Case Studies

Case Study: Relationships - Leigh and Phil.

Case Study One

This relates to a middle class well educated family with children at private school, a successful ‘artisan’ business and attractive wife who has worked in helping the husband in his business and focussed also on her children.

The husband has drifted into depression and alcoholism. The business is collapsing despite having a full order book. He is in denial, refuses professional help, is unable to work much of the time, blames his wife for not contributing more financially, but with whom he is profoundly co-dependent.
She is at her wits end and the children are now very aware of how bad things are and starting to show signs of psychological and academic strain. Her confidence and self esteem have steadily been eroded. She no longer knows which way to turn, has become depressed and approached a full breakdown.
Sue was the first one to come into psychotherapist/counsellor which she immediately found sympathetic, supportive and in which she developed a rapport.

She spoke to the therapist every week either face to face or on the phone or Skype and was extra ordinarily grateful.

It might be said that our work (as in the case of most others) fell into 3 main categories. First of all getting it off her chest was very helpful in itself. Secondarily, understanding herself, why she is who she is and does what she does! Finally, looking at changes but also coming to terms with the limitations of how much she can change herself, how she feels and the situation.

Sue eventually was able to communicate differently with Paul, her husband, take risks, became more assertive (rather than nagging, which she had been doing) or withdrawing into herself. She dealt better with her children and was able eventually to get Paul to overcome his fear (disguised as denial!) and join her in therapy (all be it initially under the auspices of helping her)
He joined an AA group and managed to persevere with attendance without becoming obsessed and although having to overcome a number of obstacles including guilt, low self esteem, his inclination to replace alcohol with marijuana  or even pain killers and his belief that Sue may have had an affair, he is now doing very well in individual and joint therapy.
Sue is now doing much better but continues to struggle with her resentment, confidence and fears.
This, as in all cases, is a work in progress.

Case Study Two

Linda is 34 years old. The presenting problem is that she finds that she freezes up in her work, is unable to focus and has huge problems with deadlines getting herself into a panic, anxiety state and missing these deadlines. This leads to incredible anxiety and low self esteem
Her mother and father are still together. She has a sister 3 years younger than herself.
Her father is very successful and probably very wealthy. The mother doesn’t work, and spends her time with friends. Linda is very dose to her father and has a mixed relationship with her mother.
Linda has always been very sociable, she always played lots of sports and games but is obsessional. But now she is so stuck that she is
easily distracted.

At school she had all kinds of problems with concentration, sitting down, writing, and focussing. She questions weather she is lazy and she always thinks that she will never do well enough She feels pressured. More evidence for being stuck is her inability to say no.

Ironically she wonders weather her problem is avoiding hard work! She idealises and is a perfectionist (keeping her stuck) She sabotages her work and has terrible low self esteem.
One of the reasons she gave for sabotaging herself was maybe that she loved what she was doing now and feared change.  She had a four year relationship but only saw him. In addition to the other work she has  worked in a pub and has gone through periods of drinking a lot. She want to enjoy herself - SO THAT SHE CAN FORGET ABOUT DIFFICULT STUFF *********

Her parents were not at all affectionate to each other or to her - she has never talked with them about her personal life - and spent virtually no time with her mother, never having hugged her. She had nannies. She always had a very close relationship with these nannies and says it was great.
She strongly remembers being asked and told to do things by her mum and never wanting to do them but felt and feels huge pressure. Now doesn’t take drugs and is trying to cut back with her drinking, both of which she did a lot in the past.

We have spent a lot of time talking about the stress of the past and the more stressed she feels the worse it gets, the more she puts off, and completely blocks things out.
After a number of sessions things seem to be going very well so this felt very good. It feels easy when she talks in therapy to be calm and rational and to looks things with perspective and not become overwhelmed.

What keeps her stuck is the extent to which she worries. It is all consuming/or she shuts down so as to not think at all about the things she should do.
What happens next is that she over complicates the situation. In a sense her problem is the attitude she has towards worrying. The solution is being able to step back etc to be able to bare it and accept that she does have anxiety, that she can accept herself and not have the worry take over and overwhelm her.

Her solution in the past has been to try to not think at all about the problem block it out completely or just spend her time sleeping (to switch off) - keeping her stuck.

She opened one session talking about her inability to improvise or take risks. The more pressure she feels the more distracted she gets, the more she feels she has wasted time, the more she feels there is no point in working, because its not perfect. One strategy we have come up wit is experimenting with allocation specific time with tasks. She finds it very hard.

