Otto's intense anxiety is quite understandable. He lives in a world where "others want to harm him" physically or psychologically, and care little for his suffering. His answer to this horrible dilemma is not yet clear--do away with them or himself? Is this a world where only the powerful survive? Are there only two choices--threaten or be threatened?
According to his memories, his brutal, sadistic mother provided the opposite of what he should have experienced as an infant. The exercise belt pregnancy trauma could have generated a primitive anxiety that literally left him shaken for the rest of his life. (Thomas Verney's book, "The Secret Life of the Unborn Child" vividly describes the potential impact of a mother's negative attitude on her child during pregnancy.) Her irrational beating of him also raises questions about her sanity. To his credit, he vowed never to hit a child. (Did he also vow never to hit a woman? His probable hatred of his mother would make such a vow difficult.) The parents hatred for each other portrays a loveless, abusive family, one that breeds mistrust and mutual exploitation.
His early memory of the carriage collapsing on his hand while he screams for help, ignored by his mother, but helped by a stranger, expresses his view of life today. He believes that a woman will not respond to his distress or needs -- an implied accusation of a woman's indifference. (The mother must have been out of touch with reality to confuse her child's crying with a cat!) His father is not there to help. It is only a stranger (man or woman?) who comes to his rescue. This could reflect his expectation that the therapist/stranger will come to his rescue and relieve his pain.
However, the memory of his father locking him in the closet for coming home late, may prompt fears of being trapped and punished by a man for breaking a rule. It would be interesting to see if he comes on time for appointments, or if he tests the therapist by coming later and later.
To his credit, he has developed a high activity level, self-sufficiency, and success in business. He may only trust accomplishment and money, not friendship or positive feelings. How aggressive is he in business? Is he kind and considerate of others, or does he conduct business like war, using it as a legal means of exploiting, cheating, or hurting others?
I suspect that his relationships with women have been primarily sexual. He may be flattered by seductive woman who overdo sexual activity and provide him with a purely physical sensation of closeness. He and his partners may mistrust and be devoid of deeper positive feelings. What does Sally give and get in this relationship? What role does money play in their relationship?
His feeling trapped in a marriage and the subsequent relief of symptoms after the divorce may reveal a pattern of feeling successful by avoiding the restriction of a relationship. His frequent trips without Sally may give him a feeling of freedom. (Possible connection to memory of being locked in a closet as a child.) As a youngest child with an older sister, who became more an more like her mother, I would wonder if the sister tormented him. He may feel a core contempt for women.
Although I would want to work with Sally, my preference would be to see them individually for a while. I prefer to make a solid connection with each person, and help each of them gain insight about how to improve the relationship before bringing them together in therapy.
He sees his own children as "manipulative users" (like their mother) yet he sees himself as a nice, compassionate guy. This improbable fairy tale will eventually have to be dissolved. He may have been financially generous with his family, perhaps even spoiling or bribing them to get what he wanted from them. He does not know how to make a friend. He probably "buys" what he desires.
I would want to know more about what he was like as a child. How did he get along with his sister? Did he have any reoccurring dreams? What were his favorite games and stories? What occupation did he want to realize as an adult? I would try to elicit more early memories in as much detail as he could offer.
The imprint of his parents (especially his mother) is so negative that the therapist may have to literally re-parent this man. Don's daily hospital visits may have paved the way for giving him the experience of a "reliable, helpful person". Much later on in treatment, I would collaborate with him on "re-doing" his memories -- creating alternative scenarios to the situations he described, wherein responsible, caring parents help him and guide him benevolently. I would want him to imagine the feeling that a child would have from such a series of experiences.
This is a very fascinating case, and the temptation is to guess freely on nearly every line of information. There are other issues that are ripe for comments and speculation that may come into the spotlight as the case unfolds. It would be interesting to find out more about his parents' childhoods and their parents. I like to sketch a multi-generational genogram, including the descriptions of each person, and their relationships to each other. This often highlights significant family patterns.
At his point, I am getting a feel for his activity level and basic movements in relation to the major areas of life: he is most active in his occupation; his love and sex life seems problematic and shallow; he appears least active in forming friendships. His feeling of community seems quite weak; he does have some courage, but tends to use it in an aggressive direction. It would be helpful to get more information about his attitude toward the therapist, any problems he may be experiencing at work, recent dreams, and a few more early childhood memories, before making some preliminary guesses about his inferiority feelings, style of life, compensatory fictional goal, scheme of apperception, and private logic.