Therapist’s Notebook

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

The Case of Shaquila and Joseph
By Ruth Campbell, MSW

Shaquila, a 38-year-old African American woman, and her husband, Joseph, have been married for 12 years and have struggled with feelings of estrangement throughout the latter part of their marriage. During the intake for couples’ counseling, they described how their communication difficulties had been exacerbated by an incident Shaquila perceived as a profound betrayal.

Prior to this, their second attempt at couples’ therapy, Joseph, a counselor at a local mental health agency and connected to a 12-Step program, had utilized individual therapy and sponsorship to gain insight into the difficulties he felt the couple was having. He began discussing his marital problems with other counselor colleagues to get some perspectives that individual therapy, previous couples’ counseling, and sponsorship had not provided for him. He did not discuss this strategy with Shaquila because he did not want to further strain their relationship. When he realized he was developing feelings for one of the counselors with whom he was sharing information, he shared this new realization with Shaquila as an insight. Joseph told Shaquila that he had a strong connection with the other counselor that he no longer had with Shaquila herself, suggesting they needed more help with their own relationship.

Shaquila regarded this revelation as a betrayal and reacted to it with devastation.

Background/Family History
Shaquila is the oldest of three children. Her father’s family lived in poverty. Shaquila describes her father’s low self-esteem, indicating he did not have enough self-confidence to pursue his dreams and ended up at working at IBM in a white collar technical job.

When Shaquila was 12, her father moved the family to a small town. He commuted several hours daily to continue working at the high-paying job back in the city. Shaquila describes him as “rigid, righteous, and opinionated,” always critical and often explosively irritable. Shaquila describes her mother as “placating, passive, and self-sacrificing.”

Shaquila was often conflicted by what she felt was her father’s critical rejection and her mother’s lack of support and complicity. During her adolescence, she avoided open conflict by often abruptly leaving any “discussion” with her father, retreating to her room, and slamming the door. She states that he often drank himself to sleep on the couch as he watched TV in the evening. She realizes now that her father was possibly an alcoholic.

Shaquila lived in a large city prior to meeting Joseph. There, she had an active intellectual life, working as a legal assistant during the day and attending law school at night. She utilized individual therapy and Al-Anon for support. Shortly after she and Joseph were engaged, Shaquila’s father died suddenly in a car accident. The couple decided to postpone having children until they both were more settled professionally. They moved to a small town where Joseph found a counseling job with a local mental health agency, and Shaquila continued commuting to the city to finish her law degree.

Initial Treatment Phase: Couples’ Work
Couples’ work was based on the Imago relationship approach, which builds communication skills and enhances trust and empathy while addressing underlying issues. There seemed to be no lack of empathy between Shaquila and Joseph. They easily agreed on goals and behaviors they wanted to incorporate into their relationship.

The focus of much of the initial couples’ work was on communication. The couple used the reflective style of communication in sessions, focusing on listening and feelings. The couple reported using the new communication skills in their everyday lives and at home. They felt somewhat encouraged at the enhancement of intimacy and empathy in the relationship. However, Shaquila often shut down or found her mind going blank when asked to use the reflective or the assertive skill in couples’ sessions. Counselors noted that the couple was unable to be assertive in session without detailed coaching. By the fourth month, Shaquila requested individual work in addition to the couples’ work.

Individual Counseling
In individual work, Shaquila indicated her discontent with the couples’ work focus and timing, saying she wanted to resolve her feelings about her husband’s betrayal. Although she had been in individual and couples’ therapy previously, she reported no diagnosis and was taking no medication. She had experienced difficulty sleeping for years because of a problem with her lower back and sleep apnea. Although she had obtained satisfactory medical treatment for both conditions prior to beginning individual counseling, her sleeping was still interrupted. She reported early morning waking with difficulty returning to sleep. Because her symptoms indicated possible depression, she was tested with the Beck scale at the beginning of the couples’ work. On that scale, she scored as moderately depressed. She pursued a referral to a psychiatrist but decided not to take the recommended medication. Rather, she addressed depressive symptoms with diet and supplements.

The continued sleep difficulty and obsessive, hypervigilant quality of Shaquila’s focus on the incident led me to attempt to reframe her issue as one of trauma. A few weeks after Shaquila had begun individual work, I administered the PTSD Checklist-Civilian (PCL-C) scale to her in order to assess the strength of her posttraumatic reaction to the stressor incident. I chose that scale because it has been shown to be a reliable and valid indicator of posttraumatic stress (Weathers, Litz, Herman, Huska, & Keane, 1993). Shaquila’s score would also serve as a baseline for determining the effectiveness of efforts to address the trauma symptoms.

When she first took the PCL-C, five months after she initially presented for couples’ counseling, Shaquila scored a 75 on the instrument. Her score strongly indicated that the incident in which Joseph shared that he had confided in and had feelings for another woman effected a traumatized response from Shaquila. Classically, she had heightened responses in the three categories that indicate a traumatic response to an event: reexperiencing, avoidance, and increased arousal. Five months after the incident, it remained registered in her psyche as a traumatic experience even through the incident does not meet the DSM-IV criteria for PTSD symptoms.

