July/August 2008 Issue

Therapist’s Notebook: Case of Taylor
Social Work Today
Vol. 8 No. 4 P. 24

Social Work Today presents a case vignette with input from three social workers—a case presenter and two discussants who offer their insights on the presenting problem, background and family history, and the initial phase of treatment.

Case of Taylor
By Marlene I. Shapiro, LCSW

Presenting Problem
Taylor is a 49-year-old Caucasian female, never married, with no children. She has experienced episodes of major depression since early childhood with one serious suicide attempt as a preteen, but there have been periods during which she functioned reasonably well.

She has been treated for years with various antidepressants and mood stabilizers but has had only two short inpatient admissions. She has seen numerous therapists since childhood and, for the past five years, has been treated by a respected psychiatrist with a specialty in serious mental illness and psychopharmacology.

Symptoms are similar to most major depressions: hopelessness, helplessness, self-directed angry outbursts, worthlessness, poor self-esteem, feelings of guilt, lack of motivation, excessive sleeping, poor hygiene, and tearfulness.

She describes herself as a “terrible housekeeper.” She says she never cleans, never opens mail, and rarely eats at home. She once reported with sadness and disdain, “Sometimes, I make a bowl of cold cereal and milk, and I stand in the middle of the dining room and eat it. That’s so pitiful!”
 
Taylor’s most striking symptom is her sense of worthlessness. She is particularly harsh with herself, using derogatory and inflammatory descriptions (e.g., “I am an ugly, middle-aged, fat, loathsome person. People turn away from me on the street. They should!”). She criticizes her intellectual abilities of which she is normally proud.

Because she is an exceptionally intelligent and articulate person, these negative characterizations are painful to hear—for her therapist, her doctor, and for Taylor.

Background and Family History
Taylor is one of four daughters born to still-married parents. Two of her sisters also experience depression, though not as severe as Taylor’s. Only one sister married and has children, but the marriage is in trouble. All have been able to work. The father is a highly paid, accomplished professional, and the mother is a homemaker. Taylor describes her mother as a “simple-minded homemaker who always sides with her husband.” She rarely says more than that about her mother.

Taylor’s descriptions of her father have always been more detailed and scathing. She describes her father as harsh and hypercritical with a history of severe teasing. “He never had to raise a hand against me. He is an expert at punishing with words,” Taylor explains. She has reported being called derogatory names critical of her mental health problems and physical appearance. Taylor does understand the connection between these experiences and her problems with depression, self-image, and self-esteem, but this insight does not seem to produce improvement. Unfortunately, due to the repeated episodes of depression, Taylor has had to depend on her father in the past eight years for financial assistance, which she bitterly resents.

Periodically, Taylor had problems in school, especially high school. Eventually, her parents enrolled her in a private school that she loved and where she excelled. She was accepted into an Ivy League university but had difficulties due to a combination of social issues, an inability to organize her work, and a serious medical illness that led to a two-month hospitalization.

Although she did not finish college, she transferred to a university in France where she stayed for several years, happily studying and traveling to many different countries. One of her major pastimes was mountain climbing, and she has climbed mountains all over Europe, Africa, and the United States. She sometimes talks about living in Europe permanently but has not pursued this beyond the most preliminary steps. Beginning in her mid-40s, Taylor began to suffer multiple health problems, some of which continue but are not life threatening. She has become more hopeless over her impending 50th birthday. The life review that this often engenders in people has become a major crisis for her as she reviews a life she believes to be worthless.

Initial Phase of Treatment
I first saw Taylor after she completed a successful course of electroshock therapy (ECT). She had fallen into an intractable depression after a broken relationship, and severe symptoms persisted despite active medication management and intensive therapy. She eventually lost her job in a publishing firm because she simply could not get up for work. Despite some mild memory loss, Taylor reported that the ECT treatment was a miracle for her. Most of her debilitating symptoms had considerably diminished despite the fact that she had no job and growing financial problems.

She had an unexpected monetary windfall and decided to reward herself with a three-week trip to Europe. She felt exceptionally energetic and returned to an old love of mountain climbing. On her return to the United States, she resumed treatment. She was full of stories about her trip, quickly found a new job, and felt reasonably content even though she had taken a pay cut. She resumed seeing her friends and talked about returning abroad to live permanently.

This improvement was short lived. Over the next year and a half, the depression and its familiar distressing symptoms returned with increasing intensity. Taylor’s doctor actively managed her medications, but she continued to decline. During a session in my office one evening, she was so depressed that she sat practically mute with tears running down her face. She was still able to work but reported that her job was in jeopardy.

After much consideration, she decided to try ECT again. However, this trial was unsuccessful, and Taylor had an unfortunate reaction and needed to be hospitalized for a few days. Since her discharge, sessions are dominated by Taylor’s depressive symptoms, self-hatred, and anger. She is frustrated with her inability to manage her home and is increasingly gloomy about her future. During our most recent session, she reported that she had lost her job. 

