Session 2

In addition to the aforementioned descriptions of her parents, in the second session, D. began describing what things were like growing up in her home when her mother would have her psychotic episodes. D. reported in this second session that when she was 8 or 9 years old she would notice that her mother’s psychotic episodes would start with her not taking care of the house. They would then progress to her mother ‘being afraid of everything’ and then to a state in which she suffered from paranoid delusions and auditory and visual hallucinations. D. reported that when she ‘was younger’, her mother ‘would have to be hospitalized one to two times a year, and by the time she was 8 or 9 years old, her mother could be hospitalized five or six times per year’. The patient reported that she felt sad but relieved when her mother was hospitalized. When I reflected how difficult it must have been to have a mentally ill mother, D. became angry and told me that what was most stressful about her mother’s schizophrenia was her father’s response when her mother started demonstrating symptoms. The patient went on to state that it was extremely stressful, frustrating and infuriating to have her father not get the severity of her mother’s mental state and suffering. He would often criticize the patient for being concerned about her mother, say that ‘she was not that bad’ and fail to take D.’s mother to her psychiatrist or the hospital when she needed treatment. When I reflected how invalidating this must have been for D., she became intensely upset stating that her father was so invalidating that she could not even stand to hear the word ‘invalidation’. We talked further about D.’s anxiety that her mother would get hurt while in one of her psychotic episodes (e.g. by walking out into the street and getting hit by a car or by jumping out of a moving car – something that D.’s mother actually did while in a paranoid state). It seemed, however, that the patient demonstrated the most intense affect when speaking of her attempts to get her father to take her mother’s condition seriously, recalling that she would often state ‘Come on Dad, aren’t you seeing this?’

Finally, towards the end of this second session, the patient presented me with a writing of hers. It was as follows:

• ‘D.
  
• Who needs to be loved
  
• Wonders about heaven and eternal life
  
• Believes in feminine images of God
  
• Often feels misunderstood
  
• Wishes her Mom didn’t have a mental illness
  
• Is afraid of flying
  
• Likes to learn about history and philosophy
  
• Never ate a peanut butter and jelly sandwich
  
• Still can’t be by herself all the time
  
• Is a germ freak
  
• Doesn’t understand why she’s so determined
  
• Gets annoyed when people brag
  
• Makes time for friends
  
• Is trying to be more patient
  
• Regrets trying to live up to other people’s expectations
  
• Is thankful for her optimism
  
• Laughs often
  
• Devotes time to the contemplative life
  
• Rarely gets lonely
  
• Hates to be criticized
  
• Can’t accept all of the teachings of the Catholic Church
  
• Has a bad habit of skipping ahead to the end of a book
  
• Always tries to do her best
  
• Appreciates nature
  
• Feels guilty about saying things out of frustrationRefuses to believe that there is no cure for OCDSOMEDAY HOPES TO MAKE SENSE OF HER LIFE’

Commentary

The first thing that struck me about D.’s poem was how sad it was. Never having eaten a peanut butter and jelly sandwich, such a normal part of an American child’s life. The lack of this experience led me to hypothesize that there must have been so many losses for D. because of her mother’s schizophrenia and her father’s inabilities to help the children cope with their mother’s mental illness. It also suggests that there were many everyday normal experiences the patient did not get to know (generating the hypothesis that deprivation experiences would be a factor in D.’s trauma). In addition, D. would tell me in subsequent sessions of how many holidays and special occasions would also ‘be ruined’ because her mother typically would have to be hospitalized before such events and how painfully sad and traumatic this was for her (e.g. ‘My last memories of my mother before she would be hospitalized was that of a completely disheveled, fearful, frightening woman…that image would be stuck in my mind throughout the holidays’). I further hypothesized that her mother’s absence, as well as her father’s neglect and lack of sensitivity to what his children needed, contributed to perhaps the most severe type of PTSD for D.: That of feeling abandoned. As it turned out, abandonment-themed PTSD flashbacks were one of the most difficult and frequent treatment targets in D.’s therapy, thereby confirming this hypothesis.

