Saturday, November 27, 2010

An agoraphobic's dream

A patient who suffers from severe agoraphobia and cannot step out of her apartment, without being accompanied by someone familiar, brought the following dream to the session:

My husband is taking me out to dinner. It is not a fancy place. May be a drive-thru fast food restaurant. I look through the menu to decide what to eat. But I can barely see the items. Then I find that my husband is not interested in the menu. He has not even come there to eat but to meet someone. I get angry, and throw the menu across. The scene shifts to inside of the restaurant. It is really dark and uncanny.
It is a stark white building. I notice there is nothing inside; no people at all. There is just one dim light. There is a whole stack of plastic menus. My husband responds to my anger, and my sending the menu sailing through the air, with even greater anger. So I start running. He begins to throw rocks at me. They hurt. I get pelted by big and small rocks as I run down the street to my house. But I can barely get past the rock throwing. Even when I reach the house I cannot get inside as I cannot get the key in to the lock because so many dirt clods and rocks are falling on me.

he patient is divorced from her husband, but they still live together for financial reasons. First thing she expressed about the dream was her surprise that her husband is throwing stones. It is so unlike him. He is not a violent person at all. It makes no sense. Also it makes no sense that she has gone to eat at a restaurant because her agoraphobia precludes that. She cannot eat in public. So the dream, according to the patient, was senseless.
She brought scanty associations to the other elements of the dream which - following the technical rules of dream interpretation - allowed me to proceed with the analysis primarily on the basis of typical symbols and typical scenarios that dreamwork utilizes to couch our ordinary thoughts in the language of dreams.
Now the patient did associate here and there to the constructions I made, and which served as guideposts that the analysis was proceeding in the right direction.
First construction which was made was that in the dream she is free of her illness and eating at the restaurant, something she can only dream about in real life. Further construction was made that eating in public in her case could mean meeting strangers on the street and having liaison with them. For underneath the agoraphobic's fear of streets lies the fear of getting too bold in demanding sexual satisfaction and becoming a brazen hussy who does not hesitate to solicit sex from total strangers - prostitution fantasy.
The patient responded with "That is so weird. So strange. I would have never thought of that."All the typical phrases which patients use - as if they have jointly conspired - to confirm the correctness of an interpretation. Then she went on to say that she had read somewhere that behind agoraphobia lies the fear of soliciting sex on the street. But she always thought that that explanation applied to low life agoraphobics not her.

I look through the menu to decide what to eat. But I can barely see the items.

This expressed two contrary impulses. Finding a dish on the meny was finding something satisfactory to eat - sexual satisfaction - while the inability to read expressed the emergence of repression and blocking of the wish which was unacceptable to her conscience.

Then I find that my husband is not interested in the menu. He has not even come there to eat but to meet someone.

This was a projection of her impulse to meet someone upon her husband out of moral sense. She is avoiding the guilt of having the impulse to solicit sex with a stranger by projecting the tendency, and hence the blame, from herself to her husband. There is of course the element of wish fulfillment, vicariously, through her husband. The unconscious hypocritical reasoning which the dreamwork uses must have gone something like this: "I have come here just to eat food and I am looking so innocently at the menu, and it is my husband who is interested in getting illicit sex, and has come here to meet someone."

I get angry and throw the menu across

his anger is actually the superego anger directed towards her unacceptable conduct - wanting sex with a stranger. Her father was very strict disciplinarian, quick to anger and take up the belt to punish children for the slightest infraction. Her superego [conscience] had become the representative of her father, and she was identifying with her father to give expression to the condemnation, with her husband taking on the role of her lascivious self and becoming the object of the fury. The throwing away of the menu gave expression to her rejection of the impulse to take interest in women - the flat menu and the food items in it represented women. In the sexual encounter that she was hoping that would happen to her, in the dream she was identifying with the male role.

Then the scene shifts to inside the restaurant. It is really dark and uncanny.