Taylor initially presented with a strong desire to get her life together, and she had two specific goals: to feel better about herself and to organize her home. “My doctor recommended you because he said you are a no-nonsense kind of person,” she told me. Taylor comes to therapy regularly, and she has been able to successfully discuss sensitive issues in her past such as a date rape in her late teens. Although she does not have an intimate relationship now and is not dating, she has several close friends with whom she sometimes goes out to dinner or to a movie when she agrees to call them. She often assumes it is their responsibility to call her.

She has developed a trusting relationship with me as her therapist and is able to follow some basic cognitive therapy techniques to examine her thinking and structure her day. However, all attempts at permanent change have been met with only temporary success. Homework assignments are done only for a few days, and physical activity has the same duration. Suggestions such as focusing on her beloved Siamese cats, connecting with friends, revisiting former interests, and learning to manage anger and the relationship with her father have all worked for a while but are never entirely successful.

There are times when she is able to draw on past accomplishments and see that she has some strengths and has done some positive things. Her life has been adventuresome and somewhat eccentric, but she resists seeing this as a genuine way to live and believes that she is a flawed person without a husband, children, a fine home, and living what she perceives to be a “normal” life.
 
Since her recent discharge from the hospital, Taylor talks about her life with disdain and despair. She has resumed referring to herself in painfully negative and derogatory terms, and she is discouraged. I have pointed out to Taylor that something very strong keeps her going in this world and helps her to survive, and I encourage her to try everything that the doctor recommends and to continue going to therapy.

Despite her severe bouts of depression, she does not want to die and firmly states that she would never harm herself. Taylor is wedded to the idea that psychopharmacology or some other yet undiscovered miracle medical procedure will be the answer to her difficulties. She reports that she is more willing to try any medication or procedure (after careful assessment) rather than having to go through the harder, slower process of therapy. Her mantra about any new therapeutic process is “What good will this do?”

— Marlene I. Shapiro, LCSW, is the program director of a partial hospitalization program for patients with psychotic disorders at Sheppard Pratt Hospital in Baltimore. In addition, she sees patients and families in a private practice.

Discussion No. 1
By Laura W. Groshong, LICSW

Taylor seems to be a study in contradictions. She wants a quick fix for her problems but has stayed in this therapy for at least a year and a half. She shifts from positive to negative feelings about her intelligence, and she sees herself as flawed for not having a “normal” life, though she is quite disparaging of her normal parents. One explanation for these contradictions could be her attachment to her negative feelings about herself, which seem quite profound. Her ability to tolerate positive feelings appears limited, perhaps because it could endanger her negative, but reliable, identity.

Despite Taylor’s attachment to her negative persona, she has pursued this therapy, which suggests that there is a role for a therapist to play in helping her find a more self-accepting, positive identity. The key to working with Taylor could be helping her realize that someone understands how much she has suffered but is not empathically overwhelmed and/or emotionally harmed by the suffering she demonstrates in her sessions (i.e., mute despair with weeping and self-punitive comments).

Taylor seems to be unaware that the way she treats herself is similar to the way she describes her father treating her, but in an internalized, self-imposed manner. The therapist’s role at this point in the treatment seems to be witnessing Taylor’s intense suffering. The description Taylor was given of her current therapist as “no-nonsense” could be a clue to what she thinks she needs (i.e., a therapist who doesn’t get lost in Taylor’s misery). This could also mean a therapist who sees that the suffering is a crucial part of Taylor’s identity and acknowledges the importance it has to her without seeing it as the only identity she could have.

The therapist says, “Something very strong keeps her [Taylor] going in this world, helps her to survive.” I see this comment as encouraging Taylor to see herself as emotionally stronger than she feels, which could be overlooking how psychologically destroyed Taylor can feel at times during what sound like psychotic episodes. The desire to avoid these extremely painful episodes could be what leads Taylor to cling to her very difficult but reliable, negative self-images and to be financially dependent on her demeaning but reliable father. Over time, the therapeutic process could offer Taylor a different experience and new ways to avoid the experience of losing her identity in overwhelming depression.

Taylor seems to be nonverbally asking the therapist to take responsibility for her awful feelings, just as she wants her friends to be the ones to reach out to her. Seeing the therapeutic process as a way to begin to own and contain her painful feelings would be a necessary precursor to helping Taylor look at the identity she has constructed and maintains.

It would be a good idea for the therapist to explore Taylor’s question, “What good will this do?” and be clear that any change that comes from therapy will likely be a long process, as Taylor and the therapist build new ways for Taylor to own and contain her feelings. Empathizing with the frustration this is likely to cause Taylor would be an important part of building a therapeutic alliance. But simply tolerating the pain Taylor experiences and encouraging her to put it in words when she can, as the therapist seems to be doing, is also a crucial part of helping Taylor.

