Creating the therapeutic alliance

In February 2002 – let us stress that we are in the middle of the country’s economic, political and social crisis – Horacio comes to consult me. He is a man of 60, heavily built, his face flushed, anxious, his breathing labored, with movements that betray extreme tension.

“I am doing very badly, the company has gone under, it is “bankrupt,” I have no credit left, a debt of six million dollars, impossible to pay, I have no reserves left, I do not know what I am going to live on!

I have to support my ex-wife and my two children (Alberto, 30, and Andrea, 28) who work with me in the company. My younger brother has also been working there with me for years.

In the company (food products), there are about 60 of us, workers and administrative employees together. What are they going to live on? They are all going to end up destitute! In the state the country is in, where are they going to look for work?!

You will not have any work either. Who is going to pay you for your consultations? The country is bankrupt!

I came to see you because my children and my friends insisted, but you will not be able to help me. What I need is money; are you going to give me any? What you are going to say to me will not solve my problem, my business is very concrete: my main creditor is petitioning for my bankruptcy, and that is the end of it, there is nothing more I can do, I am ruined.

I cannot be any worse off.”

I intervene here and say to him:

H. Fiorini (F): “I do not know how we will be able to approach the concrete problems you have, but in a crisis this intense, we must first do something: help make sure it does not get worse, that you do not fall ill. One can always be worse off. I see you as very tense, agitated; I imagine you must be neither sleeping nor eating properly.”

Horacio (H): specifying:

“Absolutely. I have great difficulty falling asleep, I wake up every two hours, in the morning I cannot get up, and I eat very badly, I do not look after myself; I ought to lose weight, I have high blood pressure or am just on the borderline, I stuff myself, I get indigestion, my liver is in bad shape; look at me: a real disaster.”

I add:

F: “That is exactly why we first need to deploy measures to take care of your health, improve your sleep, your diet. You are very worried about your company, but attention must also be paid to caring for your own person.”

H: “Yes, I also let myself go because I had a partner for three years; for me it was fantastic, a joy, and I lost her four months ago. We got on very well and she did not want to help me obtain bank credit. It was normal for me to ask her: she is connected with bankers, her ex-husband was in finance, she has a certain fortune. She did not want to take risks, she did not want to burn herself in her circle, she got angry with me, she moved away all at once and stopped calling me, knowing full well what I am going through. That finished the job of sinking me; I cannot believe that, for the sake of interests or of a social image, such a good relationship could have been lost. I was very fond of her children, and they were very fond of me. Now I think she did not love me, if she could move away like that, in such a violent way. I miss her enormously, I cannot believe it, I do not know whether I will be able to bear this loss, it is sinking me; I need courage to fight and I remember her, who disappeared just like that, all at once; I despair and I cannot manage to go to work.

Nor can I believe what is happening to my company. I have always succeeded, I have earned a lot of money, I gave my family a life of luxury, and now… it is unbelievable. I have no means left to fight with, I have nothing left to hold on to in order to get out of this hole!”

Here I intervene again:

F: “Listen, you are now bringing up other matters in your life, which are added to the concrete problems you mentioned a moment ago: they are your affective states, because of this partner you have lost, and whom you may miss all the more because you need her. And a problem with yourself, since you have been used to succeeding and you will not know how to accept that it is you who has fallen into this bankruptcy. You are setting out several planes of problems to be dealt with.”

H: “Yes, I am furious with everything, with myself too: how badly I managed all this! The recession began and I did not cut back on spending, I took out credit and I went on investing in the company, I made terrible mistakes. I was an idiot and I cannot forgive myself for it. It makes me feel very bad.”

F: “So, in addition to all the financial problems, there are those of your state of mind: your anger, your uncontrolled impulses to eat, your pessimism, because you see no way out. We can deal with all of that too: think about it, clear up what is confused for the moment; that is what we could do together.”

Horacio makes a gesture as if to say that he understands the proposal, though without enthusiasm, as if he regretted having to consult; but he agrees to come twice a week.

My interventions aimed at creating the therapeutic alliance: for that, we must share the goals of the therapy and, among other things, make clear the meaning of the proposed task. Faced with the despair proper to this moment of crisis, it falls to the therapist to offer an alternative of hope: it is possible to work on a state of uncertainty, of chaos and of desolating losses; even there, at the bottom of that well, psychotherapeutic work is possible.

Second interview

In the second interview, two central questions stand out.

H: “What drives me most crazy are the calls from my ex-wife, in tears, desperate, with no money for her immediate expenses. And I have nothing to give her. That depresses me even more: I met her when she was 21, she had no father, her mother did not look after her either, I have always protected her, including when we separated. She has never lacked money for her expenses, and now, how am I going to leave her without protection? (He weeps.) That distresses me enormously. She calls me six, ten times a day, and she does not understand that I have no money, she does not accept it.

