Therapist’s Notebook

Read this case in which the therapist truly met the client where she was and in the best social work tradition, honored her right to self-determination.

Case of Jacqueline
By Camille Call, LCSW

Coming into her first session, Jacqueline carried the information of her last physical and some other paperwork, as requested. She was seeking treatment for her chronic daily headaches. Because that seemed a bit out of the ordinary, I requested that she bring her most recent medical information. She was very willing to provide this, stating on the telephone, “I was at the doctor’s office just a month ago, and we went over all the lab reports and all the other information he had collected and everything I could tell him about the headaches. That’s when he suggested therapy might be the next best option for me.” She also reported that although she had tried all types of medication, none seemed to work, and she really preferred to not take medication as it made her feel “cloudy.”

When I saw Jacqueline, we spent two hours in an intense intake, scouring the medical paperwork and gathering as much historical information as possible. She was a good historian, able to recall both recent and remote events in her life with the best clarity I had seen in a 32-year-old woman. She was clear and articulate, did not appear to be in the throes of a painful headache, and was in very good physical condition. Jacqueline was very attractive, and one might think she could be a model.

Jacqueline was single, having never married or had any children. This had not been a specific choice on her part, “just the way life has been to me,” she stated. Although she wanted a relationship and family in her life, she didn’t seem to brood on it in any way.

She had earned a bachelor’s degree in physical education and training. Her current position was managing a high-end local gym that included all the necessities for her to continue her own physical training. As the manager, she preferred working afternoons and evenings and sleeping into the day because of her ongoing headaches. Any form of bright light was difficult for her eyes, sending what she referred to as a “headache death ray” directly to her head.

Jacqueline’s physician had documented chronic migraine and cluster headaches with relief only in sleep. All test results and lab reports, including a CT scan and an MRI, were negative.

Instead of feeling sorry for herself, Jacqueline stayed active, participating in high-risk, physically exerting activities. She was very proud of the photos she brought to the first session, showing her high above the ground ice climbing—an activity during which she claimed she was able to “forget” about the headaches because she could focus on simply being cautious and staying alive.

We began discussing Jacqueline’s past and the events leading up to the first time she realized her headaches were there to stay. At the age of 6, her best friend’s 16-year-old brother molested her. This was never reported, and Jacqueline claimed that because there was no penetration, it was “no big deal, and I don’t think it really affected me much.”

Jacqueline was entering third grade when her brother was born. This, she reported, was both fun and difficult. It was fun because she loved being “kind of a mom” but difficult because, at times, she felt like her mother paid more attention to her little brother.

Later in the conversation, Jacqueline stated that her father more than made up for her mother’s inattention, as he consistently took her outside with him to work on the car or to run errands. She spent more time after the age of 8 with her father than with her mother. She credits her “tomboylike” interests to her father’s loving and unconditional acceptance of her throughout her life.

Following the intake, we both had more questions than answers, and I became more curious about both Jacqueline and the headaches. We scheduled an appointment for the following week, with Jacqueline’s verbal thanks and grateful demeanor.

As we burrowed into treatment, we both gained multiple insights into Jacqueline’s life. At one point, she had that “a-ha” moment we all enjoy with clients from time to time. She was discussing her interaction as a late-blooming teenager, getting ready to graduate from high school and being teased relentlessly about her sexuality. Because she excelled at sports and was as academically adept as she was athletic, she couldn’t seem to fit into any of the typical high school caste categories.

Shortly after graduation and before she began her summer job, she was riding her bicycle in the early evening one night and was mugged by some of her previous high school peers, both male and female. There were about four of them, and she was in desperate fear for her safety. Fearing she might also be raped, she used her own physical and mental strength to fight them off. Jacqueline had a vague recollection of falling as she was kicking, at the same time hearing a siren. The next thing she remembered was awakening to a kind female police officer asking questions such as what her name was and the date.

Because she was 18 years old, aware of her surroundings, and had no apparent serious injuries, she signed the waiver for medical attention but did accept a ride home from police.

The muggers had scattered when they heard the sirens, and the police were unable to catch them. Jacqueline wasn’t able to remember whether she refused to name them because she didn’t remember who they were or because she was afraid of retribution. Then the epiphany came. That was when the headaches began, and they have remained ever since.

