Interpersonal Therapy Case Study of Susan Essay Sample
Interpersonal therapy is short-term therapy for depression and other problems that looks for solutions and strategies to deal with interpersonal problems rather than spending time on interpretation and analysis. In the initial stages of interpersonal therapy, therapeutic goals typically include diagnosis, completing the requisite inventories, identifying the client’s major problem areas, and creating a treatment contract.
This case study is about Susan, a young lady in her early twenties. She came to see me because her office manager had recommended that she should consult a professional to help her with her anger management problems.
At first glance, she looked like a very reasonable human being and judging by her way of talking and her outgoing personality, I found it hard to believe that she had anger management problems. On inquiring from her she said that she did not believe that she had an anger management problem, only that she was an orderly person, and when things did not function as they should anybody would get angry. She thought that the office manager was over emphasizing the issue, and she agreed to come here just to satisfy the management.
In the first session which I had with her, I came to know more details about her work and also about her personal life. She was working as a financial analyst for a clothing company, and her job required her to meet strict deadlines on a regular basis. I also came to know that she had recently got married. Both these factors could have contributed to her being in a state of acute stress at all times and I suspected that she could be lashing out at other people as a reaction to all this stress. Her job as a financial analyst was a source of lot of stress for her and she did not know how she could relieve or reduce it.
She had gotten married some 6 months back, but was now having mixed feelings about if she had made the correct choice. Her husband, Phil had been her friend for the last two years and they were close with each other. Phil had proposed to her and even though she just saw him as a close friend, she agreed to the marriage because she thought it would be fun staying together all the time. It was sometime after the marriage that she began to have doubts about the whole thing. In her mind she had imagined that things would stay as they were before marriage but now the reality of the marriage was sinking in, she now kept thinking about missed opportunities and if there might have been somebody better to whom she could have gotten married. She felt that she was not ready for this sort of commitment as yet, and that marriage meant that she would loose her independence. All these thoughts keep playing in her mind at all times.
The other factor which was also causing her problems was her need to keep things in a neat and orderly fashion. She tended to explode if there was anything out of place at her workplace or even at home. She explained this habit of hers in her parents living style. She has been taught that everything must be kept in its place, and in her childhood had been punished a number of times for failing to do so. This has had the effect of engraining this habit so firmly in her mind that now Susan cannot help but be angry and uneasy until everything is put in its proper place.
In my preliminary diagnosis, I found that even though outwardly she looked fine and refuted the fact that she had any anger management problems, she was clearly under a lot of stress and that this stress was not just due to her job responsibilities but there were other issues also which had to be brought out for her to accept her problem and find a way to resolve it.
She seemed aloof and projected a feeling of superiority towards other people and this could have the effect of alienating people. Over the course of treatment these feelings will also be investigated to see if there are any maladaptive patterns for which interventions might be required.
In interpersonal therapy, the client and therapist, focus on the present and try to work on the major problem areas identified. There are four major problem areas in interpersonal therapy. The first is _grief_, and clients typically present with delayed or distorted grief reactions. These are treated by facilitating the grieving process, helping the client’s acceptance of difficult emotions, and their replacement of lost relationships. The second major problem area is _role dispute_, in which a client is experiencing nonreciprocal expectations about a relationship with someone else.
Here, treatment focuses on understanding the nature of the dispute, the current communication difficulties, and works to modify the client’s communication strategies while remaining in accord with their core values. A third major problem area is _role transition_, in which an individual is in the process of giving up an old role and taking on a new one. In this case, treatment attempts to facilitate the client’s giving up of the old role, expressing emotions about this loss, and acquiring skills and support in the new role they must take on. A final problem area commonly broached with interpersonal therapy is _interpersonal deficits_. Clients presenting interpersonal deficits commonly engage in an analysis of their communication patterns; participate in role playing exercises with the therapist, and work to reduce their overall isolation, if applicable.
Susan seems to have issues in the area of interpersonal deficits. She needs to realize that she cannot function alone in the world and also that friends and relations have to be nurtured and only then they’ll give rich dividends back to her.
FAMILIAL AND DEVELOPMENTAL FACTORS.
The roots of her anger and her aloof nature can be traced back to her childhood where there were a number of familial and developmental factors.
She was the elder of two children, and her parents can be classified as authoritarian. This categorization has been based on the research done by Diana Baumrind (1983, 1991) on the long term effects of different styles of parenting and discipline. This style of parenting has lead to Susan becoming into a person who does not want to be seen as weak. She soon came to realize that the only way in which she could get something done was to aggressively demand it and never to show your dependence on anybody. According to Wenar & Kerig (2000), children of such parents are normally obedient and achieving, yet are also anxious and insecure. The insecurity they feel with their parents often generalizes towards other people in their adult life also. It has also been seen that some such children react to this sort of upbringing by becoming defiant and aggressive as they grow up.
