TRANSCRIPT OF AUDIO FILE:

BEGIN TRANSCRIPT:

CLIENT: Fixed the ticking?

THERAPIST: Yeah. No, no, the ticking seems to less.

CLIENT: Okay.

THERAPIST: So after today we're meeting next on when?

CLIENT: Wednesday. Thanks for finding time.

THERAPIST: Sure. I'm glad it worked out.

CLIENT: (sighs) (pause) [00:01:06] So this is the moment in which typically I would bail. (pause) [00:02:14] And after our...on any number of levels, for any number of relationships, after our meeting on Friday, I was about ready. I'm not...hmm. I come in to that discussion wanting to talk about something and we talked about other things and not really gotten to it but essentially my hope had been to think together a bit about how to manage what was clearly a kind of intensified state of distress. (pause) I brought it up, I think, I don't even remember what we talked about but it wasn't quite that. (pause) (sighs) [00:04:01] So I felt upset, I felt kind of...desperate I guess and pissed off.

THERAPIST: Hmm. (pause)

CLIENT: In each of the hand it seemed obvious and your formulation was whether I could stick around not whether I was feeling better. That was what I heard. He said "No you've made so much progress, you haven't bailed," when I asked whether there was some kind of instrumentality that would just alleviate some of this. Anyway that was what I heard. [00:05:46] (pause)

THERAPIST: Hmm. (pause) [00:07:01] [00:08:20] Well, I guess I feel like I'm in a tricky position here in the following way. To me it seems like you are...I may have this wrong but you seem to be forgetting some things that we talked about on Friday and...

CLIENT: Likely. I slept an average of about an hour and a half, two hours at night since then. [00:10:02]

THERAPIST: And it feels to me a little like your kind of spoiling for a fight with me over some of it. But I guess, it feels like it, it would be hard for me to point that and lay out some of the ways I see things differently without our maybe getting into a struggle or tussle and (pause) yeah, I mean...

CLIENT: The last thing I want is to fight. I'm worried, I'm scared, I'm exhausted...(pause) I feel as if, you know, there is a therapeutic dilemma I guess that I've certainly gone back and forth about so there's no reason why we shouldn't do so in tandem which is whether this pattern should be treated symptomatically or dynamically. I think that's really ultimately the 64,000 dollar question here. [00:12:06] And you know I feel some panic frankly, not only because the psychodynamic process is taking so long and still is not able to manage, or I am still not able to manage the kinds of tendencies or the behaviors, feelings, that have been troublesome but also that I just don't see an obvious alternative in the immediate sense. A and B pursuing the instrumental approach would mean bailing and in a state of distress I'm very reluctant to bail so that's a dilemma, I mean I don't feel like we're fighting over it, I think it's a pretty clear one. It's not like there's an obvious answer, if there was an obvious answer I guess we wouldn't need to fight either cause we'd just go in one direction or another. (sighs) This is so durable. [00:13:45] So when I say I was mad, I mean the proximal causes of my being mad were not the (inaudible) issue which is just a dilemma or rather it's like "Wow, you could have responded to the e-mail knowing that what I wrote on Friday..." could have just e-mailed back or "Oh," you know "It sucks to run out of time when you were in a bad state, and ask you to shoot out the door," or "Oh, wish you were more on time in the mornings," (pause) [00:14:56] Things that you know, on reflection are not either not something that your culpable for exactly or are fairly small yet there's this strong feeling circling around the dilemma, this displaced...and I'm aware of that. (sighs) And a second trying to preserve my rationality and yet the feelings and responses are still there. (pause) [00:16:07] (sighs)

THERAPIST: Um (pause) Well... (pause)

CLIENT: (sighs) [00:17:24]

THERAPIST: Well the lateness is entirely my responsibility. I'm sorry for that, I really should be better about that and while I (pause) it would have been sensitive of me to respond sooner to your e-mail knowing that it can be difficult and upsetting when you don't hear back and also that the limits of our time, you know, don't...are in a way kind of random relative to where we happen to be in conversation. [00:19:51] Then there are, I'm probably missing something here, there are so many things that to me kind of also line up around your kind of...the probing we had talked about a while ago of me and this relationship, let me elaborate. You also let me know you weren't going to be here this week like five minutes before, actually probably less, like on the way out the door, and I did kind of...we had already run over which is fine...

CLIENT: I got it.

THERAPIST: Yeah, I was happy to do what we were talking about but I guess I...

CLIENT: Sure.