In addition to D.’s losses, sadness, anxiety and suffering, however, my experiences with D. in our first two interviews, showed me her many strengths.² Here was a person who was incredibly resilient and determined given all the traumatic experiences she endured (e.g. ‘does not understand why she is so determined…refuses to believe there is no cure for OCD’). Her ability to persevere in the face of so much terror, abandonment, neglect, disappointment and heartbreak enabled D. to survive this traumatic childhood and to accomplish so much. In addition, she was also an original thinker and problem-solver (e.g. ‘female images of God…can’t accept all of the teachings of the Catholic Church’). Looking back, I am sure that this creativity was one of D.’s strengths that helped her survive and cope with immeasurable trauma from her childhood. Other strengths so apparent also included good interpersonal skills (e.g. ‘making time for friends’), optimism, a good sense of humour, intelligence, hard work and ability to enjoy and appreciate learning new things and nature. Without these strengths, it is easy to imagine D. having succumbed to substance abuse or suicide.

Another primary hypothesis was generated in these first two interviews. This hypothesis was that invalidation of D.’s experiences, emotions and concerns, and the traumatizing and exacerbating effects of this invalidation, was a significant precipitating and maintaining factor in D.’s psychological problems (i.e. D. had experienced damaging invalidation repeatedly growing up in her home and in the convent to which she had just moved). In addition, in the very next session, and many times over the course of our therapy together, D. would have severely upsetting reactions to me, and others, who, at times, inadvertently, invalidated her experiences. These events repeatedly confirmed my hypothesis. As a result, I learned that validation of D.’s experience was going to be a critical and essential therapeutic relationship intervention. One that not only had both immediate therapeutic benefits by itself (e.g. repaired therapeutic ruptures allowed for the processing of painful emotions and soothed the patient) but also allowed for the implementation of other therapeutic interventions (e.g. exposure, coping skills training and self-care).

Sessions 3–7

D.’s third session began with her describing traumatic and embarrassing events related to her mother’s schizophrenia and her father’s invalidation of how mentally ill the mother was. D. reported that her father would often bring her mother out with them, even though it was obvious that her mother was experiencing severe symptoms of schizophrenia (‘Dad never seemed to see what the big deal was’). The patient elaborated that she was very fearful that her Mom would scream out, act paranoid or behave in an odd fashion out in public. In addition, D. stated that she was also quite apprehensive of the reactions of those who ‘were not used to’ psychotic behaviour, fearing that they would be critical of her mother. This was something that the patient’s paternal grandmother did quite often (i.e. she would criticize D.’s mother when she demonstrated severely psychotic symptoms, saying the mother was ‘just doing it for attention’). The patient further reported that her grandmother was also very critical of how D. did many things around the house (e.g. ironing and cooking). These chores and daily activities were things that the patient had to do at a prematurely young age because of her mother’s incapacitating mental disorder and were also tasks D. had to do without ever being shown how to do them. In later sessions, D. reported that her father was also very critical of how she did these chores and that he would invalidate, criticize or beat the patient when she expressed concerns for her mother’s mental state or about the lack of food in the house.

Other fears reported by the patient in the third session included those of the family running out of money because of her mother’s treatment expenses and of her mother becoming seriously ill because of her heavy cigarette smoking. Finally in this session, D. reported how infuriating it was to have others invalidate her present-day stressors (e.g. being harassed by sisters D. lived with), by attributing the patient’s distress to growing up in a difficult situation. ‘For some people’, D. would state, ‘my mother being sick was the magic carpet explanation’.

In sessions 4–7, we assessed the patient’s OCD, compiled an initial problem list and identified D.’s goals for treatment. D.’s OCD included four different ‘sets’ of obsessive–compulsive (OC) symptoms. The first of these featured fears of contamination by germs, rituals (i.e. excessive hand washing – ‘till my hands were raw’ and washing dishes with ‘burning hot water and scrubbing until everything was spotless and germ free’) and avoidances (i.e. not eating meat if D. suspected it was undercooked and throwing out food if D. ‘even suspected’ it was contaminated). These appeared to be the first OC symptoms D. experienced, and therefore the onset of her OCD seems to have occurred when the patient was in third grade (i.e. 8 years old). This was a severely stressful year for the patient. To begin, the patient’s maternal grandmother, ‘Nanny’, died suddenly during this year. This woman had provided much positive attention and nurturing for the patient and had been incredibly supportive and helpful to the patient’s mother and the rest of the family. She served the role of a much-needed ‘buffer’ for the children against the terrifying and traumatic effects of their mother’s schizophrenia and their father’s invalidation and abuse. The patient stated in this fourth session that when her Nanny died, ‘Nobody there to help me, I had to [go through the rest of my childhood] myself’. A second series of stressors were a consequence of the maternal grandmother’s passing: The patient’s mother started requiring frequent and lengthy hospitalizations. This exposed the patient to traumas of many kinds: deprivations, abuse, abandonment, criticisms, severe disappointments, etc. Also in third grade, the patient reported that she suffered a ‘huge beating’ at the hands of her father. She explained that her father ‘beat everybody for something that [her] brother had done’. The patient further stated that she confronted her father that what he had done was illegal – an example of D. already being parentified – and that after this confrontation the subsequent beatings decreased in severity. Other factors in the development of these OCD symptoms appear to have been paternal modelling of ritualistic dish washing and cooking and the patient’s father telling D. while she was in a terrified and hyperaroused state (and thereby more vulnerable to traumatic conditioning) that dishes needed to be washed with scalding hot water and that meat had to be cooked excessively. These contamination fears/cleaning rituals waxed and waned but essentially continued into D.’s adulthood.

