Thank you, Dr. Schwartz, for pointing out the deep importance of Kathy's pathological attachments. I do agree completely that much of Kathy's forgetting her goals throughout therapy, as well as her depressive episodes were motivated by what you call "pathological attachments" and what Control-Mastery Theory calls "pathological loyalties." Indeed, Kathy felt very anxious and uncomfortable as she made progress in her treatment and that discomfort focused around her fears, as you say, of becoming healthy enough to "leave" (so to speak) her family-of-origin and to experience a fuller life. I saw in Kathy a complex set of pathological loyalties that supported a complex set of pathogenic beliefs that interfered with Kathy's ability to continue her emotional development, including her forgetting her goals in treatment and her depressive episodes. Two of those pathogenic beliefs that occur to me now might be stated as: If I get healthier than my family, I will have to leave them and I will be completely alone and without family; if I get healthier than my family, I will leave them behind and they are all depressed and unhappy which I feel I must either solve or join or else be bad (shame) and guilty. Additional beliefs will become apparent later and I'm sure people could state additional ones from the current material. Certainly, as you point out, the tragic losses in her family-of-origin contributed to many of these pathological loyalties and beliefs. Now, since vision is easy in retrospect and because I know now what happens next in the treatment, I can say that Kathy's deep sense of pathogenic guilt (and an omnipotent sense of responsibility for many of the tragic losses in the family) also played a major role in Kathy's problems.
During the treatment, when I had as much information as you have now, I also thought that this very difficult period of therapy in the Refusal to Recover section was mainly related to Kathy's need to remain loyal to her depressed family-of-origin. Many of my interpretations during that time were about her discomfort leaving the family depression and what that would mean to her. Many of my interpretations were related to her depression being an act of loyalty to her mother, sometimes her father, and sometimes her brother. And I believe these interpretations were "correct" and true. But what I noticed empirically in these sessions, in contrast to previous sessions when those same interpretations usually kind of "broke" the depression, was a COMPLETE IMPERVIOUSNESS in Kathy's responses to me. How can I describe how frustrating this was? Sometimes she just went on continuing her victim dialogue, totally ignoring me and my comments. Plus she kept talking about her deep, agitated depression. She was hopeless and helpless. Optimistic ideas and feelings she had just a few weeks earlier could not even be remembered! I felt frustrated, worried, and helpless. And here I was on videotape in my own community where this work was being studied by students and colleagues. I had to keep reminding myself that no matter what this case "proved" about our (my) work, I had to proceed as if I were in my private practice. This was all very difficult. Clinical supervision was helpful in keeping me focused on my formulation. That support allowed me to keep regaining my perspective, my patience, and my understanding my own role in this work. So I would calm down and try one more time with Kathy. This felt like forever. It was three months, but it felt like forever. I would recover my perspective, try to work with Kathy's despair, and she would shoot me down. Even in the second to last intervention that ended the sequence, she almost "broke" the depression with insight, but then returned to the very next session acting as if we had never done the previous work. The final intervention "broke" the enactment, but I certainly did not know then that it would. Furthermore, Kathy gained an amazing amount of insight about her depression following the final intervention of the Refusal to Recover section. Something different and new was going on in our work. I did not know this then, but I know it now.
What I am trying to say is that after you read the next sexion of the treatment, you will see how important mastering her pathogenic guilt was for Kathy at this point in the treatment. I did not know, then, that she would embark on this rich journey to work through her guilt over her brother's death. But before she could begin to face her feelings about her brother's death, she had to feel less responsible for both his death and her family's subsequent depression. She accomplished this work in the Refusal to Recover section. Now, in terms of ATTACHMENT, Kathy would never have accomplished this work of the Refusal to Recover section WITHOUT A DEEP ATTACHMENT TO ME AND FROM ME. Picture, for example, if Kathy needed to learn from me that she did not have to feel responsible for her mother's depression (or brother's death, or father's inadequacies), so she tests me in the treatment to see if I feel responsible for her depression and refusal to recover. Let's say Kathy and I had NOT bonded. It would not be very convincing for her if I did not succumb to excessive responsibility and guilt - because, in the example, I wouldn't really care much anyway. What Kathy really needed was for me to be deeply involved with her AND also be able to maintain my own separate mood in the face of her despair. I had to walk the fine line between concern and separateness. Instead, Kathy knew how attach I was to her. She knew it by the myriad of times I remembered in great detail what she was discussing, by the way I continually summarized where we were and where she wanted to go, and by my genuine interest in her. Without that attachment, Kathy would never have been able to achieve the insights she did in the Refusal to Recover section, nor would she have been able to do the work you will see in the next section. BOTH ATTACHMENT AND GUILT played major roles in Kathy's dynamics and I hope you will enjoy her process as much as I did.