Theo Kaminski
Recurrent self-harm, intense mood swings, and a pattern of relationships that begin intensely and end catastrophically.
The case that tests whether a therapist can hold a frame under pressure without becoming cold.
Referral
Referred from the community mental health team after his third emergency department attendance in four months. He has had two previous courses of therapy: six sessions of CBT ("useless, she just gave me worksheets") and four months of counselling that ended when the counsellor went on leave. He describes the second therapist as "the only person who ever got me" and has not contacted her since.
History
Cutting since fifteen, currently one to three times a month, to his forearms, typically after conflict or perceived rejection. He describes it as "the only thing that turns the volume down". Two overdoses, at nineteen and twenty-two, both after relationship endings, both requiring medical treatment; he describes the second as "not really a proper attempt" while also saying he had written to his sister beforehand.
His relationships last between three weeks and five months and follow a consistent shape: rapid intensity, a period of certainty that this person is different, then a trigger — a delayed reply, a cancelled plan — and a collapse into conviction that he is being discarded, followed by behaviour that brings the ending about.
He drinks heavily at weekends and uses ketamine occasionally. He has moved home after losing a flatshare. He is funny, quick, and very good at reading a room; within ten minutes he will have worked out something accurate about you and said it.
Developmental
His mother has a long history of depression with two hospital admissions during his childhood. He describes learning early to monitor her state and to manage it. His father was largely absent and is described with a flat "he’s fine". There is no disclosed abuse; there is chronic invalidation — a household in which his own emotional reactions were consistently treated as excessive and mistaken.
Formulation notes
The biosocial account
Linehan’s formulation fits closely: a biologically based emotional vulnerability — fast to react, high amplitude, slow to return to baseline — meeting a pervasively invalidating environment. From that transaction follows an inability to trust one’s own emotional responses, oscillation between inhibition and extreme expression, and behaviours that work brilliantly in the short term at enormous long-term cost.
| Behaviour | Short-term function | Long-term cost |
|---|---|---|
| Cutting | Immediate reduction in unbearable affect | Scarring, shame, escalation, hospital contact |
| Rapid intensity in relationships | Relief from emptiness; certainty | Sets up the fall |
| Testing behaviour | Resolves unbearable uncertainty | Produces the abandonment it fears |
| Alcohol and ketamine | Escape | Disinhibition, raising self-harm risk |
The mentalization account
Under interpersonal stress his capacity to hold minds in mind collapses. He moves into psychic equivalence — what he feels is simply how things are, and the therapist’s neutral face is definitive evidence of contempt. The MBT target is not insight about the past but restoration of mentalizing in the moment it fails.
Sessions with this person
Your formulation
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