I will attempt to use Richard Chessick's five "channel" model of conceptualizing Otto.
1. There is sufficient material to view the patient as replaying the Oedipal conflict with a rejecting mother who nonetheless "preferred" father over son. The suggestion of oral sex as an important determinant of Otto's problems will give rich material in future sessions. His hands itching suggest a conversion symptom worthy of exploration.
2. The object-relations model for understanding sounds almost classic Fairbairn formulations of "exciting mother." Otto also reports (after the hospitalization) about his mother not wanting him and trying to abort. My, the supressed rage Otto and his mother must have felt toward each other. If Fred is a recapitulation of his father, the rage is palpable here also, "beat up the guy and throw himself under a bus." Also the recollection of his mother beating his until his face was covered with blood suggest much in the way of child abuse. Sad. His response to the rolling stone question is one of a disturbed object-relationship conceptualization.
3. The self-psychological model of Kohut suggests a fair amount of narcissism. e.g. his expecting Sally to be available to him when he returned from his trip, and not inquiring about her upset. I have found patients with significant narcissism will call therapists from a phone book reflecting, "one shrink is the same as another." I also tend to view his rage toward Fred as rather narcissistic rage.
4. The sociocultural model would have me listen for the significance of the dinner at the "club" and why was Fred at the dinner table if his rudeness was common knowledge? The embarassment to Sally and Otto would likely be a factor in his rage. After all, "what will people think?"
5. The interactional school - Here I won't use Gill's model but will try to view the transactions from a control-mastery model. Patient first contacts Dr. Nathanson and asks to be seen immediately. From the material he presented in the first 35 minutes I would view this as a transference test, Will you contain me when I get out of control?" Then Otto is locked up as in his childhood. It seems he recompensated when Dr. Nathanson shows he can be strong and help Otto control himself. In his discussion, Dr. Nathanson sounds slightly defensive about hospitalizing Otto in a most difficult situation. I am wondering how Otto perceives this. I am interested in Dr. Broitman's conceptualization of this case as I am still rather new to Control-Mastery formulations. I also see severe characterological problems with Otto. I find it interesting that the first thing Otto wants to work on is his relationship with Sally. I think Greenson once thought that men would start with mommy and end with daddy; and that women start with daddy and end with mommy. Norm