My children and my brother also call me continually. They all expect a solution from me. If I do not find it, nobody can do anything. Logically: I have always been the one who directed everything, I have always been able to face everything, and there have always been difficult times.

I founded the company 25 years ago, there have been many ups and downs, but I always managed, I always invented ways out. Now I am destroyed. And they are asking me for solutions. They put pressure on me, I hang up on them, I tell them to go to hell, they despair, they insist, we argue continually; that too pushes my blood pressure up.”

I take into account the two questions raised and I decide to explore what is happening with his ex-wife, who does not accept as real the critical financial situation he is going through. We are also going to explore what the communication is like between him, his children and his brother: at what point they fail to understand one another, and see what is hard to understand. We are going to clarify whether anyone has an idea for a way out, whether he alone can have one, and what to do if he does not. In this interview it is very difficult for Horacio to add anything that might give us an element on these questions.

H: “I do not know, I do not know; my wife accepts nothing, I tell her to look for work, she says that is impossible for her, so she keeps demanding money from me, she will not listen to reason.

My children and my brother, the same: they want me to give them the solution, or to step aside and let them do it; but what are they going to do, since I am the director? They cannot; if I cannot, nobody can. And my head is destroyed: either there is no solution, or the solution simply does not occur to me, I no longer know what to think. There are days when I do not even go to the company, I do not get out of bed; just thinking that I have to go there is a nightmare, I shrink, I go soft, I do not recognize myself, I who have always fought.”

The patient reports the signs of a state of anxiety and depression that has already lasted several months, since the middle of the previous year. The signs of a crisis which, if it finds no way out, tends to worsen over time and to damage his health.

From the 4^th to the 6^th interview: medication and sessions with the ex-wife

Around the fourth interview, I consider putting him on an anxiolytic at moderate doses, because I observe that his anxiety, his tension, his sadness and his confusion enormously limit his capacity to associate and to work through the multiple conflicts and sources of anxiety that have reached crisis point in several areas of his life. I discuss it with the general practitioner, and it is he who prescribes the treatment. The patient agrees and begins to take the anxiolytic (alprazolam, 1.5 mg every 24 hours). Let us stress the risks of not medicating when, for months, the organism is subjected to enormous stress that inevitably leads to neurovegetative, metabolic and hormonal disorders, with predictable circulatory and digestive repercussions.

In the six following interviews, the panorama undergoes no variation. Horacio persists in setting out the same problems in the same way. My interventions aim to open up reflections on the situation. He has great difficulty thinking about it, and he adds some information: his lack of foresight also consisted in leading a lifestyle with enormous expenses – constant trips for himself, his partner and the whole family, luxury cars, weekend houses and very expensive consumer goods.

H: “I was convinced that I would always be able to afford the good life; I was wrong and I cannot forgive myself for it.”

Everything suggests that Horacio lived in a manic and omnipotent style, sure of producing large profits and of being able to allow himself limitless spending. This corresponded to a stage of the economy in which the exchange rate sustained, for large sectors of the bourgeoisie, an omnipotent fantasy of wealth in an underdeveloped country.

My interpretations of this behavior do not seem to reach him; he responds by shifting to another, more immediate plane:

“What do I say to the creditors? Neither the lawyer nor the accountant is helping me in any way. My ex-wife and my children calling me, so that I do something; and I am going crazy: what are you going to tell me?”

In the sixth interview, he focuses on the suffering caused him by his ex-wife’s calls. He speaks a great deal about how desperate it is for him not to be able to protect her; he has always played the role of a father for her, and she still demands it of him today.

He shows me the letters she sends him daily, in addition to the calls.

I propose to him that, if they agree, I receive her for an interview, or see them together. He prefers her to come alone, he does not want any more arguments about money. She agrees and I receive her two days later. She is indeed very worried about her economic situation. She brings information he had omitted: at the time of their separation, a division of assets should have taken place. What was at stake was the company’s capital; he had proposed to her not to divide it and promised her monthly withdrawals for life. She was examining this with a lawyer. She also had doubts about the bankruptcy: he might be exaggerating so as not to pay her; she talked about it with her children and they gave her no convincing answers. I suggest to her that, if she is examining the situation with a lawyer, she suspend the daily calls for a few weeks, until Horacio’s treatment allows him to consider the problems with the capacity to think about them and to provide fair answers. I add that there may have been a mistake on her part, that of having accepted verbal arrangements instead of proper contracts; a mistake she acknowledges.

From this interview onward, the manner and frequency of her demands changed: they became less emotional and more precise. Having been listened to must have mattered to her. For me, knowing her, knowing her position on the problem as a whole, was different from imagining her on the basis of Horacio’s account alone.

