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The background information reveals a very disturbed young man, with a serious history of mental illness, self-harm and suicidality. Nevertheless, he is able and functioning to the extent of having completed a university degree in mathematics and trained in accountancy. He seems to be in a demanding job, which he appears not to be managing very well.
The description of what it is like to be in the room with him sheds light on the patient’s defences: flippant humour to deflect any serious thoughts and the use of language to create a barrier, rather than to communicate. The patient reiterates: “nothing in my mind” or “nothing else”; does he have to keep his mind empty or induce the therapist to fill it for him? The empty or convoluted talk mentioned by the therapist raises the question of what that might mean for the young man: is he afraid of letting anything in, including his own thoughts? There seems to be a deep-seated anxiety about engaging in an analytic intercourse, of being penetrated by the therapist; the analytic dialogue conveys superficiality and flatness; there is a kind of externality that perhaps suggests fears regarding homosexuality.
The destructive and scathing thoughts he expresses towards others also serve defensive functions and reflect some destructive aspects of his relationship to himself.
The therapist evokes aspects of the transference relationship: awareness of being with a disturbed and disturbing patient, the experience of the patient’s flight into excitement characterised by fantasies of doing violence to others, risk-taking or self-harm. The patient’s desire to shock or unnerve the therapist with these graphic accounts reveals his aggression and a perverse wish to engage him or her in an exciting way. Together with his undermining and mocking response, the patient reflects a wish to keep his therapist under control and at a distance. According to the present account, he has said little about his parents and sibling or about important relatio