One of the most interesting aspects of the case of Otto is that it gives everyone a chance to reflect on the issue of what is or is not useful in interactions with those who seek our help. And reflection upon that issue is also a reflection on what you perceive to be your role as a mental health professional. Are you of a school of thinking that seeks cures? Or are you more interested in some aspect of what we call change? Or both? Or neither?
I was trained in the medical model which insists upon accurate diagnosis of an illness (much to the dismay of Thomas Szaz) and working as hard as possible to find a cure for that illness. Don Klein does well to remind us of this model because without diligent attention to the specifics of mental illness, our search for biologically based malfunctions in brain neurons, synapses, and chemistry will be unduly delayed. Segments of our profession have made grave errors in this direction in the past. One part of my training involved exposure to the family therapy movement which, at that time, contained many who believed schizophrenia to be the result of a double bind imposed on the sufferer by his or her family. Today, we think of this as essentially incorrect. Maybe there are some cases caused by double binds, but modern brain scanning techniques make clear that the brains of schizophrenics are devastated by some as yet undiscovered force causing them to deteriorate in rather specific ways.
At the same time, strict insistence on a medical model approach to people can lead us to think of them as statistical neurons and incorrectly reduce the complexity of any given situation by removing the person seeking help from the interpersonal interactions generated by the era, country, city, neighborhood, and family in which they grew up. One thing I missed in Don’s presentation of Otto’s case is what he felt as he worked with Otto. I believe we would have had a better feel for Otto had we known more about the affect he triggered in Don at various times in their work together.
I know I had a bit of a shame reaction to learn that Don had fooled us by presenting the case of someone who fooled him. (Shame is triggered by any stimulus that partially impedes positive affect. I was interested in the case and felt that interest impeded momentarily when I learned about Otto’s trickery.) I wonder if Don had a shame reaction. If Don had shared the feelings he experienced while working with Otto, would we have had more clues to Otto’s reasons for seeing Don? Don was trained in a era when countertransference was considered a bad thing. Did Don not share his feelings because he still retains some belief that such feelings are not good? Or did he have to keep them from us to enable him to hide the outcome of the case? Or did Otto’s presentation of self so successfully hide his own affect, that not much affect was triggered in Don?
I believe we have enough information to make the diagnosis of Malingering in this case. DSM IV defines Malingering as: The essential feature of Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.
(The use of the word malingering for this diagnosis is interesting. It is generally used in our culture in a pejorative sense. I suspect that people who behave in ways described in DSM IV as malingering trigger shame in others who then defend themselves with an attack other script as defined by Don and act in a negatively judgmental fashion towards the malingerer.)
I know of no psychotherapeutic regimen that has been proven successful in the treatment of malingering. (Hopefully someone responding to these comments does know and would be kind enough to pass on some information.) I suspect that once the diagnosis is made, a person would generally not be referred for psychotherapy. I, therefore, am glad that Don did not know Otto’s true intentions during their work together because my own professional opinion is that our job has at least two major components. One is to be skilled in our ability to make accurate diagnoses and another it to be skilled in our interpersonal interactions with those who consult us so that our relationships with those who consult us prove helpful to them. Perhaps Don would not have continued with Otto had he known what really motivated Otto’s call to him. Would you see someone who said he had just kicked someone in the groin and was now so afraid he was going to be sued that he wanted to be hospitalized so he could use that fact in his defense?
I agree completely with Jessica Broitman that Don helped Otto because they had an interpersonal interaction that was different for Otto. True, Otto never offered that much of himself for an intimate emotional interaction with Don, he is rightly (from what we learned about his past) much too fearful of the dangers of exposing himself to another. But he had the chance to learn something about people as he discussed his problems with Sally and related to Don and Don to him. Apparently he found what he learned useful because he did return later to ask Don about problems in another relationship. That he returned is a sign to me that Otto had changed because of his relationship with Don because from what we know of him, I doubt Otto would have ever considered consulting a professional about such matters before working with Don.
Thank you Don for sharing this case.