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Clinical vignette

Eileen, in her late 30s, sought therapy with me (FML) because her lifelong bouts of anxiety and panic attacks had only diminished slightly in her two previous treatments. Her explanation for her anxiety was that she had not found a mate and “time was running out’’ for her to have a child. In trying to diminish her anxiety, she became involved, repeatedly, with men with whom there was “no future.” One man had been several years younger than she, and another man, although divorced, was still intricately involved with his ex-wife.

Eileen had certain crucial requirements with respect to the men with whom she became involved. These requirements were based predominantly on how she did not want to be seen and how she did not want to feel. Eileen is poised and attractive but - and this was for her a big “but” - she is six feet one inch tall. She feels ungainly and unlike the cute little girls whose appearance she envied in her childhood. To diminish these feelings, a man must be as tall but preferably taller than she. That’s a tall order. And there was another requirement: the man’s income must be equal to or greater than hers.

At the time when she began her treatment, both of these requirements appeared to have been based on how Eileen did not want to feel about herself or be seen by others. She did not want to tower over a man and feel ungainly, and she did not want a man to be less financially solvent than she was. That would make her the breadwinner, which had reverberations in her history. In addition, if the man’s income was less than hers, it might appear to others as though she had to make concessions in order to land a man.

When Eileen met a man who came close to fulfilling her requirements, she would quite quickly live with him, and cling to him. Her sense of desperation came through in her description. The relationship would soon be over. Although in her descriptions of the relationships the outcome was quite obvious, when the ending did come it was always a surprise to her. These experiences of disillusion, recounted during our initial sessions, enabled us to get some sense of the current sources of her anxiety.

In sharp contrast to her chaotic early life, Eileen is well groomed. She grew up in an economically marginal family where clothing was hand-me-down. She called her mother “an aging hippie” who tried to support the family through menial work and part-time prostitution.

Her father was a “brutal-looking alcoholic” who abandoned the family shortly after the birth of Eileen’s younger sister when Eileen was about 6 years old. She also has an older sister. Her mother was generally overwhelmed by having to raise three daughters on her own. Eileen described her home as being devoid of rules or structure. Most importantly, they never had enough money to provide for even basic necessities, such as clothing and cleaning supplies. This history contained the raw material that defined what she was seeking but, notably, also defined what she was seeking desperately to avoid. She sought a relationship that would conceal her “sordid” background and provide her with an identity that she had sought since childhood: to be a cute girl living in a clean, affluent home with a family that she and her husband (when she acquired one) would take care of. She dreaded recreating her childhood life and sought a life that would conceal the circumstances under which she had grown up. Yet, these intentions and goals made her feel like a fraud.

Eileen became a physician and she clearly did not have an income problem, but that was irrelevant. She believed that finding a man whose earnings were greater than hers would fill the void with which she had lived since childhood. Furthermore, although she liked her work, she wanted to feel she did not have to work.

Being so tall brought with it a sense of shame. She and her sisters, who were also tall but not as tall as she, had to wear the hand-me-down clothes of their cousins. As the tallest, Eileen had to wear the discarded clothes of her male cousin. Ever since her school days, when she had felt like an ungainly, sloppy boy, she longed to feel like a cute little girl.

Given the economics of her home, Eileen and her sisters had to work from the age of 13 on. At first Eileen helped her mother with cleaning jobs, but later she worked as a waitress at a restaurant in the mall near her home. An outlet store for women’s clothing was next to that restaurant so Eileen was constantly confronted by young girls, with money, buying the cutest outfits. These girls made their way into Eileen’s identity. They symbolized what did Eileen wanted to be. Therefore, finding a man who was as tall or even taller would be as close as she could get to looking cute and not so ungainly.

Standing in her messy, neglected home, amid the litter dropped by five cats, Eileen’s mother impressed upon her that she could become anything that she wanted. That became a crucial mantra for Eileen. Of course, her mother was not aware then that what Eileen most wanted to become was a cute little girl with money.

