Rain bird t63 vs t70

case studies in psychotherapy

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Dedication

To Karen Harrington You are my future.

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case studies in psychotherapy

seventh edition

Editors

Danny Wedding Raymond J. Corsini

Australia Brazil Japan Korea Mexico Singapore Spain United Kingdom United States

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© 2014, 2011 Cengage Learning

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In Memory of Four Giants in the World of Psychotherapy

Carl Rogers (1902–1987)

Rollo May (1909–1994)

Joseph Wolpe (1915–1997)

and

Albert Ellis (1913–2007)

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contents

dedication ii

contributors ix

foreword xi

acknowledgments xiii

preface xv

1 psychoanalytic psychotherapy The Case of Simone / Jeremy D. Safran 3

2 adlerian psychotherapy The Case of Roger / Harold H. Mosak and Michael Maniacci 12

3 client-centered therapy Client-Centered Therapy with David: A Sojourn in Loneliness / Marjorie C. Witty 33

4 rational emotive behavior therapy A Twenty-Three-Year-Old Woman Guilty About Not Following Her Parents’ Rules / Albert Ellis 59

5 behavior therapy Covert Sensitization for Paraphilia / David H. Barlow 79

6 cognitive therapy An Interview with a Depressed and Suicidal Patient / Aaron T. Beck 88

7 existential psychotherapy “If Rape Were Legal . . .” / Irvin Yalom 103

8 gestalt therapy First or Nowhere? / Sally Denham–Vaughan 115

9 interpersonal psychotherapy A Case Study for the New IPT Therapist / Marie Crowe and Sue Luty 139

vii

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viii c o n t e n t s

10 family therapy The Daughter Who Said No / Peggy Papp 149

11 contemplative psychotherapies Using Mindfulness Effectively in Clinical Practice: Two Case Studies / Tory A. Eisenlohr-Moul, Jessica R. Peters, and Ruth A. Baer 173

12 positive psychotherapy Strength-Based Assessment in Clinical Practice / Tayyab Rashid and Robert F. Ostermann 193

13 integrative psychotherapies Integrative Therapy with Mr. F. H. / Larry E. Beutler 204

14 multicultural psychotherapy Alma / Lillian Comas-Díaz 215

index 219

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ix

Ruth A. Baer

David H. Barlow

Aaron T. Beck

Larry E. Beutler

Lillian Comas-Díaz

Marie Crowe

Sally Denham-Vaughan

Tory A. Eisenlohr-Moul

Albert Ellis

Sue Luty

Michael Maniacci

Harold H. Mosak

Robert F. Ostermann

Peggy Papp

Jessica R. Peters

Tayyab Rashid

Jeremy Safran

Marjorie C. Witty

Irvin Yalom

contributors

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xi

foreword

Observing an expert perform a skills-based task has always been the most effective way for an apprentice to learn a complex procedure. For this reason, witnessing and study- ing the work of those who have mastered their craft have always been at the heart of the apprenticeship system. This method of training is more effective when it has been preceded by instruction that allows novices to place their observations into a meaningful conceptual context. This book, which presents case studies conducted and written by experts in specific therapeutic modalities, corresponds to the apprenticeship aspect of a training program. The primary text, Current Psychotherapies, parallels these case studies chapter by chapter. Although a reading of that text is not necessary for a fruitful reading of these case studies, it can heighten understanding of what the therapists are doing by presenting the theoretical and applied underpinnings of their systems.

All clinicians personalize the systems that they have studied and chosen to use. Their therapy reflects their personal life histories, the scripts, values, attitudes, and dis- positions that form (mostly at a tacit or implicit level) the weft of that elusive fabric we call the psyche. None of us can entirely escape the conditions that have made us who we are, and our experiences inevitably get enmeshed in the treatment plan and the proce- dures that we use with our clients. For this reason, the therapist, as a person, becomes the primary instrument of therapy. The techniques become secondary.

Most of you who will read these case studies are motivated by an interest in improv- ing your clinical skills. A first reading will excite a sense of profound admiration for the clinicians who worked the marvels of “therapeutic outcome” described in the studies. Their virtuosity should not discourage you from aspiring to their level of expertise. One must keep in mind that these cases are not examples of their least accomplished per- formances. The editors chose them precisely because they are instructive of the highly evolved clinical skills these therapists possessed at an advanced point in their careers. Although these clients challenged their resources to the utmost, they were clients who were apt, and suitable, for the treatments these therapists were prepared to provide.