We discussed the extent to which the headaches may remain due to a posttraumatic stress event or a traumatic brain injury. Yet there is nothing that can be found physiologically that indicates a brain injury. At this point, it didn’t matter to Jacqueline; she only felt intense relief because she finally had an answer. And knowing the “why” gives it a name and often offers a way out.

Jacqueline is still experiencing daily headaches. She continues to engage in high-risk physical endeavors. She calls for a therapy appointment about four times per year “for my own sanity” and to gauge whether she is on the right track. She may never be rid of the headaches, yet her stated feelings are that at least she has some emotional relief having gained the insight she needed to move forward in life and on her way out of the headache rut.

— Camille Call, LCSW, maintains a consultation and contract supervision practice in Sitka, AK.

Discussion No. 1
By Barbara L. Holzman, LCSW, ACSW, BCD

Jacqueline’s degree of emotional constriction and detachment when talking about her history is striking. She reports the facts of her life but affective connections to them are lacking. Her emotional armor is in place. Given her history of chronic headaches for the past 14 years and two reported traumatic events, one would expect anger and frustration to be present, and their absence is noteworthy and significant.

This detachment and lack of affect has a long history. Painful events in her life, such as being molested at the age of 6, are described as “no big deal” because there wasn’t any penetration. She didn’t think it really affected her much. Her minimizing, rationalizing, and suppressing of any affective connection to what must have been a traumatic event at so many levels—her being only 6 years old, the perpetrator being the big brother of her best friend—reveals how disconnected she is from her feelings.

That molestation isn’t the only event that she hasn’t been able to emotionally acknowledge. She is articulate and a good historian, recalling events so clearly that the social worker describes it as the “best clarity I had seen in a 32-year-old woman.” However, she is unable to remember details regarding being attacked at the age of 18. Her recall of that event is vague, fuzzy, and in sharp contrast to descriptions of other life events.

Being in desperate fear for her safety, the attack must have been devastating and too painful to process. She needed to avoid and block the recall of painful details and emotions connected to the event, which she did through somatization. The headaches, which began after the attack, support that the client is dealing with a posttraumatic stress event, as her medical history doesn’t indicate that the headaches came from a traumatic brain injury.

The attack’s impact can be seen in her work schedule. She prefers working in the afternoons or evenings because any form of bright light is difficult for her eyes, sending what she called a “headache death ray” directly to her head. The structure of the gym and the hours she works are ways for her to avoid triggers that re-create the traumatic event. The gym is her safe place.

These traumatic events also affect her quality of life. She says she wants a relationship and family in her life but accepts that it’s “just the way life has been to me.” Her passivity and acceptance of the lack of personal relationships suggests emotional intimacy is threatening because of the vulnerability it would create. Her fears are barriers to her taking interpersonal risks. Her risk taking is solitary and physical, not emotional. Ice climbing allows her to forget her headaches and focus on staying alive. When she is engaged in this activity, she feels safe to experience feelings and emotions.

There is a second important theme to discuss, which deals with the issue of Jacqueline’s sexual identification and orientation. The family social history is sparse and focuses primarily on her early relationships with parents. The client felt her mother paid more attention to her little brother. Her father made up for her mother’s inattention, as he consistently took her outside with him to work on the car or to run errands. She spent more time with him than her mother. She credits her “tomboylike” interests to her father’s loving and unconditional acceptance of her throughout her life. She clearly felt loved and cared for by him and identified with his interests.

Her painful peer experiences would only have added to any confusion or concerns about her identity and her sexual orientation, even though she doesn’t directly address the issue. During high school, she was teased relentlessly about her sexuality, as she didn’t seem to fit into any of the typical high school caste categories being both athletically and academically gifted. We don’t know how she coped with the unrelenting teasing or its impact on identity formation and self-image. Did she have sources of emotional support during this difficult formative period?

The trauma of the attack added to the client’s experiences with peers, creating additional fear and vulnerability about relationships. She is described as attractive. Unfortunately, information about her relationships with either men or women after high school isn’t given. It is possible to imagine, given the client’s strengths, skills, and capacities, what opportunities might have been available if she had been able to deal earlier with the trauma that constricted her emotionally.