Eileen and I considered that she may have felt enormously encouraged and supported by her mother’s spirit. But it was particularly striking that neither through example nor action did her mother do anything to help her daughter articulate, approach, and try to achieve her goals. Yet she did instill in her daughters a desire to seek a better life. Through hard work, scholarships, and evidently enormous motivation focused predominantly on mastering her environment and gaining the symbols of prestige and respect, Eileen eventually succeeded in going to medical school and becoming a gynecologist. Alas, in important ways her success did little to alter her underlying affect tone of shame and fear of exposure to humiliation.

With respect to the three developmental pathways, Eileen’s experience of intimacy in her home was suffused with garbage. Relationships among the three sisters and with their mother were dominated by the limitations that poverty imposes and the physical neglect with which they all lived. Intimacy was a luxury that was in short supply in Eileen’s developing years. Eileen “escaped” by focusing on her school work and her determination to find a rescuer. With some feelings of resentment, she developed the skills to rescue herself through her intelligence and concentrated effort. Nevertheless, in spite of her diligent self-sufficiency, many overt achievements, and evident successes, Eileen felt that she was a fraud. It was as though she had breathed in the dust of shame that covered all aspects of her home and lived in dread that the filth and neglect would be discovered. Suffused with shame, despite her admirable appearance she considered herself to be a fraud.

As Eileen and I investigated the context and sources of this shame, we formulated a theme that connected several of her anxieties. She felt she had to carefully and thoroughly conceal her sordid family background, but doing so was exactly what made her feel fraudulent. She thereby opened herself up to being exposed as an impostor. The anxiety she felt was based on both her dread that her biological clock was ticking away and her equally powerful fear of being exposed. Then her embarrassing history of physical and emotional neglect - and perhaps even abuse - would be revealed. Those revelations would distinguish her from the other girls in her classes in school. Furthermore, her sense that she was not like any of the other girls in her grade school classes stretched even into her medical school classes. There, she felt herself to be an ungainly, boyish, dirty child. These were the repetitive patterns (fractals) that defined her sense of self. But, the boundaries were not open. The underlying affect tone of shame and fear of exposure remained unaffected, but the boundaries were not open. Eileen’s numerous contrary experiences were devalued and prevented from being assimilated into her sense of self. These included the professional respect she had earned. Her dread of being seen constituted a major source of the anxiety for which she sought therapy while in medical school. Unfortunately, in her therapy in medical school, her anxiety was linked to a fear of failure in school, rather than her fear of being exposed, and so the anxiety persisted. While her success in school and in her career resulted in a degree of greater self-respect, her goal of eradicating her sordid background and becoming “a cute little girl” remained elusive.

The discrepancy between her mother’s encouraging “you can be anything that you want to be” and her mother’s life and actions served as an early source of dread about being exposed. It also defined an unbridgeable schism in her development of an identity. The mother who provided her with encouraging words simultaneously pulled the rug out from under her with her actions - or, rather, her lack thereof. Eileen’s later and ongoing anxiety mirrored both the feeling of fraudulence and, as we were able to infer in our therapeutic work, the ever-present instability of the home in which she grew up.

Eileen’s treatment focused to a large extent on the difference between how she saw herself, how she feared she would be seen, and how she wished to see herself and to be seen. In her desire to avoid exposure she felt compelled to downgrade the significance of experiences that could support her striving, more ambitious, and capable self. Such acceptance would only add fuel to the fires of her shame and sense of being a fraud. We attempted to untangle her mother’s encouragement of seeking success from the visible evidence that her mother had surrendered to poverty. In doing so, she left her daughter alone in trying to extricate herself from the burden that her home life imposed on her. Spelling out these conflicting themes and their devastating effect on her implicitly moved Eileen toward engaging and loosening the boundaries between these diverse senses of herself. We recognized and articulated Eileen’s dilemma to protect her mother that interfered with her assimilating her success and achievements into an identity that acknowledged and dominated her being a child of chaos. She felt the childhood picture of her chaos was real and any attempt to conceal it or “pretend” it was not so, as her sisters did, would be fraudulent.

