I want to thank Jamie for presenting an excellent case for our discussion. Clearly Caroline has been helped in many important ways. I want to review some of the major tests that were passed through Jamie's interpretations and attitude while treating Caroline. I have been helped once again through in-depth discussions with Heather Folsom, M.D. and thank her for her insightful comments on the case.
So we might ask what was Caroline's plan for her treatment with Jamie? Did it shift from year to year? What were the major tests and where they passed by Jamie? I want to touch on a few of the central issues from the theoretical perspective of Control Mastery Theory. I look forward to hearing what my colleagues from other theoretical schools would identify as the central mutative factors in this therapy?
The case ends with Caroline experimenting with new relationships and finding a healthier choice for herself. She has worked to be able to allow herself to see things clearly and behave differently than either one of her parents. She worked on seeing her parent's attitudes toward sex as limited and unhelpful with success. I think Caroline wanted to find a way to feel entitled to stay alive. I think that without treatment she would have been very likely to die from either an overdose or unprotected sex. Caroline struggled to make appropriate choices for herself that would allow her lead to a productive life. She was able to termination several destructive relationship with her sponsor and boyfriends. She looked to Jamie to provide a different model for her life, a new way to reflect her thoughts and feeling that was self-protective and self-affirming.
This process began in the first phone call and continued through the next six years of the "brief" productive treatment. From the very first contact she used trial actions to try to learn new ways to deal with her problems. In the first test, concerning her decision to attend school, she looked to she if Jamie would be overwhelmed, pulled into a dramatic responses, or try to take over and give poor advice. She invited Jamie to see her as the Black Sheep of the family; to put her down as she experienced her parents doing. When Jamie saw a different image of Caroline and reflected that new, positive view back to her, Caroline was able to move forward with her plan to go to art school and excel. This passing of a test allowed a weakening of Caroline's pathogenic belief that she didn't deserve to go to school and try to create a better life for herself. We hypothesize that Caroline felt overly responsible for her unhappy parents and feared that she could never please them and therefor should never feel good about herself, or leave them to pursue her own independent, different life. If she were to do these things others (like her family members) would be irrevocably damaged. I think that these pathogenic beliefs were at the core of Caroline's problems.
This interaction with Jamie allowed Caroline to begin to see herself in a way that was different from how she felt her parents saw her. She was then able to move on in the treatment to deal with the her crucial goal which was her safely and protection. She could and did bring up with Jamie her self destructive actions involving drugs, alcohol and promiscuous sex. Jamie, unlike the first therapist took these issues as central and most of the treatment focused on helping Caroline overcome her self destructive addictive behaviors. Jamie saw these activities as Caroline's complience with her parent's views of her as worthless and began the process by setting up a comprehensive plan that involved multiple supports such as AA and NA. This act of creating such a plan allowed Caroline to see and learn a method of dealing with a serious problem that was different from her parents approach of either requiring submission or thoughtless actions. Jamie took Caroline's self destruction entirely seriously and made her safety a primary concern of the treatment. This allows Caroline to consider doing this for herself.
When the situation required collaboration, Jamie worked with Caroline's parents, showing Caroline once again, a new model for dealing with traumas, (in this case the threatened disruption of Caroline's treatment). Jamie dealt calmly with Caroline's parents taking their concerns seriously as well, and worked to protect Caroline and preserve her treatment. She helped Caroline overcome her pathogenic beliefs that she should not see her parent's clearly or do better than other family members.
Control Mastery Theory emphasizes that Caroline's use of testing to work in her treatment. We suggest that she used turning passive in to active testing, (repeating the traumatic experience of her childhood in the treatment by acting toward Jamie as her parents had toward her) in order to learn a new way to deal with the traumas. She presented experiences of not being able to be counted on- changing the rules and stories, creating relapse dramas for Jamie in order to see how she would handle omnipotent responsibility. Would Jamie be traumatized by not being perfect.? Could she deal with being criticized better than Caroline did? When Caroline expressed suicidal affects did Jamie worry to the point of sacrificing herself as Caroline was pulled to do with her family? Would Jamie be overwhelmed with confusion as Caroline had been as a child when she tried to sort out how to please her parents? We believe that Caroline used transference tests to see if Jamie would treat her in the same manner in which her parents had and which was traumatic for her. These tests included: exploring criticizing therapy to see if Jamie could tolerate Caroline having a different opinion from her which she had told us her father couldn't. Her relapses were in part, a way of testing Jamie's belief in Caroline's abilities to change, to have a good productive life. She invited Jamie to give up on her as she was tempted to do herself. She tested to see if Jamie would become harshly critical, or become discouraged and anxious. I am sure that there are many different ways to understand Caroline's trial actions in the therapy and I hope my colleagues will offer their explanations and understanding of theses activities.
Jamie's responses to Caroline's tests showed her that there were new and different outcomes possible. This enabled her to question the veracity of her pathogenic beliefs, her firmly held scripts about the dangers of taking actions or making changes in her life. Her entire world view began to shift and allow for new plans and dreams to emerge. Caroline began to feel like she could in fact take the risk of being different from her parents and how she felt her parents wanted her to be. She was able to allow herself to know and express the pain of her traumatic childhood. This new freedom and understanding was the basis of her healing, allowing herself to create a healthier life for herself and make safer choices. I think she was a lucky lady to find Dr. Edmund!