Lack of success in finding the fulfillment of the wish - inability to read the menu, and its getting thrown away - leads to the complex getting reenacted on a different venue. And the wish tries to find an outlet at a much deeper [regressed] level. Being inside a structure like a restaurant or a house or a Mall, especially which is dark and uncanny, is fulfillment of the wish to return to the womb. So it is the familiar 'womb fantasy'. The patient frightened of soliciting sex on the street, shown here as looking for food at a drive-thru restaurant, and hoping to see its fulfillment through her husband, to whom she is attempting to present the women [the menu items] while simultaneously opposing it, out of jealousy - throwing the menu across - now shifts the stage for the acting out of the two contrary impulses on to her mother's womb.

It is a stark white building.

his is an allusion to death. Fantasy of returning to womb - the fantasy of rebirth - is regularly accompanied by fear of death. Birth of our children, heralds our own death. White is often used as an allusion to death. So she wants to die and reemerge as a new avatar.
Now we know from countless other dreams that the womb fantasy is always undertaken to fulfill the wish of the dreamer to go back to the womb and reemerge as a better fortified avatar. And this fortification is invariably connected with the deepest wish of women - to be born again, and this time with a penis, so as to do a better job of her life in her masculine reincarnation.

I notice as to how no one is in the restaurant. No people at all.

The association to this was how Kroger -the supermarket - is so full of people and how even the thought of facing them triggers a panic attack. So the fear/panic of crowded places - the core of her agoraphobia - is a defense strategy the mind of the agoraphobic uses to suppress the impulse to have illicit liaisons with strangers. In the dream, however, she has managed to conquer this fear. And she has done this making all the people who would stare and disapprove of her disappear. With no disapproving people around, she can indulge in her fantasy.

There is just one dim light. There is a whole stack of plastic menus.

The whole stack of menus alludes to a row or pile of women. The patient's relationship with men had been severely disturbed in childhood primarily because of her father's harshness and ruthlessness. She felt more comfortable with women, and in the unconscious her sexuality sought satisfaction from women. In the dream the desired women were being portrayed by flat menus. The dim light was allusion to clitoris, and the inferiority of female organ, and thus an allusion to her rejection of finding sexual satisfaction with women. Patient's taking special pains to mention that the menus were of plastic was expression that I may desire women, but real intercourse with them would be artificial and non-satisfactory.

My husband responds to my anger, and my sending the menu sailing through the air, with even greater anger.

Wish fulfilment had blocked the restraining influence of public by showing no people at all in the restaurant. But the moral sense was making a comeback finding expression through showing her husband getting angry [at her brazenness]. Sailing of the menu through the air was an allusion to sexual satisfaction as well. In fact this was the core of the dream. It was the most vivid element of the dream. And she did emphasize as to how dramatic was her sending of the menu across the room. The dream was woven around this wish. It alluded to her going back to the womb, stealing the penis from there from the father, while parental intercourse was taking place, and then flying away with it. The familiar feeling of being at the top of the world after satisfactory sexual act. It is best captured by the song "Oh what a feeling, dancing on the ceiling."The fear that it will arouse the ire of her father - who in the dream was being represented by her husband - whose penis she was stealing, brought an end to that section of the dream.

So I start running. He begins to throw rocks at me. They hurt. I get pelted by big and small rocks as I run down the street to my house.

ow the wish is on the retreat and the punishment for it takes the upper hand. She could make the public and the public opinion disappear for a moment at the restaurant, but the moral sense was returning with a vengeance. The association to the rock throwing at her was to the Biblical woman who was about to be stoned by the crowd for adultery. She is running back to the house - womb - away from the trysts of life which will invite dirt and rocks to be thrown at her.

Even when I reach the house I cannot get inside as I cannot get the key in to the lock because so many dirt clods and rocks are falling on me.

his was the last to replay the two opposing impulses. Entering the house by opening the lock with the key would have been symbolic depiction of intercourse. But the hail of abuse, represented by the rocks and mud clods, and the fact that she does not know how to use the key -penis - holds her back.

he dream ended with her waking up in fright.

