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January/February 2009 Issue

Therapist’s Notebook
Social Work Today
Vol. 9 No. 1 P. 22

Read the presenting problem, history, and treatment of a woman with serious mental illness. How do your observations compare with those of the two therapists/discussants?

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

Case of Hannah
By Marlene I. Shapiro, LCSW

Hannah was a 50-year-old, single, highly intelligent, college-educated white woman who was self-referred to my private practice. She was a talented sculptress who made her living creating small and large pieces of sculpture and objets d’art for her own business. Although ill with major depression with psychosis (sometimes diagnosed with schizoaffective disorder) since her 20s, she had only two severe episodes in her life that were resolved with medication and without hospitalization. When she became ill, her family supported her until she recovered. In between episodes, she did not take medication for years at a time and was highly functional. However, her third episode was so severe that she was hospitalized for four months before being discharged to the day hospital where I first met her.

Hannah was born outside San Francisco, the youngest child of a well-to-do, close-knit Catholic family who were minimally observant in their religious practices. She had a sister and two brothers who were doing well. By all reports, the family members were supportive of each other and enjoyed being together. Hannah lived in San Francisco until her mid-40s when she moved to an East Coast city after taking a trip to see an art exhibit there. In the basement of her new home, she constructed a studio and successful business. She made friends easily and was active in art and religious communities, the latter a group with very strict observances.

Several years after her move, she began to isolate herself, first from her family and then from the art and religious communities. She refused calls and visits, leaving her home only for food and art supplies. A worried neighbor caught a glimpse of Hannah and was dismayed by her physical condition. The neighbor called Hannah’s family, who contacted a local psychiatrist to perform an evaluation. He found her to be psychotic, malnourished, withdrawn, and preoccupied with religious ideas, praying on her knees for hours at a time. The doctor had her immediately committed to a hospital.

When hospitalized, Hannah, who stood 5-foot-7, weighed less than 80 pounds. She had been eating only one small meal per day and reportedly spent long hours in prayer. Initially, Hannah refused medication and ate very little. At her family’s urging, she decided to cooperate with treatment. Even so, she spent four months in the hospital before she was ready for outpatient care. After discharge, she lived in a halfway house on the hospital grounds and attended a day hospital. Gradually, she improved and returned to her usual high level of functioning. She was friendly, gregarious, and her hyperreligious behavior ameliorated.

Ready to leave the halfway house, Hannah requested 24-hour support, so she transitioned to an assisted living home near the hospital for several months. At this time, she asked to see me privately, and I agreed. She found a volunteer job on her own with a nonprofit organization that advocated for children with mental illness and used her artistic skills to create promotional material for the group. It was during this period that she decided she would not return to her former art career or her former religious practices, as she believed they precipitated her psychotic episodes.

After a few months in assisted living, Hannah was ready to live independently. She found her own residence, a house in a middle class neighborhood that she shared with several other female professionals. She found part-time work in an art supplies shop and, with some of her money and help from her family, she purchased a car. She appeared to be happy about her life, and her recovery seemed complete.

I met with Hannah for about one year. She was insightful, verbal, personable, and had an excellent sense of humor. At her baseline, she did not appear to be suffering from any mental illness, although she dressed idiosyncratically (long skirts and long sleeves). In therapy, she reported making new friends and establishing closer ties to her family, even visiting them for holidays, though she found this difficult at first. She came to therapy regularly and initially spent a lot of time talking about the “wild and crazy youth” of her 20s when she dated often, drank, and described herself as very popular, implying that she did things she would not approve of now. Her 30s had been spent building up her art business.

She often spoke of her recent relapse, her guilt at having made her family suffer, and her humiliation at having to be dependent during her recoveries. She agonized over her proclivity toward perfectionism and was clearly still very hard on herself. “Nothing I ever did was ever good enough for me, and it still isn’t,” she explained. She missed being more religious and not practicing her art but continued to be anxious that participation in either would precipitate another psychotic break. These decisions created significant tension and conflict in her. For example, she found she was enjoying eating better but was disgusted with herself for not being able to restrict her intake as drastically as she preferred. She decided to carefully resume her religious studies (though not the practices) because she believed she was “not good enough.” Her notion of what constituted ideal religious practice involved much sacrifice and asceticism essential to spiritual goals that she could not yet define.

Hannah’s family paid for her therapy. Six months before Hannah terminated therapy, she reported that her family was concerned about the length of time in therapy and the cost, although no one in the family had contacted me directly with any concerns. From that time on, the tenor of the therapy changed. Her religiosity resurfaced and intensified. Two months before Hannah terminated treatment, she took herself off her medications and was off them for a month before telling the doctor or me. Her rationale was her unhappiness with a modest weight gain, but she also believed she did not need the medications. She stopped seeing her doctor for medication checks but continued to see me.

During this period, she alluded several times to “traumatic” events in her past but was adamant about not discussing them, despite my careful exploration and gentle encouragement. She kept saying that she needed to be able to discuss these events more openly but wasn’t sure she wanted to bring them up. I could not seem to reassure her, and she was not willing to explore the issue further.

