulsive gesture), said: "No! Not that! ".
After the session, Volodya said that the plot got "to the point and the "consequences will be terrible." Analyzing this session, those feelings that the patient experienced can be assumed that the mother for the patient is very significant "threatening or punishing" a figure that plays, perhaps, the main role in the formation of neurotic reactions and somatic symptoms. Disapproval of the mother, loss of her love causes the patient to fear the very existence (death). We can assume a violation of object relations at the oral stage of development.The experience of loss of an object is very often found at the beginning of a psychosomatic illness and forms depressive personality traits:
- "uncertainty I or weakness I (broken basic trust);
- spiritual emptiness due to reduced sensory experience and automatically-thought processes;
- compensatory expression of bodily sensations, hypochondria;
- oral-narcissistic disorders;
- defensive behavior - complaining actions that include intense desires for dependence on key figures in order to re-take frustrating objects and compensate for the offense. This behavior is very typical for the patient.
Fear of punishment, guilt and remorse in connection with aggressive impulses in the patient are very strong, which in the future could lead to their somatization: hypertension, disorders of the gastrointestinal tract, anal problems, sleep disorders. These somatic symptoms reflect an unresolved conflict between aggressiveness and the inability to manifest it (due to the strictly moralistic super-ego of the patient). However, the patient did not associate his physical symptoms with conflicts in the emotional sphere. The attempt to actively include Volodya in emotional relations only increased his anxiety due to the inability to verbalize feelings. And later Volodya complained about somatic diseases even more.Using the theory of explanation of psychosomatic diseases by F. Alexander (1881-1964), it is possible to establish (theoretically) the connection between the patient's somatic symptoms and his experiences. Patients with hypertension experience a tension between aggressive impulses, on the one hand, and a sense of dependence, on the other. Alexander associated the emergence of increased pressure with a desire to openly express hostility while simultaneously requiring passive and adapted behavior.
If there are violations of the stomach, intestines in the foreground is the desire for confidence and security. To achieve them, patients regress to the original infant behavior patterns. Thus, when faced with a threat, a person faces a problem of personal responsibility. The inability to assume responsibility for one's own life leads to regressive defense mechanisms. A desire for security can be joined by a desire for power, the problems of giving and holding, and, on the one hand, the pursuit of success and obtrusive obedience and, on the other hand, stubbornness and rejection, can be played out. Fear, the need for love and self-doubt are often replaced by gastrointestinal problems.
Only a bodily symptom remains prominent in such cases. If the affected organ or symptom is excluded by medication or by surgery, then often the mental symptoms - depression, fear - appear. According to Alexander, chronic constipation is observed in depressive, outwardly calm, but internally tense individuals. They stated their installation as follows: "I can not expect anything from others and therefore I can not give them anything, I must keep what I have." Freud in this connection spoke about the triad: stubbornness, love of order, thrift; their extremes: intolerance, pedantry and stinginess.
There is some connection between chronic constipation and patient experiences: a protest bodily reaction; an attempt to retain, in order to master and survive; retreat in fear; fear and protection from too much return; Defecation is associated with dirty motivations perceived with guilt or as dangerous, and therefore rejected.Since Volodya did not associate his physical illness with psychological problems, did not want to discuss them, during the work with the patient the psychosomatic symptoms were not investigated in such detail, but studying the patient's illnesses theoretically, analyzing the history of his childhood, upbringing, characteristic patterns of behavior, we can conclude that the development of diseases is associated with early relationships with significant figures and, to a greater extent, with fear of losing this relationship, i.e. lose love, protection, which is tantamount to a threat to the existence of an individual.
Volodya during the sessions can be analyzed as follows: first the patient behaved calmly and painstakingly presented psychosomatic complaints every session, and since these complaints were not dealt with in detail, from a medical point of view, and we tried to identify the mental causes of the diseases, sought to recreate psychological portrait of the patient and characteristic patterns of behavior in interpersonal relationships with significant people, Volodi was displeased with the results of the analysis.Almost always the patient was in a calm, sometimes indifferent state - the excitement came only when the subject of the conversation became unconscious and conscious sexual or aggressive impulses, the manifestation of which is the main problem of the patient. For example, during the interpretation of a dream in which he experienced ambivalent feelings toward his parents (4.03.98), or while working on an individual program.