Wednesday, November 17, 2010

Aggressive impulse at the root of easy distractability and multi-tasking

A 29 year old girl who came for Suboxone treatment reported that the reason she was addicted to Vicodin, and now kind of addicted to Suboxone, is because they attenuate her distractability. She claimed she can rarely keep her focus on a task long enough to complete it unless she is taking Vicodin or Suboxone. Every task undertaken, after sometime, is interfered by a creeping anxiety and premonition of disaster happening somewhere else, and her mind begins to search for some other project that she was supposed to do, and forgot, and which, if not immediately attended to, will cause problems and she abandons whatever she is doing to take up the new task. The cycle repeats itself with the new project, leading her to pick up yet another project, till there are so many open projects that she feels overwhelmed and gives up on all of them.
If she can't find something to do that has the potential to distract her in the outside world than she searches for pimples on her face and bursts them lest they grow too big and offensive and make her object of ridicule. When asked as to why others would they find the pimples offensive she said because they are ugly and it will invite them to attack her.
Now we know that Attention Deficit Disorder and Obsessional Neurosis are two sides of the same coin. The aggressive/destructive impulse, which these people are plagued with more than others, has to be suppressed and an impulse opposite in its intent [constructive in nature] has to be put in its place to keep the hostile impulse from getting hold of the motor apparatus. The hyperactivity of the ADHD child is a compromise formation between these two motor trends, to wit, destructive and constructive.
The easy distractability of ADHD patients is also a play between these two opposing impulses. The person is beseeched with an impulse to cause harm. This he suppresses with doing something constructive that will not only occupy his motor apparatus so the harmful impulse cannot take hold of motor movements, but also because by doing something constructive he hopes to please the person/s towards towards whom the destructive impulse was aimed at.
In this girl, the destructive impulses were directed towards her mother. In her conscious mind, she was completely unaware that she harbored extensive rage towards her mother.
Her mother was abused as a child, and had numerous mental problems herself, and she was mean towards her children. However, mother had also been in therapy all her life, and had taken the kids to her therapist to undo the damage her erratic and mean behavior was possibly doing to them. In these therapy sessions, the children had learnt not to hate their mother for her meanness on the rationalization that she was mentally ill. So the girl had learnt to not consciously feel angry towards her mother and also to believe that she harbored no resentment because she understood the roots of her mother's behavior. Nevertheless in her unconscious the desire to give tit for tat for her mother's meanness had persisted.
It was these revenge impulses, laced with furious rage, that sought motor actions and had to be kept at bay by doing some constructive project [that would please her mother].
Now in mild cases of obsessional neurosis, or where obsessional neurosis is sublimated towards useful goal, and this includes majority of mankind, for our world's do-gooders are no more than those who have harnessed their destructiveness to fuel the opposite impulse of constructiveness in such a fashion that the latter almost always manages to triumph over the former, the pathology is only apparent in that the person obsessively wants to do good - herein lies the psychology of hyperfocusing in ADHD.
But where the destructiveness is too powerful, as was the case in this girl, the constructive activity fails to keep the former in check for too long. The person gets a premonition that her good intention is going to be trumped by the evil one, which will result in some disaster happening [anticipation of punishment for the evil designs], and the conscious mind perceives it as a rising anxiety. And to take care of this anxiety she looks around for some project that was supposed to be done but which has not been done and which she deems as a potential candidate for causing trouble and she leaves whatever she was doing to take care of this new project. Herein lies the psychology of distractability. The destructive and constructive impulses are equally matched and the projects undertaken get interminably procrastinated.
The phenomena of multi-tasking arises from the same complex as well. Here projects are not abandoned but pursued simultaneously. When the anxiety arises about destructive impulse messing up the task at hand, the person, instead of putting additional energy in the constructive efforts, or abandoning the project and moving on to something else as the ADHD distractable person does, does not abandon the first project but takes on another, and then yet another, and juggles between all of them, and if he does it successfully then he is looked upon with admiration and if he messes it up he is viewed as a bumbling fool.
Now to her preoccupation with pimples. They symbolized siblings. She was trying to hurt her mother by identifying herself with her mother and destroying the mother's potential children. As if the desire to harm her mother had been displaced on to harming her mother's children. The penance for such fratricidal behavior was also expressed from the same act. The pimples stood for her children too, which she was destroying as a retribution for doing the same to her mother's children. It is interesting that despite her being at the peak of her femininity she had no interest in settling down and having children. As if all her interest in life had been consumed in managing this interplay between aggression and love impulses which strove to fight with each other in every aspect of her life.