Authur Freeman
She lived with her husband in a northern suburb of a large city and worked in a far southwestern suburb of that city; this amounted to a 2-hour daily commute in either direction. Her husband worked near their home. To ease the commuting problem, she maintained a small apartment near to her work. They had lived apart for two years, with Marie seeing her husband only on weekends to avoid the 140-mile round trip commute. She was employed as an equal opportunity officer and assistant to the president of the corporation was thinking of firing her. The other major conflict regarded her marriage and her wanting to stay married. She had been married for seven years, but there had been no sexual intercourse in the marriage (or outside of it) for the last three years. Intercourse was painful for Marie, and therefore avoided.
Marie is the second youngest of four children, having two brothers (ages 36 and 35), and a sister (age 28). Her mother is a teacher, and her father a retired chemist; both are still physically active. Marie described her childhood as relatively unhappy, with episodes of depression from about age 12 on. She was the butt of insults and teasing from her second oldest brother, who would constantly call her "elephantiasis," a reference to her being overweight and later having acne.
Marie described herself as an unpopular child with very poor social skills. She was seen as "brainy" and uninvolved in the social activities of her childhood and adolescent peers. She had no dates throughout her adolescence and first started dating in college. She met her husband when she was 24years old; they dated for two years and married. She reported having few friends, except friends at work with whom she did not socialize.
Marie always did well in school. She graduated from high school with high honors and attended a small, prestigious private college, where she received high honors and was a member of Phi Beta Kappa, graduating summa cum laude. She continued her graduate work at a large university, getting her M.A. and Ph.D. in history. For the past three years, she had been responsible for the implementation of equal opportunity and affirmative-action programs at her company.
A recent medical evaluation showed that Marie was in good health, 15 to 20 pounds overweight, with no other medical findings. Previous therapy included seeing a social worker once or twice a week for four years while she was a graduate student; Marie described the therapy as "helpful" but was unable to verbalize what she learned. She felt that the therapist was supportive and offered a critical, listening ear. More recently, Marie had been involved in reevaluation (peer) counseling. For the past two years, she and her husband had been in sex therapy to deal with the lack of sexual activity, but the result of the sex therapy was that they terminated therapy without initiating sex.
At intake, Marie appeared well-groomed and neat. She was cooperative throughout the interview. Her mood was depressed, and she appeared sad and cried several times during the session. She wad, however, able to smile and laugh appropriately, and her speech and thought were no hallucinations or delusions, but some minimal depersonalization. She was oriented in all spheres.
Major problem areas. The major areas of difficulty identified were: (a) her depression, (b) low self esteem, (c) marital difficulty, (d) sexual problems, (e) vocational difficulty. Marie's intake diagnosis was: AxisⅠ--dysthymic disorder; AxisⅡ--R/O obsessive-compulsive disorder; AxisⅢ-- none, AxisⅣ-- marital difficulty, job difficulty (moderate); and AxisⅤ-- excellent functioning.
Result of testing. On intake, Marie's Beck Depression Inventory score was 42, placing her in the severely depressed range. She endorsed 10 of the 21 items at the highest level.
An assessment of her suicidal thoughts on the Scale of Suicidal Ideation (Beck, Kovacs, & Weissman, 1979) indicated a score of 6, endorsing a weak with to die, with her reasons for living and dying about equal. Her general attitude toward suicide was ambivalent, with her reasons for contemplating a suicide attempt being to escape and to solve her problems through a surcease of the depression and difficulty she was presently experiencing. The major deterrents to her attempting suicide were her husband the thought that "it is going to get better."
Marie was seen for a total of 28 sessions from the initial interview to the termination interview, over a period of eight months. She was seen twice weekly for the first two weeks of therapy and then approximately once weekly thereafter.
Formulation of the problem. The patient presented several discrete problems: (a) an overriding sense of hopelessness with a consequent suicidal ideation; (b) marital difficulty (i.e. relating to her husband and maintaining the marital relationship); (c) sexual difficulty involving abstinence from intercourse because of physical pain and discomfort; (d) career difficulty- specifically, a sense of dissatisfaction with her present position in terms of whether or not she could effectively do the kind of job that she felt she needed to do; and (e) lack of a social support network..
Conceptually, the patient was a perfectionist who utilized an all-or-nothing approach to problem solving. A major goal of treatment was to have her alter this dichotomous thinking to allow herself to experience and accept being successful. Because of the suicidal ideation, a rather immediate set of interventions focused on Marie's sense of hopelessness to relieve the suicidality and make it less likely for it to pose a danger to her. A second part of treatment protocol was an exploration of the marital/sexual difficulties with a part of the treatment discussion focused on the sexual problems.
After termination of therapy and in 21/2 years of follow-up, the patient has (a) changed her job so that she now works at a job for higher pay and equal prestige only four miles from her home; (b) eliminated the issue of hopelessness and suicidality; (c) become more conscious of health and physical appearance, lost weight, and maintained the weight loss; (d) described her marital relationship as excellent, with she and her husband maintaining an active and gratifying sexual relationship.
By directly addressing her cognitive distortions and the often-irrational underlying belief systems, Marie was helped to think more clearly, behave more functionally, and cope more rationally. This initial session excerpt is from the sixth session.
T: Okay, where do you want to pick up? What do you have on tap for the agenda today?
M: Well, first item would be the purpose of the taping. I want to talk about that.
T: Sure.
M: What it will be used for and so forth. And then the topic that I wanted to discuss is body image, appearance, all related to self-esteem, being fat, feeling that I am fat and ugly. Clothes, buying clothes. When I categorized my problems, those came out as part of self-image.
T: So, it relates to some of the homework you were working on?
M: Right, and that's if for what I have.
T: Okay, so we want to look at the homework and to review how things have been going since the last session.
M: Okay.
T: Okay, what do we have? We have three things. The purpose of the taping, the whole thing of body image and how that relates to your homework, and there is some other homework, too. And just how things have been gong since the last session.
M: Why don't we do that one-second, since it is going to bring you up to date?
T: Okay, and the taping first. What do I do-I guess the body image is part of the homework, or the homework….
M: Why don't we do the homework third, and then get into the body image from there?
T: And let's save the majority of the session for that.
M: Okay.