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THE CASE OF JOSEPH Part One
Stephen Kusch, Ph.D · 5/24/99 at 6:05 pm ET
In his first telephone message to me Joseph sounded anxious, polite and deferential. We made an
appointment for that week. He missed the appointment, calling the next day to say, very
apologetically, that he had forgotten about it.
During his first appointment the following week Joseph, sitting on the edge of his seat,
immediately apologized again. When I reassured him that it wasn't a problem he relaxed. He then
launched into a confusing, vague story about how he was being threatened by a man in his
apartment building. Another neighbor, a crack addict and friend of this man, had asked Joseph to
depoit a check. When the check turned out to be bad, the bank refused to cash it. Joseph was vague
about the threats, saying he just felt scared that this man was angry and that something might
happen. In an agonized tone he also said that it was his fault, that if he hadn't been so stupid none
of this would be happening.
Since the problem with the check had begun, several weeks before, he had been having difficulty
sleeping. He had trouble concentrating on his work (he had been employed as a file clerk and
office assistant in an engineering firm for about eight years), and had recently called in sick
several times. He was worried that his absences could jeopardize his job.
Joeseph was of medium height, slightly overweight, with unkempt, wispy black hair and glasses.
He smelled heavily of cigarette smoke and body odor. He was dressed in blue jeans and a denim
jacket. He told me he was thirty-two years-old, and had grown up in a working class neighborhood
in southern California. Later in the session he told me with an air of embarrassment that he was
"homesexual." Throughout the session he was deferential, giving special consideration to my
questions and addressing me frequently as "Dr.Kusch." He was very anxious and fearful, but I
couldn't tell, given the vagueness of the details, how well-grounded his fears were. He was
oriented, his memory was intact, and his thinking seemed somewhat concrete. He gave good reason
to suspect that his judgement and ability to plan and organize his life were impaired.
There was something about Joseph which I found to be extremely sympathetic. He was obviously
very kind (too kind: he had offered to cash the addict's check despite his own reservations), and
desparately wanted help of some kind, although I had difficulty figuring out what. Although
fearful, and polite to a fault, he was also unusually trusting of a stranger, divulging to me both his
feelings and details of his life in surprising detail. It was easy to imagine him being victimized. He
seemed completely unable to protect himself, like a shellfish washed up on the beach without a
shell.
From early on -- from the missed appointment and subsequent apologies, and the tale of the bad
check --I formed two basic impressions about Joseph's problems. I also tried to form a hypothesis
about how these two impressions might relate to each other, so that I could begin with a simple,
unifying blueprint for helping Joseph.
The first impression was that he believed himself to be completely at fault when any conflicts
arose in a relationship (e.g. he was visibly surprised and relieved when I wasn't angry at him for
missing the appointment). The second impression was that he did not expect any protection in the
world. I hypothesized that the link between these two impressions was that Joseph felt so badly
about himself that he felt unentitled to any safety or protection. As a corallary, I hyothesized that
as a child he had been left severely unprotected, had run into trouble, and then (not knowing how
little protection he was given) blamed himself entirely for his troubles.
During this first session Joseph continued to say things like, "I can't believe how stupid I was,"
sometimes holding his forehead clutched in his hand in an attitude of despair. It seemed to me, in
fact, that his self-blame was causing more anxiety and depression than the actual threats (whatever
they were). I told him that I didn't think his actions had anything to do with stupidity, and that he
had obviously acted out of kindness. I also said there were reasons why he got into trouble, and
that we could figure them out together. I reiterated that his problem had nothing to do with
stupidity. He looked at me with gratitude (i.e. as if undeserving of kindness). He then said, "I must
think that because my father always called me a 'moron.'"
Before the session ended we explored the alleged threats by his neighbor. We spoke at length about
how he could protect himself (e.g. by staying with a friend and/or calling the police), and about
what else he could do to enable himself to concentrate at work. Joseph also told me during our
first meeting that he had been hospitalized in the past, and that he had been given diagnoses of
paranoid schizophrenia and bipolar disorder. He began to tell me a long, convoluted story about
his first break, about ten years before. The story of his break, and eveything leading up to it,
became one of the dominant topics of therapy over the next year and a half.
Next vignette: history, predictions, course of treatment
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