THERAPIST: And two of the things you forgot as far as I can tell from our session were like right at the end. [00:21:20] It seemed to me quite different then how it seemed to you, it seems like (inaudible) to strong but that we got to the point where you were kind of like "Oh yeah, I can see how I'm doing this again," where you said "Marshall, you don't understand, this week is really like when the chips get cashed in. This is like the big week," and I said something like "How many times..." I didn't say it as craftily as this but sort of like "This is usually...this feeling of it being imminent and in a crisis right now is probably something that has come up half a dozen times since you've had this job," and you said...that doesn't feel like quite what I said but whatever it was that I said you said "Yeah, actually your right. It really does sound..."

CLIENT: I don't remember thinking actually "You're right," I remember thinking "Yes, that's true." It was less a revelation than just an acknowledgment.

THERAPIST: I'm quite sure you said something like "It sounds much more conspicuous," or it sounds like...I'm quite sure you gave some acknowledgment of like "Yes this is kind of my pattern here," or like...

CLIENT: I remember...this doesn't seem very productive. I don't remember that conversation that way. [00:23:07] I also prefaced this by saying that there's a dilemma that I'm displacing onto interactions that I don't feel intrinsically angry about so you don't need to defend yourself, I agree with you...

THERAPIST: I'm not, I'm not actually defending myself. What I'm interested in doing is I'm interested in honestly trying to look at what you're doing, like...

CLIENT: What I'm doing?

THERAPIST: Yeah like (sighs)...

CLIENT: What am I doing?

THERAPIST: Like (pause) sure on one level I feel bad that we have to stop in the middle of an important point or I feel like it would have been good of me to send you an e-mail earlier and it seemed too bad to me that we got to the point at the end where, at least at that moment it had seemed to me and reading it like, you know, you were kind of clear in how we were talking about it then to the kind of pattern of how things have gone earlier in the hour but my point is less like, I feel bad its more that you seem in this consistent way to like (pause) want to be making it unconsciously... like making it about ways I'm not there for you. [00:24:57] Or I'm not helping you.

CLIENT: But I'm...Marshall I'm not. I had said something in passing about being kind of pissed off and you asked me to elaborate and I was describing it but I thought what I had said was there's a real therapeutic dilemma here and to the extent that I felt kind of momentarily irked or hurt or what have you, it was completely secondary to any displacement of this real, genuine dilemma that I, we, have been unable to resolve and doesn't have an obvious alternative solution to...in other words I don't care about...all of this stuff is true and I had annoyance or hurt or I was probing, any of these things, but I mean, god they just pale in significance to the fact I'm sleeping an hour and a half at night and I can't, I'm not functioning very well and I feel desperate enough to just bail once again and reinforcing this pattern that's completely fucked up my life and I don't know what to do. [00:26:21] So you know, our interaction, I guess in some sense our interaction, is just a mechanism in itself at one level at least, but...

THERAPIST: That's why I'm interested in it. I'm not interested in it because I think it to be in any way approaches the magnitude or significance the extent of your distress, I'm interested because there's like an analogy or (unknown word) or isomorphism, between what's going on here and what's causing your distress in the first place. I care because it's a handle, not because it's the problem, but the handle on the problem makes it the problem. (pause)

CLIENT: I don't know, I mean is it the handle in the problem? If it's the handle on the problem we should be able to identify the problem. If we can identify the problem we should be able to respond to it in some way. If it's a handle on the problem than what your presenting to me is a notion that (pause) all of this distress or some significant portion of it, is about probing relationships that otherwise feel ephemeral. [00:28:15] Unreliable...fragile...

THERAPIST: Either actively probing yourself or responding to changes that don't have anything to do with you such as Jack leaving in three months...you know, in ways to demonstrate it feels very catastrophic, in other words I wouldn't call his leaving your probing, you don't have anything to do with that but the issue is about people being there for you or not and sometimes you kind of probe to jostle things to help affirm that someone is there and sometimes you just, you know, respond in a sort of...tragically like anxious and painful way when somebody is leaving, has left, isn't there, something like that. (pause) [00:29:34] Also (pause)

CLIENT: Yeah...

THERAPIST: Um (pause) it's a little complicated to explain, I think...I think you also (pause) I think, it's either later but I couldn't say exactly how, it seems to me there are two fantasies you have about things which don't line up with the way they...one of which is in some sense that people will be there for you in an ongoing way, that people don't leave or that's the problem, is that people leave or people aren't there, I'll elaborate in a minute, and that there is an answer to be found here or a solution to be found here or anywhere to the problem that you're having. The problem that you're having is to do with the difficulty maintaining a sense of yourself and a sense of connection to other people when the relationships are jostled in the way that we're talking about. [00:31:22] That's a problem that's addressable and workable in a setting like this but not a problem that's addressable and workable by sort of arriving at an answer or by keeping people from leaving. (pause) [00:32:40]

CLIENT: What was the first part you were going to elaborate on?