Horacio and the interview with his children and his brother

In the following session, Horacio focused on the conflicts with his children and his brother. The misunderstandings continued, and so did the telephone arguments; he did not want to see them in person “because they hurt him more.” They did not know how to help him, they did not know whether, now that he was in treatment, they should let him isolate himself or try to accompany him all the same. They told him they wanted to consult me. I proposed a meeting with them.

The interview allowed each of them to set out their concerns, their view of the company’s problems and their ideas for facing the crisis. A debate was opening up.

Horacio disqualified every proposal that sought a way out: he had already thought of it and discarded it. Within this debate, I perceived a group situation that seemed to me necessary to interpret. They did not know what to do with this leader, the founding director of the company; they wanted him to let them act, to step aside for a time, but that brought them guilt and the fear of contributing to depressing him even further. They considered that he was paralyzing them, that he was swallowing them all up in his paralysis; and at the same time they feared being unfair by marginalizing him.

As this situation became possible, viable, I proposed to them a plan of immediate action, for two weeks. They would not speak to one another every day; the days when he did not go to the company, they would accept as “sick leave” that he was taking. Each would work in the sector of the company for which he or she was responsible, according to their own initiatives, which would be explorations of possible ways out, and not “solutions” to be justified. Afterward, they would be evaluated together.

The cooperative: a shared proposal for change

The second family interview once again involved misunderstandings, confusions and clarifications, but in a climate of less tension. Horacio’s brother was meeting with the whole staff, sharing the worries and the plans of action. Horacio, for his part, could not call the staff together: he was emotionally very caught up in having “failed them and now leaving them without work.” People were beginning to accept that someone else might do what was impossible for Horacio.

At a deep level, what they all had to face was an experience of castration, operating on a history of omnipotent leadership. In the individual interviews, I work on this central interpretation. I do so from an empathic closeness, with the pain that everyone is living through on account of the losses and falls that the crisis has brought to each of them. That pain is not foreign to me: we are living it as a society. It also matters to understand what is singular about this group’s pain: they are witnessing the fall of a mythical being, a nurturing father endowed with unlimited powers.

Twenty days after our second group meeting, Horacio’s brother brings a proposal he has worked out with the whole staff. They would take charge of the company by forming themselves into a cooperative; they would draw no wages until it was up and running again. This was the appearance of an original model: it became effective and spread to many companies that found themselves in similar conditions of shutdown. Horacio was able to accept the proposal; he stressed that it would never have occurred to him, he thought that, under this plan, he would cease to be the owner but that he could sell the company’s products and live on his commissions. His state of mind improved; his anxiety had decreased over the past month.

The children’s fear, made explicit at the second meeting, was that the father would sabotage a way out that would not take place under his direction; we paid attention to this risk. He raised minor obstacles, but essentially he tolerated the changes, he was able to accompany them. My attention focused on the process of tolerating changes that come with losses, essentially the loss of a magical role held for years. I frequently interpreted the difficulties in assimilating this process; I underlined to him that, in his internal world, the conflict at stake was between tolerating the changes that circumstances imposed or resisting them. Sometimes he assented in silence, with a contained rage, huffing, but also slowly understanding the excess proper to his risky behavior, careless with regard to his economy, which he had turned into a way of life.

In the following sessions we worked on the various anxieties mobilized, the precautions to be taken, his resistances to tolerating the losses.

I come back to the moment when Horacio finds himself facing the plan the staff had worked out. It was a key moment: this was something that did not come from him. Horacio received the idea with surprise:

“It would never have occurred to me; if they can do it, it would be a solution, at least an attempt, since there are heaps of problems.”

He expresses it with doubts and a certain caution.

The negotiations moved forward; they took a legal form that was pioneering and that afterward spread to many companies in the country that found themselves in similar conditions: the staff leave the debt in the hands of the owners and undertake a new stage of production and marketing for which they themselves are responsible, drawing pay only when sales allow it. When this reorganization appeared viable, Horacio came round to the idea:

“I can be a salesman for this new company; I will earn little, but I can live.”

He was able to adopt this behavior, which presupposes a deep movement: being able to leave the role of owner and take that of one member among the others, together with the whole staff.

A new partner and the end of the treatment

Four months after the beginning of his consultations, Horacio met a woman at a dinner; he found her attractive, he went out with her and started a relationship:

“I made my situation clear to her; what matters to me is that she is a simple person, she is not approaching me out of self-interest, and that is what I need now.”

The relationship consolidated; it proved very stimulating for them both. The improvement of his morale and the decrease of his anxiety were evident. He began to make the planned sales. The bankruptcy remained in the hands of the lawyers; the debt was converted into new values in pesos. They negotiated deadlines to repay it over six years; he estimated that, with a normal flow of sales, the company would be able to pay it.

Eight months after the beginning of his consultations, Horacio proposed to end the regular treatment and to hold periodic follow-up interviews; we carried them out: four in nine months showed a stabilization of his changes.