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March/April 2009 Issue

Therapist’s Notebook
Social Work Today
Vol. 9 No. 2 P. 24

Read the case history of a young woman from a troubled family who is struggling with substance abuse, bulimia, and relationship issues. How do your observations compare with the two therapists/discussants?

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

Case of Michelle
By Laura W. Groshong, LICSW

Michelle sounded upbeat during her first call to request an appointment, cheerfully telling me, “I think I have a borderline personality disorder, maybe attention-deficit disorder. I’ve been doing a lot of reading about emotional problems.”

She looked younger than her 25 years when she arrived for her first appointment: very good looking, well dressed in a “hip” way, carefully made up. There was a seductive yet anxious quality about her. She seemed cheerful as she had on the phone, but the information she relayed was at odds with her smile, good eye contact, and easy manner. She sat up on the couch at first but gradually leaned over during the session, so that by the end, she was almost in a prone position.

“I feel sad inside, but no one knows. I can’t sleep. When I started doing martial arts about a year ago, it helped for awhile, but it isn’t helping any more,” Michelle explained. She didn’t want to go back to using drugs, which she had used regularly since she was 15, some prescribed and some not. She said she had been off all drugs for the previous five months.

Michelle’s explanation for her problems was, “I think it’s because my family is codependent.” She wanted to become more independent emotionally but became anxious if she had an independent role. Her parents didn’t “believe in” therapy because they had both tried it without much success, but she wanted to try it again anyway. She had been to therapists twice before for a few sessions, at the ages of 16 and 21, for anxiety and depression.

Michelle didn’t know how to trust anyone but hated feeling like she was totally alone. Her major anxiety was her inability to tell whether she was crazy or “for real.” Just before coming for treatment, she had a dream about losing her glasses, which captured her anxiety about being real or crazy. They were the wrong prescription to start with, but she couldn’t find a store that was open to buy new ones, so everything was blurred.

Finally, there were work problems, the most important and immediate reason why she was seeking therapy. Her job as a receptionist for a high-profile software company was a source of pride, even though she felt she was treated like a slave by the staff.

Background and Family History
Michelle was raised in a family in which there was not much nurturing. She and her brother, who was six years older, were mostly on their own as their parents struggled with their own emotional problems. Her grandparents on her mother’s side were warm to her during the infrequent times she saw them but also critical of her mother for “acting like a kid.” As Michelle described it, there was a lot of socializing, followed by periods of her mother drinking and going to bed in a depressed state and her father coming home only to sleep. Sometimes, Michelle’s mother would slap her or pull her hair in frustration and anger for reasons that Michelle didn’t understand. Her father paid attention to her successes but ignored her the rest of the time and told her he didn’t expect her to ever be successful financially. She described her parents as alternately very needy, demanding, and domineering, as she did herself, saying, “We’re all codependent.”

Michelle tried to focus on success in academics, art, and sports; she did well academically at a private school until she reached high school and was a fine painter and star soccer player. These successes ended when Michelle was 14 due to her parents’ bankruptcy. She dropped out of soccer, stopped painting, and had to go to a public school that she hated and from which she barely graduated.

Michelle remembered some good times when she was 4 or 5 years old and her mother would let her dress up in her fancy clothes and would sometimes take her on all-day shopping trips. Most of the time, however, Michelle felt that she had to take care of herself, especially when her brother left home when she was 12. Her father expected Michelle and her brother to take care of themselves, as well as her mother when she was drunk.

Her mother’s distress reached a peak when she became despondent and took an overdose of pills about one year after the bankruptcy. Michelle said with irritation, “I guess it’s not surprising that I’m messed up when I had to call 911 for my mother.” Her mother told her it was an accident, and her father also seemed more irritated than concerned. Michelle decided she wasn’t going to “watch out” for her mother anymore.

Her bulimia, which started at the age of 15, increased as Michelle tried to suppress the anxiety and depression she felt. She had experienced suicidal thoughts “for a long time” but never acted on them and thought she never would. She said she had never felt sexual desire and was not very concerned about it; in fact, she felt more in control of her life by not having sexual feelings.

