Jan/Feb 2008

Therapist’s Notebook
Social Work Today
Vol. 8 No. 1 P. 40

Social Work Today introduces a new feature article that presents a case study in each issue with participation from three different therapists. One therapist will present the case, and two others will discuss it from their individual perspective. We hope the article will introduce new ideas, approaches, and techniques to practitioners wishing to enhance their therapeutic skills and insight.

Editor’s Note: Cases are fictitious. Any resemblance to actual clients is coincidental.

Case of Melissa
By Charles A. Rizzuto, MSW

Identifying Information/Presenting Problem
Melissa is a 34-year-old, married, Caucasian woman with one child, Beth, aged 13 months. At the time of intake, Melissa’s husband, Jerry, 36, was serving in the Army on active duty in Iraq.

There are a number of presenting issues. Shortly before Jerry left for the Middle East, the couple had several troubling arguments that stopped just short of physical violence. Melissa said that she regrets these incidents and even though her behavior was uncharacteristic, it worries her. She denied any actual physical violence between them. Melissa hoped treatment would address this issue, as well as her long-standing problems with anxiety and depression.

Until a few years ago, Melissa would have frequent anxiety attacks, some with no precipitants. The attacks had become less frequent, but in recent months, they increased. Although the anxiety did not prevent her from performing daily chores outside the home, Melissa was having problems in crowds and wondered if she was agoraphobic. She had never been formally diagnosed with panic attacks or agoraphobia and had never been in ongoing treatment for these complaints. However, she had seen a psychiatrist for antidepressant medication and an anxiolytic she uses as needed, usually at bedtime, and to help with occasional panic attacks. Melissa attended a group once that helped her develop breathing exercises and self-calming techniques to reduce the intensity and frequency of full-blown panic attacks.

A few months after Jerry’s deployment, Melissa and her daughter moved to the West Coast where her mother resides. Ongoing conflict with her mother was identified as another reason for seeking treatment. Melissa was also living in near-constant anxiety about Jerry’s well-being in a war zone and identified coping with this situation as an important reason for psychotherapy.

Background/Family History
Melissa has no siblings. Her father left her family when she was 7 years old. Subsequent contact with him was sporadic. Melissa says her father never showed interest in her upbringing and provided no financial support. She is estranged from him.

Currently living in the same town as her mother, Melissa describes her as selfish, volatile, and abusive. With Jerry gone and few other resources, she depends on her mother for babysitting and other needs such as companionship. However, the price is high. Her mother is unsupportive and frequently emotionally abusive. Contact with her mother has precipitated Melissa's anxiety attacks and depression.

Melissa reports that her mother was often an absent and abusive parent. After her parents divorced, there was a steady stream of men (some “creepy, low-lifes” by Melissa’s description) whom her mother often entertained at home. Moreover, the mother occasionally engaged in sexual activity in front of Melissa, was frequently absent for days at a time, physically and emotionally abused Melissa, and threatened to give Melissa up for adoption unless she behaved herself. Melissa says she could never tell what might set her mother off and learned to be extremely cautious around her. She believes her mother has grown even more abusive and irrational over the years.

Melissa married Jerry four years ago and says they have a good marriage. They had known each other since high school. Jerry went on active duty several months after their daughter was born. Her mother had encouraged the move to the West Coast, leading Melissa to hope that her mother would be more welcoming, helpful, and supportive. But by Melissa’s report, that has not been the case. Melissa wishes she did not have to rely on her mother as much and hopes that when Jerry retires from the armed services in several months, she will be able to depend on her mother less and feel less indebted to her. She notes, however, that the Army could decide to postpone Jerry’s retirement.

Initial Treatment Phase
Melissa presented as a reasonably intelligent woman who carries with her a fair amount of anxiety generated by a number of current life stressors. She has a history of panic reactions that may be related to a childhood replete with various relational trauma. Melissa seems motivated for treatment and clear about the problematic aspects of her upbringing and its multiple losses but is limited on any real insight connecting past to present. Early treatment involved allowing her to talk about her past and the ways in which her present life, with its losses, anxieties, and lack of support, reflect and, in some cases, even replicate a painful and lonely early life.