Becoming a skilled clinician is like becoming skilled at any other complex hu- man activity. It is the work of the “long-distance runner.” It is building a repertoire of techniques and broad strategies that fit a consistent theoretical paradigm, honing vari- ous clinical skills, and learning to recognize the appropriate moments to use them. It is the work of fashioning coherent treatment plans for particular individuals who will be facing us filled with hope and anxiety. It is becoming a therapist with a therapeutic personality—the privileged instrument of every successful therapy, polished by the in- evitable stresses, frustrations, and failures of life and of our profession—for not every therapeutic relationship turns out as we had hoped it would.

This book raises questions that go far beyond the boundaries of psychotherapy as that discipline is generally construed. The concerns and the personages that are de- picted in these cases implicitly evoke issues of cultural anthropology, social psychology, hermeneutics, psychopedagogy, developmental psychology, and cognitive science.

Psychotherapeutics has borrowed the terms etic and emic from cultural anthro- pology. The former, etic, characterizes a nomothetic or universal approach to framing theories of personality development; the latter refers to principles that are more culture sensitive and culture bound. An emic approach refrains from generalizing principles

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xii f o r e w o r d

beyond the group in which they have been found to be valid. In the limiting case, it treats each individual as possessing his or her own “culture.”

Inclusion of the case on meditation reflects the editors’ recognition of the rich- ness that non-Occidental philosophies and approaches to healing can bring to the Western therapist. Of course, this East-West conceptualization of the culture speci- ficity of any therapy is not a true dichotomy. Like any other psychological, anthropo- logical, or sociological variable, culture specificity lies on a continuum. All the case studies in this book can be placed somewhere on that continuum.

Readers of this book will no doubt experience an approach-avoidance dilemma with several, if not most, of the therapies described here, for there are drawbacks and benefits for each system. The editors make no apology for that and expect both the practitio- ner and the trainee to struggle with the issue of choice. The decisions you make about therapy will be quite personal. Some prefer a predominantly intrapsychic approach to therapy; others a more contextual, social engineering approach. Some like the freedom of a time-unlimited model; others a time-limited, even very brief, model. Some will pre- fer didactic and directive methods; others will be inclined to the Socratic, client-centered approaches. Some will veer to etiological and history-focused exploration; others will prefer teleological, motivational, or even exclusively present-focused perspectives. Some will prefer a reductionistic model; others a holistic model that involves exercise, nutrition, physical fitness, medical exams, and heavy social penetration of clients’ ambient worlds. Some of you will prefer the highly cognitive; others the principally affect-centered. You will find examples of all of these among the 14 case studies of this volume.

The following case studies will be rich ore to exploit, but in mining them, you will inevitably transform them. These studies are like rushing streams, of which the Greek philosopher Heraclitus spoke, into which you can dip your foot (or even plunge). You cannot, however, do the same thing twice, not because the case history will change, but because you will have changed at a second reading. Be that as it may, you have a banquet table set before you. The chapters were a pleasurable and useful read for me. I have no doubt they will also be for you.

Frank Dumont Professor Emeritus

McGill University

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xiii

We are grateful to dozens of colleagues and friends who have taken time to discuss psycho- therapy with us and to share their ideas about how it can best be taught. Sometimes, these conversations took hours and went on late into the evening; at other times, a friend would make a casual comment that would later shape our decisions about which cases to include in Case Studies in Psychotherapy. Although Current Psychotherapies chapter authors usually selected the case study used to supplement their chapters in Case Studies in Psychotherapy, we sometimes solicited outside advice and opinions, and we are indebted to the following individuals who helped in a variety of ways with the preparation of this book.

