Therapist.
I am a 35 years old woman, a CBT psychotherapist since 2018 and I have 6 years of experience with MIT.
Client: Mark is 38 years old and he is a secretary in a medical testing laboratory. He lives in a small town in the South of Italy. When he begins psychotherapy, he feels dull and devitalized, and bears almost no hope for a life with a meaning. He’s been depressed for the last few months, he can’t figure out why and he tells me that it’s been happening to him often in the last few years. Mark asks for professional help because he has trouble waking up, and is lethargic. He has no life plans, nothing amuses him or motivates him to act. Mark claims that all his acquaintances are and moving forward in their lives while he fails to do anything.
Outside work, his days are empty and deprived of pleasant experiences. He has no friends, and finds awkward relating with others. He has had only one romantic relationship, lasting three years, with Luisa, a nurse, who left him two months before he started therapy. Mark reports that Luisa told him she was tired of his passivity, since he refused to go out, did not maintain social relationships and, above all, did not take any initiative such as asking to go to a restaurant of to organize a trip together. Actually, she complained that he boycotted her. For example, Mark, during their last summer together, did not accept Luisa’s invitation to spend the holidays at the beach together and when she left with her friends, he got angry. Or Luisa had organized to spend with him New Year’s Eve in Switzerland. On the day before, Mark backed out without providing any feasible alternatives. Mark recounts the loss of Luisa as a painful event but is convinced she will return to him because ”she will find no one to listen to her like I did .” Yet he has not heard from her since the day she communicated that she had decided to leave him: she never responded to his text messages or phone calls. Depression likely stemmed out of this romantic breakup but, as typical in persons with pathological narcissism, Mark is unable to realize that specific events triggered the negative mood (Dimaggio et al., 2009). Mark and his sister Sandra are orphans: their father died from an accident at work when Mark was 6, and their mother died after 6 months of the onset of cancer, when Mark was 19. Mark’s aunt, her mother’s sister, had no children and she adopted them both.
Sandra has a cognitive retardation due to brain malformation, and is not autonomous. Physiotherapists and nurses care for her, but not on a full-time basis, so Mark is often the only caregiver, he spends almost all his spare time caring for her. The few times Mark does something for himself, he lies to his aunt and sister: “I’m doing late at work ”.
Mark refuses the rare invitations from colleagues, out of lack of interest or overt contempt: “They do silly stuff… pub, beer and chips . Mark is partially aware of being driven by envy, another reason for avoiding social interactions. He indulges on self-talk filled with anger and contempt for others. During social exchanges he is a silent spectator, a judge or is just hostile. For example, if a colleague asks him for a few hours off, even though he would have a chance to meet his needs, he does not accommodate his schedule.
Mark feels damaged for not having been able to attend university so to have a more rewarding job: “I could have had a great future and instead I’m after Sandra and in a lab making appointments ”. When his mother discovered she would die soon, she told him he was the sole responsible for Sandra. Mark bears that burden as a duty he cannot escape from, one that comes with frustration at impaired autonomy. He is envious of his carefree peers.
Mark reasons for seeking therapy are vague: “I want more control over my life ”, but he barely knows what he likes. As many with NPD, he does not know what he likes and prefers, outside the domain of the quest for status (Dimaggio, 2022). Mark also expected that I could ”magically” help him and that I would understand everything at a glance. These led me to focus on the therapeutic contract from the very first session, in order to prevent his disappointment.