I thought it best to wait until all of the discussants had commented on this case, but apparently Henry Stein is busy with a conference and I don't want to wait much longer. This is one of those peculiar situations in which everybody is right.
My own view of this case is that it was quite successful. Otto came into therapy for reasons that were on the verge of sociopathic; he had decided to hide behind a hospital, to blame his emotional explosion on madness---a strategy he thought would protect him from later legal difficulty. This was never a criminal case, but rather a civil action in which the other man would have sued him for some sort of damages. Nothing in his presentation of self during the first session prepared me for the degree and intensity of the discomfort he described over the succeeding days, and I hospitalized him only because he said the magic words that compelled me to do so.
Yet beyond and beneath this immediate situation was another issue that I considered more serious. Otto knew quite well that he was in emotional trouble. He knew next to nothing about the ways one might go about getting help, for, as many of the observers have noted, neither parent operated as an affect-modulating other or what the self-psychologists call a selfobject. He was aware that I took him seriously, that I was sensitive to his moment-to-moment emotions, and that I was willing to work with him to figure out how to relieve emotional discomfort that he was ill-equipped to describe or define.
In the overwhelming majority of my cases, I can take a full history in one or two sessions. That it took 8 sessions for me to gather all the data I presented as his personal history reflects the degree of tension he experienced at all times during those early meetings. Every story he told was the source of tremendous pain. Even today I am not sure why he was able to tell me as much as he did; in retrospect, I cannot be sure whether he did so because he felt that to avoid my enquiry might make me suspicious that he had exaggerated his initial symptoms, or whether he had become interested in the process of anamnesis. For better or worse, then, someone had asked him to tell his life story, and tell it he did.
I viewed him as a trauma case, an abused child who had grown up by living in an emotion-free capsule whenever possible. His world was cognitive rather than affective. His social life centered around his business. His female companions were limited to those who were similarly limited in their ability to achieve depth of relatedness. We used to use the expression "feral child" for people like Remus and Romulus, the boys who were nursed by a she-wolf and for whom Rome was named. These children, who sometimes come out of the forest after years of wandering, are truly afraid of human interaction. The modern equivalent would probably be a street child.
In every interaction with Otto I took care to identify as many emotions as possible, much as if he had never heard of emotions. I explained how other people felt in certain situations, and I was able to explain how his actions and emotions affected them. Even though his conscious reason for seeking help was quite primitive, there was no doubt in either his mind or mine that he needed a great deal of help. In each of the 22 sessions we worked, Otto made it clear in the early minutes that it was difficult for him to take time from his very important work; by the end of the session he had taken out his appointment book to make sure we could find a mutually convenient time to meet again.
As I mentioned earlier on this forum, I spend a lot less time thinking about diagnosis than most people. What fascinates me is the simple observation that people do not come to us unless and until some affect has become magnified to such a level that they cannot handle it by their usual affect management scripts. It is our job to figure out the source of that affect, the scripts that have failed, and to look for hardware glitches that might have revved up the affect to a level beyond the normal. We give medication when the affect cannot be modulated by psychosocial means, couples therapy when the action involves the relationship more than either of the individuals, and many forms of individual therapy as we investigate and teach the patient about the ways affect can make good things better and bad things worse. Like Michael Franz Basch, to whose memory this year's Tomkins Institute Colloquium is dedicated, I believe that every case is a Brief Therapy case until there appears to be some reason to work at greater length and depth. Otto was a short or medium term case, a man whose personality was quite adequate to handle almost every situation it encountered, but who needed outside help when disorganized by this level of humiliation.