Several years into treatment, Joseph was promoted at his workplace to a position entailing somewhat more authority; however his salary increased only slightly. He began to express more and more frustration at his low pay, at his repetitive duties, and the difficulties he had making ends meet. More seriously, he began to feel more pressured and more fearful about making mistakes. His delusions also intensified, it seemed, in proportion to his fears of failure and blame. In other words, it became increasingly clear that his delusions resulted from general feelings of vulnerability and blame, and not exclusively from fears or other feelings about his sexual impulses or orientation (although such feelings continued to play an important role). At this point in the therapy Joseph had formed a very close and very trusting -- albeit deferential -- relationship with me. He talked freely about his relationship with another man, and the love he felt for him, and sometimes discussed sexual concerns. I saw all of this as part of an ongoing unconscious test to see whether I would blame him or not want to help him. He also continued to go many months without paying his bill (eventually he would pay me, but once or twice he asked me not to cash it because it would bounce). Although these actions seemed to put him in a submissive relationship to me, I saw them more importantly as an opportunity to find out whether I would use the bill as a pretext to reject him. I did not interpret this, but discussed his fears of rejection. When he told me it was terrible not to pay me after “all my kindness” I just simply disagreed; in response, he told me how his brother had once fiercely attacked him for not repaying a small loan immediately. As Joseph’s work pressure and delusions intensified, he became pessimistic about his chances of recovery, saying many times that his paranoia was a punishment, and asking rhetorically and dramatically why being gay was such a crime. He experimented (with his psychiatrist’s help) with changing the dosage and timing of the neuroleptic meds he had been taking for the past 12 years, but this did not help him in any significant way. I continued to take his worries very seriously, acknowledging how difficult and awful this was for him, but I also remained optimistic. He would say things like, “Why or why don’t they (the men who supposedly wanted sex from him) leave me alone?”, or “I feel like if I don’t go along with them I’ll be punished” (or “I know I’m being punished for not doing what they want”). I would say, “That’s also exactly how it was for you growing up: you were punished for not doing what they wanted.” In response to my interpretations Joseph revealed more and more about the brutal abuse he had suffered as a child: continual name-calling and yelling from his father (out of control), and beatings and tongue lashings from both his older brothers (with his mother’s indifference or active encouragement). He described being kicked across the room, being thrown into walls, and on one occasion, having his lip split for “talking back” – all at the hands of his brothers. By age ten, he was attempting to placate his brothers by making their beds and doing other chores, but rather than thanking him, they came to expect his help and berated him when he was late. Joseph told me his father sometimes tried to stop the brothers, but was powerless (the father never hit him). Two sisters took his side and were sometimes able to protect him: he told me that for this reason he still distrusted men and felt closer to women. As time went on Joseph’s feelings towards his brothers and their incessant torment began to play a more central role in our sessions. I felt very strongly that my fundamental role was to be a strong, authoritative (but not authoritarian) and protective father; to help Joseph defend himself internally from his brother’s blame (i.e. his unconscious belief that he deserved their abuse). In one important test, Joseph complained to me about a niece who always argues with her parent: “I don’t know why kids do that.” I told him that it was normal for kids to do that, that it helped them learn how to be strong and assertive. He replied (mimicking in a frightening voice): In my family you ARE NEVER EVER EVER ALLOWED TO TALK BACK TO AN ADULT –NEVER!!!!.” Regardless of one’s views on the psychological meaning or origins of homosexuality, I therefore believe that that Dr. Levy’s predictions about the case – particularly Joseph’s need for a protective male figure, are extremely accurate. Although Joseph’s delusion did not abate entirely, he began to feet more confident that they were psychological in nature, that they were not a punishment, and that he could and would get over them. Disconfirming his belief that his paranoia was a punishment in fact proved to be an extremely important part of the treatment, helping him feel entitled to optimism and confidence. He also expressed increasing frustration about his low pay and hard work, and I supported his desire to quit and find a better-paying job. Although this took some time, he was eventually successful. At the height of his delusions (while still in his old job) he told me of a fundamentalist co-worker who was trying to convince him that if he prayed more he could overcome his sinfulness. It was clear that these comments had severely agitated hem, raising his worst fears about himself. We discussed this for several sessions. One day I began joking with him, advising him to go tell her his prayers had worked. Not only had they worked, he was now actively looking for different women to sleep with…Praise the Lord (etc., etc.) Joseph laughed for the first time in weeks, and after that day we continued to have fun talking about his miraculous “conversion”. I believe this intervention was very pro-plan because it allowed him to defend himself by disregarding a powerful authority (in this case, a woman whose fundamentalism represented the views not only of society but also of his bible-thumping, abusive mother). This supported Joseph in what I believe was his fundamental unconscious goal in the treatment: to disconfirm his belief, acquired from years of abuse, that he did not deserve to defend himself (and that defending himself actually merited more abuse.)
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