Authur Freeman
Marie is a white, Catholic, 33-year-old married female who was referred by her family physician. She described her self as depressed -so depressed, in fact, that for the past year she reported that she had been "paralyzed." She described the depression as affecting her work life, her marital and sex life, and her social life. While not presently as depressed as she had been several months earlier, she did not feel that she was as functional as she had been at the peak of her productivity. She described her marital difficulty as being in part due to conflict with her career needs and her husband's life-style. Marie was fearful of making any changes in either her career or her marital status, as she was afraid of losing her husband and then feeling that she was unlovable and would never be able to live with anyone.
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.
These interactions involved setting the basic agenda and then setting the priorities for the session. Note that both patient and therapist collaboratively established the session goals.
M: I just don't know. It would be interesting for me to hear it.
T: Sure, that's always available.
M: Yeah, it will be interesting evidence for me. I'm always scared about seeing it because just that [sic] I hate hearing myself on audiotape. I also hate seeing myself on videotape.
T: (Marie suddenly looks quite sad) What is going on? What are you thinking?
M: I'm ugly. I'm awkward.
T: She says with a quiver in her voice.
M: This really is not good. (starts crying) The tissues are too far away.
T: We can remedy that. That's easy to remedy. Here you go (hands her the tissues)
M: My mannerisms are peculiar, annoying, and embarrassing. If I met me I would think I was pretty unattractive, both physically and in behavior.
T: So there is a thought that goes, "I'm ugly, awkward, and if I met me, I would be pretty upset."
M: Well, not just me, others would be unimpressed.
T: Would I be unimpressed?
M: Yeah.
T: What might I say to myself?
M: She's a loser. She's weird. I don't want to associate with her.
T: She's weird, a loser, don't want to associate. So you have all of these-a whole stream of automatic thoughts that just kind of-not just a stream; sounds more like a cascade.
M: Right, a waterfall. (Marie starts crying again)
T: A waterfall and it really does begin to fall, doesn't it?
M: Yes, right.
T: That is probably an apt image, because as you start thinking those things, you're feeling what?
M: Umh, sort of sorry for myself. Poor me. I'm so horrible.
T: That is certainly sad.
M: Yes, very sad, yes.
T: Because even as I just ask you this, your voice begins to quiver again. And what evidence do you have that all this is true? That you are ugly, awkward? Or that it is not true? What data do you have?
In this way, the therapist helps Marie to look at the "hot cognitions," those that occur immediately in the session. Rather than the two of them talking about her sadness of last night or last week, the sadness sits on the desk between patient and therapist and can be used to explore the thoughts that generate fresh sadness within the session. This is followed by examining the data that Marie uses to maintain her dysfunctional ideas.
M: (answering the last question above) Comparing myself to people that I consider extremely attractive and finding myself lacking.
T: So if you look at this or that beautiful person, you're less?
M: Yea.
T: Or if I look at that perfect person, I'm less? Is that what you are saying?
M: Yes.
The therapist introduces a schematic focus with this question. Marie's perfectionistic thinking has been discussed in previous sessions, and the resent statements can move beyond the present case to reflect the more dynamic issues.
T: (continuing) That they are somehow perfect and you are…
M: Yeah. I always pick out, of course, the most attractive person and probably a person who spends 3 hours a day on grooming and appearance, clothes shopping, and I only compare myself to them. I don't compare myself to the run-of-the-mill… I have begun to try to contradict all this stuff, and that's why I know that.
T: I would like to hear some of that.
M: Okay, well, we are getting the body image stuff. Well, I have done very well this whole week. I'm a lot less depressed. I have done a couple of really tough dysfunctional thought analyses which I feel I have made very good progress on, and I find myself thinking in those terms so that the thoughts come up again and I find myself contradicting the negative thoughts, the automatic thoughts, almost automatically-especially the ones I have written out. I have enjoyed what I have been doing this week. I didn't commute much this week, so that helped. But I don't think that was just that. Ti seems that it was more than that because there have been days when I haven't commuted. When I have stayed and I have been depressed, too. I've been in bed all day.
T: So, overall, you are saying that you had greater touch with the pleasure experiences.
M: Yes.
T: You felt more competent?
M: Yes
T: Handled things much better?
M: Yes
T: And less depressed?
M: Yes, all of those.
T: Phew!
M: Yes, it's a lot.
T: Quite a lot, isn't it?
M: And it does seem to be related to some of the dysfunctional thought analyses I did.
T: Can you just briefly capsule one for me?
M: Well, actually there are two that I gave you last time which I keep sort of coming back to.
T: Which two are those?
M: 15 and 16, number 15 and number 16. I don't exactly remember what they were on, but I know they are very important. Ahh, [number] 15 was when I cancelled our therapy appointment right after the surgery because I felt a lot of pain and I didn't feel motivated to do the homework. I felt really lousy about myself because of that. And [number] 16 was when we decided I should work on more specific problems and I started out with low self-esteem, and that was the morning I spent ruminating in bed and had 250 automatic thoughts in three hours. And spent the whole afternoon doing the homework and contradicting that.
T: And the result was what?
M: The result was that although I didn't immediately stop being depressed, gradually that evening I felt less depressed, and then that weekend I felt even less depressed and by Monday I felt pretty good, and then this whole next week from Monday to Monday.
T: You are getting a sense of mastery.
M: Yes.
TABLE 12-1 Problem About Which I Have A Lot Of Dysfunctional Thought(Marie).
Priority Problem
8 Relationship with Alan
1 Feelings of low self-esteem
5 Resistance to doing "work" work
5 Resistance to doing any work (correspondence,
washing clothes, etc)
12 Sex with Alan
9 Food, especially chocolate
6 Career-goals in general, and should I change
jobs now in particular
2 Meaninglessness of life
11 Body image, exercise
10 Appearance, grooming, clothes shopping
14 House maintenance
13 Money-feelings about spending it, earning it
7 Wasting time-frittering my life away, not
accomplishing anything important
21 Aging
20 Children-OK not to have any?