In Jacqueline’s treatment, the therapist began where the client was. The presenting problem dealt with her headaches. Her reaction to medication—that none seemed to work—and that she preferred to not take medication as it made her feel “cloudy” reflects the importance to Jacqueline of being in control. Her presentation of historical information and medical records also reflected this need. Being in control is the coping mechanism she uses to deal with the helplessness and vulnerability resulting from her traumatic life events, and the therapist accepts this.

The client experienced relief when she finally had an answer to the headaches’ origins. Once that epiphany happened, Jacqueline decided that she had gotten what she wanted from treatment. The therapist honored Jacqueline’s right to determine her path, and regular appointments were discontinued.

Jacqueline recognizes that the therapist respects her choices by continuing contact on a minimal basis “for her own sanity.” A therapeutic alliance has been established. If Jacqueline decides that she wants to resume ongoing treatment, the foundation is in place for her to do so.

— Barbara L. Holzman, LCSW, ACSW, BCD, has been in private practice in Phoenix for 30 years.

Discussion No.2
By Jeanette Sinibaldi, MSW, LCSW

Jacqueline’s case presents the therapist with the challenge of working with a client who has an agenda regarding specific issues but has resistance with continuing the therapeutic process.

Jacqueline is forthcoming about her history, but the information presented leaves an unsettling impression that this young woman is avoiding any real answers about knowing or understanding herself in any depth. Many times, we are faced with clients who are satisfied on this level, and we accept their level of comfort and relief, as the therapist indicated. The therapist did what was necessary and accepted how far the client chose to go. The therapist may, on one of the quarterly visits, ask whether Jacqueline would like to work any further to learn some more about herself, to see if she is ready to move onward psychologically. There is much material to work with, as presented in her case history and, if motivated, Jacqueline could use therapy to its highest value of awakening.

One of the ways of evaluating a client such as Jacqueline is to examine the use of psychological defenses. Since she is an intelligent woman and came to her own recognition of her headaches having begun after a traumatic experience, it is not out of the question to teach a client like this what ego defenses are and how we use them.

Understanding anxiety and how we react to stress is an important factor in Jacqueline’s case. She exhibits defenses of denial, intellectualization, repression, and compensation.

We all use and need ego defenses to be whole individuals, but understanding them can be educational to a client. Jacqueline would understand that her defenses are there as protection from the onslaught of anxieties that currently cannot be coped with. Teaching and demonstrating various ego defenses helps clients understand how they have used them in their life.

As we become aware of ourselves and how we operate, our maturation hopefully brings us to the higher level defenses of altruism, humor, identification, introjection, and sublimation.

Jacqueline was teased relentlessly about her sexuality in high school and violently attacked by males and females from the school. This incident appears to have been a serious one, and we do not know for sure if Jacqueline sustained a traumatic brain injury. She would need to have a battery of tests by a neuropsychologist to see whether she has any cognitive deficits, as they often do not show up on CT or MRI scans.

Emotionally, I would suspect Jacqueline has much repressed anger that she has not even touched on regarding this incident. With all that Jacqueline experienced in her high school years, it appears that she has not dealt with the intense, underlying emotions that she seems to have buried. She did not fit into any high school groups, which leads me to believe there was social isolation as well.

Finally, is Jacqueline’s high-risk behavior connected with her inner emotions? The therapist can engage in conversations about fear and control with this client to examine what is behind these activities. Does she need the feelings of exhilaration from the risk of these intensely dangerous activities? How does she experience adrenaline rushes? Since the therapist has an understanding of her family history and her inner dynamics, these questions can be discussed with the client to help her become more insightful about herself and how she is living her life. The goal is to open her scope of options and choices in her world because she now has a wider perspective on life.

Clients such as Jacqueline are a wonderful gift to any therapist because we can see them on an ongoing basis throughout various times in their lives. We may see them more regularly when they have issues to resolve and then not hear from them for a few years and may get an occasional call that they need to work on something that has come up. I have several clients that came to me as teens and are now grown with children of their own. They are amazingly mature people because they used the therapeutic process as an educational tool. They are the highlights of our profession.

— Jeannette Sinibaldi, MSW, LCSW, is in private practice in Queens and Long Island, NY.