Dr. Nathanson's comments and questions provide me with an opportunity to clarify some important issues. While I doubt that I can explicitly confirm or disconfirm his hypotheses at this point in the case, I definitely CAN clarify some of the issues. And yes, I agree that most successful therapy probably combines empathic attention to the patient with "carefully modulated attempts to make change through whatever system is dearest to" the therapist's personality. But then, isn't that why many different theoretical orientations produce successful therapies? Although I am in no way fluent in the shame literature, I have read and studied some of Dr. N's work which I have found to be profoundly enriching to my clinical work. In fact, the patient in this case, Kathy, suffered deeply from intense shame as well as guilt. I think that the more precise shape and content of these emotions will become more evident in reading the next section of the case. Dr. N's hypotheses about shame are absolutely relevant to this patient. I cannot comment, however, on the specific hyptheses because of the language problem we all have in this abstract field of psychotherapy. So, yes, shame is profoundly important in this case; so is guilt. I think that although a discussion of "shame" vs "guilt" (or "shame" and "guilt") would be extremely interesting at some point during this case, it would be more relevant to the case if such a discussion followed the next section where you will understand much better, I hope, what's going on with the patient.
I do want to clarify something about the language I am using in this presentation. Whenever at all possible, I am using Kathy's language, not my own. I found fascinating the change, the "transformation" as I call it, in Kathy's descriptive language from that first really "irritable, colorless" presentation to the ending which "transforms" into a creative process of writing, dreaming, story-telling. But if you felt "a little in the dark" after reading the first few sessions, then you know some of the affect I was feeling also. I was confused, interested, and perplexed. What she was saying and the associated affects were sometimes making sense to me and also sometimes not. Later Kathy will analogize this phase of treatment to "a puzzle." And that's what I felt like I was doing in the first phase - trying to find all the pieces to the puzzle to see how they fit together. I'm really glad you bring up the issue of the word "vulnerable." That word is very important to Kathy and I too had difficulty understanding exactly how she was using it. It took probably the first year of treatment to get a complete understanding of what she meant by "vulnerable." Her "vulnerability" was part of her depression, but it was more related to a feeling of being alive and real, though there were also threads related to humiliation, as Dr. N suggests. Another of Dr. N's hypotheses concerns Kathy's "illness" being "precipitated by the betrayal of her son...." I am interested in alternative perspectives on this case, but I saw Kathy's illness being precipitated by the "loss" of her son. Kathy's depression was part of a puzzle in that it was NOT on-going. This was the second depression of her life. The first happened 6 years previously, following an abortion. I heard something related to loss in both of those triggers to her two depressions.
By the way I totally agree with Dr. N about the uselessness of the "D" word in clinical work. In fact, Kathy's full description of what she meant by "depression" was not clear until almost a year of treatment. So, as you read the case, you will come to understand what she is talking about. I would never have used the "D" word in the first session, except that she kept bringing it up in a hostile manner. In retrospect, I can see that she did not want me to focus on the "depression" for which she felt great shame, but on the pride she wanted to feel in the "sunshine." I completely agree with Dr. N's comments on healthy pride. After the second hour with Kathy, I understood much better that what she needed from me was to help her focus on her goal of seeking what Dr. N calls "efficacy experiences." As Dr. N carefully notes, "efficacy experiences feel best when they are performed in the sight of those who love and celebrate" you. Kathy's early life taught her the exact opposite: that efficacy experiences performed in the sight of those who were supposed to love her made those people hate her, feel weakened by her, and even destroyed one person. These issues are directly related to what I see as Kathy's "pathogenic beliefs" and you will see how I address those throughout the rest of the treatment. But I quite agree with Dr. N: "sunshine" for Kathy is about pride, spotlight, attention, recognition. Indeed, Kathy has a healthy, ambitious wish to move "upward on the shame-pride axis." In fact, that is her goal for this treatment. And it was my job to try to help her accomplish this goal. I would be greatly interested in hearing from Dr. N, during this presentation, any additional or alternative ways I could have helped Kathy accomplish her goal. I look forward to our continued dialogue.