Case Studies

Case Study 1 includes a transcript of a session with Simone. After reading the transcript, evaluate Simone’s behavior using Psychoanalytic Theory.

Case Study 3 includes a transcript of a session with David. Briefly conceptualize David’s symptoms from a Client-Centered perspective.

Case Study 6 includes a transcript of a suicidal and depressed patient. Briefly conceptualize this case from a Cognitive Therapy perspective.

Compare and contrast the main techniques of rational emotive therapy, behavior therapy and cognitive therapy.

Compare and contrast the view of psychopathology described in Freud’s theory with the view described in Rogers’ client-centered theory.

Simone case

 

Simone was a young African American woman with whom I worked for four years. Dur- ing this period, I saw her three times per week. At the time she began treatment, she was 26 years old. Simone initially sought treatment because of a “general feeling of emp- tiness” as well as a moderate problem with bulimia, which involved both binging and purging. She was working in a health-food store on a part-time basis and was primarily supported financially by her father. In college, Simone had majored in fine arts, but she was not doing anything related to her college education in the time she was in treatment with me. She was extremely attractive, intelligent, articulate, and well dressed. From the beginning I was struck by her lively and playful manner and her sense of humor. I also began to notice early on a tendency on her part to vacillate between states of narcissistic grandiosity during which she denied any needs or self-doubts, and (less frequently) states of openness and vulnerability during which she was able to admit to feeling extremely alienated and lonely.

Simone was brought up in a middle-class family in the suburbs. She attended a relatively affluent, predominantly white school. When I asked what the experience of being one of the only black children in the school was like for her, she denied any feel- ings of discomfort or of not belonging. She told me that most of her friends throughout her life had been white and that she had never given it much thought. During the course of treatment, we explored whether being in treatment with a white therapist had any significance for her. At first she denied that this was the case, in the same way that she denied having any feelings about being the one of the few African Americans in a pre- dominantly white school. Gradually over time, however, we were able to explore this issue in greater depth.

Simone had two older brothers and one younger sister. Her father had an MBA and was a business executive when she was growing up. Her mother was a nurse. Simone’s father left her mother when Simone was 6. Her father and mother had maintained an on-and-off again relationship over the years, and her mother had always maintained the hope of reuniting with him.

When Simone was a child, her father’s presence was unpredictable. He would peri- odically (e.g., once every one or two months) come home to spend a weekend and then invariably leave early after having a fight with her mother. Simone described poignant memories of running down the road after his car crying. She maintained that initially she would be excited when she knew that her father would be visiting. Eventually she stopped feeling any excitement (as a form of self-protection) and then transitioned into a third state in which she felt no feelings but pretended to be excited to avoid alienating her father.

Simone’s father continued to maintain a relationship with her as she grew older and even now would periodically contact her, take her out for lunch or dinner, make plans to see her again, and then inevitably disappear from her life again. When Simone spoke about her father, I often had the feeling that there was a semi-incestuous quality to the relationship. It was difficult for me to put my finger on why I felt this way. Simone never acknowledged a literal sexual boundary violation in their relationship (and it seemed to me quite possible that there never was one), but the way she discussed their relationship often had a type of romantically charged quality to it. She conveyed a sense of awkward- ness and shame about their interactions, and her perception was that her father also felt awkward—“as if he was on a date.” Another factor contributing to my speculation that there may have been some time of sexual boundary violation in Simone’s childhood was that she sometimes spoke about experiencing a type of “disgusting energy” emanating from her that drove people away. (My experience has been that the feeling of being disgusting in some fundamental way is not unusual for clients who have been sexually violated as children.) The possibility of a sexual boundary violation having taken place in Simone’s childhood was not a topic that was ever fully explored in work together. I speculated to myself, however, that a boundary violation of this type may have affected her ability to have romantic relationships with men. I also wondered to myself whether some type of sexual trauma with her father or another man in her childhood may have affected her way of relating to me and her difficulty in accepting support and nurturance from me.

Simone maintained that when she was a child her mother had been highly er- ratic, alternating between episodes of intense anger and periods of fragility and de- pendency on her. Simone remembered learning to be vigilant to shifts in her mother’s mood in order to avoid triggering an outburst. She also remembered learning to take care of her mother emotionally—a way of being that had become characteris- tic for Simone. She described her mother as emotionally needy and dependent and felt extremely judgmental of her. This critical perspective on her mother contrasted with an idealized view of her father, who she viewed as independent and with whom she identified.

