Background and History JT is a 29 year old male from a middle class family.

He appears rather plan looking and wears causal clothing to each session. He currently lives with his mother as his parents are undergoing divorce. JT is a paraplegic, caused by a motor vehicle accident caused by reckless driving on his part. JTs presenting symptoms include anger, frustration, sexual aggression, social frustration, recurring suicidal thoughts, depression, feelings of worthlessness and emptiness, lack of confidence, fantasies, anorexia, masochism, expressions of compulsive behaviors, attention seeking behaviors, and questions of identity. JT expresses the importance of control. He finds that he needs to control his pain and emotions and feels overwhelmed when there is a lack of control. JT reports that he does not like crying or feeling emotional because he needs to have a sense of control. He engages in masochistic behavior by holding a lighter to his wrist or extinguishing cigarettes on his arm. His self-inflicted injuries display his need for control. He feels that if he can control the amount of pain he is administering to himself then he can control how he expresses his pain. JTs need for control is also expressed through his anorexia. After switching medications JT endured a period of weight gain. He described himself as being overweight and unhappy with his weight gain. From this unhappiness, JT became anorexic. The refrain from ingesting nutrition therefore exemplifies his need for control. JT reports feelings of depression mainly deriving from his inability to find a significant other. Although he has recently had contact with a woman via internet, he claims that she did not have the same level of intellect as he and terminated the companionship.

Diagnosis Axis I: 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic Axis II: 308.183 Borderline Personality Disorder JTs presentation is consistent with the DSM-IV-TR definition of having Bipolar I Disorder, most recent episode manic. This disorder is characterized by having one or more Major Depressive Episodes and episodes are not accounted for by Schizoaffective Disorder and do not superimpose on Schizophrenia, Schizophreniform, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Associated features include suicidal ideation and attempts, violent behavior, occupational failure, irritability, and agitation. JT expresses criteria for Hypomanic Episodes which include: A) a distinct period of abnormally and persistently irritated mood; B) is more talkative than usual, increase in goal-directed activity and has excessive involvement in pleasurable activities that have a high potential for painful consequences; C) his episode is associated with unequivocal change in functioning that is uncharacteristic of the person; D) the disturbance in mood and the change in functioning are observable by others; E) his mood disturbance is sufficiently severe to case marked impairment in occupational functioning or in usual social activities or relationships with others and; F) symptoms are not due to direct physiological effects of substance abuse. JTs presentation is also consistent to the DSM-IV-TR definition for Borderline Personality Disorder (BPD). BPD is characterized as a pervasive pattern of interpersonal relationships, self-image, and affects with marked impulsivity, beginning in early childhood and present contexts. JT demonstrates the following criterion: 1)a pattern of unstable or intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation; 2)identity disturbance; 3)impulsivity; 4) recurrent suicidal behaviors, gestures, or threats; 5)affective instability and; 6)chronic feelings of emptiness. Case Assessment and Plan Hypothesis I: Relationships/isolation

According to existential theory, there are 3 types of isolation, which includes interpersonal, intrapersonal, and existential isolation. Interpersonal isolation refers to geographical, physical, psychological and/or social distance from others (Sharff, 2008). Interpersonal isolation can also refer to a type of isolation that is due to a way of being in relationships which is not satisfying relational needs (Hoffman, 2004a). Intrapersonal isolation occurs when one separates parts of oneself by using defense mechanisms or other methods to be unaware of ones own wishes (Sharff, 2008). This form of isolation results from the splitting of oneself off from themselves and their relationships. This prevents an individual from being fully present in their relationship or with themselves. This form of isolation also connects with the idea of loneliness occurring from a way of being in relationship (Hoffman, 2004a). The third type of isolation is existential isolation which is being separated from the world. When one is confronted with death existential isolation becomes powerful since the individual will typically question the meaning of their life. The feeling of being totally alone and helpless creates feelings of nothingness. Since JTs accident was severe and life threatening, he demonstrates existential isolation. Since existential isolation becomes more powerful after being confronted with death, JTs behavior of questioning the meaning of his life and his worth is consistent with existential theory. Along with questioning the worth of his own life, included is the relationships he has with other people. His lack of an intimate relationship may be a root of his depression and lead to questioning his own identity and worth. Since he does not have a close relationship, even a platonic one, he feels that his life is empty and worthless, causing existential isolation. His feelings of being alone and helpless thereby causes feelings of nothingness. Not only is JT existentially isolated, he is also demonstrates interpersonal isolation. He is physically isolated since his mobility is hindered and limited and he is socially isolated since he lacks the ability to cultivate relationships. His irritability and frustration creates a social gap, inhibiting others from getting intimate with him. Therefore, JT lacks intimate relationships and experiences feelings of worthless ness and emptiness feeding into his depression. Hypothesis II: Dreams/Fantasies

According to existential theory, dreaming is a mode of existence in the world. Dreams have events that are not connected and are special for the dreamer: they are openings to understanding the dreamers being. The existential-phenomenological emphasis opens channels of conscious awareness that enable people in therapy and in everyday living to awaken to their own visions, hopes, and dreams. The individual consciousness comes to light in therapy and in dreams and invites selfresources and self-directions for change in self-growth and in significant relationships. (Sharff, 2008). JT manifests his desires to be dominated through his fantasies. By having fantasies of a muscular woman dominating him, JT also reflects his attraction to control. Although, in his fantasies, it is not he who contains control, the element is still present therefore highlighting his attraction to control. His desires of a strong, muscular woman who is dominating may also be a reflection of what he hopes to be like. But since he is handicapped, these desires may be manifested through other beings in order to replace his personal aspirations. JT may also be expressing his emotional attachment to his legs and feet through his foot fetish. His foot fetish had not developed until after the motor vehicle accident which caused the paralysis in his legs. JT reports fetishes involving a woman with big stinky feet walking on his back barefoot. Although he cannot feel his own feet, his developed foot fetish may be an expression of his emotional attachment. He may feel like he appreciates feet more now that he cannot use his own and project his appreciation through his fetish. His fetish may therefore reflect his aspirations of limb usage in order to attain self-growth.