At this point, Hannah seemed to be stuck. Hoping to jump-start the process, during one session, I brought up goals in general, and Hannah seemed very surprised. She said, “Don’t feel guilty because all I do is chat. You help me keep tabs on my thinking. You help me try out some of my thoughts so that sometimes I really take a look at how I see things and can reassess them.” Hannah forcefully resisted attempts to “go deeper.”

Shortly before our final session, Hannah said she wanted to talk more about her use of therapy. She said, “I don’t believe in cutting things off completely with a therapist. I need to see a professional, as friends are not dependable. I want to use talk therapy, but the talk needs to come from a stream of consciousness. You are led to a place you would not go yourself. You get things resolved that you cannot resolve on your own. I am socialized now. You have socialized me again. But all my problems still exist—deep problems that lead to depression, despair, and suicidal thoughts. And these aren’t being touched. I need to know what I am going to do with my life now.”

Hannah announced that she needed to work more intensely on the trauma in her life and spiritual matters even though she thought that this might prove dangerous. But she declared that I was not a “spiritual seeker,” and she believed that I was “missing the point.” She thought that I had the skills to provide a “stabilizing situation to people who are completely fractured.” However, she felt that unless I had similar experiences (being fractured and being more religious), I could not be as effective as she needed me to be. “You would consider all this religious preoccupation as a warning that a relapse was about to happen. You would not want a patient to go there. I believe that I need a pastoral counselor,” she said. We struggled with these issues, but our discussions were not productive, and internally, I began to agree with her. Maybe I wasn’t the “right” therapist for her now.

Finally, in one of our last sessions, Hannah said she wanted to see another therapist and asked me for a referral. Since we had struggled with this so often without making progress, I gave her several names. Hannah preferred a female. She decided to see my suite mate, who was a psychiatrist with an analytic approach. Hannah made an appointment with her and decided that they would be a good fit.

Termination continued when a new problem unexpectedly emerged in session. Hannah expressed a sudden interest in my note taking. She thought I took too many notes and wondered if they were secure and who else might have access to them. She actually refused to go on speaking during that session if I continued to take notes. I had explained my note-taking process at the beginning of treatment, but I explained it again and then I agreed to stop.

Before our last scheduled session, Hannah e-mailed me for the first time ever, saying that she felt I had an understanding of her struggles and that she appreciated the referral. She wanted to spend our last session reviewing all the notes I had taken in the past year, after which she wanted copies. She asked that I then destroy the originals. I explained that this was my work product but offered to write a summary and discuss it with her. She agreed to a summary initially, and I let her know that this was going to be a large undertaking, that it would take time to write the summary and time to discuss it, perhaps two more sessions or one long session. Hannah dropped her request and stopped coming to therapy. I checked to make sure she was seeing the referral since she was off medications and struggling so hard to separate from me. She had continued to see the doctor. This was the end of our contact.

During the course of therapy, it became clear to me that while Hannah did well in therapy, she held back some significant traumatic events that may have propelled the therapy forward. We had a trust issue that I have not completely figured out, and this was frustrating. However, she continued to see the doctor to whom she was referred, and this assured me her needed treatment would continue.

— Marlene I. Shapiro, LCSW, is the program 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. 1
By Charles A. Rizzuto, MSW
The therapist clearly developed a strong working alliance with this client and saw her through some very difficult processes. Most importantly, following Hannah’s long period of hospitalization and assisted living, the therapist helped the client reestablish an independent life. That included part-time work, a stable living situation, new social connections, and closer ties with her family. At her baseline of functioning, Hannah initially did fairly well and seemed to possess some insight. She appeared intact enough to discuss some difficult aspects of her earlier life and was able to articulate what seemed like the downside to her earlier intense religious practice and its link to her decompensation. She trusted the therapist enough to reveal the harshness of her self-judgments (e.g., regarding the religious practices and her eating patterns), as well as the presence of unspecified “traumatic” events in her past. The therapist clearly realized the potential importance of the trauma issues but wisely heeded Hannah’s resistance to “go deeper,” particularly since, now off her medication, Hannah was likely heading toward decompensation. Ego-supportive treatment to mitigate anxiety, develop coping strategies, and shore up adaptive defenses was the appropriate course of action.

How do we understand Hannah’s eventual decision that the therapist is no longer right for her, and that she needs a clinician who is religious and would not see Hannah’s religiosity as a sign that relapse is imminent? On the surface, there is the issue of religiosity, which sometimes poses a dilemma for clinicians. It touches on our core social work obligations to accept our clients and respect their right to self-determination. It also often poses a challenge to our knowledge of intrapsychic processes and our understanding of the role of defensive maneuvers and other potentially maladaptive postures.

While it would be inappropriate to challenge the client’s religious beliefs, it could be useful to help the client develop additional coping resources, ones that do not have the self-punitive aspects that this client’s religious practice seems to involve. It would not be inappropriate to gently remind the client of her own stated misgivings about her rigorous religious practice and the acknowledged relation to previous difficulties. In the end, however, the therapist is right to respect the client’s wishes for transfer, though clearly and understandably this was a struggle for her. Referring to a psychotherapist who is also a prescriber was a good idea.