Simone was extremely shy in school and saw herself as ugly. Her first romantic re- lationship was at the end of high school. She was involved with a boy for a year but had no sexual relationship with him. When he left school to attend college, Simone became briefly involved with his best friend. On one occasion she had sexual intercourse with him and experienced this as traumatic. When she described the reasons why she had experienced the event as traumatic, it was the first point in our work together that I began to get a sense of some pockets of semidelusional ideation in Simone’s thinking that were generally kept well contained. She told me that before this incident she had believed she would give birth to a child through immaculate conception and now this could never happen.

After her relationship with this boy, Simone began to have lesbian relationships and was involved in a lesbian relationship at the beginning of treatment. Before treatment, Simone’s longest romantic relationship (subsequent to her first high school boyfriend) had lasted one month. Her typical pattern would be to end romantic relationships when she began to experience her partner as being too “emotionally needy,” apparently an inevitability in her mind. When Simone began treatment, she did not see the absence of long-term romantic relationships in her life as a problem or as something she wished to change. Over the course of treatment, Simone and I spent considerable time exploring the factors contributing to her feelings of emptiness as well as her binging behavior. She fluctuated dramatically (both within sessions and various stages of the treatment) in her ability to look at her own feelings and actions in a self-reflective fashion. At times when she was feeling safer and more open, however, she was able to express a desire to im- prove the quality of her relationships with people, a wish to be in a long-term romantic relationship, and a curiosity in understanding interfering factors. We explored the way in which her father’s unpredictability had contributed to the development of a counter- dependent stance on her part. In addition, we explored the way in which she had iden- tified with her father (and his apparent emotional aloofness) and repudiated the more vulnerable dependent aspects of herself that she associated with her mother (whom she saw as pathetic). We also explored the way in which her binging was connected to a desire to fill an experience of emptiness inside of her as well as the relationship between her dissociation of dependent feelings related both to her feelings of disgust when she experienced romantic partners as needy and her own difficulty in allowing others to relate to her in a nurturing fashion.

At different points in the treatment, Simone revealed additional elements of semi- delusional ideation (e.g., a continuing belief that she would still give birth to the mes- siah, a belief that certain people she met had special powers, a belief that she could read other people’s minds). At such times Simone disclosed information tentatively and with a somewhat self-deprecatingly humorous style as if to say, “I don’t take this completely seriously.” She vacillated in terms of how trusting of me she felt and how willing she was to reveal beliefs of this type. Her fear that I would not understand or could not fully embrace her beliefs was an ongoing focus of discussion.

Throughout the treatment, Simone was preoccupied with various new age beliefs and ideas. She would spend hours browsing at new age books on bookstore shelves in what seemed a desperate attempt to fill what she described as a “hole” or an “emptiness” inside of her. Inevitably, Simone would leave the store feeling unsatiated—bored with the activity but not fulfilled. In time, we came to understand this activity of hers as simi- lar in function to her binging behavior—that is, a desperate attempt to fill an internal experience of emptiness.

A few months after beginning treatment with me, Simone became involved with a cult, and this involvement continued and intensified over the first two years of her treatment. An important focus of exploration involved her concern that her spiritual interests were incompatible with psychotherapy. In addition, the effects of Simone’s dissociated depen- dency needs emerged more fully in the cult. Although she initially felt quite skeptical of the cult and its leader, over time she became more involved in the cult. The allure of being able to completely surrender to the cult and its leader became more and more apparent to her. The prospect of having somebody completely take charge of her life and tell her what to do and not to do in any given situation was undeniably appealing to her.

As discussed previously, there was a continuous alternation in treatment between periods when Simone seemed quite open and able to engage in an exploratory process and periods when she was highly defended and rejected any attempt on my part to ex- plore underlying feelings or look for deeper meaning. Although these alternating states never completely disappeared, over the course of treatment they became less frequent and intense, and Simone became better able to explore both her internal experience and the meaning of our relationship to her.

