4.1
Clinical Example of Complex PE Case Formulation: Lindy
Lindy is a 30-year
old European-American woman who has come to therapy with multiple problems,
including extensive history of cocaine abuse and other self-destructive
behavior such as suicide attempts, compulsive spending, and self-cutting. Unsurprisingly, she met the criteria
for Borderline Personality Disorder, as well as PTSD, Bipolar Disorder II
(depression and hypomania); a previous therapist had diagnosed her with a
dissociative disorder. When her
intake worker asked her what she wanted to work on in therapy, Lindy listed 22
different problems (most clients list 5 to 10). She gave the following as her most important problems: fear of abandonment, a tendency to get
enmeshed in relationships and lose her sense of self, and a lack of an adequate
support system following a recent move.
Unsurprisingly,
Lindy’s therapist, Anna (a second year graduate student at the time) is hard
put to make sense of the wide range of problems Lindy brings to therapy, as
well as the weekly crises she presents or her drastic mood shifts within
sessions. Anna is of course aware
of her client’s diagnoses, but tries to set them aside in order to enter her
client’s experienced world.
Thinking of one’s client as “a borderline” tends to distance therapist
from client and interferes with empathy.
Therefore, Anna and her supervisor think of Lindy instead as “having
borderline processes.” But what
does this mean in Lindy’s case?
Over time, by carefully observing a wide range of small indicators
(“micro-markers”) expressed by Lindy in therapy sessions, and in her
narratives, they gradually develop a tentative, working understanding of her
characteristic style, the ways in which she processes her experiencing, her
recurrent task markers, and her treatment foci.
In order to develop
an understanding of her main ways of relating to herself and others, Anna and
her supervisor pay attention to Lindy’s stories and how she relates in therapy
(and later in conjoint sessions with her romantic partner). They notice that she tends to ignore
her needs, sometimes starving herself, while trying to please other people,
particularly her partner. However,
she periodically breaks out of this self-sacrificing stance by spending
compulsively or adopting animals.
Thus, she vacillates between over- and under-regulated emotional
states. Anna is also struck by
Lindy’s ability to totally switch perspectives on something (such as how she
feels about her partner) to such an extent that she can not even remember how
she felt before (a borderline process).
While all people have contradictory feelings, needs, and self-aspects,
many of Lindy’s contradictory aspects have little or no contact with each
other.
Anna and her supervisor also pay attention to small indicators of
Lindy’s ways of relating to her own experiencing and working in therapy. They notice that her attention is
sometimes wrapped up in external events (e.g., her romantic partner’s
unreasonable behavior), and that she sometimes expresses herself in the
abstract language of self-help and 12-step programs (e.g., referring to herself
as “codependent”). They also see
that she is generally able to express vulnerability to her therapist, and that,
when encouraged to do so, she can turn her attention inside, to search for
unclear, complex experiences, and to enact strong feelings or different aspects
of herself. However, she is not
very good at self-reflection (that is, making sense of her experience
afterwards), or at translating awareness into plans for action.
Over the first 5 sessions, Anna and her
supervisor are particularly struck by Lindy’s frequent feelings of being
overwhelmed and having unresolved feelings about her romantic partner. From these and from the narratives she
presents in sessions, it becomes clear that her main problem is difficulty in
emotion regulation, generally triggered by her fear that her romantic partner
will abandon her. When this
happens, she becomes overwhelmed with fear and emotional pain, and spends
compulsively, cuts herself, or contemplates suicide. In addition, continuing conflicts with her partner over her
spending and his controlling manner and emotional distance emerge as
central. As a result, Anna helps
Lindy learn how to regulate her emotions more effectively by using Clearing a
Space (see Chapter 9) and Empty Chair Work (see Chapter 12). When it becomes obvious that the
relationship with the romantic partner is continuing to generate severe
distress in Lindy, these problems are addressed directly in 9 sessions of
emotionally-focused couples therapy, with Anna and her supervisor as
co-therapists. After the end of
the therapy (and after the relationship with the romantic partner ended), Lindy
reports that her relationship with Anna and the Clearing a Space task were the
most helpful aspects of the therapy.
Materials designed to
accompany the book Learning Emotion-Focused Therapy: The
Process-Experiential Approach to Change from APA Books.
©2003 Robert Elliott, Jeanne Watson, Rhonda Goldman, and Leslie Greenberg
http://www.process-experiential.org/learning