The most difficult part of responding to a written case description is that the process distances the reader from the affect present in the consultation room and especially from the patient-therapist interaffectivity so necessary for empathy and developing a "feel" for the patient. Dr. Nathanson's presentation is replete with references to affect but still, I sense that I do not know what this man is like. There are some signs that trouble me deeply concerning his ability to form intimate interpersonal relationships. For instance, I personally have never had what I would consider a successful therapeutic encounter with someone who picked my name out of the phone book.
Perhaps this is just bad luck--although it has saved a great deal of money not having to advertise in the yellow pages--but therapy is such a personal endeavor that one wonders why this man would pick a therapist simply for convenience. This is likely a sign that he just wants to be "cured" by the doctor and is not interested in becoming personal. I have known patients like this who told me the most intimate details of their lives and yet never opened up and became vulnerable in the therapy setting.
There is further evidence that this patient has difficulties with intimacy is his apparent inability to use strengths developed in his 3-year relationship with Sally to help him feel better. In fact, the entire process has distanced him from her and probably made her feel even worse that she told him about the incident at the club in the first place. He seems to have little or no feelings for what she might be going through. One can imagine a completely different outcome if their relationship were stronger--imbued with deeper emotional intimacy and trust. Perhaps she might have said to him "Listen to what that idiot so-and-so said to me at the club while you were away. And all the time I was hoping you would come home soon so we could do that." In other words, by not being able to use Otto to help her with her discomfort, Sally is indirectly telling us that there is a great deal of distance between she and Otto. It would be helpful to meet with Sally or, preferably, with Sally and Otto together to ascertain the level of intimacy in their relationship. This will provide many clues to Otto's extreme reaction and his ultimate capacity for intimacy.
Putting my concerns about Otto's capacity to be emotionally available to another human being aside for the moment, it is clear that this man is in serious distress. I believe he had a shame reaction to Sally's report of what the man said to her at the club. I sense that Otto is a "proud" man and beneath the somewhat macho pride of such men I always suspect a defense against feelings of inferiority or being seen as a fool. These men always have a competitive nature that drives them to stay on top and never be bettered. It would, therefore, be natural for Otto to respond with shame and jealousy that someone is coming on to his woman and that she is sufficiently threatened to not be able to tell about it right away. Such vulnerability to shame is rooted in this man's past and we will only learn about it fully when we hear more of the history. But for now the intense negative shame response of the present is resonating (or looping) with unresolved shame-related issues from his past is triggering a great deal of distress and anger in this man. And anger, as we have already learned, is a big problem for Otto. He fears expressing it to woman because he believes he is a danger to them--and for now he may be right. This leaves him in a terrible dilemma because his negative affect is backing up inside him, causing it to intensify and giving him physical symptoms. He needs relief of the intense negative affect--and some sleep--before we can consider working with the deeper issues he faces.
-Vick Kelly-