Early in our second meeting Joseph told me that ever since the episode of the check cashing had begun, he had been been experiencing an increasing sensation that there was a "bubble" in his head. The bubble, he explained with a gesture, exerted great pressure on his forehead and temples, and made it diff~cult to concentrate. Sometimes, in fact, it was excruciating. This was not the first time he had experienced the bubble: he had first felt it over ten years ago when he had had his break, and one of his sisters had brought him to the hospital, because he was "losing it." Joseph began telling me the story of his break, and in so doing told me the story of his childhood and adolescence. He was to continue telling me this story, with variations and new perspectioves and details, over the next couple of years. Joseph told me the bubble first appeared around the time that he was "outed" by a woman in his office During this period or before it Joseph had also begun having his first sexual relationship with a man. He told me the story of his first experience in an apologetic, embarrassed tone, explaining that on that occasion he just hadn't been able to stop himself from being aroused. He was sure that this man, Ted, had started the whole thing, and he wished he had never been involved with him. What "whole thing"? I asked him, and he pointed to his his head, indicating the bubble. Ted, he explained, had tried to get him involved in a prostitution ring that was also connected to his office. Ted never said anything explicit about this, but he made his meaning clear by discussing how he himself had intentions of making money by offering himself to older men .At about the time he was outed, Joseph began to feel that there were men in his office, closeted bisexuals mostly, whom he "was supposed to come on to. He was still feeling this pressure at his prese~office, and whenever it intensified, so did the bubble. Actually, the bubble also appeared when he was anxious. I asked Joseph if he was attracted to any of these men (considering the classical hypothesis that his paranoid delusions might be a reaction formation against deeply forbidden impulses). He said there were some he felt attracted to, but others not. Some he thought were attracted to him, like a man who had "brushed up against him." He tried to look unattractive for this reason. I asked him if in general he had difficulty saying no to unwanted advances, and he told me that he sometimed did have problems with this, and he worried about hurting peoples' feelings. He said this was one of the reasons that he was almost never involved in the "gay scene." Joseph went back to talking about the prostitution ring, and about his being outed, and at some point I commented that I had two impressions about what he was telling me. One was that it sounded like being outed was one of the most terrible things that could possibly have happened to him, because he felt that being gay was tantamount to being a criminal. And the other impression was that he seemed to believe that his least action (dressing attractively, for instance) could have dire consequences, against which he could not, or should not, defend himself. In other words, he seemed to feel so terrible about being gay that he felt that he should be punished. Joseph thought for a long time, and tears came to his eyes. He finally told me that he did feel he was being punished. When I asked him why he told about how he had come out to his father, a year or two before his break. He "confessed" to his father, a Catholic and an immigrant, because he had feared that he was going to find out anyway. His acted as if he "had lost a son." He told Joseph that he was disgusting, mentally sick, and "going against God's way". (In high school, boys had taunted him endlessly, and when he finally told the principal and got them reprimanded, he found the cars to his father's car slashed and the windows smashed.) Joseph vividly remembered getting down on his knees and imploring his father to "forgive him," and his father walking away. As he told me this story he cried, as he did in many subsequent sessions when retelling it. He said if he had known what it would do to his father, he never would have told him. When I asked what he meant he confessed that his father had died of a heart attack a year later. Joseph said his father had often been mean, but he was "my only father and I loved him." Rather than using a classical drive explanation for Joseph's symptoms (i.e. one based on the concept of a reaction formation) I began to hypothesize that his delusions were a direct symptom of profound guilt (towards his father) and profound shame about being homosexual. I predicted an improvement (first of all a decrease in his extreme anxiety) if my interpretations and attitude focused more directly and more broadly on his guilty and shameful feelings (especially his omnipotent beliefs about being responsible for his father's death). Beginning in this session, I first expressed surprise at his idea that he caused his father's death, and explored his ideas at length, finally disagreeing with them and explaining the reasons for my disagreement. He was very relieved. I also interpreted to him that I could imagine a psychological explanation for the "bubble"and for his fears, and that I thought he probably felt "worse than a criminal" for being gay and so lowly that others would only see him as a prostitute. I also interpreted that he might believe his sexual feelings were so bad and so damaging that others could "read his thoughts" and see him as coming on to them. Joseph told me that this made sense, and that he was surprised a previous therapist had not talked this way. He said he did feel really guilty, not just about being gay, but in general. He began telling me about being beaten repeatedly by his mother, for as far back as he could remember. He had also been beaten up by his brothers for "not obeying them." Next Vignette: More history, course of treatment
THE CASE OF JOSEPH, PART II
Steve Kusch, Ph.D. • 6/28/99 at 5:56 pm ET
(a different office from the one in which he was now working). At the time (age 22) he was still living
at home with his father, and his other siblings and halfsiblings, all older than him, had long since moved away; his mother had passed away when he was eleven. He remembers overhearing his co-worker whispering to another employee that he (Joseph) was "homosexual." Within days, or
maybe sooner, people in the office were looking at him strangely, or winking, or making odd comments, like, "Joseph, how's your new life?" Then he began to notice odd expressions and comments outside the office, for example, in a convenience store. He felt humiliated, embarrassed,
scared and depressed. He began to feel like he was going crazy. Another woman in his office announced to him one day, "You know, we have people like you put in a hospital until they learn to accept who they are." This remark sounded particularly omniscient and therefore menacing.
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