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Case of Mary
1. What are your basic statistics?
Your name is Mary and you are a fifty-cight-year-old, European-American woman. Your husband died in a car accident about one year ago coming home from work during a bad storm. You had been married for thirty-two years. You and your husband had three children. They arc now all married. Two of your children, Beverly and Jason, live in distant cities but Cynthia lives with her family about twenty minutes from you. You are the manager of a midsized department store and live alone in an apartment near the store. You have come for help to a practitioner who is in private practice.
2. How do you behave in the interview?
You arc well groomed, intelligent, verbal, highly analytical, and introspective. You can easily explore your thoughts, but you struggle more in considering your feelings as you lend to function very much as a thinker. You respond openly and articulately to all general questions about your life. You feel comfortable with eye contact and don't hesitate to question the interviewer if you don't understand what you are being asked to do. You ask questions, not in a challenging manner, but rather to gain clarification so that you can respond appropriately. You very much want to behave appropriately in all circumstances, and you get uncomfortable when you don't know what people want from you.
When asked about the symptoms that brought you in for treatment, you are hesitant and respond tentatively. You begin responding without hesitation to any questions that are asked of you, but then pause and turn inward as you struggle to respond clearly. Your ideas flow logically, and there are no signs of cognitive confusion, unusual thoughts, or delusional thinking despite the fact that you feel unsure how to respond.
If asked mental status screening questions, you admit to some depression and anxiety but you deny any suicidal ideation. If pressed on the suicide issue, you say honestly that you consider suicide an illogical course of action. You deny any use of illegal substances and admit only to highly infrequent uses of alcohol. You drink one glass of wine at occasions such as weddings and anniversaries. If asked further questions about alcohol, you say you don't approve of people who drink too much.
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3. Why are you being interviewed?
You referred yourself for treatment at the insistence of your daughter Cynthia. She came to your apartment last week without prior warning. She found you in a dirty bathrobe staring off into space. As you are usually a very vital person, who is always impeccably groomed, your daughter was seriously disttirbcd by this situation. Your daughter sat next to you and refused to leave until you made the phone call requesting this appointment. You are annoyed that Cynthia is interfering in your life, and you feel that her actions were condescending and unnecessary. On the other hand, you do admit that you have been unusually down recently and that it has affected your work. You have been feeling generally unfocused for the last few months. You are struggling to make simple decisions such as what to wear to work. Y'ou arc having difficulty making schedules for yourself. You have lost your appetite and have been having trouble sleeping. It may take you more than an hour for you to finally fall asleep and then you wake up at 4:00 a.m. and arc unable to go back to sleep. These sleep difficulties began right after your husband's accident. At that time, you were having episodic difficulties going to sleep, but most of the time you did not have any difficulties, fn the last three weeks, you have had problems every single nighl and have become very sleep deprived.
If asked what you think you will get from therapy, say you expect that you will get help logically evaluating what has gone wrong and what you need to do differently. You have not been in treatment before and if asked how you are currently feeling, state you are embarrassed to be here.
4. How do you feel?
You indicate that you have felt very anxious in the last three weeks because you did not go to church on the anniversary of your husband's death. It was unusual that you did not attend because you have always attended church regularly, and your Protestant faith has been an important source of guidance in your life. The service you missed was special because it was in honor of your late husband and all of your children had come from out of town to attend it. They went to church ahead of you to help with the arrangements. They waited three hours for you to show up, but you never did. You spent most of this time at your local hospital, but you didn't tell them this. They made frequent calls to your house and left phone messages that you intentionally ignored once you got home from the hospital. When they came back to your house, you lied to them and said that your car broke down on the way to the church and you had to be towed to a garage, if asked about this, you twist your hands and say you feel very guilty for lying to them and admit that you told your children that you had not brought the church phone number with you so il was impossible for you to call them from the garage to tell them what had happened.
In fact, half an hour before you were supposed to leave for church, you felt an overwhelming sense of doom. You took a walk to try and calm yourself down. This has been a standard practice of yours for years, and it usually has been quite effective in calming yourself down when you arc upset. On this instance, however, it did not work. Rather, halfway around the park, your heart began to hammer so loudly you were sure others could hear it. You felt like you could barely breathe and you broke out into a sweat. A neighbor, who was out jogging, noticed your difficulties and drove you to the emergency room afraid that you were having a heart attack. You had a complete medical screen and all the tests came back negative. The doctor told you that you had probably had a panic attack. Rather than being relieved to hear this, you felt tremendously embarrassed to have gone to the emergency room for no good reason. You apologized repeatedly lo the doctor lor wasting his time.