At the beginning of treatment, I had the sense that Simone had one foot in treat- ment and one foot out the door. She would often miss sessions (claiming that she had forgotten) or arrive 15 to 20 minutes late for sessions. For the most part, she would resist any attempt to explore feelings or factors underlying her inconsistent and late at- tendance, although occasionally she would be more receptive to exploration. I found myself feeling anxious that she would leave treatment precipitously, and I was concerned that any attempt on my part to explore her ambivalence would hasten her departure. I found myself feeling concerned that she would experience my attempts to explore her ambivalence as reflecting my own neediness, and I was more hesitant than I usually am to explore a client’s ambivalence about treatment.

Over time, part of our work together involved exploring the way in which her skittishness about commitment to treatment evoked anxious feelings in me that in turn made it difficult to bring myself fully into the relationship and express my own feelings of caring toward her. I began to conceptualize what was taking place as an enactment in which Simone’s own anxieties about dependency led to a lack of invest- ment in our relationship, which in turn fueled feelings of anxiety and shame about my insecurity. My own conflicts about dependency and a concern about seeing myself as needy were being triggered by Simone’s avoidant style, and they interfered with my ability to constructively explore Simone’s contribution to what was taking place between us.

Another more subtle element of my countertransference feeling emerged more clearly over time. When I first met Simone, I experienced her as especially attractive and was impressed by her lively, playful manner and sense of humor. I had found myself looking forward to working with her, and I won’t deny that my attraction to her played some role in this. Over time, however, it occurred to me that Simone’s physical attrac- tiveness developed a type of abstract, disembodied quality for me. Although Simone continued to have a playful manner, I did not experience it as flirtatious at all, and I was somewhat surprised by what I experienced as a complete absence of any sexual at- traction on my part toward her, despite the fact that I continued to find her beautiful in an abstract sense. I wondered to myself whether this aspect of my countertransference might be related to a tendency on her part to desexualize me in her mind in order to make our relationship safe for her. This is not a theme that evolved more fully or that we had time to explore during our work together.

Over time, I became aware of a quality of narcissistic grandiosity in Simone—a belief on her part that she had all the answers and that nobody else, including me, had anything of value to say to her. This attitude is not one that emerged explicitly at first but gradually over time as I became aware of my own countertranference feelings of not being able to say things that she really took in, and I was able to use my feelings as a point of departure for exploring what was going on in our relationship. Gradually, Simone was able to acknowledge that she didn’t believe that I might have anything useful to say to her. Ultimately, she was able to articulate an underlying fear that if she did become more receptive, she would become dependent on me and vulnerable to abandonment. Over time, Simone and I were able to collaboratively make sense of her counterdependency and narcissistic defenses in term of her experiences of abandon- ment as a child, and she became more open to input from me. A central dilemma that emerged for her was the conflict between (1) fearing dependency on others and feeling that nobody (including myself) had anything of value to offer her and (2) desperately wishing that others would be able to introduce their subjectivity in a way that would help her feel less alone.

We explored these themes in a variety of different ways throughout the treatment. To provide one example, I will describe the way in which a dream that Simone reported in the fifth month of our work together led to an exploration of her ambivalent feelings regarding dependency in our relationship and provided hints of her complex feelings about sexuality, men and dependency, and our relationship. She reported this dream shortly after her father had invited her to temporarily move into an apartment he owned and in which he would stay periodically when he came to the city on business trips. Simone:

Jeremy: Simone:

Jeremy:

I’m with some people on a beach and they’re playing with a puppy. And they’ve got the puppy partially submerged under the water . . . maybe to soothe it. But it’s not happy. And so I decide to take over. . . . I see a male dog who I think is it’s father . . . but it’s interesting because this male dog has udders. So I take the puppy and put it on its father’s udders and then the puppy seems happy. What do you make of the dream?

Well, maybe the dog is actually my father, and maybe it has to do with me moving into his place. That make sense . . . and I’m also thinking . . . and this is really just playing around with the images . . . so don’t take what I’m saying too seriously, maybe the male dog is me.

I say this in a very tentative way so it will be easy for her to dismiss without feeling too dismissive and also in an attempt to gauge how capable she is of acknowledging feelings of intimacy and dependency in our relationship at this point.

Simone: Jeremy: Simone:

I hadn’t thought of that. How does it feel? I don’t know . . . I’d have to think about it.

She then goes on to tell me another dream fragment.

Simone:

Jeremy: Simone: Jeremy:

And then in the dream, I see my old adviser from college, Emma . . . she’s a woman, but then I look at her shadow and it’s the shadow of a man. What do you make of it? I don’t know.