Shaquila agreed to attempt one of the most effective treatments for trauma according to research – exposure (Foa, Keane, & Friedman, 2000; Foa & Rothbaum, 1998). After an orientation session and breathing retraining to allow her some control over her anxious reaction to the material, Shaquila recorded her experience of the trauma and listened to the taped material at least once per day, using the breathing technique while listening. She reported that she used the imaginal exposure technique on the trauma itself and on previously experienced difficult events in her family of origin (none involving rape or physical abuse).

After a few weeks, she reported that the discipline of listening to the recorded material was interfering with any rapprochement that was being elicited by the couples’ work. She terminated the effort to use exposure to reduce the PTSD symptoms within two months of starting. Shaquila had never begun the in vivo exposure technique that is part of the treatment. At the end of the individual work, seven months after the initial incident, she retook the PCL–C, registering a score of 46. Symptoms in the hypervigilance category were diminished to one moderately disturbing symptom. Symptoms in the avoidance category had increased to four, and symptoms in the intrusive category had diminished to three.

Later Phase of Treatment
In couples’ work, Shaquila requested that she be able to freely question Joseph’s actions concerning the “other woman.” The strategy of close questioning had been discouraged by the counselor up until this time. All agreed, however, that this strategy, in a controlled setting, might alleviate some of Shaquila’s hypervigilance concerning Joseph’s behavior.

During the three question-and-answer sessions, the counselor acted as coach to elicit and moderate feeling communication. Shaquila’s questions were oriented toward understanding how Joseph’s behavior differed from her own, what motivated him, how attracted he was to the other woman, and how he had acted with her. After three such sessions, Joseph indicated high frustration since he did not feel his answers satisfied Shaquila. The couple and counselor agreed to end that particular phase. Shaquila seemed to relax more and participate more willingly in couples’ sessions. When Shaquila was retested on the PCL-C, nine months after initially presenting for treatment, her score was 42.

— Ruth Campbell, LCSW, has been working in the mental health field for 20 years, specializing in addictions and couples’ therapy.

References
Foa, E., Keane, T., & Friedman, M. (2000). Effective treatments for PTSD. New York: The Guilford Press.

Foa, E., & Rothbaum, B. (1998). Treating the trauma of rape. New York: The Guilford Press.

Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (1993). The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. Paper presented at the Annual Meeting of International Society for Traumatic Stress Studies, San Antonio, TX.

Discussion No. 1
By Marlene Shapiro, LCSW-C

Shaquila and Joseph required months of treatment and more than one modality of therapy. Alternate diagnoses were considered, tested, retested, and treated (e.g., trauma in Shaquila’s past). This is a second attempt at marital therapy, and both had previous individual therapy. The husband talked with his sponsor and his professional colleagues about his marital problems; his wife has been to Al-Anon. However, in the end, we are left with a curious lack of information as to whether this 12-year marriage can be saved.

This marriage with estranged partners is in crisis. Joseph has become involved in what sounds like an emotional affair with a coworker while talking about his marriage and tells his wife that he no longer has the same feelings for her, that he feels closer to his colleague. Shaquila feels betrayed and devastated but agrees to marital therapy again.

We are told the couple worked hard in therapy, learning new communication skills, which they successfully implemented at home. They “have no lack of empathy” for each other and reported increased intimacy. Then they got “stuck.” Shaquila often “shuts down” or her mind goes “blank” when asked to use reflective or assertive skills in couples’ sessions. As a couple, they need “detailed coaching” to be assertive with each other. After four months of couples’ therapy, Shaquila asked for individual therapy. Here is where the marital therapy derailed.

In social work, we “start with where the client is” (and make sure he or she feels heard), but did this happen? I believe the key to this case is the betrayal that repeatedly surfaces but is not fully addressed until after several months of marital and individual therapy. When Shaquila’s individual therapy began, she “indicated her discontent with the couples’ work focus and timing.” She wanted to resolve her feelings about her husband’s betrayal. Instead, a lengthy journey ensued through Shaquila’s history, current symptoms, a psychiatric consultation, the development of additional diagnoses, and repeated testing to measure her level of depression and trauma. After considerable effort and training, Shaquila stopped individual therapy because she felt it was interfering with “any rapprochement that was being elicited by the couple’s work.”

Shaquila again asserts herself, insisting on being allowed to directly address the perceived betrayal in couple’s work, to freely ask Joseph him about the “other woman.” Is this successful? I am not certain since Joseph’s response is a high level of frustration, and the counselor and the couple agree to end this part of the treatment after three sessions “to alleviate some of Shaquila’s hypervigilance.” Shaquila is described as more relaxed, but we know little about Joseph’s feeling and nothing about the state of their marriage.