She needs to be prepared for relapses. She must be mindful and not to give in to the conflict between perfect at one extreme and being rubbish at the other

Case Study Three

Joe is now 33. He has as a brother 4 years older than him. His parents have lived separate lives in the same house for many years.

Joe’s presenting problem was one of difficulty in relationships.

He is an up and coming star having received a number of awards.

But Joe has a stutter that has been very bad in the past but he believes that as a result of some of the work we have done has got much better.

His father was hugely successful, made a lot of money and now he doesn’t work. There was no stability with his father who suffered from manic depression. Joe latched onto his mother, has an idealised relationship with her and she with him. She idealised him compared to his father. He has lived with his mum right up until the present.

He has been prone to excessive alcohol. He is also extreme and excessive in his work and his view of his abilities.

He is very stuck in his attitude towards relationships. He has, most recently, been totally obsessed with a girl before and after she ended there relationship.  He and his girlfriend had an extraordinarily co dependant relationship. One had to be up and the other had to be down.

He spoke very early on about having been sexually abused by his brother lasting for 4 years - it got to a point where he wanted it and sort it out. This has informed every intimate relationship since. He says he is fairly convinced he is heterosexual but finds that he is very passive and submissive. He has toyed with the idea of having a relationship with another man. He has come close but never done it - he believes it wouldn’t satisfy him but that he doesn’t want it. He feels that it would debase him in a way that he would deserve because of the past.

In another relationship she was extremely pro active, knew what she wanted and got it, she took control of him and he let it happen.

He talks about going for people who are not available or who don’t want him as a kind of punishment and this punishment is fulfilled when everything goes wrong. He is fixated on sex which he doesn’t think is right

At the end of a relationship it feels catastrophic and he becomes obsessed with the person being with someone else -but it almost turns him on!

He associates with being the person he was with in the last relationship. He sees that this is because he spent 4 years in the female role and it is so important to him to be wanted.

He oscillates between being passive/vulnerable/impotent/submissive.

Case Study four

Ann and Mike

Mike is 35; he has a brother 3 years younger than him and a sister 4 years younger. When they were all very young they went to live in France. The dad remained behind on their return. Mike then took on the fatherly role.

His mother is an alcoholic and his dad a serious womaniser.
Ann is 6 years older than Max, her father died before she was born. She has a brother who is 3 years older than her. Ann has had several miscarriages.
The presenting problem is that Mike has an alcohol problem binging and obsessively the looking forward to it.

They met 4 years ago and they have been together for 3 and half years. They Julia has been in individual therapy in the UK for 14 years and has in the past been on medication for depression and anxiety but she is off them now because of  fertility treatment. Perhaps she wishes sometimes she was back on them and when she talks about it she starts to cry because she talks about her miscarriages and the anxiety of not sleeping. She has virtually never had any conflict with her mother. Ann says that she allowed Mike to have what he wanted which effectively was leading to him being out of control. They cross match. They are attracted to similarities in each other. They are both extremely creative artistic people, they are both incredibly reasonable and sympathetic. But have very different insecurities.

They are also attracted to the differences. Mike can be very exiting, irresponsible, extraordinarily extrovert, funny, very pragmatic. He appears to be very secure. Ann seems very vulnerable. Ann’s mother and family are very conservative, “good” people with an absence entirely of extremes.
Mike’s parents were both very liberal and easy going. Ann has become the rule maker, which both of them are very uncomfortable with.

There was a point where Mike reached where he thought maybe he would move on somewhere in the relationship with someone else. For Julia this was the worst moment in her recent life but he quickly changed his position.

Ann often edits what she says. Mike just says what he thinks.
They both say that after their sessions they have the best conversations with Mike much more willing to talk and compromise and Ann much more willing to come forward. Mike can be much focussed and very selfish or self obsessed. Through our work he has become much more mindful and aware. We talk now of OPTIMISING VERSES MAXIMISING.

If they would talk about something trivial or not very important he would feel that it was a waist of time.
For Ann to be happy she feels the need for definitive control in order to be secure.
She can’t understand why the same things don’t make him happy.

Mike felt very helpless in the face of his mothers drinking so he looked for what he was in control of and feels that someone else sees it as a problem but he actually wants to keep it that way. He wants to convince others that he is in control and reverse the helplessness of his childhood. Max becomes the problem as the drinker, Julia becomes him as he was as a child trying to fix it and not be helpless.
There is a mutual projection and ambivalence both afraid that the bad part will spoil the good. Mike offers to be the bad one with his drinking and Ann becomes the good one. They need to both own both bits rather than maintain the myth.