I know from what you’ve told me previously that the last time you visited Emma you felt uncomfortable with her because she felt needy to you.

Earlier Simone had told me that Emma symbolizes neediness to her.

Simone: Well it’s like the way she was always trying to look after me and offer me guid- ance, it felt like there as a kind underlying desperation . . . or neediness . . . like maybe she needs to relate to me as a daughter or something.

I wonder to myself if this might be another reference to our relationship. Perhaps Sim- one experiences my attempts to help her as representing a form of neediness on my part. But I decide not to explore this potential allusion to our relationship because of a concern that she will find it too threatening. Simone continued to talk about the dream at the following session.

Simone: I was thinking about that dream I had about that male dog with the udders . . . and it makes me feel uncomfortable.

Jeremy: Are you willing to explore what feels uncomfortable about it? This is a form of defense analysis.

Simone:

Jeremy: Simone:

Well there’s something yucky about it. I don’t really like to think of myself as getting nurtured by you. There’s something scary about it. Scary in what way? Well it would mean that I’m dependent on you and that brings up a whole bunch of feelings.

We continue to explore the range of feelings it brings up: fear, yearning, revulsion, fear of abandonment, and so on.

Simone: You’re not really a father figure for me . . . it’s like you’re not really male. It’s like you just exist in my head

Jeremy: Simone: Jeremy: Simone: Jeremy: Simone:

Can you say more about me not being male? Well you don’t give me advice or tell me what to do. Would you want me to give you advice? No. Why not? Because then I would become dependent on you. You’re not like my father that way. Things are complicated with him.

At this point, Simone transitions into talking about her complicated feelings about what she refers to as “the sexual energy” between her and her father. She speaks about how her father always makes it clear to people that she is his daughter when he takes her out for dinner—as if to make sure that they don’t assume they have a romantic re- lationship. She speaks about the fact that on occasion she has slept at her fathers’ place when he is out of town and that she feels uncomfortable sleeping in his bed because she knows that he “entertains people there.”

I speculate to myself that it is important for Simone to desexualize me in her mind because the potential of my playing a paternal role with her is threatening because of the sexual connotations for her. But again, I don’t say anything at this point because I feel it would be premature.

The following session Simone spontaneously brought up the possibility that maybe the male dog with udders in her dream does represent me. We continued to explore what this possibility meant to her during this session, and the intertwined threads of conflict around dependency, sexuality, and romantic relationships with both men and women continued to unfold and become further illuminated through- out the treatment.

Approximately halfway through treatment, Simone became romantically involved with Jim, a 30-year old African American musician. Jim was the first male Simone had been romantically involved with since her adolescence. Over a period of time, Simone was able to genuinely contact her desire for Jim and her hope that things would work out between them. I never expressed a preference for Simone to become romantically involved with men rather than women, nor was I aware of experiencing such a prefer- ence. Although Simone was not able to explain her new interest in a romantic relation- ship with a man, I speculated to myself that the process of beginning to become more trusting of me, a male therapist, helped her to begin to experience men in general as safer and less likely to abandon her in the same way that her father had. This possibility was not, however, something I felt Simone was ready and able to explore explicitly in treatment, so I did not introduce it.

Ultimately, Jim rejected Simone. My impression was that she experienced this as ex- cruciatingly painful, and she subsequently shut down and began once again to deny her need for him or for anyone else, including me. During this period, she flirted with the idea of leaving treatment and leaving the city to join an ashram associated with the cult she had joined. After a futile and extended attempt on my part to explore what was going on for her, I settled into providing more of a supportive, containing environment for her in which I would by and large attempt to mirror or empathize with the manifest level of her experi- ence. After approximately two months of this, Simone began to become more emotionally open again, more receptive to exploration, and stopped talking about leaving treatment.

Subsequent to this, Simone began dating a number of men and ultimately settled into a relationship with a man named Scott. It was in the context of this relationship that she had sexual intercourse with a man for the first time since her adolescence. She subsequently moved in with Scott in a rather precipitous fashion and lived with him for approximately three months. During this period, she struggled with intensely am- bivalent feelings about the increased intimacy and fears of dependency and engulfment. We spent considerable time in therapy exploring the difficulty she had in negotiating between his needs and her own, and we also explored the parallel between the issue emerging in the relationship with Scott and the transference.