Michelle became attached to a somewhat older musician boyfriend who moved into the basement of her house with her parents’ consent, supplying her with drugs—“Mostly cocaine, it’s classier”—but also marijuana and speed. He occasionally hit her but was mostly supportive and had problems with depression. “I wanted to fix him, but we were too codependent,” just like she viewed her relationships with her family. She finally broke up with him and then was “kicked out” by her father at the age of 18 because she had no money for rent.

Michelle described a history of drug use for the previous 12 years, including marijuana, cocaine, speed, alcohol, Adderall, and Xanax, but she had stopped taking any drugs for the previous five months “to see if I could.” The Xanax helped her chronic sleep problems, but she didn’t like the “downer” feeling she got from it.

Michelle said the only people she could trust were her mother and her boyfriend. About her mother, she said, “She was compassionate when I would tell her I’m upset but really just wanted me to share my Adderall with her.” Of her married older boyfriend, she said, “He was so sweet to me; in fact, he paid for my therapy.” She saw love as “one person being in charge and one being dependent, then getting disowned without warning,” but it was better than being alone.

Course of Treatment
I told Michelle that I would not be able to see her unless she had a physical to rule out medical problems resulting from the bulimia and drug use. Her physician reported, somewhat surprisingly, that she was in basically good health, except for her sleeping problems. She claimed he knew about her drug use and bulimia but asked me not to talk with him directly, as she wanted our treatment to be “private.” I doubted that Michelle had given him all the information, but I accepted this condition.

Over the course of the first three months of therapy, I saw Michelle once or twice per week. She became less upbeat and began to describe herself as easily hurt, a fact which she felt no previous therapists or family members had taken seriously but said she felt I was taking her seriously. Michelle told her parents she had entered therapy, and her mother vigorously opposed it, questioned my qualifications, and said I was creating a rift in the family by encouraging Michelle to be independent. Michelle seemed almost panicked at the thought that her mother would disown her if Michelle “made her mad.” It seemed likely to me that Michelle had a symbiotic tie to her mother, which seeking treatment was threatening. Additionally, her parents refused to pay for treatment. She did not have mental health benefits on her insurance plan.

We discussed her relationship with the older married man who was supporting her treatment and felt like the most caring person in her life. She didn’t mind having sex with him, even though it wasn’t pleasurable for her. She realized she was leading him to think that she would marry him if he divorced, which he said he planned to do. We discussed the meaning of “leading him on” and whether that was a pattern in her life and how much she saw this kind of relationship as the way all relationships worked. But she felt like she was the one in charge. She began to understand that she was taking advantage of him and dominating him by using sex to get money. After about four months in treatment, she broke off the relationship. Michelle and I discussed the financial impact on her treatment and reduced her fee, but the financial strain, among other issues, eventually would lead to her leaving treatment.

Another major topic was her job and the increasing distress she had with her bosses and coworkers. “They don’t care about me and order me around.” She brought in a cake for everyone else’s birthday and when no one did on hers, it was the last straw. She bought herself a cake, ate it all, and then had a bulimic episode. This represented her “throwing up” her hurt and angry feelings, purging her desire to hurt others that went with them. We were able to discuss the way bulimia was a way of harming herself instead of others. She finally found another job as a manager in a retail clothing store, which was more satisfying.

She said that seeing me was extremely helpful and that she was feeling better, even that she felt like she had some “epiphanies” about her life that she had never considered, mainly that she might not turn out to be a financial failure as her father had told her she would and relationships didn’t have to be about domination. Her feeling of success increased as she began painting again and brought some of her work to the sessions. Her affect changed as she explained her art to me, becoming highly excited and pressured. She wanted me to love her for her art and was disappointed when I didn’t value her art more than I valued her as a person.

End of Treatment
After about 10 months, Michelle began cancelling sessions and said she was doing better. She liked her new job and even felt others saw her as a terrific manager. She found a boyfriend who was her age and not abusive to her. He was concerned about her lack of sexual responsiveness and encouraged her to talk to me about it. She agreed it might be a problem but was having trouble paying for treatment and decided she would have to leave. The end of our work was mutual and friendly. We left open the possibility of her coming back in the future.

— Laura W. Groshong, LICSW, is in private practice in Seattle.

Discussion No. 1
By Donna M. Ulteig, MSSW, LCSW, ACSW, DCSW

Michelle experienced the falling apart of life as she knew it at the age of 14, a developmental age in which identity formation is a major task. With her parents’ bankruptcy came a change in schools and a loss of activities, friends, and status, the end of childhood as she knew it. She had to start all over again in this process of figuring out who she was.