The discrepancy between her mother’s encouraging “you can be anything that you want” and her mother’s life of failures was jarring, As her mother was encouraging academic success and achievements, she was surrounded by her three ill-cared-for children in their ramshackle squalid, chaotic house, dressed in the soiled, torn, worn-out, hand-me-down clothes donated by assorted male cousins

Eileen’s sense of herself and underlying affect tone was organized through the sensory, visual, auditory, olfactory, and proprioceptive experiences that accumulated and impacted her during her formative years. Her professional choice of gynecology, after her youth dressed in shabby men’s clothing, I imagine, gave her a hands-on sense of the female body and thus might provide reassurance as to her own femininity (we spelled this out as “They, women, are like me and I am like them. We are women and that’s how I know I am not a man; I am a woman.”) We spoke about her career choice in the context of her liking the women who trained and taught her (“a new mentoring family”), and she had felt comfortable in that assignment. Furthermore, she was now well respected at the hospital with which she was affiliated and had good relationships with the interns she trained. Eileen did not bring up her work as a problem area, but rather as an aspect of her life that had incorporated her mother’s support and her own awareness that she was very smart. To go to college on academic and hardship scholarships and then to medical school required considerable work. She encountered no problems in her intellectual pursuits; however, her social life in college was problematic and she had her first experience with therapy there. Her relationship problems were evident by then and were addressed on a rather superficial level. She felt supported by her therapist but her anxiety remained. As mentioned earlier, she tried therapy in medical school because of her relationship problems and anxiety. What she was seeking in therapy, then as now, had not been recognized.

When Eileen and I discussed her previous treatment, we could see that her relationship problems could be understood better as manifestations of her shame-dominated sense of self and her fear that she would betray her sordid home life and upbringing and reveal the squalor and poverty from which she sprang.

Eileen and I articulated that what she wanted was a cleansing of her sordid background so that she would be freed of the shame it engendered. I said to her that what she could take with her from her home was her enormous capability to overcome significant obstacles and imposed limitations, and she could feel success in spite of the restrictions imposed by her family upbringing. We spoke about the strengths and resources she had developed, and I thought that these qualities were largely unrecognized by her. She was reluctant to accept these qualities as hers lest, by doing so, they would become tarnished by her background. We then were able to link her not crediting her achievements with her dread and conviction that she was a fraud.

Although Eileen had become the best-functioning member of her family, her older sister, who was not quite as tall as Eileen, had found a wealthy man whom, according to Eileen, “she exploits and who supports her.” Eileen was still, after many years, profoundly envious of her. She said she would gladly trade places with her. Eileen admitted quite sheepishly that she wanted a man who was wealthier than her sister’s boyfriend. Her younger sister has been lost to the world of drugs and in that sense is estranged from the family.

Eileen considered her height to be one of her deficits. She recalled that during her adolescence she eyed the cute, feminine-looking girls enviously. An obsessive doubting about her femininity ensued. These doubts most likely had earlier roots but were reinforced during this time. To conceal her shame and doubts, Eileen developed highly skilled compulsive and competitive patterns to be the best and to leave no opening for exposure or criticism. However, these patterns, while contributing to her academic success, never sufficed to squelch anxiety about being exposed and shamed, the affect down pull of her underlying shame ridden affect.

As we explored her relationships with men, Eileen told me that when she found a man who earned more money than her and was also taller than her, only then would she feel that she had been freed from the chaotic home of her childhood. Being rescued from her home and provided with a context that concealed her origins not only applied to money but to her “size” as well.

In an early session Eileen reported a dream. She was in her childhood home and there was a tiny man, more like a cute boy, dressed in a sailor’s suit. With some embarrassment she said she was sure it was me. Although she had quite quickly formed an open and trusting relationship with me, there was a problem. She is much taller than me. She needed a man to make her feel “cute and feminine,” and, because of my size, that was not me.

Being short had been an issue for me in my adolescence. My best friend was about 6 feet tall. (We became friends because we were both stamp collectors.) When we went to dances or parties together, we implicitly understood that the tall girls were for him and the short ones for me. When the tall ones were particularly good looking, I regretted my shortness and felt jealous. Although I have now come to accept my size, Eileen reminded me of those adolescent days and the feeling of inferiority over my height. More than sensing into her state of mind as an observer, I shared her sense of fragile self-worth. In contrast, that I now had one of these very tall, good-looking women sitting opposite was not lost on me. I did not have to relinquish her to my tall friend - who, coincidentally, had become an analyst.