Since Melissa would often come to sessions in an anxious state, such as in the aftermath of an argument with her mother or a distressing call or e-mail from her husband, significant time was spent reinforcing skills she had learned in the group she attended regarding self-regulation.

The goals of this reinforcement were trying to short-circuit acute stress reactions and panic attacks, practice setting limits with her mother, and develop other avenues of support through a network of friends and the community.

After several months of treatment, Melissa reported that her anxiety had diminished, and she was able to set limits with her mother and make use of other supports successfully. Her attention now began to focus more on her desire to have her husband home, which seemed a real possibility.

Four months after treatment began, Jerry returned from the service and retired from the military. All was calm initially, and Melissa reported considerable relief from her anxiety and worry. However, there was a rapid deterioration in home life. There were no savings, Jerry could not find a decent job, and he also missed an important deadline for securing ongoing veteran benefits.

He began working as a handyman, keeping late hours and leaving most of the household work to Melissa, who was becoming suspicious that Jerry was using drugs and engaging in an extramarital relationship. The level of conflict continued to escalate, though no physical violence was reported. Melissa was having sleeping difficulties and increased anxiety. She had occasional panic attacks; it felt as if she was back where she started.

At this point, a referral to couples treatment was indicated as an adjunct to Melissa’s individual therapy. Melissa was interested but could not get Jerry to agree to it.

— Charles A. Rizzuto, MSW, is a member of the summer adjunct faculty at Smith College School for Social Work and maintains a private practice in psychotherapy and supervision in Holyoke and Amherst, MA. He consults frequently in the areas of sexuality and loss/bereavement.

Discussion No. 1
By Gail S. Levinson, MA, LCSW

The number of presenting problems is daunting, and they appear to have been transient and somewhat disconnected. The therapist is following many threads yielding sporadic successful knots only to find them unraveling at the point of new real life challenges.

For instance, anxiety and panic diminishes during the course of early treatment only to reemerge when the client’s husband returns. The client’s ability to self-regulate her anxiety and set limits with her mother do not appear to sustain when her husband returns. The therapist and Melissa appear defeated, as they seem to be back at square one. The husband’s unaddressed emotional problems and his resistance to participating in conjoint treatment make this an unlikely option. Rather, it reflects another example of how little regard he has for Melissa and his marriage. Directing much energy toward this approach would not likely serve the client or enhance the marriage at this juncture.

As a clinical social worker, I tend to approach my work with attention to both the clinical/psychotherapeutic focus and the social work person-in-environment approach that provides the foundation for the social work profession.

I recommend that the client be referred for a new psychiatric evaluation with an eye on a more definitive diagnosis and appropriate medication. While it is alluded to in the case description, I suspect that chronic posttraumatic stress disorder stems from Melissa’s childhood. This is reflected in the choice of a partner who treats her in a fashion reminiscent of her mother and returning to her mother for help and understanding when he leaves. At this point in treatment, I would recommend using this diagnosis to guide the work in a fashion that addresses the viability of her marriage, develops insights into the parallels in the two relational dynamics of these two primary connections, and capitalizes on the skills and limit setting Melissa developed in dealing with her mother.

Upon her husband’s return, Melissa experiences firsthand the reality of his presence and the quality of their interactions. Therapy can more directly address discriminating between Melissa’s fantasies and desires for a relationship quality that isn’t or may not have been accurate prior to Jerry’s tour of duty. Perhaps it is time to revisit the early arguments that almost turned violent. In short, this may be the moment to ask Melissa to inventory her marriage. How potentially viable is it? Is her husband similarly toxic to her like her mother? What are the pros and cons of staying or leaving?

As indicated in the case review, when confronted with her mother’s erratic and abusive behavior as a child, Melissa found that remaining passive and undemanding was the best way to cope. Does this continue to be her coping style in her marriage, enabling her husband to act out and minimally participate in the daily family responsibilities? If so, what has Melissa learned about interacting with her mother while Jerry was gone that could reinforce her sense of self-efficacy?

