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The core issue in this clinical material is termination, moving from online to inperson (co-present) meetings.
Pauline's early life is rife with complex cumulative trauma in which conflictual attachment issues were prominent features of her underlying developmental psychopathology. This is her first session returning to the therapist's consulting room (after 16 months online due to COVID-19) with only two months left of NHS short-term in office psychotherapy. The patient cancels the first return session due to ‘illness’ (a somatic defence and a test of the therapist's will?). The therapist believed this was resistance and that the patient was using somatic illness (the patient's first line defence to avoid conflict) as an excuse and so the therapist refused the patient's request for another Zoom session, for good reason. The therapist believes that only in-person (co-presence) will allow a successful termination to take place.
Throughout treatment Pauline lived with her nuclear family (parents and younger brother) in close quarters. She experienced her father as enraged, dangerous and absent emotionally. She has a younger brother who is developmentally impaired and aggressive and has no boundaries, often bursting into her room and destroying her property. Her mother was described as withdrawn and unprotective. Pauline hates mother for not divorcing father and protecting her children. Pauline's response to the cumulative developmental trauma was to withdraw, shut down, be passive and develop somatic distress and restrictive eating. In high school she was also bullied for being overweight. According to the therapist she ‘developed an extensive list of psychosomatic symptoms which we have gradually come to understand as reflecting the damaged and fragmented state of her internal world’.
Pauline's history is consistent with Mucci's (2018) notion of someone with a ‘borderline body’, using primitive somatic defences to avoid separation. Her living situation at home (descr