At a time when unconscious impulses were beginning to "break through" into consciousness, Volodya was enveloped in a strong excitement, causing him to fear. There was a desire to end the session. The patient was very nervous, emotional, behaved like a rebellious child, but he nevertheless came to the next session. However, two months later, he gave up his studies for the second time, explaining this refusal by saying that "psychoanalysis does not help: inside everything is empty, uninteresting, boring, the state of health is worse". At the same time, the patient contradicted himself: he wanted to leave and was keenly interested in plans for the future. This can be interpreted as the ambivalence of parting, which a person experiences at a break with significant figures in early childhood, i.e. the incompatibility of the wishes of parting and the fear of parting (the group appears to have become a significant object for the patient).
Volodya seemed to have little attention, especially his psychosomatic illnesses, he was offended, demanded increased attention to himself. The last session in the first half ended with the fact that Volodya noted the appearance of "innervation in the urethral region" along with the available "old somatic symptoms". In this case, one can speak of a change in the bodily symptom, which indicates that the patient's defenses are insufficient to maintain his neurotic structure. On the other hand, it can be assumed that the psychological problems of Volodya, which formed somatic diseases, were not worked out enough and only superficially touched upon the deep causes of neurosis, so a partial replacement of the symptom occurred.
Perhaps, the "innervation in the urethral region" can be seen as an awareness of some shameful actions (enuresis, masturbation), which in childhood caused fear of punishment, feelings of guilt and shame. So, in connection with this, the patient remembered a boy who, like the patient himself (as he said, "like everyone else in his childhood"), had cases of masturbation and enuresis. When the patient talked about this, he did not raise his eyes, felt guilty. There was an impression that the words "as at all he was justified before the mother or in front of him.Speaking about the urethral region, you can theoretically disclose its functional significance in the child's psychosexual development: according to O. Fenichel, "the most important feature of urethral eroticism is narcissistic pride, which is contrasted with shame as a special force directed against urethral temptations and it is assumed that Ambition is a form of struggle against shame. Along with this, there is a sadistic pleasure, corresponding to active penetration, together with fantasies of destruction and damage. Urethral problems are very closely related to anal, and they are transitional to the phallic stage of development. "
However, the transition to the genital stage of development can not yet be said, since the most important problem for the patient was the anal problem. The patient has a very strong system of prohibitions on the part of the parents on sexual acts, the manifestation of aggressiveness for any independent action. He is constantly under psychological pressure, which comes from his inner attitudes, experiences a constant "stress" (fear).
After a break in therapy for three months, the patient's complaints became more desperate: "Life is bleak, very boring, uninteresting, no matter what you want to do, no methods of treatment do not help (this refers to psychotherapy) - it's best to quit, step back , the desire to study in group was lost. According to Volodya, the state of health worsened: new symptoms appeared - stomach ulcer, pain in the heart.
Analyzing the complaints of Volodya, one must pay attention to the words "boring", "uninteresting", which he uses quite often in his speech. According to Fromm, boredom is characteristic of a hypochondriacal person, this is a state of chronic depression. I'm bored - the position of the person who accuses the environment of lack of attention, i.e. stimuli, irritants, - the position of an internally passive person. The consequence of the uncompensated boredom is aggression. Perhaps, a sense of own helplessness causes aggression, which is strongly superseded and suppressed, and since there is an "internal prohibition" on its manifestation, this aggression is directed to itself, causing depression, and is partially projected onto others. "
Volodya was asked to take responsibility, make a choice himself: to engage in psychoanalysis further or not. He apologized and continued his studies further. (This situation has been repeated several times.)