How scary to also have to assume life and death responsibility for her mother the following year. Her mother’s suicide attempt when Michelle was 15 (and Michelle’s rescue of her mother by calling 911) put her in a very frightening position. She tells her therapist that she made a decision after that event to not “watch out” for her mother anymore, but she remains tied to her and panics at the thought that her mother might disown (abandon?) her for making independent choices. It was then that she also began her binging and purging.

It sounds like the mother had vacated her parental role long before that suicide attempt. Her mother had checked out with her drinking and depression, and her father by his absences from the home. Even her brother left as soon as he could. How ironic that Michelle presents in treatment with a goal of being more emotionally independent when she has been independent of parental guidance and nurturing for some time. The emotional price she pays in the struggle to take care of herself is 15 years of acting out and distress with drugs and an eating disorder. Her parents were so preoccupied with their own issues that they allowed an abusive older boyfriend to move in with the family. He hit Michelle, used her medication, and supplied her with cocaine and other drugs. These addictions persisted for 10 years, depriving her of emotional growth during that period.

It is hard to understand why Michelle felt that she could trust her mother, given her mother’s propensity to being unavailable or unpredictable, slapping Michelle and pulling her hair without provocation. From her father, she learned that she received attention only by being successful, at the same time that he predicted her financial failure. By both parents, Michelle was ignored, neglected, and controlled but not protected. How unfamiliar it must have felt to have a therapist who was attentive to her needs, requiring her to complete a physical exam, then faithfully addressing her emotional needs for more than 10 months of intensive treatment. She was taken seriously—and she bloomed! What an example of how healthy dependency in therapy can yield independence.

Michelle presents with all kinds of self-imposed labels—codependent, attention-deficit disorder, and borderline personality disorder. Already, she is doing the therapist’s job. The therapist notices a fairly together presentation of self but a presentation with contradictions. Michelle looks happy and confident but complains about her treatment at work and her inability to sleep. She wants to individuate, but her mother (out of her own needs) encourages dependence. She depends on an older married boyfriend for caring and support but is able to end this relationship as she grows in therapy.

She considers herself dependent, yet makes an independent decision to come to therapy, even when her parents do not believe in therapy, vigorously oppose it, and challenge the therapist’s qualifications. She describes herself as needy, demanding, and domineering, yet these qualities do not seem to express themselves in therapy. In addition, she has had five months of being drug free after 10 years of addictive use. There is considerable evidence that she is strong and highly motivated.

I wonder with the therapist how Michelle is able to connect with others as well as she does. I suspect that there is a missing piece of her early history, when perhaps her parents were more consistently there for her or a grandparent provided that stable attachment. She does remember fun times with mother at ages 4 and 5 and admits that her mother can be compassionate. In any event, I take issue with Michelle’s belief that she has borderline personality disorder, given that her substance abuse and eating disorder were displayed in adolescence and early adulthood, that manipulation and abandonment fears were absent in therapy, and that she was able to end therapy appropriately. Moreover, there is no report of relationship idealization and devaluing or inappropriate rageful anger.

Michelle’s dream before entering therapy encapsulates her anxiety about being “crazy or for real” and speaks to her dilemma. She loses her glasses (through which she perceives her world), but they were the wrong prescription to start with. She has no new glasses, no new perceptual abilities, and her vision is blurred. No wonder she is confused about what she should do, and no wonder she is too anxious to sleep.

While Michelle may have personality disorder issues, for me, a more helpful way to conceptualize Michelle’s issues is to identify the patterns that were problematic for her. She identifies that she hates feeling alone, that she is anxious about independence, and that she is easily hurt. She has a history of being in relationships that are about control and domination, and she is unable to enjoy being sexual with a partner. She expects her emotional needs to be met at work and by men who are domineering or unavailable. Her wish is to be cared about nonabusively, and her fear is feeling alone or abandoned.

That these issues are addressed in therapy is evidenced by the successful conclusion—a new job in which she feels valued and successful and her new same-age, nonabusive relationship. She tells her therapist that her learning in therapy, the insight that relationships do not have to be about domination, and her observation that she does not have to be a financial failure have been very helpful. Her sexual nonresponsiveness remains a problem, but since this is her way of needing to maintain control, it may dissipate as she can engage trustfully with a partner. The door to returning to treatment is open, and I suspect she will enter again.