A marital history is essential. What are Shaquila and Joseph like as a couple? What do they do together for fun and how often? Does Shaquila’s work and study schedule preclude the couple spending time together? Are they content with their careers? Did moving to a small town affect their relationship? What is their sexual history? Has the couple postponed having children because they wanted to be “more settled,” or are there other reasons that impact the marriage?

There are many roads to explore in this case, but unless the betrayal is dealt with sufficiently to satisfy both Shaquila and Joseph, it is going to be a difficult voyage. Finally, it may prove helpful for the therapist to explore her apparent reluctance to address the affair initially and directly. It appears to have made the betrayal an unmentionable topic and possibly prolonged the therapy.

— Marlene I. Shapiro, LCSW-C, is the 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. 2
By Laura W. Groshong, LICSW

There is a recent article in Science News that this case presentation evokes for me. Tom Siegfried wrote “Odds Are, It’s Wrong: Science Fails to Face the Shortcomings of Statistics,” which appears in the March 27 issue, and one of his conclusions is that “the proper use of statistics makes relying on scientific results a safe bet. But in practice … statistical methods make science more like a crapshoot.” The outcome of Shaquila’s treatment seems to be based on the tests used to assess her posttraumatic stress (i.e., the PCL-C Scale). I was left with questions about the meaning of this scale as an accurate assessment of her progress in her individual or couples therapy.

The presenting problem for Shaquila seems to be her anxiety about being emotionally rejected by her husband through his attraction to his colleague. In the information provided about Shaquila’s family background, it appears that she is ambivalently identified with her mother and father, pursuing her father’s unmet dreams of success by becoming an attorney but struggling with impulses to be self-sacrificing and appeasing like her mother, that broke down in the face of her husband’s complaints about the relationship. It appears that there may be a lack of emotional boundaries. It is unclear how Shaquila sees herself and understands her intense feelings toward Joseph.

The shifting between the couples therapy and individual therapy in the case report—technically about Shaquila—added to my confusion about what the primary problem was in this case. The primary treatment method appears to be couples counseling.  The shifting between the couples counseling and individual counseling created confusion for me about which problems belonged in the relationship and which problems were individually based.

My main impression was that there appears to be a lack of differentiation between Shaquila and Joseph and perhaps a need to see each other as an extension of themselves in different ways. Their decision not to have children may have partly been based on the need to fill in the emotional gaps each contains for each other without the ego demands that raising children would bring. The meaning of Shaquila becoming an attorney and Joseph being a counselor is unclear but likely significant.

One possibility is that Joseph’s warmth felt therapeutic to Shaquila when they first met and her professional success felt like an ego boost for Joseph. By bonding with each other without maintaining some differentiation, the relationship may have become smothering for Joseph as Shaquila’s need for emotional reassurance from him grew untenable. Joseph may have liked having someone like Shaquila who depended on him emotionally to avoid some anxiety about his own internal world but became resentful of her emotional needs over time.

Joseph may be the emotional person for both members of the couple, while Shaquila is the one who has more status in the world as an attorney. (Again, this is very speculative, as there is no information about the way she views herself or Joseph views her as an attorney.) His discussing their marital difficulties with colleagues and then telling Shaquila about this demonstrates a lack of respect and/or understanding about the way their relationship has been constructed. The violation here may be less about having feelings for a colleague and more about his bringing another person into the delicate enmeshed world. This lack of boundaries may be the basis for the ongoing problems the couple has faced, also speculative as the problems are not detailed.

There is apparent therapeutic value for Shaquila in using breathing techniques and listening to her own taped experience of feeling traumatized by Joseph. Based on that result, the following sentence was confusing to me: “After a few weeks, she reported that the discipline of listening to the recorded material was interfering with any rapprochement that was being elicited by the couples’ work.”  The results of the PCL-C Scale would suggest that there was improvement in her level of anxiety and her ability to confront her husband. If that was inconsistent with her reaching a mutual understanding with Joseph, perhaps there had been an unconscious agreement that Shaquila would not express herself in a way that was critical of Joseph.

The questions I am left with are as follows: Did Shaquila and Joseph wind up having more tolerance for each other’s feelings and separateness? Did Joseph realize why his actions might have been hurtful? Did Shaquila accept her responsibility for her feelings and letting Joseph know how she wanted him to treat her? Did they realize that they needed to respect each other as individuals? How much was trauma the basis for Shaquila’s distress and how much was she in need of missing ego strengths that left her in a kind of ongoing emotionally vulnerable state?

This case may illustrate that Shaquila was helped by Foa’s techniques to address the anxiety and anger caused by traumatic experiences, but the material available here is not convincing to me. The statistics say she improved, but there was a limit to how much she could continue to work on the relationship as well as her own distress. Underlying self-esteem problems or her ability to develop a more individuated relationship with Joseph may be issues that needed further attention.

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