Beginning early in the treatment Joseph worked extremely hard at trying to understand his delusions, and expressing alternating hope and despair about his prospects for "getting rid of them." Frequently he ammassed piles of evidence in favor of his view that his delusions were founded on reality, weaving bits of detail, fragments of conversations and even facial exptressions he had observed ten years before into a theory that he was indeed still being targeted to join a prostitution ring. At the same time, he almost always showed openess to understanding his problem in psychological terms. From almost the very beginning of the therapy my consistent stance was to explore fully, but ultimately disagree with his ideas, offering interpretations regarding the guilt and humiliation he had experienced for years, his feelings of dirtiness and his expectations of punishment. I also noted that he was consistently relieved when I disagreed with him, often responding to my interpretations by revealing more about his childhood and adolescence. One of the most painful experiences to emerge during the first six months of treatment was that he had once, while sleeping alongside his father roughly a year after his mother's death (age 11), masturbated against his father. Joseph recalls not feeling sexually attracted to his father per se, but says simply that it "felt good." According to Joseph, his father had pretended to be sleeping, but was actually outraged and "disgusted", telling several neighbors, and asking the police to keep an eye on his son, for fear that he "would wind up in the wrong crowd".(All of this makes Stephen Day's hypotheses about Joseph feeling prostituted to his father very cogent) It is impossible to tell from Joseph's narration whether his father actually told these people; but the theme that emerges powerfully is that Joseph at that time started to feel guilty, humiliated and also frightened that he was being watched and talked about. His feelings about this sometimes emerged directly in sessions as a variation of his delusion: that the man he first had a relationship with told the other employees in Joseph's office that Joseph liked to have sex with family members; to J., this provided one explanation as to why he is "supposed to have sex" with his co-workers. In other words, in J's mind transgressions turn into commands. Again, I consistently interpreted this by saying that he felt he should be punished; he agreed, revealing on several occasions that he sometimes felt his delusions were themselves a punishment. Indeed, J's delusions often returned, or were intensified, at times when he feared making a mistake at work. On the other hand, he would report to me long periods of having no delusions, after sessions in which I made strong statements to the effect that "he did not deserve to suffer like this." This supports an additional hypothesis about his delusions: that he feels they are deserved punishments and therefore feels guilty when he does not suffer from them. Another theme J. returned to again and again was his guilt towards his father, both for his one-time sexual transgression, and for being homosexual. He spoke at great length about his father's desire to see him become "normal", about his obvious disappointment when -- even back when J was five or six -- he saw his son playing with dolls and "playing dress-up." After about two years of treatment, J. showed up one day with flowers, which he said were for his father's grave. He told me he planned to "go have a talk with him." When I asked what he planned to tell him, he turned to the side, and flowers in hand, began talking to his father (this was not delusional -- he knew his father was not present); as tears rolled down his cheeks, he both apologized for "ruining" his father's life, implored his father to change his mind, and gently but passionately rebuked him for his stubborness and meanness of spirit. At the end of the session I asked him whether he was now going to the grave, and he smiled and said, "Now I don't need to." After this session J. experienced the longest period of being non-delusional since his break - a period of about two or three months. After about a year and a half of treatment Joesph became involved in his first realtionship in ten years. Prior to this, he had begun to bathe and shave regularly and wear clean, attractive clothes. He also began to have longer periods when he did not experience any delusions. He expressed strong feelings of hopefulness, and strong feelings of gratitude towards me; at the same time, he worried at times that I would reject him for not paying the bill. I don't think that Stephen Day's hypothesis about J's seeing me as a prostiute is correct -- it is more in line with the case to see J's reaction as a guilty expectation of punishment if he does not meet others' demands -- i.e, similar to the way he expects punishment for not acceding to (delusional) sexual demands by co-workers. I would state his pathogenic belief in this way: "I am so bad that I am not entitled to protection or autonomy, and I will be justly punished for not acceding to the demands of others."
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