Negotiating Alternative Constructions of Disorder Between the Client and the Therapist During the Psychotherapeutic Dialogue

The case of a 67-year-old man, who had a year-and-a-half long psychotherapy with the author of this article, is presented to illustrate the process of negotiation between client and therapist about the meaning of his symptoms. Mr. B’s symptoms were intrusive pictures of a sexual nature, pointing towards obsessive-compulsive disorder. However, he had a number of psychotic breakdowns throughout his life and had been diagnosed as schizophrenic on several occasions. The exploration revealed that his construing of his symptoms—and, more so, his construing of self—were highly influenced by his 12 years of psychoanalytic psychotherapy. He was pre-emptively holding onto this framework, which might be explained by his limited ability to organize his experience around a functioning core identity. One of the lessons for the psychotherapist was about limitations in the person’s ability to change. Some experiences might have occurred in formative years—whatever they may be—and work like imprinting (or “freezing of the meaning-making process”), which made the constructs developed at that time held on to as if “life depends upon them”. In the case presented, both client and therapist moved slowly (if at all) towards re-construing of the disorder, respecting the existing framework that had almost become an identity. The main therapeutic tool was the psychotherapeutic relationship that worked as a “container” for a very fragile self.