Therapist’s Notebook

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

The Case of Andrew
By Donna Ulteig, LCSW, ACSW, DCSW

Andrew sits on my couch leaning forward with his elbows on his knees, the palms of his hands resting on his forehead. He is a 50-year-old father of four who is inconsolable. Andrew periodically releases sobbing sounds as he grieves the suicide of his youngest child two weeks earlier, 20-year-old son Nathan, a junior at an out-of-state college.

I listen as he describes the tragic and dramatic death. Nathan’s girlfriend had broken up with him the week before and overwhelmed with hopelessness for his own future, he had impulsively jumped in front of a commuter train with dozens of witnesses. Andrew and his wife received the call about Nathan’s death just after finishing dinner and then drove 500 miles to identify Nathan’s remains. They found a suicide note in his apartment, left in plain sight on his desk, that reflected Nathan’s hopelessness about ever having loving relationships. They also found several empty vodka bottles.

Just weeks before his son’s death, I had met Andrew for the first time. His psychiatrist, who had prescribed several medications to help with his long-term, major depression, referred him.

Andrew had an 18-year history of treatment for depression with medication but had never been in outpatient psychotherapy. He now wanted to work on closer relationships with his wife and children.

I was surprised when I first met Andrew. He was a slim man, smartly dressed, with a runner’s build. He had participated in marathons and triathlons as a way of managing his depression. He had a stable job, a responsible position as a manager in a large corporation, but believed he was a failure at work socially and that his performance at work was barely acceptable. He also believed he was boring and had nothing to offer in relationships.

During our initial session, Andrew spent most of the time discussing how worried he was about Nathan, who had dropped out of school for a semester the previous year due to depression. Nathan was the “problem child,” always distant and bristly with his father but able to be warm with and confide in his mother. His older siblings—Rebecca, 27 and married; Kyle, 24 with a steady girlfriend; and Heather, 22, a recent college graduate—had to “walk on eggshells” around him. Nathan had a girlfriend, but it was a rocky relationship. Nathan had not confided this information to his father; Andrew heard about it from his wife. Nathan missed classes when he and his girlfriend, Melissa, had fights. Andrew wondered whether Nathan was following through with taking his antidepressant medication and thought he was drinking too much. He knew Nathan had discontinued treatment with a professional in the school’s counseling office. Andrew’s wife told him that Nathan had a personality conflict with the counselor, and she had encouraged Nathan to find another one. Andrew is jealous of her relationship with Nathan and feels shut out.

Andrew also talked about his marriage to his only girlfriend and high school sweetheart that took place immediately after college. His wife of 29 years, Joan, a math teacher in a local middle school, now wants him to do more of the housework but micromanages him, telling him how he must load the dishwasher, vacuum the floor, and trim the bushes. The pattern in their relationship is one in which he defers to Joan’s wishes but feels resentment that is now stronger than the love he once felt. Andrew believes Joan thinks he is moody and wants him to talk more about his feelings, but when he tries, he says Joan deflects the conversation back to herself. He does not know how to be heard in this relationship, so he avoids conflict and is nonassertive. Another part of their pattern is that Andrew “trashes himself” and then Joan “picks him up.” He thought that after a few individual sessions he would invite Joan to join him in therapy.

At this, my third session with Andrew, he is acutely distressed, and his talking is interrupted by choked sobs about the loss of his son. He focuses on the similarities between him and Nathan and discusses his own struggles with suicidal impulses as a younger man before his own treatment. Like Nathan, Andrew was the youngest in his family, and closer to his mother than his critical, punitive father. He blames himself for being a poor role model for Nathan and saw in Nathan his own passivity and inability to articulate feelings. He blames himself for not dropping everything and going to see his son thinking he may have prevented Nathan’s death.

