When a patient consciously intends a particular outcome and a different, unhappy outcome occurs from their action, it is always vital to investigate whether or not the unintended consequence was an accident or was unconsciously determined.
Early in her treatment a young woman patient who consciously was highly committed to therapy, was rushing to get to her appointment on time yet ended up missing the appointment because she had been involved in a minor car accident. In the following session, she explained that she had pulled out of her garage (in the building in which she lived) and when she pulled into traffic, a car hit her from behind. She hadn't seen the car and while upset at missing her session and by the accident, dismissed its significance with an airy, "accidents happen." Therapeutic tact dictated that I approach the incident with some care.
I reviewed what I knew about this young woman. She had entered therapy because she was depressed by her chronic failures in relationships. Men tended to take her for granted and treated her poorly. She often "forgot" appointments and dates and then would express surprise at the ensuing diminution of interest by whichever man she was dating. I also knew she was underemployed; she was very bright but could not keep a job for long, in part because she was disorganized in her work, tended to be late with assignments, and often forgot meetings.
In terms of her back ground, she came from a well-to-do New York family with a "brilliant", idealized Father and a devalued "hausfrau" Mother. Her brother was a successful lawyer and she was "only" an assistant in an advertising firm. Additionally, her father paid her fee and she had agreed to be responsible for paying for missed sessions (a usual arrangement.)
What could all this possibly have to do with a car accident?
Over the course of several sessions, we were able to discern an interesting sequence of events. The night before her missed session (which was an early morning appointment) she had dinner with her parents. She had found her Father to be somewhat overbearing, but was unaware of any particular reaction on her part. She didn't like all his questions about what was going on in her therapy but understood he had the right to ask since he was paying for it (sic). She was annoyed at her Mother for being obsequious toward her Father but this was an old story. At the same time she was on shaky ground with her job; her boss (a man about her Father's age) had mentioned they were happy with her work but reminded her she had to make a better effort to get into work on time. She was certain she set her alarm extra early the morning of the accident but overslept, probably because of the second glass of wine at dinner the night before. However, when she checked her alarm the next morning, she discovered it was in the "off" position. She recalled rushing to get to her car and speeding up the garage ramp; she "probably" did see the car out of the corner of her eye, but thought it was far enough away that she could slip into the street; she was wrong and had the accident.
There was enough in her description to lead us both to question what had happened. There were also more clues that the "accident" was over determined. In her therapy she had been pleasant and thoroughly compliant with all my recommendations. She had originally been referred for Psychoanalysis, but in my early evaluation I had felt she was not terribly curious about herself and her willingness to enter an intensive treatment out of compliance with an authoritative recommendation rather than an internally driven discomfort, didn't auger well for such a treatment at such a time. I recommended a twice weekly exploratory Psychotherapy to help us both clarify whether or not a more intensive treatment would make sense and we were in the early stages of our work.
With all this in mind I explored with her the dinner with her parents. She revealed for the first time that she had wanted to see a female therapist but her Father had insisted on a referral to a Male Psychiatrist. She volunteered that this had not made her angry and though she been worried about being able to work with me felt things were going pretty well. I mused aloud that if she had been angry at her Father at dinner, a second drink might have seemed like a good idea to help her stay away from her anger. She agreed that a little anger might have been appropriate and then suddenly recalled the dream she had on the night in question:
She was with her older brother and they were playing a board game. He accused her of cheating, threw the board over, and punched her; the punch woke her up and she noticed she had overslept.
Her initial association was that she might have been cheating; when they were children and played together she often cheated. Her older brother knew she cheated and tolerated it with good humor; he had never hit her.
I wondered who was angry with whom?
Over the next few weeks we learned that she was only compliant on the surface; she had successfully managed to keep herself unaware of how enraged she was at so many of the people in her life, her overbearing Father, her nasty boss, her rejecting Therapist (recall I was only meeting with her twice a week, not the four times she had expected), her passive Mother; interestingly, the only one she wasn't furious with was her brother. She realized that the second glass of wine, very unusual for her, had calmed her at dinner. In her therapy I had been exploring her relationships and she was only beginning to realize her inner life was not as placid as she liked to believe. Finally, even with over-sleeping she had enough time to get to her session, but had been so blinded by her anger, she had raced out of the garage; in fact, this was not the first car accident she precipitated by risky behavior. With a mixture of anxiety, anger, triumph, and wistfulness, she realized she had used her anger to hurt everyone!
She hurt herself by endangering her life, her car, her job, and missing her session.
She hurt me (in the transference) by "standing me up."
She hurt her Father by making him pay for a missed session.
She hurt both parents by hurting herself, the repository of so many of their hopes and needs.
As to the question of whether or not her unconscious caused the car accident? It is impossible to know for sure, but it is clear that her unconscious mind created the conditions that made the car accident extremely likely. Further, the unconscious anger and resentment was surfacing through the work in her therapy and would have made itself manifest in one way or another before too long.
My point in this post is that many unintended consequences (such as this patient's car accident) are anything but "accidents." I think this is a useful rubric and will try to extend it in tomorrow's post.
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