Bernard Beitman University of Missouri–Columbia Juris Draguns Pennsylvania State University Ken Freedland Washington University Glenn Good University of Florida James Hennessy Fordham University Lockie Johnson Saba University School of Medicine Judy Kuriansky Columbia University Tony Marsella University of Hawaii Richard Nelson-Jones Cognitive Humanistic Institute, Chiang Mai, Thailand Tom Oltmanns Washington University Paul Pedersen University of Hawaii Chris Pearce California School of Professional Psychology Paul Priester University of Wisconsin–Milwaukee Morgan T. Sammons California School of Professional Psychology Sombat Tapanya Chiang Mai University Robert Woody University of Nebraska–Omaha Christoph Zepeda California School of Professional Psychology

acknowledgments

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xv

Psychotherapy is a difficult calling. Its practice requires creativity as well as intelligence, ingenuity as well as training, and hard work as well as good intentions. It is easy to do badly but exceedingly difficult to do well. Its ranks include both charlatans and grand masters. Psychotherapy involves skills that are almost never completely mastered, and it provides opportunities for, and indeed demands, lifelong learning.

Unfortunately, the very features that make psychotherapy so fascinating also make it difficult to teach or explain. Those of us who presume to instruct others in this arcane craft realize that modeling is our most powerful tool, and it is often more heuristic to show students what we do rather than tell them what we do. However, all of us realize the limits of our own training: There are myriad clients with multiple problems, and their needs are protean.

One way to deal with the limits of our own experience and training is to expose students to role models through case histories such as those collected in this volume. Each case in Case Studies in Psychotherapy is written by an experienced psychothera- pist, and each parallels a chapter in the tenth edition of the companion volume, Current Psychotherapies.

Hundreds of thousands of students have used Current Psychotherapies to learn about the theoretical underpinnings and fundamental methods of a dozen or so thera- peutic systems, and the cases in the current volume have been carefully selected to ex- pand and supplement the information in the parent text. This seventh edition includes new cases to illustrate psychoanalysis, client-centered therapy, positive psychotherapy, and contemplative approaches to psychotherapy. These cases illustrate the clinical work of some of the leading figures in the world of psychotherapy.

The serious student of psychotherapy can benefit greatly by reading Case Studies in Psychotherapy in tandem with the core chapters in Current Psychotherapies. I’m con- vinced students who make this investment will appreciate more fully both the beauty and the art of psychotherapy.

Danny Wedding dwedding@alliant.edu

preface

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case studies in psychotherapy

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2

Editors’ Introduction This case study illustrates many of the concepts described in more detail in the Safran and Kriss chapter on psychoanalysis in Current Psychotherapies. It is also an excel- lent introduction to long-term psychotherapy (Dr. Safran worked with Simone for four years, typically seeing her three times each week).

The case shows a therapist and patient working together to resolve transference and countertransference issues, and it illustrates the key psychoanalytic concept of reca- pitulation of the past in the present. Simon’s relationship with her parents is explored in depth (including the “sexual energy” exchanged between father and daughter), and Dr. Safran is able to help his patient understand how the “hole or emptiness inside her” might relate to her bulimia. The case also shows how the therapist and patient worked through termination issues, and it illustrates the ways in which psychoanalysts use dreams in therapy.

It will be useful for you to consider what recommendation you would make if you were a claims reviewer for an insurance company and you were asked to justify the need for four years of treatment for this young woman. Should there be limits to treatment or should it be open ended with termination set by the therapist and patient? How often do psychotherapy patients present with a history of childhood sexual abuse? Were Simone’s beliefs about the likelihood of her becoming pregnant through immaculate conception genuine delusions?

It will be especially useful for you to compare and contrast the way Dr. Safran approaches this case with the approaches advocated in other chapters in Current Psy- chotherapies. Is psychoanalysis the treatment of choice for bulimia? Do this patient’s other problems justify four years of psychotherapy, or is psychoanalytic treatment best conceptualized in terms of personal growth rather than symptom reduction? Does the fact that Simone continued to periodically binge after termination suggest that treat- ment wasn’t effective, or is relapse almost inevitable in cases such as this?

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3

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

P S Y C H O A N A L Y T I C P S Y C H O T H E R A P Y

1 the case of simone Jeremy D. Safran

Excerpt from Jeremy D. Safran, Psychoanalysis and Psychoanalytic Therapies (pp. 122–134), copyright 2012 by the American Psychological Association. Reprinted by permission of the publisher.

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4 j e r e m y d . s a f r a n

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.

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