At the previous session, before Nathan’s death, we had decided together that Andrew would write a letter to his son, a safer mode of communication than trying to talk on the phone. He believed that Nathan would not listen or would hang up during a verbal conversation, and he was worried that he would not be able to clearly express the love he felt. Andrew produces the letter he had written, a statement of love and concern that was nonblaming and invited closeness. He had finished the letter to Nathan the day before Nathan died but had not sent it. He berates himself for not getting to it sooner, for not following his strong gut feelings of concern for Nathan. In spite of this self-blame, Andrew denies feeling suicidal himself, noting that he would never want anyone else to feel as bad as he does, and citing a religious belief prohibiting suicide that had kept him alive as a young man.

Andrew continued in therapy for six more months, working hard to deal with his sense of failed responsibility at work and to his family, a core belief that was not readily amenable to cognitive therapy. He began to understand that he continued to treat himself the way his father treated him, as a loser and a failure, and that it was unreasonable to expect maternal nurturing from a wife who wanted an equal partner.

He grieved Nathan as he grieved his wasted years of empty relationships. Andrew seemed to be a man who had had a part of him die that he now wanted to live.

Andrew never invited his wife or family to a session in spite of my continued encouragement to do so. He and Joan attended several meetings of a Survivors of Suicide support group, and Andrew was able to forge stronger bonds with his other three children, reaching out to them in ways that he had not reached out to Nathan. He is now able to believe that the glowing performance appraisals he receives at work describe him and not an imposter. He also has been able to openly and appropriately disagree with his wife. He was surprised that he felt closer to Joan after being assertive even though she did not change her behavior toward him. His overall ability to articulate feelings has helped his social interactions at work. He is more accepting of himself as an introvert who needs time alone.

He has yet to completely forgive himself for what he feels is his part in Nathan’s death, and the family has not processed its grief together.

— Donna Ulteig, LCSW, ACSW, DCSW, is in private practice with Psychiatric Services, SC, in Madison, WI.

Discussion No. 1
By Charles A. Rizzuto, LICSW

Andrew comes into therapy with a long history of depression that has been addressed until now with only medication. After a couple weeks in treatment, his son commits suicide. The therapy lasts a total of about six months. During this period, his life proceeds in the shadow of that devastating loss. Thus, based on events in the client’s life, what started as psychotherapy for chronic depression turns into crisis intervention and then, we would expect, into bereavement therapy. If the treatment had lasted longer and the bereavement work had been completed successfully, the treatment may have changed once again into something resembling ongoing psychotherapy for depression—and other issues.

Each of these treatment formats involves a differential stance by the therapist and a particular set of possible techniques. As with all clients, an important early task for the clinician that evolves over a period of initial contact is determining the appropriate “analytic distance” to assume with the client—how to be with the client as a step before determining what to do with the client. This distance will vary from patient to patient and will depend very much on the bipersonal field created by patient and therapist in the room, but it will also vary with the client’s moment-to-moment needs. In this case, there are some important changes in this analytic distance necessitated by the changes in the client’s life and needs over the brief period of therapeutic involvement.

With Andrew, therapy has barely begun when he is thrown into crisis by the death of his son. Crisis intervention is a very particular kind of ego-supportive work. The therapist must remain a real, soothing presence to the patient and concentrate in his or her interventions on trying to help restore the client to psychological balance and his precrisis level of functioning. With the sudden loss of his son, Andrew is understandably in shock and psychologically disorganized. The work needs to be very much in the here and now and will often involve behavioral and supportive techniques to help the client become reconsolidated in the aftermath of a destabilizing crisis. We’re not interpreting dreams or transference but instead shoring up adaptive defenses and collaboratively brainstorming with the client ways to decrease anxiety, diminish somatic symptoms, and cope adaptively with aspects of the crisis response. The work is active and somewhat directive. During this stage, it is usually considered too early for true grief work to begin. It is generally accepted that concerted, focused work on the loss itself is best begun several weeks after the death so the client has a chance to more fully accept the reality of the loss.

Once this initial period of crisis passes—usually four to six weeks—the work of mourning can usually begin in earnest, and the therapist’s part will vary according to the patient’s needs. Everyone mourns differently and the therapist’s job is to facilitate this process patiently, however it may evolve and for however long it takes.