In this case, a new set of serious psychosomatic diseases in the patient is of interest. Theoretically exploring ways of causing pain in the heart and peptic ulcer of the stomach, it can be concluded that psychodynamics in these diseases reflects all previously considered neurotic symptoms that cause somatic diseases that the patient already had. According to many psychotherapists who were engaged in sociopsychosomatics, "the time of the onset of the disease is distributed unevenly, and accumulates around certain events, when they are perceived as threatening, overly straining, unbearable or causing internal conflicts".
In patients with neurosis of the heart psychodynamically in the foreground is the ambivalence of parting, i.e. the incompatibility of the desire to part and the fear of parting, which means experiencing the loss of the object. This presents a great psychic threat, since in this case there is a narcissistic disorder, which the patient experiences as a narcissistic offense. Hence the emergence of self-doubt, general unhappiness. In hypochondriac, cardiac symptoms appear within the framework of a depressive syndrome.
In the case of Volodya, all this was clearly demonstrated to them after a three-month break in therapy.
According to Alexander, "in the occurrence of peptic ulcer of the stomach, a huge role is played by a conflict in which the needs coming from the oral sphere of experiences (the desire to be spoiled, rewarded, dependent) turn out to be frustrated. A peptic ulcer occurs when the unconscious or conscious desires of dependence meet a failure. " The unconscious fear of being abandoned causes constant tension: every doubt in acceptance and love can cause a panic reaction.
To such strains can lead and fear of an authoritarian figure. Steps towards independence and independence are not undertaken, the patient struggles to reach the break of the psychological umbilical cord, become independent of the mother. He remains with a desire for protection and assistance, strongly attached to the maternal figure, hence the inability to "stand up in competition with the father", find recognition and affirmation of himself as a man.
This psychodynamics of peptic ulcer disease, proposed by F.Alexander, in this case practically confirms the development of the neurotic structure of Volodya's character and the formation of psychosomatic symptoms.
Observing the patient during therapy, you can pay attention to the specific psychological protective mechanisms specific to this type of personality: displacement, isolation, rationalization, intellectualization, reactive education.
Repression is very characteristic of the patient: something unpleasant, threatening simply is removed from the consciousness and held at a distance from it. This process is applicable absolutely to all aspects of life: situations, fantasies, desires. Repressed desires begin to disturb the patient when they are poorly held in the unconscious, break through into consciousness, causing a feeling of fear and guilt. In this case, unconscious desires stand in the way of positive aspects of a patient's life - health problems, relations with people, women. Awareness of them will help to solve a lot of vital problems.
Great value for Volodya was thought processes and general cognitive abilities. Any affect: anger, guilt or fear - is not manifested, crushed or rationalized in it. Words are used to hide feelings, not express them. It is not known what feelings are hidden behind slender intellectual reasoning. Asking what Volodya feels in this or that situation, one has to receive an answer what he thinks at this moment. There was a feeling that the patient could not express a single feeling without experiencing anxiety and shame. Therefore, getting into situations in which emotions played an important role, Volodya felt hard. One can also note an obsessive repetition of situations, as if in order to regain control of the past, for which the patient feels guilty, including "Oedipal unresolved situations." All compulsive actions are aimed at redemption of this feeling.
To study the unexpressed affects, the repetition of important situations for Volodya, the method of psychodrama was used. "Psychodrama is a method in psychotherapy in which clients continue and complete their actions through theatricalization, role play, dramatic self-expression. Both verbal and non-verbal communication is used. There are several scenes depicting, for example, past events, unfinished situations, internal dramas, fantasies, and involuntary manifestations of mental states "here and now". These scenes are either close to real life, or outwardly internal mental processes .
Several subjects were suggested for the patient, but not all of them had therapeutic success. The subjects were aimed at living ambivalent feelings for parents; experiences of fear of death, due to a serious illness; a test of guilt, various family situations: divorce, treason, etc.
Volodya was active, with interest, participated in all the plots, performing various roles. It was noted that when the plot touched on the patient's psychological problem, he experienced tension, began to control his actions. Tracing the changes in vegetative reactions (rapidity of breathing, reddening of the face, sweat on the forehead, trembling of hands, tension of the back, etc.), it was possible to notice which situations, roles, words unconsciously or consciously Volodya reacts.