When Melissa was a child, she had minimal opportunities to arrest the abuse or leave. However, as an adult, she has many more resources at her disposal. Is it inherently better to stay in a relationship with toxic people because of the relationship title (i.e., husband/wife, mother/daughter) when the quality of treatment is poor, if not potentially dangerous?

It is apparent that this therapist and Melissa have established a solid relationship, and the therapist is a consistent coach and cheerleader. The therapist can reinforce the successes Melissa has had in reestablishing herself in a new location on her own and making strides with her mother. Locating and facilitating additional social supports, such as a women’s outpatient support group, are also likely to provide Melissa with vital sources for reinforcement and confidence building as she decides what she wants to do about her marriage and future.

— Gail S. Levinson, MA, LCSW, is in private practice in Wilmington, DE, and is the treasurer of the Clinical Social Work Association.

Discussion No. 2
By Noreen Keenan, PhD

I am a psychoanalytically trained therapist. Psychoanalytic psychotherapy involves working with the unconscious through interpreting derivative material (i.e., listening for unconscious communication via stories and dream content that has meaning for the conflict the client is trying to resolve). According to Sigmund Freud, people repeat maladaptive, neurotic behaviors as adults in an effort to resolve earlier trauma and conflicts. When the therapist interprets the unconscious meaning that these behaviors have for the clients, allowing them to work through accompanying feelings, the clients should be better able to let go of the behaviors and ways of relating that cause such pain and conflict and cultivate healthier and happier relationships.

Melissa’s history is being an only child, abandoned by her father at an early age, and raised by a narcissistic and sadistic mother who also abandoned her emotionally and psychologically. This could explain her uncharacteristic attack on her husband just prior to his deployment to Iraq. On a deeper level, this may have generated feelings of fear and panic because of earlier abandonment. Also, children who are abandoned by one parent and abused and neglected by the other would be predisposed to having an overly developed superego, being highly anxious, and having an enlarged sense of guilt and prone to assuming unrealistic responsibility for others (e.g., being a perfect mother and/or responsible for her husband possibly being killed in Iraq).

Melissa’s therapist did a good job of helping her access community resources and shoring up her strengths. It may also be worth exploring whether Melissa is suffering from postpartum depression.

It’s unclear if Melissa has a career or work life, which would be beneficial for a number of reasons. Jerry’s return home and difficulty with finding a decent job introduced financial and psychological hardship to the marriage. If the couple is totally dependent on his earnings, this imbalance would understandably cause marital strife. Jerry’s retirement from the Army could also raise fear of financial insecurity in Melissa.

I support the therapist’s style of listening for how Melissa’s current losses and conflicts are connected to those in her earlier life. It’s notable that Melissa didn’t make the connection. I wouldn’t see this necessarily as lack of insight on her part but as an understandable avoidance of raising more issues of loss and sorrow. The therapist probably tried to make a conscious connection, which in psychoanalytical practice isn’t as powerful and acceptable as an unconscious one. It may be easier for Melissa to connect the dots if the therapist used unconscious session material (i.e., Melissa’s own words in disguised form to guide her toward this insight and understanding).

If Melissa were to say something such as, “One of my friends was supposed to make a play date for me to go to her house with my baby and just hang out. Then, out of the blue, she canceled without any good excuse or offer to reschedule,” a psychoanalytically oriented therapist may respond with, “That must have been very disappointing and frustrating. It probably felt similar to when important people in your earlier life left without further contact or offers to make amends.”

It’s important that the therapist be consistent and reliable, not canceling sessions precipitously, showing up late, or failing to make interventions in a timely manner. If this does occur, he or she will hear about it in Melissa’s derivative communication, and the therapist can use it to provide a model of rectification, interpreting around it and allowing it to be used for Melissa to further resolve her earlier neglect and losses. For example, the therapist could say something such as, “When I had to cancel last week’s appointment, it made you feel like you did when you were a child and your father/mother [insert event here]. I need to be more aware not to do it in the future.”

Marriage counseling for Melissa and Jerry is a great idea, and the therapist should suggest that Melissa ask her husband to come in for a one-time consultation in the interest of helping his wife.

— Noreen Keenan, PhD, is in private practice in Albany, NY. She is analytically trained.