THERAPIST: I think I...

CLIENT: You did?

THERAPIST: Did...yeah. The issue is that the problem is not the state of the world, like that people leave or that people aren't there for you at times in important ways...those are problems but really the problem is that (pause) the problem which you can get some traction is the internal one that goes along with that which is how those kinds of changes or betrayals, you know, really tragically and for good reasons in your history, unfortunately really shake you up and really make it difficult for you to (pause) work or live in (inaudible) way. [00:33:56] (pause)

CLIENT: I don't know how to fix that. (pause)

THERAPIST: As best I know this is sort of the only kind of thing there is to fix that is continuing to look at how it happens, what are the feelings and fantasies that get stirred up, how can you sort of be...

CLIENT: I mean...

THERAPIST: But part of the problem is when you get in this state, it does feel like we haven't done anything or got anywhere about it and I'm not, again it's going to sound like I'm trying to defend myself here but I'm actually really not, I'm certainly not disagreeing that this is still there, I'm certainly not disagreeing that it's not still a tremendous problem, I'm not disagreeing that at times you don't get as stirred up as you ever did, well not as you ever did but as you often did, I am saying that your more in touch with habits, with what's happening as it happens, that you seem to be Philrally coming out of them quicker, you Philrally can anticipate them a little bit better and know what causes them, you sort of are much more in touch with what's going on and my impression is that kind of the severity and duration of the bout is less. [00:35:59] Not that they're not still there and not that they're not still awful, not that they still don't happen all too often, that's all true, but I think when you're in the middle of them it also feels like you've gotten over it which is not what you say at other times. Again I know it probably sounds like I'm trying to defend myself and the work we're doing here but that's much less what I'm interested in doing than in sort of waving my arms around and saying this isn't how it looks to you at other times, as you've told me. (pause)

CLIENT: I mean I guess I'm not pushing back against that notion. I'm not disagreeing with you, the very fact that its recurring, the whole formulation here, is that it's recurring.

THERAPIST: Yeah.

CLIENT: On the other hand each time I go into it, there's not just a proximal cost, but there's a cumulative effect. I feel, I mean you say that I come out of them quicker and have more reflectiveness about them and so on and so forth but what I feel is that each time I go through them my level of energy to transcend them is depleted. [00:37:55] In other words there is an isometric phenomenon here, on the one hand your experience on the other hand fatigue. On the one hand I recognize them better, on the other hand it's so demoralizing each time it happens and in some sense knowing but not being able to intervene feels even worse.

THERAPIST: Yeah it probably does. It still beats not knowing which has been the course for most of your life. Part of moving forward on it is going to be being aware of bearing more of the pain and frustration and capacity that goes along with it because that actually gives you more flexibility to act. It's kind of like, not quite the same thing but...

CLIENT: I've always acted. I have always acted in almost every one of these situations I've acted. Have I acted in ways that were constructive and led to the augmentation and...

THERAPIST: I'm saying something, I'm probably not communicating this very clear, I'm saying something like it's the difference between being numb with grief and feeling overwhelmed by grief, you know, you're feeling when somebody comes in with a loss and is trying to grieve and at first is numb and then becomes overwhelmed, and they say like "This hurts, this is overwhelming..." [00:39:57]

CLIENT: So there's an odd phenomenon that is associated with these bouts, the really bad ones, like it is right now.

THERAPIST: Yes! It's really bad right now.

CLIENT: There's this numbness that is one characteristic feature of them, you know there's this disconnection, there's this inertia, there's just a sense of not being an agent and then the pattern has been that I'll act, I'll say "I need to do X" x usually involving blowing it all up and in the course of doing X, I get clarity back, I get, in other words, the numbness and the action, although the action is not constructive, they're kind of antithetical. It's not the case that the departures are an outgrowth of numbness, rather they're an attempt to alleviate it, to address it, I've always seen that the numbness is a problem, it's obvious. [00:41:28] The immobility, the distraction, the dissociation...but the way that they present themselves to me is as a choice between what feels like a very limited menu of possible responses intended to intervene...

THERAPIST: What is the partners in help that was one of the things I asked them...(ph?)

CLIENT: How?

THERAPIST: Well that's kind of what I'm asking you. So there's a period when you know, over last summer, probably June or July, Phil said he was probably going to take this job on the West Coast some place and pretty soon after...you also had a conversation in which it was made clear to you that there really wasn't a place for you there, that I think it was around your getting a position and after that it was like three, three and a half months where you were quite shut down and you would tell me you'd go in and spend ninety percent of your time not working for those three and a half months and sort of beginning maybe six weeks or so into that you started talking to people at work and there was a kind of, probably not in the scheme of things slow, but at that time compared to the stressor and how you were really slow feeling process of getting...