— Donna M. Ulteig, MSSW, LCSW, ACSW, DCSW, has been a partner in the private practice group Psychiatric Services, SC in Madison, WI, for 23 years.

Discussion No. 2
By Camielle Call, LCSW

Michelle presents with classic personality disorder traits, particularly within the first few paragraphs describing her character. There are multiple mixed messages seemingly thrown at the therapist; it’s incredible that she was able to wade through so much to get at the crux of Michelle’s issues.

Undeniably, at the still-impressionable age of 25, Michelle has lived more in her lifetime than many of us ever experience. Early on, she had to deal with verbally abusive, needy, and neglectful parents. She felt abandoned by her brother when he left home at the appropriate age of 18, while Michelle was still only 12. She also felt, rightly so, that she had to raise herself from that time forward, as well as “watch out” for her mother in the seemingly constant role-reversal position in which she had been placed.

Although Michelle’s life before the bankruptcy may have appeared model and idyllic to others from the outside (attending a private school and excelling in academics, art, and sports), the situation at home was far from ideal. Yet, like many dysfunctional youth, Michelle was expected to pick up the crazy puzzle pieces and pretend to the world that life was good. This alone is enough to make any youngster feel out of control—or in Michelle’s words, not be able to tell “whether she was crazy or ‘for real.’”

In practice, a client with a personality disorder is both easily identified and difficult to work with. Typically, this person is a woman who is very bright, knowingly manipulative, and quick witted. Michelle’s clinician seems to be able to keep up with her, even to the point of not backing down when apparently challenged by Michelle’s family, who accused the clinician of causing a rift among them. As a therapist, I would feel intimidated by this event but also empowered that perhaps Michelle was beginning to become more independent in not only her thinking but also her behavior. Despite her panic at possibly being disowned, Michelle continued in therapy, apparently believing it was helpful on a personal level.

The therapist’s concern is that there was something positive missing in Michelle’s description of her life—something that could explain the multiple issues, including the ongoing ambivalence and symbiosis with her mother. If Michelle were my client, my initial intake and subsequent follow-up would have included questions directly related to her mother and the interdependence (possible enmeshment?) there appears to be between the two. I would explore the mother’s history to ascertain a clearer picture of Michelle’s disorder(s) and gain a greater sense of how to approach guiding her to health. Further, I would explore Michelle’s general caretaking behavior (i.e., whether this is extended beyond her mother to others who come and go from her life or if this conduct is strictly reserved for her mother).

Beyond the relationship with her mother, I would investigate Michelle’s relationship with her father, both as a child and currently as an adult. The little we know about Michelle’s history thus far indicates that Michelle seeks out older male approval. There could be something in her story related to her own father that has brought her to this point in her life, including the extensive high-risk behaviors with which she continually flirts.

Regarding these behaviors, I wonder whether there is sexual abuse at the core of Michelle’s personality formation and subsequent growth. I would also explore this issue. Many of the indicators point to this: claiming to have a personality disorder; use of both legal and illicit drugs; inability to extract self from others; eating disordered behaviors; sexually acting out with older men, allegedly beginning at the age of 15; believing that a relationship is “one person being in charge and one person being dependent”; expecting others to leave her without warning; and her reference that “no previous therapists or family members had taken [her] seriously” until she found her current clinician. This last statement is classic and one in which a therapist often finds both flattery and a desire to take a quick step back. By taking a step back, the clinician can more easily and more effectively work with the personality-disordered individual without getting caught up in her ongoing drama. Once a therapist becomes a part of the drama, yet another symbiotic and unhealthy relationship begins to form.

It appears that this clinician did not get caught in the trap of personality disorder traits. Instead, she remained steadfast and consistent, which was what Michelle needed—someone who was there when promised to provide honest and effective feedback and show respect for both the person and the problem, appropriately differentiating them. The therapist has left the door open for further communication with Michelle, has offered to be available when Michelle feels the need to return for further treatment, and has mutually extracted herself from the therapeutic relationship for the time being. By keeping the relationship professional, the clinician is able to continue to work with a particularly difficult client, should she decide to return.

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