Eileen believed she needed a man to make her feel “cute and feminine,” and she feared that was not going to be me. To emphasize the serious nature of her problem, she then described her shame at wearing the old clothes of male cousins. Even now she needed to buy some clothes and shoes from the men’s department of stores. The size requirement for a mate was nonnegotiable, she told me. I said to her that she could certainly decide on the shape of man to whom she is attracted, but at this point needing someone to be taller than herself might be linked to her doubts about her femininity and that is something that we might explore further. We also investigated her fear that my being short might not work in rescuing her from the chaos of her childhood. Was she engaged in yet another unsuccessful therapeutic attempt to fulfill her expectations? We addressed this concern by focusing on the numerous resources and persistent motivations that have enabled her to succeed and transcend her background.

Motivations to explore and master were trounced by aversiveness: not to be like her mother and reproduce her mother’s failures. We also explored how Eileen had come to organize her identity but failed to include her intellectual abilities and ambitions. She had teachers all through grade school and high school who gave substance to her mother’s statement that “you can do anything that you want.” Or, put differently, she sought out teachers whom she admired and who offered to help her develop the skills she needed to fulfill her ambitions. Medical school became a goal in her high school years, abetted by her watching television programs that took place in hospitals where, she explained to me, the doctors were always “scrubbing up.” I observed that it served as the ideal profession through which to rid herself of the accumulated grime of her childhood home. Yet no amount of medical school scrubbing had, as yet, made a dent in the chaos of her home life.

There was another element in this dream that led to a number of different themes: the sailor suit. These suits were typically worn by young boys from the wealthier homes who went to Eileen’s school. They were the boys who would grow up to date and become the partners of the cure little girls that she envied. These boys were in another league, and she would never be in their league. We were able to address one transference question: whether I, or anyone who had not lived in her home, could ever understand her. She feared that this was another unbridgeable gulf between us (in addition to the difference in our sizes). She feared this alienated her from becoming part of the community of cute people. Recognizing and articulating these fears was all that was required for Eileen to feel that I, one of the cute but as yet unattainable people, understood her dread.

An interpretation that she was attempting to “belittle” me, or an expression of her envy of me, did not fit well into the spirit of the session at that time. Although such an unconscious message cannot be ruled out, the more direct message, contextualized, was that she typically felt herself to be ungainly, not feminine, and exposed, for all the world to see her shameful and sordid background. In this way she communicated to me the issue that had not received sufficient recognition in her two previous treatments and the aspect of her sense of self she wanted us to address.

In those treatments, utilizing interpretation and insight, Eileen’s underlying feeling state of being trapped in unmodifiable shame had not been engaged. Perhaps my being short was a blessing in disguise in Eileen’s treatment. It crystallized her somewhat vague, but persistent pessimistic self-state in the therapeutic ambiance. It became manifest and directly engaged in our transference-countertransference. Thus, my recognition and articulation of this issue directly impacted Eileen’s experience of herself in relation to me and fed into a gradual increased sense of hopeful possibility both in her conscious awareness and her underlying affect tone of pessimism and shame.

But there was more. There was yet another aspect to the sailor suit. Some of the men her mother brought home were sailors. For Eileen, sailors were men who were here today and gone tomorrow. The sailor suit thus also referred to the unpredictability and the unreliability of men, beginning with her father who abandoned the family. The sailor suit covered the instability of the world in which Eileen grew up.

As we explicated these various themes, the underlying ambiance with which Eileen had lived became clearer. I spelled it out as

there is nothing firm, nothing I can count on. I have to find someone who can provide that for me or I have to provide it for myself. But anyone who could provide me with that stability is out of my league. So that is hopeless.

These diverse feelings added up to the underlying anxious tone that Eileen brought into her social relationships and her therapies.

As we articulated what had been the ever-present underlying ambiance that provided a backdrop for Eileen’s experience, her view of herself gradually shifted. Her clouds of identity began to come together to form a new cloud. Spelling out the myriad of feelings that Eileen had retained from her childhood experience and her determination to find a life for herself that would both conceal and eradicate that experience were reconfigured as these were my experiences and challenges. I have worked hard and succeeded in making a better world for myself than the one in which she grew up. Thereby Eileen could begin to access experiences that contained her resources and strengths, experiences that had previously been denied access to her self-organization.