Taylor appears to have built her identity on primarily negative images of herself, her mother, and her father, with little capacity to question the way she now projects these images onto herself and others. Despite her conscious wish to be different from her parents, who she felt were cruel and/or neglectful, Taylor nonetheless continues to expect to be treated in these hurtful ways. In the absence of others doing so, she treats herself cruelly. Her ability to form a connection to the therapist is a good sign, but the miserable internal world she has lived in needs to be identified and discussed, particularly the way it is expressed in the therapy.

Managing the feelings Taylor stirs up in the therapist would be a major part of the therapist’s work. My primary goals for working with a patient like Taylor would be to look at her self-punitive comments as a way of avoiding critical comments about the therapist, helping her put her nonverbal anguish into words, and letting her know that this is a difficult process for both Taylor and the therapist but one that can be successful if Taylor is willing to work toward changing her self-punitive identity with the therapist’s help.

— Laura W. Groshong, LICSW, is in private practice in Seattle.

Discussion No. 2
By Richard G. Kensinger, MSW

I utilize a biopsychosocial/spiritual perspective with most clients. As I explore developmental history, I focus on temperament and particularly on early personality development. Personality begins to show itself around the age of 3 and is thought to be malleable until somewhere in the third decade of life. I am most interested in attachment and bonding dynamics. From my vantage point, Taylor has introjected a “sterile” mother and a “dysfunctional” father in response to the early psychosocial climate and environment during her youth. So her “self” and “other” split object relations are negatively distorted.

Through the lens of Erik Erikson, I look at the stages of psychosocial development: trust/mistrust, autonomy/shame or doubt, initiative/guilt, industry/inferiority, and identity and role integration/confusion or what I refer to as diffusion. Taylor has not mastered these opportunities. Drawing from John Bowlby, I look at the common reactions to as serious disruptions or fractures of significant relationships: shock, protest, despair, reattachment, or detachment. I see plenty of evidence of these dynamics, which Taylor projects onto current and future relationships.

Taylor shows an insecure attachment with both aggressive/ambivalent and avoidant features. Globally, I consider her to show an “asocial” personality orientation. She likely feels vulnerable and fragile in close, intimate relationships.

In my clinical experience, an early childhood onset of depression has been rare. We know that in adolescence and adulthood, women are at great risk of major depression. I am struck by Taylor’s suicide attempt during the latency period. I wonder if the presentation of puberty was a potential trigger. In terms of suicide, women are more likely the attempters and men the completers. What method did she use? I always explore the meaning of these incidents, questioning the client’s reaction to them then and now. I find it remarkable, considering her overall suffering, that she has not attempted again.

I am very concerned about her degree of hopelessness. Aaron T. Beck and Judith S. Beck indicate this to be a high risk factor for suicide. I would also examine the degree of helplessness and worthlessness, as I have found this “suicidal triad” to be more predictive of risk. Taylor displays what the Becks refer to as the cognitive triad: negative view of past, self, and future. In addition, she clearly displays an external locus of control that leaves her vulnerable in facing psychosocial stressors.

I would like to know more about her sibling position and her current and former connections to her sisters. I am curious about any dynamics related to having a father with no sons. I suspect that her siblings also feel vulnerable about intimacy.

With all clients, I conduct a protection/risk inventory. Here is my assessment of Taylor’s: Her intellect and articulate qualities are assets. She has some friends. She used to really enjoy mountain climbing. Her therapy attendance is consistent. She showed a very positive response to her first series of ECT. Her risk factors include the degree of hopelessness she feels, her detachment from others, her persistent dysthymia, her marginal or poor response to appropriate psychotropic medication, and her long-standing negatively distorted self-concept.

I am curious about her experiences with previous therapists, and I am especially interested in her transference to her present one. I would like to know more about the clinician’s countertransference to this client.

My diagnosis is recurrent major depression with persisting dysthymia. When they occur together, some refer to this as double depression. In fact, some evidence shows that nine of 10 persons with dysthymia experience a major depressive episode. I also see Taylor as evidencing a mixed personality disorder in the “wary cluster (Cluster C), with avoidant and dependent features.” In my experience, persons with disordered personality respond marginally to the use of psychotropics.

A course of cognitive behavioral therapy is appropriate for her. I also would consider a course of interpersonal therapy. Both approaches are known to be effective in treating major depression. More importantly for Taylor, I recommend a movement away from individual to group psychotherapy. In group therapy, clinicians have access to various therapeutic factors unique to group, which give them additional leverage to be useful to our clients. I think that it will be important to see her through menopause and beyond.

Finally, I inquire about each person’s spiritual beliefs in terms of the meaning it gives to their life in times of suffering and in times of relative well-being. In summary, I see Taylor’s prognosis as guarded with continuing treatment and poor without it.

— Richard G. Kensinger, MSW, is a clinical consultant and trainer and a faculty member in the psychology department at Mount Aloysius College in Cresson, PA.