According to observations, you can see what a strong impression on him produced the plot, where the fear of death was worked out (the interpretation of this psychodrama was made earlier). Also of interest is the plot of psychodrama, where unconscious feelings of guilt were tested. Contents of the story: Volodya with a friend in some situation ... An accident happened, a misfortune happened to a friend. For example, it is paralyzed. The friend's mother is angry, upset. Volodya should talk to her, explain what happened. Unfortunately, the line of the plot moved aside, and the emphasis was placed on the experiences of the friend's mother. But it was noticed that the subject matter of the plot greatly excited Volodya, which manifested itself in vegetative reactions: the face turned red, the look frightened, confused, tension in the body, holding the breath. As soon as the main character became the "mother of a friend", Volodya relaxed again and felt calm and confident. It turns out that such a case was in the real life of Volodya. Only a friend died in life. At that time Volodya could not talk with his friend's mother and is still afraid to meet with her, because he feels guilty. This topic, unfortunately, has not been worked through to the end.
The scenes in which aggressive feelings were required, such as anger, irritation, anger, anger, first caused feelings of shame and embarrassment. Volodya insisted that this is how he behaves in life, not wanting to change anything, even in a game situation. For example, playing out aggressive feelings, it was necessary "to scream at a soldier who went off on his own in dismissal", "arrange a family scandal" etc. But with each occupation these subjects were repeated, and Volodya began to feel more confident in them. All the plots of the psychodrama in one way or another confirmed Volodya's passive vital position, characteristic patterns of behavior: difficulties in establishing interpersonal relationships, instantaneous reactions of "care" (compression) in uncomfortable situations, restraint of feelings, rationalization, etc.
Nevertheless, as you participated in the activities of psychodrama, you could see how the patient was liberated. The discovery of feelings turned out to be more spontaneous, he felt much more confident, played some games with pleasure, was in the center of the group's attention (he was not removed as usual), took an active part in the discussion of subjects.
Since psychodrama is a group process, it is important to consider the therapeutic effect of the group on the patient. It could be noted that some of the problems characteristic of Volodya also took place among the other members of the group: restraining emotions, lack of spontaneity, fear of aggression, etc. This allowed us to work in a more confidential environment, in some ways the "therapist-client" line disappeared. Discussion of the feelings and behavior of participants occurred on a democratic basis, devoid of value, in an atmosphere of emotional security, self-esteem and acceptance.
Such an atmosphere of benevolence, empathy in the work could not but bring good therapeutic results. According to observations at work, it can be said that Volodya taught & quot ;, allowed to show their feelings, including aggressive ones, without fear of condemnation and punishment, neither shame nor guilt.
In the therapeutic situation, adequate emotional interaction can not take place without taking into account the transfer and countertransference, i.e. repetitions in relations with the analyst of feelings and attitudes, habitual in the past with significant people (first of all, with parents). The transfer is an unconscious process. Although the patient's feelings toward the analyst can be fully realized, the very fact that they are brought from other, earlier relationships is not realized.
The value of the transfer is great. It allows you to penetrate the patient's past and see how early experience associated with meaningful individuals changes the reactions of the present. Countertransference is also important in psychoanalytic work, since it is a response to the transfer of the patient. As internal experiences, it helps the analyst to better understand what effect the patient's behavior has on him and others. In therapy, which was held by Volodya, the transfer was not analyzed with him, because, first, there was not enough time to work with the transfer; secondly, in some way there was no normal working alliance with the patient; thirdly, perhaps the patient was not ready to experience frustration and anxiety. Nevertheless, transfer relations arose in the course of work. Especially when you consider that the transfer reactions are inherent in patients with obsessive-compulsive disorder.
At the beginning of psychoanalysis, Volodya had a choice of three part-time students. He preferred a woman, married, older than his age, who, perhaps unconsciously, in the psychological portrait is most like the image of his mother. At the first meeting, Volodya suggested interpreting, in his words, an "indecent dream". In this dream, the classical situation of the Oedipus complex was played out. It turned out that Volodya's story was a provocation. This dream, he subtracted from psychoanalytic literature. Volodya tried to check the analyst for sincerity.