The exact contours of the therapist’s work with Andrew are not so clear from the case summary. For example, how did the therapist assist Andrew in getting past the gruesome shock of his son’s suicide and the traumatic experience of having to identify his son’s remains? We also get no clear sense of how the mourning per se proceeded or how the therapist worked with Andrew in this difficult process. One does get the sense that the therapy, while not ignoring the patient’s need to mourn, spent the better part of the six months of treatment working on long-standing relational and self-esteem issues. I wonder, for example, about the therapist’s efforts to have Andrew bring his wife to their sessions when it is clear that he is someone who has chronic feelings of not being attended to and not having his needs validated by important people, including his wife. A referral to concurrent couples or family therapy, however, may be in order at some point.

In a mourning process like Andrew’s, I would be concerned about a number of factors that might complicate the bereavement and impede its progress. Andrew has a long history of depression treated only with medication. It appears to have been only partially successful, given the level of self-deprecation and discomfort still present. Research indicates that the successful outcomes in treating depression are correlated with medication in combination with talk therapy. Generally speaking, persons who are susceptible to depression or are experiencing a certain level of depression already tend to be at greater risk for difficulties successfully completing a bereavement process after a major loss.

There are, however, other factors in this case that could lead to complicated grief, prolonging the mourning process, undermining its success, and even intensifying Andrew’s preexisting depression. Andrew seems to identify closely with Nathan. Both were the youngest child in their families, both were close to their mothers and distant from their fathers, and both were treated for depression. Andrew also experiences a great deal of guilt concerning Nathan’s death, blaming himself for not visiting Nathan immediately when he was in extreme crisis. Shame also affects his response to the death: Andrew feels that, as someone who is passive and unable to articulate his own feelings, he provided a poor role model for his son and was less of a parent—perhaps less of a man—than he should have been. The circumstances of the suicide might also evoke shame in family members. These factors—identification with the deceased, guilt, and shame—often make mourning more difficult.

Another complicating factor is the level of support Andrew is receiving at home. We naturally turn to other family members in such cases of loss. But family members are often so bereft themselves that they cannot provide a level of support needed by significant others to work through grief. Moreover, Andrew describes his wife as someone he has not generally been able to rely on for support. He is used to deferring to her wishes, and he feels unheard in the relationship. This is a powerful statement for someone who historically has had difficulty expressing his feelings and letting himself be known to others. Lack of adequate support in the patient’s environment can complicate the bereavement process.

With regard to the treatment of Andrew’s long-standing depression, it seems that the therapist may have been using cognitive techniques. There are clearly potential benefits to be derived from this modality in work with depression. It is not surprising to hear that certain core beliefs do not appear amenable to the cognitive work being implemented. It may be that it was just too soon, given the complicated bereavement process, to be working in a very concentrated fashion on the depression. Furthermore, I would wonder about the nature of the depression itself. It seems as if it has been quite difficult to treat, and Andrew has derived only limited relief through many years of medication. So in light of various elements of the case—the serious self-esteem issues present; aspects of Andrew’s upbringing such as his critical, punitive father; personality traits like his tendency to be avoidant and nonassertive; his choice of an unavailable, nonempathic spouse—I would wonder to what extent the depression is of a more characterological nature. In such a case, long-term therapy of an ego-exploratory nature along relational lines would be my recommendation once the mourning process has had some success in freeing him up from excessive, debilitating grief.

— Charles A. Rizzuto, LICSW, 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. 2
By Barbara Holzman, AM, LCSW, ACSW, BCD

Andrew’s feelings of worthlessness, his beliefs about being boring and having nothing to offer in relationships, and his assertions that his work performance is barely acceptable are so pervasive that they permeate all of his relationships. In spite of all the facts that belie his beliefs about himself—he holds a responsible, stable position in a large corporation, he has a wife and family even though he feels distant from them—his cognitive and feeling distortions about his value and worth remain entrenched. It appears as though he is operating from the perspective of “my mind is made up so don’t confuse me with the facts.”