At the end of the case presentation, the therapist notes her sense that there was a “trust issue” she needed help understanding. This is a very good point, though I believe the trust issue would be best addressed within the context of what may be serious trauma. Some of the facts of the case—particularly Hannah’s psychiatric history and her long periods of functioning well without medication—point in this direction.

We are told that the treatment relationship began changing significantly after Hannah’s family expressed their concerns about the length and cost of her therapy. To what extent might these rumblings have stirred up abandonment fears in Hannah, which then pushed her to seek the structure and guidance of more rigorous religious practice? If indeed there is serious trauma history, as Hannah indicated, these fears may be related to this history and to Hannah’s attempts at coping with trauma-related symptoms over the years. In turn, the trust issues the therapist wonders about may be closely related to the trauma, and Hannah’s abandonment fears may be manifesting themselves in the relationship with the therapist.

In what ways did these issues play out in treatment? For example, the client stated that she would now not approve of certain things she did in her “wild and crazy youth.” This criticism might be seen and interpreted to the client empathically and cautiously as a transference communication: The therapist would not approve of them either. Such an interpretation might have led to a discussion of trust or to the trauma issues themselves.

In what ways did fears of being abandoned by her previously supportive family evoke fears with regard to the therapist and the treatment? Was the patient’s sudden reaction to the note taking, for example, related to these fears and to trust issues? The client may have been moving toward decompensation at that point. Is she fearful about what the therapist is saying about her in the notes or of how the therapist may be using the notes? On the other hand, is her desire to see the notes more about her connection to the therapist, how important the therapist is to her (and vice versa), and a desire for—and fear of—greater closeness? These are areas that might have been explored gently with the client. Addressing this aspect of the relationship might have enriched the termination process considerably—perhaps even averted it.

As in most clinical discussions, an exploration of countertransference phenomena would be an essential component. Relevant areas of focus in this case might include the therapist’s attitude toward religious beliefs and practice and toward medication compliance (another ethical issue), understandable but unrealistic desires the therapist may harbor to “fix” this client whom she clearly likes, fears the therapist may experience regarding the client’s fragility, and the degree to which the therapist may feel she has failed the client.

— Charles A. Rizzuto, MSW, is a member of the summer adjunct faculty at Smith College School for Social Work and maintains a private practice in psychotherapy and supervision in Holyoke and Amherst, MA.

Discussion No. 2
By Gail Levinson, MA, LCSW

Conundrum is the first word that comes to mind with this case. This presentation reflects a diagnostic quagmire of possibilities. Does schizoaffective really describe Hannah’s illness? Are we looking at a client with bipolar I with psychosis that goes into remission? Might Hannah have an undiagnosed eating disorder? Additionally, there are elements of the course of the outpatient treatment that remind me of the qualities of people who have borderline personality disorder—people who seem to “flame out” and run from treatment at a point in the relationship when closeness or connection becomes too frightening. Hannah’s accusations about her therapist’s “lack of sufficient spirituality” and the quality or nature of techniques used seemed to come up late in the course of the therapeutic alliance.

 The apparent ease with which the therapist seemed to “internally” agree with her became the point in time where the case was lost. At the same time Hannah was moving toward termination, she also had identified that the therapist’s strength was in helping “resocialize” her, but she wasn’t up to the “real work” of delving into “all the deep problems that lead to depression, despair, and suicidal thoughts.”

My sense is that the treatment began to unravel around the time Hannah stopped her medication. Hannah presents an interesting paradox in terms of being able to identify the severity of her illness because of her intelligence, talent, and long periods in apparent remission. This case also raises the question of how much her socioeconomic standing and extraordinary family support contribute to her “flying under the radar” for relatively long periods of time when she may have benefited from more continuous and consistent treatment. The level of decompensation she endured before her four-month psychiatric hospitalization would not likely have occurred had there been greater oversight.

While it is far easier to look at the course of treatment from a distance, I wonder if the therapist may have been blinded by Hannah’s strengths and unable to see that Hannah was becoming ill again when she started missing her spiritual practice, questioning the therapist’s techniques, and seeking the “real underpinnings” of her illness (akin to seeking her undefined spiritual enlightenment). At the risk of sounding jaded, my personal belief is that there probably isn’t anything to be gained by trying to delve into the deep recesses of Hannah’s psyche that would either explain or resolve her biologically based mental illness. This therapist’s approach was both appropriate and clinically indicated.

Given Hannah’s history of mental illness, it might have been appropriate to encourage an evaluation and participation in the day treatment program around the time Hannah’s religiosity began to resurface and certainly when she finally admitted she had discontinued her medication. Had this occurred, perhaps the treatment relationship between this therapist and client could have been preserved and the continuing descent into paranoia (e.g., the time agonizing over and discussing the clinical notes) may have been avoided. I wonder if this therapist lost the way via the intellectual seduction and competencies of Hannah, the artist who effectively took control of the treatment process.

— Gail S. Levinson, MA, LCSW, is in private practice in Wilmington, DE, and is the treasurer of the Clinical Social Work Association.