This was the unconscious resistance of Volodya to the beginning of psychoanalytic work. Each session added information about Volodya, but his emotional life remained closed. As soon as an attempt was made to move deeper into the problem, Volodya twisted and turned what had been achieved into nothingness. This was irritating, because there was no real progress. The situation changed when Volodya worked with the image of the quagmire, which caused the repressed sexual and aggressive impulses from the unconscious. They manifested in his fantasies and dreams of hostile content aimed at the image of the analyst (mother): the girl (blonde) dies in various situations, in the first variant she is swallowed up by the quagmire, in the second - falls under the wheel of the trolleybus. Volodya was in an excited state, which caused even fear.
Analyzing his fear in this situation, Volodya believed that this is the fear of the threat of destruction, hatred. Thus, the patient unconsciously, on the one hand, demanded love and care, on the other - he experienced hostile feelings, hatred, ie. showed ambivalence of feelings to the analyst (mother). This spontaneous emission of emotions reinforced the patient's usual fear of any contacts, and he took a defensive position - isolation - refused to engage in analysis further. But on the next session, he still came.
After a while, the patient had thoughts of suicide. His condition aroused alarm. There was a feeling that Volodya was waiting to be persuaded to continue his studies further, but he himself had to make a choice.
Moreover, the analysis of the current situation showed how Volodya tries to cause the surrounding people to feel guilty for everything that happens to him, to take responsibility for his fate for himself. This can be said about the infantile connection with the mother that has survived so far. The patient's expressions that the analyst "sees it through", "it's impossible to deceive", "always gets to the point" is associated with the fact that the patient is always under the control of the analyst, as may have been in childhood under the control of the mother; on the other hand, there are associations of physical penetration (possibly violent).
All "suicide attempts", refusal to attend classes, complaints about well-being, that "nothing helps, it gets worse" can be viewed from two sides. First, as a resistance to the awareness of repressed forbidden feelings, and since this causes a strong fear, there is a desire to be isolated from a frightening situation. Secondly, in the process of transfer, as Volodya's ambivalent desire to reject, "punish the mother", cause her to have a strong sense of guilt, for what is happening to him and, conversely, the fear of rejection on the part of the mother, the desire to get close to her, to achieve her love and attention.
Almost every session of Volodya demonstrated, on the one hand, a silent resistance, on the other - there was a feeling that Volodya simply needed the presence of an analyst, regardless of the topic of the conversation. However, very often there was a sense of boredom and a desire to shake him, to make him open to elementary feelings. Thus, the patient periodically evoked aggressive feelings and a desire to distance himself.
It is interesting to note that often after the sessions, Volodya apologized for anything: an unsuccessful session, a plot of psychodrama, that he did not live up to expectations, etc. Within the framework of the transfer, this can be interpreted as forgiveness, which the patient asks for from his mother, ie. experiences conscious and unconscious feelings of guilt, perhaps for inconsistency with strict maternal standards or for his aggressive impulses towards her.
Considering the transfer relations as a repetition of early childhood relationships, we can conclude that the figure of the mother was very significant for Volodya. He retained infantile dependence on the mother and an unconscious insult to her. He desired her love and protection, while at the same time felt aggressive feelings towards her. Probably, the mother's figure was not only desirable, but also punishing, requiring compliance with certain rules, decencies and norms.Probably, the typical pattern of Volodya's behavior in childhood is suppression of all feelings (resentment, hostility and even love), belittling and exaltation of oneself or others, external compliance and inner protest that causes aggressive emotions (irritation) in others. Investigating the transfer relationship, we can assume that Volodya himself provokes others by his behavior (for example, arrogance or stubbornness, indifference or sudden withdrawal) to distance himself from the patient. Care patient isolation from society, forced loneliness is a reaction to the eruptions of an unconscious, repressed hostile or sexual feelings that cause fear.
