Attachment theory and cognitive-behavioral therapy.
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The Case of Laura
Laura is a 47-year-old woman who presently lives with her common-law partner of 15 years. They do not have any children, and Laura noted at intake that this was her explicit decision, as she never wanted any. Laura has a bachelor of arts and a law degree, and is currently employed as a partner in a law firm. Her family doctor referred her for treatment of depression…
History of Presenting Problem
Laura presented with a history of chronic feelings of dissatisfaction with her life, marked by recurrent periods of major depression. She reported that her most recent episode of depression which began approximately 8 months prior to the intake appointment was precipitated by a number of stressors, including the departure of several coworkers (which resulted in an increase in her workload). She felt that she did not have a good balance between personal life and work; she often skipped lunches and worked until 8:00 P.M. In addition, Laura reported that she was saddened this summer when her family doctor advised her that she is currently in menopause. She indicated that although she never wanted to have children, the fact that this chapter of her life has closed has been difficult for her to accept. Finally, Laura indicated that since the death of her father 5 years ago, she has been increasingly involved in her 86-year-old mother’s care. She has always found her mother to be a difficult woman and has been having increasing conflict with her, which leaves her feeling both resentful that the responsibility has fallen on her shoulders and guilty for having these negative feelings and thoughts.
At intake the results of [the diagnostic interview]… were consistent with a diagnosis of major depressive disorder, recurrent, moderate as defined by the most recent version of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR; American Psychiatric Association, 2000). Her symptoms of depression included sad mood, loss of interest, difficulties sleeping (e.g. middle insomnia), fatigue, difficulties concentrating, and self-criticism. Laura also reported symptoms that would meet DSM-IV-TR criteria for social phobia, generalized. She reported experiencing anxiety in a number of different social situations (e.g. parties, meetings, speaking to people in authority, being assertive, formally speaking to peers, and maintaining conversations). She reported fears that she will not have anything to say; that she will appear “boring,” “socially inept,” or foolish; or that others might become upset, grow defensive, and reject her. Laura indicated that she invariably experiences anxiety in these situations and recognized that her fear is excessive. She believed that her anxiety was interfering with work (e.g., being less able to network, turning down speaking engagements), and that she might have more friends if it were not for her anxiety.
Family History
Laura grew up with both parents and two younger brothers. Her mother was formally trained as a nurse, but stayed home to raise her children on the insistence of her father, a pharmacist. She indicated that her mother was the matriarch of the household. Laura recalled that her parents frequently fought in front of the children, with her mother typically becoming angry and screaming at her father while he ignored her and read the newspaper. She suspected that her mother was unhappy in their marriage and felt very isolated. Both parents would often physically punish the children, hitting them very hard with boards. She remembered several instances of abuse where her mother or father would walk her down to a cold room in the basement or the back shed and repeatedly hit her with a board (40 or 50 blows) – enough to leave her “black and blue for weeks.” This abuse stopped when she was about 14 years old. She also noted that her mother often made her feel as if she was “a sneaky, bad child,” whose natural tendency would be toward dishonesty and malevolent behavior were it not for strict discipline. As a result, Laura would often over-compensate and be “extra good” to prove to her mother that she was not devious or troublesome. She also had memories of her father as an emotionally distant and cold person. She did not remember receiving any physical affection from him and noted that he would become visibly uncomfortable if she gave him a hug (which she rarely did). She found that she could only connect with him when talking about work, and was terribly saddened after his death because she felt that she had lost the opportunity to “really get to know him.” Regarding her upbringing, Laura wrote in her diary, “I never got the message [that] someone would love me – that I was loveable. I NEVER got that latter message.”
Laura suspects that her mother might have suffered from depression, but is unsure because her mother has always been reluctant to discuss these emotional difficulties, preferring to show a “stiff upper lip.” She reported that a distant relative committed suicide during the Great Depression. She also reported that both of her grandfathers were “alcoholics.”
Relationship History
In terms of her relationships, Laura felt she had let many friendships slip away over the years due to increased job stress, especially over the past 4 – 5 years. She rarely disclosed personal issues or troubles to friends, including her romantic partner for fear of upsetting others or being seen as a complainer.
Laura described a good relationship with her partner, but she admitted to “keeping her distance” and being uncomfortable opening up and sharing her private thoughts and feelings with him. Laura had not had many boyfriends before him, commenting, “I wasn’t ever much into relationships.” It was her decision never to marry or have any children. She noted that she never saw herself as being “maternal” and was never interested in being a mother. As a result she was confused as to why she is so saddened by menopause and the knowledge she can never have children, but she did note that menopause “underscores my feeling that I don’t really love anyone.”
Mental Status
Laura arrived on time for her intake appointment. She was very well groomed and formally dressed. Her affect appeared depressed, which was congruent with her reported mood. She cried at several points during the interview, but appeared uncomfortable with the tears and apologized for becoming emotional. There was nothing remarkable about her speech, and no motor or perceptual abnormalities were noted. Laura was friendly and cooperative throughout the assessment, and her alliance potential was judged to be good. There was no evidence of active suicidal ideation or intent.
Reference
McBride, C. and Atkinson, L. (2009). Attachment theory and cognitive-behavioral therapy. In J.H. Obegi & E. Berant (Eds.), Attachment theory and research in clinical work with adults (pp. 434-458). New York: Guilford.