Eileen was also determined not to follow the example of her sisters, who pretended not to notice their surroundings, the squalor of their home. She was determined not to exclude what her sisters were determined to pretend did not exist. Her younger sister lived in a world dominated by her drug addiction, and her older sister with the “rich” boyfriend looked down on her family as though she had never been part of it. Eileen prided herself on being truthful and not “pretending.” But doing so came at a price. When we explored what prevented her from including the resources and abilities that she possessed, she brought up another dream image:

I hung my white coat [the one she wears at the hospital] on a hook in the closet at the hospital where I always hang it. My coat dropped to the floor and fell on the winter boots there. It got all dirty splattered with snow and mud.

The dream sounded an alarm. Keep your professional life away from the dirt of the outside world; it will sully what you have achieved. She needed to keep her resources apart from her history lest, by including these strengths, they could become tarnished with the messes of her childhood home. By keeping her academic and professional accomplishments apart from her sense of self that remained organized by her childhood shame she attempted to keep her resources unsullied by a past that left her shame ridden.

Shortly after the session in which we worked on the meaning that integrating her resources with the sense of self derived from her childhood, Eileen arrived for a session in a very, very revealing blouse. I was in a dilemma now. I did not want to embarrass her or make her feel self-conscious, but I also did not want to ignore this nonverbal but obvious communication to me. I gave her an obvious affectionate smile, laced, with just a touch of lust. She smiled back at me. And that was it.

In the course of the session that followed, Eileen indicated that she was not going anywhere special after the session, suggesting that the blouse was meant for me. I heard this as her appreciating that I responded as subtly as I did. She was also signaling me that the blouse represented some pride and acceptance of her feminine and erotic sense of self. And, indeed, I could see that she was showing me a fractal of much that she was proud of.

Looking back on Eileen’s therapy, bringing these divergent and until then bounded aspects of her sense of self together - the childhood history and home life, the professional and academic world in which she also thrived, and her sense that she was proud of her physical appearance -resembled the merging of the cloud formations that were bounded as well as possessing open boundaries.

At long last Eileen could also begin to feel a sense of pride in her achievements, struggles, and accomplishments without fearing that they would be tarnished in the process

In our work on this shift, we continuously came up against Eileen’s fear that she would be thrust back into her childhood world and lose her accomplishments. In this fear we recognized that she had actually now begun to value her achievements and that the newly organized sense of self had begun to absorb her past and recent achievements and strengths. I said to Eileen that you can’t worry about losing something that you don't think you have.

Eileen’s sense of herself was co-constructed in the context of our dialogue. Her trust that I saw her - the competent doctor, the attractive woman with a sensual body - and not her sordid past led to a shift in ambiance between us from pessimism to hopefulness and trust. We brought together images and recollections that appeared in different sessions as well as from different times in her life: the rag-like clothes and the unkempt home of her early childhood, the “encouragement” from her mother echoed by her teachers from her puberty years, as well as her ambitions and intellectual resources that she had disregarded both to protect them and not to join her sisters since she considered them as demonstrating her fraudulence. The spirit between us gradually took on a joint quality of seeking, of inquiry, of shared feelings (twinship) that was reflected and responsible for shifting the underlying affect tone from shame to pride and from pessimism to optimism.

One’s identity, like one’s sense of self, is organized along a temporal dimension. By bridging past and present experiences and future expectations, Eileen integrated previously sequestered experiences that reflected aspects of herself that could accrue to a cohesive sense of self. Furthermore, this integration enabled us to understand the image of the tiny analyst figure as a depiction of Eileen’s self-consciousness about being so tall and her longing from childhood to be one of the cute, cared-for girls. The image contained both her fear that I would not be big enough to help her as well as her wish to become a “small and cute” person as she had always wished she could be. Perhaps the “cute” analyst could help her become a “cute” patient? At the end, she felt the cute analyst could accept her as a tall woman, and that she had not been feeling like an ungainly boy was revealed by her blouse.


Jaobson, E. (1967) The self and the object world. Madison, Ct.: International Universities Press.

Lichtenberg, J., Lachmann, F. and Fosshage, J. (2011) Psychoanalysis and motivational systems: A new look. New York, NY: Routledge.

Chapter 3

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