A second set of OC symptoms involved ordering and straightening out things. Rituals included putting things away in a certain way or in a certain place or doing things in a specific order, a certain number of times, or in a certain way (e.g. the morning routine and packing her school bag). They also included repeating rituals. For instance, while reading or praying, the patient reported that it ‘felt like it did not count’ if she was not concentrating hard enough or focusing on every single word, so she would ‘do it all over again’. These rituals were attempts to neutralize the feeling that things ‘were not right/out of control/chaotic/disorganized’. The patient stated that she had to do these rituals ‘until it felt right’. Stressors that existed during the onset of these OC symptoms (ages 9–11) included the patient’s mother not being home, physical abuse by the father, the absence of the patient’s Nanny and the patient’s sister and younger brother developing ‘emotional troubles’. It was during this time that the patient was pushed into the role of taking care of these siblings, and it was during this time the patient recalled feeling ‘that things were out of control in the family, and that [she] felt totally overwhelmed’.

Obsessive fears of somebody dying comprised the third set of OC symptoms and seemed to have their onset around age 14. D. attempted to neutralize these obsessions by performing certain actions in an exact way (e.g. having her foot land in the exact centre of a step while descending a staircase) or by repeating an action to prevent a disaster from occurring. D. reported that she was very ashamed of these obsessive fears and in fact had never told anyone of these fears for the past 26 years; that is, until she told me in this session. Consistent with this, the patient reported that she had also not revealed much of the traumatic events in her life until the start of this therapy. D. further reported that she traced the onset of these feelings of shame to ‘around age 12’, in response to her paternal grandmother saying disparaging things about the patient’s mother and ‘constantly belittling and criticizing’ the patient for how she did various household chores, chores, in fact, that were often developmentally inappropriate for the patient to be doing in the first place (e.g. ironing clothes).

Around this time, D. developed her fourth set of OCD symptoms. Primarily, these symptoms involved D. repeatedly checking to make sure she had done something (e.g. having her keys, putting homework in her school bag, setting her alarm clock, having her money and locking the car door). The patient explained that these checking rituals neutralized the feeling that she had not done something (i.e. ‘that it didn’t “register” that I had done it’). It also appears that these rituals served the function of ensuring that D. had not made a mistake that she would then be belittled or criticized for.

The severity of D.’s OCD symptoms fluctuated throughout her life, depending on the amount of stress she was under (e.g. ‘at times, the OCD was so severe, it took over my life’). The patient described a major exacerbation of these symptoms when she moved into the new convent described above. At this time, D. reported that she ‘would be trapped at school doing OCD rituals for hours, not getting home till 9 pm and missing dinner completely’. The aforementioned stressors, ‘people yelling at me, blaming me for things I didn’t do, giving me way too many jobs to do’ and experiencing invalidation (i.e. ‘no one seemed to understand how stressful this was for me….everyone kept telling me I’d be fine’) appeared to fuel the exacerbation of the patient’s OCD (and PTSD). It is certainly easy to see how the experiences of being verbally abused, blamed and invalidated would be especially stressful for the patient given her traumatic history of these experiences from her father and father’s mother. In fact, as confirmed by many experiences in her therapy with me, instances where D. felt abandoned, blamed, criticized or invalidated by me were not only stressful for the patient but also triggered PTSD flashbacks for her. Indeed, these experiences also triggered these flashbacks for the patient during her time at the new convent. The exacerbations of her OCD and PTSD in combination with being cut off from her friends culminated in an inability to sleep, loss of appetite, loneliness, ‘crying all the time’, headaches, oversensitivity, generalized anxiety/worry and – in an attempt to cope – over exercising. In addition, D. seemed very distressed by the fact that when she was so consumed by various symptoms, ‘nobody said anything’ – reminiscent of her father’s response to her mother.