CLIENT: That's right. [00:43:15]

THERAPIST: And getting something going there...

CLIENT: Right. So yeah, there's...

THERAPIST: And so I'm assuming that your referring to sort of moving ahead with the, initiating moving ahead with the company as the activity and what was going on at work as the paralysis and you were saying that and I agree with this, but clearly your quite aware and you always are aware that "Hey I'm not getting any work done at work. Some part of me wants to but I sit there and I spend ninety percent of my time doing something else," so I know in that sense your very clear it's not working and your very clear that you're paralyzed. I think what you were clearer about that time cause we happened to be talking about it was what had triggered it and some of how that had shaken you up, that these two conversations...we came back at first after you were frozen to those conversations a number of times, "I don't know why this is," like remember those things? It was this whole thing of feeling like you don't have a place and feeling like you were or were being promised one and then it goes away and that...

CLIENT: Yes, yeah...

THERAPIST: And you were mad about it and you "I probably wrote them a little bit about it and I'm also really shaken up over it and I...," all that stuff. [00:45:08] That sort of...I'm not saying that's the biggest insight in the world, clearly it wasn't unfortunately but it would wax and wane, like, you'd come in one day and had it an then another day and didn't have it and...

CLIENT: Yeah.

THERAPIST: And (pause) we talked about in the beginning when you were talking about the bank. I didn't know I think until when you told me a little while ago that Jack was leaving soon, I didn't realize it was in three months and I also just have had other stuff going on too I know but we even talked about as you were starting at the company like "Hey this is going to be tough, you've got this short term contract and it renewed and it's going to put you in just the sort of shaky position that is so evocative and the Jack's going to leave and that's going to be tough..." (pause) I'm like, probably sixty or seventy percent agreeing with you that like this hasn't helped you overcome that, I mean I think it's been productive in the time frame and ways these things work like...I wish it could go faster but I don't feel bad or like it failed, or that your calls or more important when they're...but so like sixty or seventy percent I agree that there's still a lot going on but I'm trying to disagree, I'm just saying that actually in some ways, things are also quite different, like you know what brings this about, like we can as we talk about it, you know, you come into more contact with it and it tends to settle you down a little. [00:47:15] I don't know what's caused this last part but it seems like part of it is our interaction on Friday and things but...there are probably other things, again we're going to have to stop in a minute but I want to give you a chance to...say something else if you have something else to say. (pause)

CLIENT: (sighs) I don't know. I feel burdened by the tractability and this pattern and I feel exhausted by the feelings, stresses, sleep deprivation, all of that that it brings on and I feel pretty terrified by the implications that it's having for my ability to secure a professional place for myself. [00:48:56] I don't see a solution and that...I mean I don't see in this...the immediate term, a solution and that frightens me.

THERAPIST: Mm hm.

CLIENT: I can't say anything more than that.

THERAPIST: Right.

CLIENT: On the other hand frankly I agree with your analysis and it's been my analysis before we were talking together so...I don't, you know Gall sees me in great distress and she says "Go to your PCP and get him to prescribe a benzodiazepine..." I'm like "I've tried the benzodiazepines and in this state it doesn't help," or "I've tried this and it doesn't help." She says "Maybe there's something else..." Anyway so the last word for today is that I just...I'm kind of at my whit's end and I don't see an easy way out, that's pretty scary.

THERAPIST: Yeah. [00:50:06]

CLIENT: And you know, I mean, at the end of the day it's my job to implement something so it's on me...

THERAPIST: We haven't talked much about your history with trying meds but we could I think...by prescribing one sort or another, its (inaudible) could be helpful for (pause) if there are things you haven't tried and I really don't know cause we haven't talked about it. I think some of that could be helpful certainly...that kind of thing can help a lot. (pause) I think that's probably the best bet as far as like a short term solution to this.

CLIENT: (sighs) Yeah. [00:51:12] (inaudible)

THERAPIST: Which is different and your right, doesn't provide a lot of relief usually in the short term.

CLIENT: Okay, maybe you can send a couple of navigating the system to find somebody who's decent...so if you can think of a couple prescribers send them my way and I'll think about it, maybe there's something (inaudible)

THERAPIST: Okay. Let me know if you want to talk more.

CLIENT: What's that?

THERAPIST: Let me know if you want to talk more.

CLIENT: Okay thanks.

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