John

In my first year of graduate training, I was seeing a 36 year old inpatient at a state psychiatric hospital. This man was taking a daily dose of antipsychotic medication 10 times larger than the dose that would put you or I into a sound sleep for 24 hours; and he still walked around with tight muscles, a squint, and various nervous tics. His habitual resistance in sessions was confusion. To the simplest of statements he would say something like "I donít know what that means. Does that mean... or is it ...?" and so on. 

One day, John admitted in passing that he felt "like a criminal". "Like a criminal?" I asked. He immediately began his litany of "Well, I donít know what a criminal is. Is a criminal someone who... or is it ...". This time I rather impulsively interrupted with, "Oh, come on, John, you just used the word; you know what it is". I was horrified and expected violence or a psychotic breakdown, but John just looked at me and said, "Yes, I do". I was worried by my uncontrolled statement, especially since Iíd not yet read or heard of any therapist behaving that way. (I was in my first year of training, just barely understanding how to listen and keep my mouth shut during a session.) In those days, I went over every moment of every session with supervisors and I reviewed this one as well. To my surprise, my supervisor said, "Well, when the relationship is there, you can say almost anything." 

By way of proof, John responded quite well to this relationship and made some unexpected progress. For example, early in our work told me that he was so physically tense because if he were to relax "buildings would come crashing in, bridges would fall, fires would burn". We never discussed this point directly, but towards the end of treatment (about 5 months later), the same question arose of why such tension in his body; this time Johnís answer was "I might get crazy, break things, smash windows." This is quite a change! Heíd progressed from a psychotic ("crazy") perception of the world, in which his feelings can cause distant buildings to fall and fires to burn, to the more commonplace fear of losing control of himself.

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