The Blue Mask: Uncovering the Cause of the Nightmare

Psychiatric TimesPsychiatric Times Vol 25 No 14
Volume 25
Issue 14

Mr V had appeared at our appointment in a panic, after an episode of premature ventricular contractions and a terrifying nightmare. In the dream, he was threatened by a blue, masklike face with white circles for eyes and 2 slits for a nose.

Mr V had appeared at our appointment in a panic, after an episode of premature ventricular contractions and a terrifying nightmare. In the dream, he was threatened by a blue, masklike face with white circles for eyes and 2 slits for a nose. The teeth were large, metal triangles that interlocked perfectly. The mouth was surrounded by barbed wire; the lips, hot and red. If the mouth bit him, my patient knew he would be ripped apart and burned.

What was going on in therapy and in Mr V’s life that might have caused this nightmare? How did the disturbing dream relate to his overeating-a problem now threatening his health? And how did both the nightmare and his overeating relate to the death of his father more than 10 years earlier? To answer these questions, we need to back up a bit.

Mr V was a pleasant, intelligent, businesslike man who was grossly overweight and whose eyes carried the look of a terrified child. He had consulted me 9 months earlier because he was having trouble sleeping. At that time, Mr V had been abruptly terminated from his work as an architect-something for which he had been totally unprepared. His psychotherapy centered on helping him understand and deal with the terror that had burst forth from under a heavy blanket of infantile denial and repression.

Mr V had lived a good life with his wife, with whom he had raised 4 well-functioning children. His equanimity was totally disrupted when he was fired. He began to experience claustrophobia and nightmares, many of which had the theme of anxious frustration . . . he was going to be late for class . . . he was trying to solve a problem at work and did not have the in­formation to complete it. Waking up in a sweat, he would play games on the computer, only to find the nightmare waiting for him when he lay back down. Recently, a beloved cousin had died of cancer, which had increased Mr V’s anxieties about his own death. He missed the frequent phone conversations with his cousin and was terrified that he would not be able to hold up under the kind of agonizing death his cousin had endured. “Helplessness is now my thing,” he volunteered. “I have always felt I could take care of anything: fix the car, the computer, anything. It is hard finding myself helpless in the face of these anxieties.”

Who was concealed behind the mask?
Fast-forward 9 months to Mr V’s “blue mask” nightmare. Whose terrifying face had emerged from under a blanket of oblivion? To be sure, the dream had appeared as we were grappling with Mr V’s weight gain, which had begun when his elderly father died a decade earlier. But there was a layer of trauma beneath the loss of his father.

Previously in treatment, we had been piecing together Mr V’s feelings of abandonment, rage, and guilt when he was 1 year old, after his mother had suddenly become completely deaf and severely depressed. Mr V was able to link this trauma with several other devastating episodes in his life. For example, when he was 9, he had suddenly lost his train of thought in the middle of a speech. A common enough experience, yet his natural self-confidence was permanently undermined. In college, Mr V had been rejected by a Catholic fraternity that he had confidently assumed would accept him. This had shaken him so thoroughly that he barely passed his courses from that point on. Mr V had never fulfilled his professional potential. Commitment to his job had kept this insecure, frightened, and very angry man functioning at a relatively low level.

Mr V had lived all his life with the anxiety that there was something behind him that was going to attack him-that he would be attacked “out of the blue” as his mother had been. As the anger at his mother and the shame he felt about it came into consciousness, he could empathize with her feelings about becoming deaf: her panic and her need to withdraw from the world. Watching his own associations-a process he was proud of-concrete memories began to emerge that revealed his resilience in fighting back at his mother who, he learned many years later, had actually held him responsible for her deafness. Perhaps as a deflection of his rage, he and a friend had made a bomb that they exploded at the village dump. He remembered confessing to a priest that he had said “angry words” to his mother, had called her “a rat,” and had seen her hurt expression. He heard himself standing up to her and shouting, “I won’t!” As our work progressed, the terror in his eyes began to fade away.

I believe that behind the blue mask in Mr V’s nightmare was his mother’s depressed, angry face, which had so terrified him as a boy. It was also his own angry face, wanting to tear and bite his mother for destroying his peaceful existence. But why, then, had the nightmare occurred when we were working on his weight gain, which had begun when his elderly father died?

Filling an emotional void with food
Mr V’s life was now actually in danger because of his weight. When frustrated, he could not resist the urge to fill the emotional hole in his stomach with macaroni and cheese. As our treatment began to process Mr V’s reaction to his father’s death, it was clear that we had entered dangerous territory. Why had his father’s death caused the overeating? Why was Mr V finally allowing the terror of his mother into consciousness by means of the dream?

