Clinical material

Background

Harry is a 24-year-old man. He works as an accountant in large successful firm, having studied mathematics and applied mathematics at university. He was referred for psychotherapy due to increasing concerns, both his own and those of his managers, about his capacity to cope with the pressure of the workload. Having had a positive experience of psychotherapy in the past, as a young adolescent, it was felt that this kind of space might again be helpful to him. Harry has a significant history of mental health difficulties. He started self-harming, by cutting himself, in his early teens, and attempted suicide on a number of occasions, all of which seemed to have been heightened during particular transitional periods: from primary to senior school, college to university and now, once more, as he negotiates the beginnings of adult life.

My first impressions of Harry were of a very bright, intelligent, articulate young man who manages a deep level of disturbance and underlying fragility with a façade of humour and flippancy. He uses his intellect in a very defensive, concrete way, which often disables both of our thinking, using word games or talking in riddles that apparently say something and yet simultaneously say absolutely nothing. This seems to be Harry’s default position. However the humour and flippancy often give way to depressive thoughts about himself and his future. Harry can also reveal destructive and scathing attitudes towards others that appear to mask the more vulnerable, needy parts of himself.

Being in the room with Harry, at the beginning of his therapy, I was very aware of being with someone who was both very disturbed and disturbing. Any fleeting moments of meaningful contact between us such as making links between his behaviour and his feelings, or a collaborative sharing of ideas about what might be occurring for him on an unconscious level, were regularly displaced by perverse excitement about self-harming or risk-taking ac