Over time, Simone found living with Scott increasingly intolerable, alternating between feeling that he was too needy and very occasionally acknowledging fears of abandonment and rejection. Eventually, she left him and then moved in with another man who was a member of the cult. At the same time she began to discuss the possi- bility of leaving treatment again, maintaining that she was feeling better and that she had accomplished the goals she had at the beginning of treatment. Over a period of time, I gently and tentatively explored with her the possibility that her wish to leave treatment was motivated (at least in part) by a desire to avoid the type of intensely ambivalent feelings evoked by the intimacy of our relationship. Gradually, she came to acknowledge that this was true and then began to settle in a phase of treatment during which she remained considerably more trusting and open for an extended period of time.

Although even during this phase Simone continued to vacillate between periods of self-reflection and periods of shutting down and emotional withdrawal from me, the in- tensity of these swings decreased considerably. During this phase, Simone substantially decreased her binging behavior and became less preoccupied with eating. She began to work on her art for the first time since ending college and was able to experience this as a source of satisfaction. Simone and I continued to explore her feelings of ambivalence about intimacy and her fear of dependency in both our relationship and relationships in general. She also began to talk more openly about feelings of being “different” because most of her friends were not black, and we began to explore ambivalent feelings about being in therapy with a white therapist. We explored the way in which Simone did not feel completely at home in either the white or black worlds and the way this contributed to her general feeling of alienation and isolation.

In the final six months of our work together, Simone became romantically involved with a new man named Jamal, and this relationship developed a more stable quality than her previous relationships had. Although she was not without feelings of ambivalence, she was better able to tolerate her feelings of dependency on Jamal and was less self- critical of her need for him. She began working on a more consistent basis in the health- food store and developed a plan to save up enough money to return to college with the help of her father’s financial assistance and take courses.

Two months before ending treatment, Simone began to raise the possibility of ter- mination. This time, however, things had a different feeling about them than they had previously. It was clear to both of us that she had made some important changes in her life. Although it was far from clear what the future would hold in terms of her current romantic relationship or her plans to return to college, there was a mutual sense that she had started on a different path than the one she had been on at the beginning of treat- ment. We set a termination date in advance, and over the remaining time together we explored both ways in which she had changed over the course of our work together as well as her feelings about termination.

At first, Simone denied any ambivalent feelings about leaving treatment and ex- pressed an eagerness to “do things on her own” now that she no longer needed my help. I wondered to myself whether it might be a bit premature for her to leave treatment and had some concern that she would not be able to maintain the gains she had made. I also wondered whether her plans to terminate were once again related to her fears of intimacy and abandonment and distaste for dependency. At the same time, however, I considered the possibility that my reactions reflected my own reluctance to let go of her and perhaps a certain narcissism on my part and an overestimation of the significance of my own role in her life. I disclosed some of these feeling to her, and this facilitated an ability on her part to begin to explore some of her ambivalent feelings about leaving treatment. She was ulti- mately able to acknowledge anxiety about becoming too dependent on me, fears about how her life would go after she left treatment, and, also toward the end, feelings of sad- ness about ending our relationship. When we ended treatment, I made it clear that she was welcome to contact me any time just to let me know how things were going or to schedule another session if she wished.

I received a letter from her about two years later. In it she told me that things were basically going well in her life. Apparently, she had left Jamal approximately four months after she had terminated treatment with me. Three months later, she had become ro- mantically involved with another man, and they were still in a stable relationship. She was working for a small group as a graphic designer and was finding the work challeng- ing but satisfying. Simone wrote that periodically she would still lapse into periods of binging, especially during difficult periods in her life (e.g., breaking up with Jamal). She wrote that in general, however, her binging was much more in control than it had been when she began treatment. Overall, Simone felt that her treatment with me was helpful, and I concurred. I had a sense that our work together reached a level of depth that al- lowed her to make significant changes in her life and significant internal changes as well. I also had the sense that there were many themes left unexplored and that Simone could potentially have benefited from more treatment. It seems possible that she may go into treatment again at some future point in her life, and she might even contact me at some point to explore the possibility of further treatment. At the same time, however, I be- lieve that no story ever completely unfolds in any treatment. At any given point in time, a specific client and therapist are only able to go as deep and accomplish what they are both ready and able to accomplish at that time.