Mr V’s father dearly loved his only child whom he would often take to work with him and give him tasks to complete. In effect, his father had saved the little boy from “the face behind the mask.” All day long, mother and child had existed in a state of tension, struggling to control their anger at each other. At dinnertime, they stood together at the window watching anxiously for the father’s car to appear. Once dad was home, all was well. They could relax, enjoy their dinner and evening of games and conversation. I believe that the little boy inside Mr V had felt protected from his devouring and destroying mother, so long as his father was alive. When his father was dying, Mr V, the adult, had honored his father’s request to “let him go” by withholding tube feeding.

Mr V, the adult, was relieved that his father was no longer suffering. But the little boy standing at the window-waiting for his savior-father to come home-was terrified. The car no longer rolled into the driveway to save him. Anxieties regarding his mother-heretofore submerged-began to surface in Mr V’s dreams. Literally and emotionally hungry, Mr V began to try to quench his anxiety with food. At the same time, apprehension regarding his own death had increased.

Fortunately, Mr V and I were able to work through these issues in therapy. Having dared to relive the fear for his life when confronted by his mother’s angry face, Mr V had a positive dream. It was his job to insert 2 prongs into something in an assembly line. Instead of the usual frustration, he was successful. He woke with a good feeling. All his life he had lived with a “mangled” mind, but he had not known what to do about it. Now, in therapy, he had found an answer. Memories began to appear of positive experiences with his mother. In a series of dreams, Mr V came to realize that even though his father was dead, he carried his father within himself and no longer needed to be afraid. Our work on recovering his supportive loving relationship with his father reduced the urgency to overeat because he had reestablished his father as a protective strength within himself. In one session, Mr V wept for most of the hour, but these were tears of gratitude for his father’s continued presence. Mr V was a man now, not a little boy.

I was impressed by Dr Young’s report on the Blue Mask patient. It is always gratifying to see the way a therapist can link associations to uncover deeper issues. Dr Young also made her points with no recourse to jargon, just clear and concise analysis. I am curious to know some of the details on the nature of the patient’s transference. Well done.

IN RESPONSE TO DR ROSENBLOOD’S REQUESTDr Young clarifies her views on the use of transference in the psychotherapy of Mr V and gives us a glimpse of the remarkable changes brought about in Mr V’s life, thanks to his treatment.

I think of the therapeutic relationship as made up of 3 parts: the real relationship, the therapeutic alliance, and the transference relationship. With Mr V, the real relationship was vital in putting him at his ease, enabling him to establish a good working alliance. In doing psychotherapy, I was taught to deal actively with the transference only if it is negative or getting in the way. The positive transference, which made it possible for him to relate to me as he did, came from the excellent “working together” relationship he had had with his father, and the first year of his life with his mother before her deafness, as well as fragments of a continuing loving relationship that had been blotted out of consciousness until late in treatment.

As to the countertransference, when I once heard an expression of impending rage, I found myself circumventing it with a personal anecdote. Perhaps, unconsciously, I was afraid the depth of his rage might destroy the therapy. To my surprise, the anecdote became very useful in explaining to him the process of “working through”-of going from intellectual understanding to truely grasping how feelings-aroused by traumatic childhood events-had adversely damaged the whole "feeling" area of his life.

After Mr V dared to recover his rage at his mother for blaming him for her deafness and for using him as a support in her almost psychotic frustrations, his whole world began to open up. Happy memories began to return. He dreamed of his young father in vivid color. One evening he had a remarkable reawakening. The sunset was beautiful, the sky clear, and he experienced an overwhelming sense of joy unlike anything he had ever known. He found himself being friendly, engaging in conversations even with strangers. He hardly recognized himself. He felt like a totally new person.

Soon after Mr V’s third year in therapy, it was clear to me that he had mastered the art of self-reflection. I felt he would soon be able manage his life on his own. One day he proudly told me he had lost 30 pounds-2 “bowling balls” of weight he was no longer carrying around. I suggested we think about setting a termination date.

Shortly thereafter, Mr V reported the following dream: A white cat was hurt, and he could see through the skin that the bones in 1 front leg were completely broken. But as the cat walked along, Mr V noticed that with each step, the leg was a little better. Gradually it was completely healed. He was stroking the cat. When he woke up from the dream, it was his own left arm he was stroking!

I wondered if this dream was a response to my suggesting we think about ending therapy. How had he felt about terminating? He had mixed feelings. He was pleased I felt he had accomplished so much. But he was sad because he would miss me. He had enjoyed talking with me because it had helped him to understand himself. Suddenly he remembered that in the dream, as the cat walked away, it had turned around and smiled! In the process of Mr V’s therapy, the murderous masked face that had set off a cardiac arrhythmia had gradually morphed into a gentle, smiling cat.

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