The psychosomatic diseases that are caused by this fear allow, on the one hand, to ease this fear, and on the other, to confirm the inability to take responsibility for one's life. This was also evident in the migration - the stereotype of children's relations was regressively animated: the analyst was perceived as a mother who left the patient as punishment. Then Volodya's response to abandonment could well be heart pain and stomach ulcer and exacerbation of other somatic diseases.
Analyzing the psychoanalytic work with Volodya, we can draw the following conclusions. In the emergence of a patient's neurosis, which can be characterized as a compulsive disorder neurosis (obsessive-compulsive neurosis), the family scenario of toilet training is very important. This is the first situation in a child's life, when he has to give up what is natural for him, in favor of what is socially acceptable. The state where the child is controlled, condemned and forced to perform the required, generates his anger and aggressive fantasies, which are then superseded. And we can assume that an excessively strict accustoming to a toilet assumes the same strict attitude to the child and at the oral stage of development, since there are obvious violations of the relationship "mother-child."
Thus, the basic affective conflict is anger in a state under control, struggling with fear of punishment and condemnation. You can also talk about the presence of a depressive syndrome. For aggressive feelings, often the desire to eliminate an opponent is hidden: in love or in another sphere. In the case of depression, a violation of genitality is observed. Instead, the patient is suppressed by outbursts of his own aggressiveness directed against his own personality. Passive-oral conflicts revolve around desires to finally receive satisfaction. If this does not happen, the patient experiences disappointment leading to anger, an affective state of impotence and helplessness.
The nucleus of this neurosis is the unresolved Oedipus complex, which causes unconscious feelings of guilt and shame. Fear of punishment (castration) for incestuous desires unconsciously persecute the patient. Aggressive impulses that act in the unconscious cause the patient strong fear, against which he uses all sorts of mental protections, mainly repression, isolation, reaction formation, all kinds of rationalization, etc. Psychosomatic symptoms also serve as an attempt to overcome unresolved neurotic conflicts. Defending himself physically, the patient is doing himself a great deal of harm, since this form of protection poses a threat to his very existence. The affect of anger remains undefined and, as it were, "stuck" in the body, provoking a potential output that disrupts the systemic activity of internal organs.
About the fate of Volodya. Three years later, he defended his Ph.D. in Philosophy. Got a job. Gradually, under the influence of the therapy, I parted with the diseases associated with defecation. Periodically appears on psychoanalysis courses as a guest, listens to individual lectures and disappears.
Another story. Irina Askoldovna listened to my lectures. Once I was asked for an individual meeting. She was a slim, lean woman, with a straight back and a warning smile. It turned out that Irina Askoldovna almost from childhood suffers from intestinal problems. Constipation painful and painful. The patient does not work anywhere, does the house, the husband is a very well-off person. She, naturally, can afford any diet, can buy expensive medicines. But the use of a little ...
We started with her "recollective work, but immediately came across huge difficulties. Irina Askoldovna remembered little, answered sparingly, sincerely tried to convey some details, but she could not do it. Flow The unconscious happened, as always, unexpectedly. First a strange scene arose in the patient's memory. Mom scolds the elder sister Pauline, but for which - it is unclear ... Ira gets confused under her feet and always asks the question: "What did she do? Broke the window, huh? ". Mom says: "You have nothing to turn around, it's small yet ...".
Irina Askoldovna thought: really, what was it? And with this questions she went to Pauline. She, having listened to her, suddenly became sad, strict. She asked:
- Have not you guessed?
My patient was terribly surprised: what are we talking about? It turned out that his father was deliberately engaged in the corruption of his elder sister. He touched her genitals, caressed them and prepared her for love pleasures. When Polina said this to her mother, she was very angry and began to scold the girl: "It's her own fault, because I told you ...". It all ended in divorce. But when the children were small, the father bathed them himself. In the house there was a huge wooden trough. The pope pursued not only hygienic goals. Pauline tried to excite, and Ira just thrust his finger into the anus ... So gradually we began to recall the details of childhood, the origins of an old disease. A year later Irina Askoldovna finally got rid of intestinal problems.
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