2.2. Case Formulation
Michael’s mother was angry and dominated the family through verbal intimidation and unprovoked rages. He was physically abused by his mother from his preschool to early adolescence for the slightest infraction of house rules and inevitable behavioral slip-ups such as spilling milk at the dinner table. His father was disengaged and distant and did not protect him or his sister. He believed his mother intensely disliked him but did not think this was necessarily related to his being gay. He coped by ignoring the problems at home, avoiding his mother’s attention as much as possible and saying as little as possible. Michael was careful to cover up his attraction to boys. He dated girls and kept an emotional and physical distance from boys. He had superficial friendships with schoolmates. He did not share anything about his home life, his fears, or his sexual feelings. Being unseen and unheard protected Michael in his early years but ultimately led to him feeling like he did not really know who he was or worse, that he really did not have a “self.” If asked, he could not have described who he was in any authentic way. He had no ambitions other than a dedicated drive to leave his family home as soon as he could.
Following high school, Michael obtained a job as a fact-checker at a San Francisco newspaper and moved into the city. He was surprised and energized by the presence of a gay community and unexpectedly found himself falling in love with a mentor. They moved in together and Michael began to blossom. Drew, his partner, was his first love and a positive role model as a gay man: confident, gregarious and active in the community. A couple of years into this “perfect life” the AIDS epidemic came full-force and Drew died. Many others in the gay community became sick and died as well. During his therapy, Michael stated that this short period of happiness was also the source of all of his unhappiness and anger. He was angry at this turn of fate, stating he’d rather not have gone through this period than to know happiness and then have it taken away from him.
Drew’s death made him feel that he did not deserve to be loved. Irrational though it was, he felt abandoned. He felt unloved and unlovable, a belief that had been instilled in him during his childhood. His losses left him with deep and enduring feelings of inferiority which were expressed in his anger and his social isolation. He also developed the belief that there was no point in having loving relationships: they only led to loss.
Michael had initially been shocked by the hostility towards the gay community at the height of the AIDS epidemic and the callous, dismissive attitude towards the suffering and deaths of so many. Later, his personal losses stoked an anger that was at first directed towards social injustice but which eventually generalized to almost all social interactions.
By the time that Michael had entered therapy, the many traumas of Michael’s adulthood had resulted in the reinforcement of the old coping strategies from his childhood abuse, namely social withdrawal and emotional numbing. Along with these came the addition of chronic anger and expressions of hostility and disappointment towards everyone with whom he interacted.
In treatment, he talked a lot about straight culture and straight people with a strong focus on negative dynamics between gay and straight communities stating “We are under attack, they are trying to exterminate us.” The emergence of the COVID epidemic heightened these beliefs. He saw himself and all minortized people as without power, ignored and dismissed by the dominant culture and consequently at increased risk for illness and death. Michael would blow up at instances of discrimination and micro-aggressions. While the anger was justified, the intensity of his reactions left him feeling exhausted and bad about himself. He wanted to be able to hand the chronic minority stressors he experienced in a better way.
There were times when his anger biased his interpretation of neutral situations or created barriers to his intended goals. For example, he’d been at a clothing store and took some time considering his purchase. When he paid for the item and the cashier concluded with “Have a nice day” he could not help but reply: “Oh, you must be happy to get rid of me.” He received feedback from his support group that he was so angry that people were having difficulty supporting him.
Michael was motivated to try the STAIR Narrative Therapy program for many reasons. He felt angry much of the time and bad all the time. He wanted to feel better emotionally. He did not feel he had a purpose and questioned why he had survived. He wanted to have a place in society. He was lonely and wanted to have some social connections but at the same time experienced other people as emotional triggers, who were threatening him or putting him down. The social isolation had left him profoundly unhappy. He wanted to have a relationship without pain.