I forget who said it first on this forum, but I really do think that the overwhelming majority of highly successful psychotherapists combine rapt empathic attention to the output of the patient with carefully modulated attempts to make change through whatever system is dearest to their own personalities. The case under discussion here surely exemplifies this bimodal approach as well as any I've ever studied. A patient with a long history of maternal empathic failure arrives at Dr. Bloomberg-Fretter's office split between her concise cognitive grasp of her problems and the fact that she feels simply awful. As soon as she realizes that she is safe in this therapeutic space, Kathy begins to live out this split with vigor. Whatever Dr. B did, therapy worked, and worked wonderfully well. Those of us who do not speak with Dr. B's vocabulary are left more than a little in the dark, and I suspect that our unfamiliarity with her language is more than partly responsible for the relative paucity of responses on a forum noted more for controversy than reticence. In this first response to the case, I'd like to ask our presentor to clarify a few issues.
I am, of course, primarily interested in the affects broadcast and received during the therapeutic encounter. Any of you who know my work have heard me joke that I am the sole member of an international commission pledged to wipe out the use of the term "depression." I've been in the psychotherapy business over 30 years, and I cannot remember a single case in which that term helped me understand a patient. In general, when I read the "d word," I substitute the term "chronic dysphoria" to reference the idea that someone has felt awful for a prolonged period of time. I know that careful analysis of the patient's output will help me decide whether the ongoing chronic negative affect is distress-anguish, fear-terror, anger-rage, dissmell, disgust, shame, or some combination of those six basic innate negative affects. Let's see what that approach might give us here.
Kathy presents initially as "colorless" and "irritable." I can't see her face, but that sounds like the Avoidance and the Attack Other poles of the Compass of Shame. Questions about her "depression" were met with "skepticism, challenge, and hair-splitting debates that bordered on anger." Sounds even more like the Attack Other pole of the Compass. The Present Illness was precipitated by the betrayal of her son (another trigger for shame) in the context of an unfriendly divorce (who doesn't have shame about having failed at marriage?) Careful, polite questions about her past reveal one story after another that suggests empathic failure. Dr. B's use of the lay term "vulnerable" is most likely a paraphrasis of Kathy's revelation that she lives always on the edge of humiliation. But most important at this stage in the anamnesis are Kathy's references to "stories" about people who have achieved in some special way---people who have experienced healthy pride for what I have described as efficacy experiences associated with positive affect.
As a psychiatrist fascinated by the study of emotion, I cannot avoid the tentative conclusion that Kathy lives at the border of shame, that her "depression" is some form of chronic shame, and that her interest in stories of achievement represents a wish for movement upward on the shame-pride axis. If my analysis is correct (doesn't have to be, even though that's how the case reads from my vantage point), then the pivotal scenes in therapy are indeed related to the image of sunshine.
From the standpoint of affective life, what is sunshine? I suspect that the warmth and brightness afforded by well-modulated solar radiation is an analogue for the feeling of empathic contact. Basch and I have described empathy as a subset of interaffectivity (see my article "From Empathy to Community" in the latest issue of The Annual of Psychoanlaysis [1997, dedicated to the memory of Mike Basch]), and I have expanded interminably on the hypothesis that shame affect rewards any impediment to empathy and thereby derails intimacy. Furthermore, Kathy's use of this sunny image reflects her awareness that efficacy experiences feel best when they are performed in the sight of those who love and celebrate us.
Now we've got a lot more information about this phase of the case. Kathy works in the transference with an empathic therapist, offering one analogue after another of healthy pride and debilitating shame rewarding her attempts to be her real self rather than the rather limited self she was allowed to be in the context of her family of origin. If this analysis fits the case (only Dr. B can tell us), then it would lead us to suspect that Kathy's time in therapy will include several cycles in which she moves toward intimacy and ruins it as confirmation that (in the language of shame psychology) she is unlovable.
If you like to take the position that psychopathology is about pathogenic beliefs, then the list of cognitions I've offered for the eight shades of shame (Shame and Pride, 1992, page 317) might fill the bill. If you prefer to see these cognitions, these patterns of thought, as analogues of our universal experiences of failure and loss, then they are no more than the way each of us "thinks" when in the throes of shame affect. In this latter case, therapy is aimed not at the beliefs, but at the nature and scope of the shame experience typical of the patient at hand.
And now back to Dr. Bloomberg-Fretter for confirmation or discomfirmation of my hypotheses.