Both are fair, agreeable, and reasonable. But Ann’s problem is considerable anxiety. They are both efficient and business like. She can be messy and chaotic sometimes and he irresponsible sometimes. They both have a fascinating split of good mum bad mum. She is stuck in needing to have a plan in order to be comfortable

He is stuck in the anxiety about responsibility which he dips in and out of. Ann is worried about the future, having to drag Mike away from work to her and a child but they are discussing these things so much more openly now that one cant help but be optimistic

Case Study Five

Sue is 31. She has a sister 9 years older than her and a brother 12 years older than her. She is very stuck.

She starts off by saying she has this perfect wonderful family. The point being that she is the one that is not perfect.

The presenting problem is that “I shouldn’t be here”. “She was an accident and feels maybe she is the problem. She has a very good job but huge pressure from her mother to be 100% available for her. She feels that that’s maybe the price she has to pay for being here. She talks about her perfect siblings. But actually her sister became anorexic round about the time Sue was born. And is very screwed up. Her brother has ME, but married to this perfect wife.

Sue feels a victim, bullied by her brother and father and particularly bullied at school but never said anything, and tried to block it out.

She was self harmed and suffered from incredible anxiety. She usually resents the pressure put on her.

She feels very let down by everybody but especially her mother and by men in her life. She feels she cannot trust anybody.

Her mum becomes the child and very needy of Sue. Sue feels obliged to protect her mother all the time but she treats Sallie as if she’s her best friend, telling her much too much about her personal life.
 Like so many the more she feels helpless and stuck the harder she tries, the more she has to do.
She feels that maybe she is here to rescue her mum and her brother etc. Sue feels guilty all the time and doesn’t want to be the victim anymore. Her feeling is that she shouldn’t trust people because they will let her down. She takes everything so personally and feels that it is her fault.
She feels that she shouldn’t have been born and that by being born she caused the problem. Now she is too frightened to be in relationship. She knows only one strategy which is just trying harder and in so doing projects her own problems onto her family, boyfriend, and work and has to take care of everyone. The mature position is to acknowledge the child in herself and to look after it.
Maybe the child equals the Id, the adult the ego and the parent the super ego. We need to cope with and allow for the needs of all 3.

Mostly she projects the child in her self (neglected). She can’t help but project the child onto her family and clients, trying to look after it in them. But this leads to a very needy self. What she wants is for me as a therapist to provide the alexia of control and this need for control again becomes the heart of her stuckness.

This is all a fantasy. The aim is to let the self be something in the middle - good enough: Neither omnipotent nor impotent.

A very important turning point was giving herself permission to see the family as not normal. She is allowed to be OK even if this is uncomfortable and feels weird.
Its ok to not feel completely in control.

Case Study Six

Mary spoke of emotional difficulties that have gradually crept up over the last three years. She sought help following comments by her friends and colleagues that she did not appear very well. She consulted her G.P and broke down crying. She was subsequently referred to us following an annual health review carried out by her company occupational health.

She reported feeling better after only a few sessions. Looking back she recalled symptoms in and around the early part of the year and increasingly so in the summer when she felt lifeless. She was struggling with interrupted sleep and with difficulty waking up. When signed off sick for the period of three weeks she slept excessively up to eighteen hours a day. Her mood was particularly low which has now felt better. She gained weight  to the tune of three stones and has just about began to lose this in recent weeks. She suffered with anxiety symptoms and came close to panic attacks with fears “I will lose control”. She continued working through these difficult weeks but at weekends would stay very much at home and feared going out. She began to avoid shops which looked too busy.

Life Events and Stress

Her father is terminally ill and her mother who suffers with breast cancer collapsed earlier this year. Mary was working fourteen to sixteen hours a day.

Mary’s parents separated when she was 12. She is the oldest of 7 children. She described her family as dysfunctional. She has had very little contact with her father who did not attend her wedding. There are poor relationships with her sister-in-laws. She recalled her childhood as odd with a history of emotional abuse at the hands of their father. Her father also used physical means to discipline the children. Mary was sexually assaulted twice when young. She did well academically and wanted to prove to her father that she can stand up on her own feet and not, as he had often spoken of girls in the role of wives who just have babies. She has had five previous relationships two of which were of an abusive nature. She had an abortion at aged 15 which she often thinks of. She described her marriage as very close, supportive and her husband as a gentle person.

Her symptoms had largely developed against a background of increased workload and her inability to say no arsing from a low self-esteem. She has a need to placate and so accept more responsibility such that she becomes indispensable.

She started eating excessively and occasionally drank in excess to cope with the high levels of stress which further added to her low self-esteem and the depressive symptoms.

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