INFLEXIBLE INTERPERSONAL COPING STRATEGIES
To help Susan with her problems, I had to identify the formative patterns and thoughts which made up her core conflict. The core conflicts are those central problems of key issues which pervade the clients’ life. Only after know exactly what these are, can a proper treatment plan be made for her.
The childhood experiences of Susan had made her into a person who did not like to show weakness in emotions. Her father was an army officer and the family had to move every couple of years to a new place. This meant that Susan never had the opportunity to make long term relationships other then with her immediate family. At every place, she would have new best friends, with whom she would swear to be always in touch but after moving to another place, she would not make the effort of keeping in touch. This process of having friends and leaving them has now given her a feeling that all relationships are superficial.
The same feeling is now being projected in her marital relationship also. Instead of trying to bond with her husband, she feels that she would have been better of not getting married and thereby getting tied down and loosing
Using Horney’s (1970) adapted interpersonal theory, we can categorize her as using the _’moving away from others’_ inflexible interpersonal coping style. Her way of coping with her emotional and developmental need of having long term relationships with people other then her immediate family were not possible because she was always moving from one place to another. To compensate this need, she adopted the reasoning that close friends were not needed at all, and that she was superior to them anyways so did not need them.
INTERVENTIONS USED AND ITS EFFECTS
The techniques of interpersonal therapy were developed to manage four basic interpersonal problem areas: unresolved grief ; role transitions; interpersonal role disputes (often marital disputes); and interpersonal deficits (deficiencies). In the early sessions, the interpersonal therapist and the client attempt to determine which of these four problems is most closely associated with the onset of the current aggressive episode. Therapy is then organized to help the client deal with the interpersonal difficulties in the primary problem area. The coping strategies that the client is encouraged to discover and employ in daily life are tailored to his or her individual situation.
There are seven types of interventions that are commonly used in interpersonal therapy, many of which reflect the influence of psychodynamic psychotherapy: a focus on clients’ emotions; an exploration of clients’ resistance to treatment; discussion of patterns in clients’ relationships and experiences; taking a detailed past history; an emphasis on clients’ current interpersonal experiences; exploration of the therapist/client relationship; and the identification of clients’ wishes and fantasies. Interpersonal therapy is, however, distinctive for its brevity and its treatment focus. Interpersonal therapy emphasizes the ways in which a person’s current relationships and social context cause or maintain symptoms rather than exploring the deep-seated sources of the symptoms. Its goals are rapid symptom reduction and improved social adjustment. A frequent byproduct of interpersonal therapy treatment is more satisfying relationships in the present which is what we also focused on in our treatment of Susan.
Interpersonal therapy has the following goals in the treatment of aggression: to diagnose aggression explicitly; to educate the client about aggression, its causes, and the various treatments available for it; to identify the interpersonal context of aggression as it relates to symptom development; and to develop strategies for the client to follow in coping with their aggression. Because interpersonal therapy is a short-term approach, the therapist addresses only one or two problem areas in the client’s current functioning. In the early sessions, the therapist and client determine which areas would be most helpful in reducing the client’s symptoms. The remaining sessions are then organized toward resolving these agreed-upon problem areas. This time-limited framework distinguishes interpersonal therapy from therapies that are open-ended in their exploration. The targeted approach of interpersonal therapy has demonstrated rapid improvement for patients with problems ranging from mild situational aggression to acute aggressive behavior.
To understand her anger problem and show her that issues can be resolved in an amicable manner, I asked Susan to narrate an incident in which she had become aggressive with a work colleague. She told me about one time when she had been working on a particular file and while she was in her bosses office, her colleague had come to her desk and assuming that she had finished with the file had taken it away. When she came back and could not find the file, she raised an uproar, and on learning that her colleague had take the file without permission, had stormed to her desk and without listening to any explanation, took the file and hasn’t spoken to her after that.
To make Susan understand the magnitude of her overreaction to this simple misunderstanding, I stated aloud about how crucial this issue was for somebody to have to react to it in such a strong manner. This initiated a dialogue about her tendency to overreact and made her realize that given the simple nature of the problem, her reaction was not justified and that if she had taken a few minutes to consider her approach or to hear the explanation of her colleague, she might not have reacted this way. In this way Susan became an active participant in the treatment process and started taking ownership of the treatment process. This was an important turning point in the treatment because now Susan started looking and analyzing her behavior patterns and her old logics and schemas were being put under the microscope by Susan herself.