You have told no one, including your neighbor, about the results of your evaluation. If probed about this, you express a lot of anger toward yourself for what you consider "your foolishness." You don't know what came over you. You don't deny that it was an anxiety attack, but its cause is a mystery to you. If the interviewer helps you, you are then able to reflect on this experience and slowly come to the conclusion that the attack was related to your pain-
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ful memories of your husband's death. If asked how you adjusted to his death, you say that you were very distressed at first but thai you were back at work after a week and doing everything you were supposed to do. You feel that you have adjusted well to the loss, given your circumstances. You believe your faith guides you to be hi control of your emotions and accept God's will and be stoic about your loss.
If asked many questions about your husband, you become tearful and overwhelmed by emotional pain. You respond to cmpathetic remarks from Lhe interviewer by revealing more details about your husband's accident and how it affected you. The accident occurred when your husband was rushing home, during bad weather, to be present at the baptism of a grandchild. You didn't do anything to encourage him to drive in bad weather but feel thai he knew how much you wanted him to be home and that this probably led him to his driving too aggressively. You admit to having suffered intense loneliness and misery since his death. Whereas you have continued to work and function well as a manager, your personal life has become empty. As the anniversary of the death has approached, your feeling of being lost has deepened. You have been able to gel to work, but you spend a lot of time silling at your desk and feeling like you are in a fog. When you are at home, you have almost completely stopped doing housework because you feci there is no point anymore in caring for the house now that he and your children are gone.
5. How do you think?
If asked about your thoughts, you say that in the past you have prided yourself on your logic and your ability to solve problems. Everyone in your family, including your husband, always depended on what they call your common sense and good judgment. You actively analyze any problem and always come up with a highly organized plan of action to solve it.
Al this time, however, you really can't think. You are having trouble figuring out how to get "back on track." This makes you angry because you feci that you should be able to handle this current situation logically. You should have been able to calm yourself down and get to the church. You should have stood by your children. You let everyone down by not showing up. You see your anxiety attack as completely irrational. If asked why you think you had the attack that day, you get flustered and indicate that you don't understand why you just can't get on with your life as it has been so long since your husband died.
You arc a firm believer in taking action to solve all problems. So, if asked what you want from therapy, you say that coming in for this session is a good idea because you didn't make it lo the church, and this is a problem that should be looked into and fixed.
6. What do you like about yourself?
You like how dependable you are and how easily you can shift focus from one task to another and get everything done well. You also think it is good that other people come Lo you when they need help. If asked why this is something you like about yourself, say you like knowing that you are someone everyone can depend on.
7. How have you been doing at work?
You worked for years in low status jobs to work your way up lo being a manager. You are very proud of the skills you have developed, and you enjoy the opportunity to push yourself and see just how well you can make your store function. You also believe that working hard and being successful means you are living a well-spent life. Thus, you are never satisfied with your performance as a manager. You always feel that there is something to be discovered that can make things better. You are very proud that each year you have received a high merit bonus because the owner of the store appreciates your work. You say that the store is doing well, but you are still sure things could go even better.
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CHAPTER 7
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8. How have you been doing in school?
This question is nol applicable to this client.
9. How is your health?
You are in good health. Your recent screen at the emergency room showed your heart and lung functions to be excellent. You have begun to show some signs of osteoarthritis which was troubling for a whiie, but you arc now on a twice daily medication that keeps your discomfort under control. You don't have any troubling side effects from the medication. The emergency room physician gave you a prescription for Xanax that you had filled but have not taken.
You get a full physical every two years as dictated by company policy. You don't really feel it is necessary, but you can see the logic behind the policy. You haven't decided what you will say the next time you sec the internist because this doctor will have gotten a report from the emergency room and the whole episode is still very embarrassing for you to think about.
10. How do you relate to others?
Everyone in your personal and professional life sees you as a resource. You have always been dependable, reliable, and helpful. Your children learned good skills from you and usually solve their problems themselves. However, they have confidence that, when they need you, you will always be there. Each of your three children has told you how shocked they were when you didn't come to the church. They were terrified you had been in an accident like their father.
You have always had a very calm and friendly manner of relating to people at work that has made your employees have confidence in your decisions. You have shown concern for your employees' lives without being intrusive. This has led many of them to confide their life problems to you. You see them as your responsibility and feel that happy home lives make happy and productive employees. You do not express any direct resentment that so many people are leaning on you for their social support. However, if asked, you express some feelings of being overwhelmed with trying to work through your husband's death while so many people were making demands on you. Your employees did try to help you by sending flowers and food. But, you feel it is inappropriate for a manager to lean on her employees. You have put up a good front for them so that they believe you have adjusted well to the loss.
You and your husband used to socialize regularly with several other couples. Typically you played card games together and had dinner parties. You avoid these couples now. You feel out of place as the only single in the group. Immediately after the death, the wives called you regularly to chat and dropped by with food. However, you never called them, and their calls slowed up and then finally stopped. You feel that this phase of your life is over.