I suggest that Eric Erickson’s Psychosocial Stages of Development, which address stages of an individual’s life cycle, provides us with a dynamic framework to understand the source of Andrew’s beliefs and feelings about self. His father’s treatment of him was “punitive and critical.” He saw his son as “a failure and a loser.” Ridicule and shame may have been components of his interactions with his father. As a result, Andrew wasn’t able to successfully negotiate the second stage of development, Autonomy vs. Shame and Doubt. Not only did Andrew’s father fail to protect him from shame and doubt by supporting and encouraging Andrew to stand on his own, he was the source of Andrew’s engrained feelings of shame and doubt. For example, his belief that he is an imposter at his job implies that it is only a question of when he will be exposed as a fraud.

In addition to chronic feelings of shame, feelings of doubt that often accompany shame are present. Andrew’s ingrained doubts about himself and his abilities to relate to his inner and outer world, profoundly affecting the nature of his interpersonal family and work relationships. Because the self-doubt is so internalized, he can’t accept validations of worth and as a result, his experiences and relationships are viewed through the lens of shame and doubt.

Erickson’s model helps us to understand the genesis of Andrew’s deeply ingrained cognitive and feeling distortions about himself. It may also help us to understand why, in spite of dealing with a chronic, severe depression for more 18 years, he did not accept psychotherapy as part of the treatment plan. Given Andrew’s intense feelings of shame and doubt, one can understand his avoidance of treatment, which he could perceive as being in an “exposed” position. He chose to deal with his depression through medication and running, which allowed him to be in charge.

The emotional price Andrew paid for being stuck developmentally is seen in his relationships with his wife and his children. His deep concern about his youngest son, the one whom he appears to identify with the most, is his focus when he first seen. His son’s tragic and very public death could only have fueled Andrew’s chronic feelings of shame and doubt while adding guilt and remorse for not acting on his concerns sooner. Without an established sense of autonomy, his capacity to show initiative, to “listen to his gut” and go see Nathan, was compromised. Andrew wasn’t able to completely forgive himself for what he saw as his part in his son’s death because he didn’t take action.

Although the primary focus of this discussion has been to explore the impact of shame and doubt on Andrew’s personal and interpersonal relationships, there are other clinical issues. Did Nathan have an undiagnosed bipolar disorder? His symptoms of irritability, moodiness, and impulsivity, as well as the family history of mood disorder, are all red flags that may have been missed in Nathan’s treatment. Also there is a question whether Andrew’s chronic, severe depression is an undiagnosed bipolar disorder.

Another clinical issue is the choreography of Andrew’s marital dance with his wife. She was his only girlfriend in high school and they married right out of college. Many questions about the nature of their interactions and changes in their relationship over time in terms of intimacy and partnership (as opposed to the mother/child interactional pattern he had with her when he was first seen) weren’t addressed. The impact of self-doubt is seen in his responses to his wife. He isn’t able to appropriately assert himself with her and is conflict avoidant and compliant but resentful. After recognizing how he was replaying the past in his interactions with his wife, he was able to own and express his feelings, be more assertive with his wife, and feel a sense of accomplishment from doing so.

Erickson’s developmental model is one way to understand the dynamics involved in Andrew’s deeply flawed sense of self and how shame and doubt affected his life. Distorted cognitive and feeling beliefs about himself governed his interactions with family, friends, and coworkers, creating a situation of second guessing himself and others. The crisis precipitated, first by the concerns for Nathan’s welfare and then dealing with his suicide, and turned that crisis into an opportunity for self-growth and change. Andrew began a process of introspection and critical examination of the origin both of feelings and beliefs.

With that understanding he was able to loosen the shackles of shame and doubt and his lack of self-worth to engage more fully and emotionally with others, especially family. Nathan’s death was Andrew’s opportunity to confront painfully unresolved emotional issues that he had lived with for years. Positive internal and interpersonal changes resulted from his doing so. Through treatment, he was able to find meaning in his son’s death and use that knowledge to give his own life new vitality and enriched emotional relationships. Although there are unresolved grief issues, one can hope that additional growth and change will continue for him and his family.

— Barbara L. Holzman, AM, LCSW, ACSW, BCD, has been in private practice for more than 30 years in Phoenix, treating individuals, couples, and families on an outpatient basis.