Interpersonal deficits are the focus of treatment when the client has a history of inadequate or unsupportive interpersonal relationships. The client may never have established lasting or intimate relationships as an adult, and may experience a sense of inadequacy, lack of self-assertion, and guilt about expressing anger. Generally, clients with a history of extreme social isolation come to therapy with more severe emotional disturbances. The goal of treatment is to reduce the client’s social isolation. Instead of focusing on current relationships, interpersonal therapy in this area focuses on the client’s past relationships; the present relationship with the therapist; and ways to form new relationships. I explained to Susan that she had adopted a ‘sick role’.
The concept of the ‘sick role’ is derived from the work of a sociologist named Talcott Parsons (1951, pp 436-437), and is based on the notion that illness is not merely a condition but a social role that affects the attitudes and behaviors of the client and those around him or her. Over time, the client comes to see that the sick role has increasingly come to govern his or her social interactions. She has to leave this role aside to function in a productive manner.
Now that the core conflict has become clear and the inflexible interpersonal coping strategy being used by her has also been determined, we now use interventions at suitable points to help Susan. The most important thing to do here is to try to help Susan recognize the high emotional price she is paying for her interpersonal coping strategy. We need to do this in a very careful and understanding manner. This is important because this coping strategy is one of the basic pillars on which Susan has been supporting her whole life style on.
To help Susan, I asked her to tell me about how she felt every time she had to leave a best friend behind. She narrated that in the beginning she felt very sad and even had fantasies about her friends coming up on the road to stop her parents from taking her away. But as she grew up, this routine of loosing friends became more normal and she stopped thinking too much about the whole thing.
Based on her inputs, I commented on her resourcefulness in tackling a very emotional issue and coming up with a coping strategy to help bear the blunt of the impact. In this way I made sure that she did not see me as a threat or feel that I did not understand the pain which she had to go through each time. The next step was to inform her about the price she was still paying for sticking to this strategy even though it had outlived its usefulness. This step is very critical because it can cause a ‘narcissistic wound’ to the client. Kohut (1977) has explained the concept of a narcissistic wound which can be so painful to a client’s sense of self. If the clients see that their coping strategy is failing and they don’t see any better alternate to deal with the situation, they start seeing themselves as utter failures and can even see suicide as a response to this failure.
I asked her to describe if she was still moving from one place to another these days. She replied that she had been working in the same company for the past three years and had been living in the same city for the past five years and had no plans of moving. I then asked her about her current friends and colleagues. She said that she had friends at work but nobody whom she was very close. On inquiring about her husband she said that she was thinking of leaving him because she felt that their choices did not match and they pretty much argued about small things on a daily basis.
Using this information as a basis, I explained to her that using her coping strategy was keeping others from reaching her and that if she would allow them to get near; she would receive all the love and affection which she originally wanted from her childhood friends. To this end, I asked her to make small changes in her living style. As a start I asked her to invite her friends to go on small trips or maybe take the out for lunch once before we meet for the next session.
To help her in having a healthier relationship with her husband, I suggested that she try to be more vocal about the things which bother her about him and have a meaningful dialogue with him but also to hear his side of the story and not see her approach as the only correct way of doing something.
Further, I asked her to make a list of things doing which she felt inner peace, and incorporate them also into her daily schedule.
In the next session, I asked her if she did as we had planned. I confirmed that she had gone on a lunch with her friends and one of them had called her over for dinner this weekend. She said that she was feeling a bit lighter now since she was not always on the defensive and was making an effort to take things in stride.
With her husband, she told me that she had a long talk about how she was feeling, and how this could have been as a result of her coping strategy which she has been following throughout her life. She said that her husband very understood about the whole thing and promised to help her in any way he could.
She had also enrolled for guitar lessons which she said were one of her passions when she was a child, but had left them while growing up. Playing the guitar again made her relax and she said that now she did not become as agitated about things as much as she used to in the past.
I feel that interpersonal therapy is psycho educational in nature to some degree. In working with Susan It involved teaching Susan about the nature of aggression and the ways that it manifests in her life and relationships. In the initial sessions, aggressive symptoms are reviewed in detail, and the problem is accurately identified. I then explained aggression and its treatment and also explained to Susan that she has adopted the “sick role” which she’ll have to get out of in order to live a healthy life. The expected outcomes of interpersonal therapy are a reduction or the elimination of symptoms and improved interpersonal functioning. Working with Susan provided her with a greater understanding of the presenting symptoms and encouraged her to find ways to prevent their recurrence in the future. She left therapy with strategies for minimizing triggers and for resolving future aggressive episodes more effectively. So while interpersonal therapy focuses on the present, it also improved Susan’s future through increased awareness of preventive measures and strengthened her skills for coping with the issues present in her life.
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