11. How do you view your life?
You arc currently very motivated to change because you are quite puzzled by your current difficulties. You "shouldn't" be feeling down or anxious as "nothing" is really wrong at this lime. You are willing to follow all the directives of the interviewer. You view your work as being the highlight of your life at this time. You believe that you are at the time of life when intimate relationships are best left for younger people. Thus, you have no plans to reach out to form any new relationships with a man.
EXERCISES FOR THE INTERVIEWER
Exercise 1: Develop a diagnosis for Mary
A. What criteria does Mary meet for an Axis I diagnosis of Major Depressive Disorder and/or Bereavement?
Name two other Axis I diagnoses that you might want to rule out for Mary and indicate what additional information might be needed to differentiate between the diagnostic choices for her.
Does Mary meet all the criteria for an Axis I disorder? Should the diagnosis be deferred, or is a diagnosis not needed?
B. What criteria does Mary meet for an Axis II diagnosis (Personality Disorders and Mental Retardation)? Should a diagnosis be deferred, or is a diagnosis not needed? Explain and be as specific as possible.
C. Is there anything you might report for Vlary on Axis 111 (General Medical Conditions that arc potentially relevant to the client's mental disorder)?
D. List all specific psychosocial and environmental stressors that arc influencing Mary at this time for Axis IV. Indicate if each stressor is mild, moderate, or severe.
E. What is your global assessment of Mary on Axis V (current and highest in past year)?
F. Double-check your diagnostic choices starting at Axis V and proceeding backward through Axis I to determine if you may have overestimated or underestimated the impact of the situational, biological, or individual psychological factors on Mary's current functioning. Should you change anything? Be specific in describing why or why not.
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Exercise 2: Practice deepening interview with Mary
A. What might you do, nonverbally, as you listen to Mary to let her know that you are attending closely to what she is experiencing? Behaviors to consider include eye contact, orientation of your body, posture, facial expression, and autonomic behavior.
G. Review your diagnostic choices again from Mary's point of view. Do your choices support the discussions you have had with her? Would she be disturbed by your choices? Be specific in discussing why or why not.
B. Mary tends to make comments that are too general for you to understand her situation. In response to the following comments from her, write an open-ended, follow-up question to probe more deeply into her experience.
Maty:  Things are better than they were the first year after my husband died.
Mary:   My daughter was surprised by how I looked and by the state of my apartment.
Mary:   My health has been okay I guess.
Mary:   My employees trust me.
C. Mary has many feelings bottled up inside of her that need to be expressed and understood. In response to her remarks, write two types of comments. Have the first be a simple, reflective listening comment and the second be a more complex, empathetic comment to either validate her experience or let her know you understand what, she is experiencing. If Mary is expressing more than one feeling, or is ambivalent about a situation, make sure you make comments that take this into account. Use information from Mary's profile to guide you. An example is provided.
Mary: Why does my daughter interfere so much in my life? I am so tired of her condescending attitude.
1. You find her behavior condescending (reflective listening).___
2. You are an adult and 1 can understand why you wouldn't, appreciate your daughter telling you what to do. It feels disrespectful (empathetic comment).__
Mary:   I don't want to be here in therapy asking for help. I am a strong person.
Mary: 1 reach out to my employees when they are in distress and so they reaily trust, me. I am proud of that, but sometimes it is too much.
D. Assume that Mary has hinted about suicidal ideation. Develop a series of open-ended and closed questions to assess her risk for suicide using each of the following prompts as a guide. An example is provided of one open-ended question and two closed questions for prompt 1.
Prompt 1: Level/amount of current psychological pain
How would you describe your feelings of pain over your husband's death? Have you ever felt so bad that you didri t feel you could go on/ On a seale of 1 to 10. how would you rate your pain right now? _ _ _ _
Prompt 2: Level/amount of current life stress
Prompt 3: Existence of suicide plan
CASE OF MARY
Exercise 3: Thought questions related to Mary
A. Consider who you are as an interviewer and write down what you think might be most difficult for you in establishing rapport with Mary based on your age, ethnicity, gender, socioeconomic status, sexual orientation, religion, physical characteristics, age, and personality style. What specifically might happen?
B. Is there anything you could do to enhance your ability to establish an effective working relationship with Mary? Be specific and detailed in describing your ideas.
Prompt 4: Ability to carry out suicidal plan
Prompt 5: Use of substances that increase impulsivity
Prompt 6: Reasons for wanting to die
Prompt 7: Reasons for living and quality of current support system (family, friends, work, religion)
Prompt 8: Past attempts
C. Assume that Mary lost a lesbian partner instead of a husband. How might this change your reaction to her?
D. What will you say to Mary if you believe she is at serious risk for suicide?
E. How might Mary's Protestant work ethic and cultural desire to always control her emotions be influencing her ability to grieve for her husband?
Prompt 9: Friends or relatives who have attempted suicide