Commentary

At this point in time, D. seemed to be suffering from severe and complex PTSD manifested by high levels of chronic anxiety; fears of abandonment, invalidation and criticism; flashbacks; dissociation; sleep disturbance; cognitive difficulties; etc. She also obviously was suffering from severe OCD. I hypothesized that D.’s PTSD was her primary and most ‘central’ problem, with her OCD ‘a close second’. I conceptualized D.’s problems in this way because the PTSD-related problems were so pervasive, easily triggered, earlier learned and often incapacitating. In addition, onset of D.’s OCD occurred in a highly stressful and traumatic environment, and aside from the usual maintaining factors of anxiety reduction/neutralization of obsessions, D.’s compulsive rituals served various functions in her life. For instance, washing and checking rituals helped her avoid verbal and physical abuse; rituals designed to reduce the fear of a loved one dying and increase a sense of safety in her life occurred in an environment where there was an actual risk of her mother or one of the children dying (e.g. the patient’s mother was having command hallucinations to kill her children and the mother threw herself out of a moving car) and ordering rituals provided a sense of control in a home environment where things felt dangerous and chaotic, and in which D. felt abandoned.

Comprehensive Problem List

Through the course of the first seven sessions with D. and the completion of several self-report inventories³ [e.g. Beck Depression Inventory (Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961); Personal Problems Checklist for Adults (Schinka, 1985)], the following problem list was generated:

1. PTSD – D. had experienced multiple, perhaps countless, traumatic events in her life that involved the threat of death, serious injury or loss of physical integrity to herself or others (e.g. her mother holding a butcher knife over D. as a child and telling D. that ‘the voices were telling [the mother] to kill D.’; not having food in the house during times when D.’s mother was hospitalized; being left alone in the house as a child with inadequate food or heat; being beaten by her father and witnessing her mother throw herself out of a moving automobile). D. responded to these events with intense fear, helplessness and, as child, disorganized behaviour. She also demonstrated flashbacks, dissociation, nightmares, intense psychological distress (‘crying fits’) and physiological reactivity when exposed to PTSD triggers; efforts to avoid conversations associated with the traumas; feelings of detachment or estrangement from others; sleep disturbance; difficulty concentrating and hypervigilance. Beyond these diagnostic criteria (Diagnostic and Statistical Manual of Mental Disorders; DSM-IV; APA, 1994), and clinically more useful, we organized D.’s PTSD into types of traumatic experiences. The clinically most important types of trauma for D. seemed to revolve around the experiences of invalidation, abandonment and being criticized. When D. was triggered by these types of experiences, she could dissociate or become completely incapacitated for days (e.g. being curled up in the foetal position on the floor). Other important types of traumatic experiences that caused intense sadness or agitation for D. included experiences that triggered memories and feelings of being trapped, neglected or deprived and disappointment (‘having special occasions ruined’).
   
2. OCD – D.’s OC symptoms are described in detail above and clearly reflect the themes of trying to prevent disastrous things from happening to her or loved ones and of trying to avoid making mistakes that would lead to physical and/or verbal abuse. In addition, one could hypothesize that another function of D.’s OCD symptoms was to provide a sense of control, predictability or certainty in a world where there was none, on account of her mother’s schizophrenia and her father and grandmother’s physical and emotional abuse.
   
3. Severe and chronic anxiety – In addition to the fears and anxieties associated with traumatic memories and triggers and with her OCD, D. suffered a great deal from what she would describe as ‘nearly constant high levels of anxiety’. This anxiety appeared to have resulted from the additive and cumulative effects of repeated trauma, constant fears of being criticized, obsessive fears, psychosocial stressors and the experience that D. had to cope with all these threats completely on her own.
   
4. Stressors and the traumatic effects of D.’s recent move and current living situation – As D. wrote in an early therapeutic homework assignment, at the time of her referral to me she had recently ‘moved into a new – and hostile – convent and had no supports. [She] repeatedly asked for help, but everyone kept saying not to worry about it and it would be fine.’ Specifics of this highly critical and stressful living arrangement are described above, but to me what it most striking is that these experiences mirror D.’s experiences growing up: High levels of criticism, the presence of a woman with paranoid schizophrenia and massive invalidation of D.’s experience.
   
5. Moderate to severe levels of depression – D. complained of many depressive symptoms including depressed mood, lowered energy, suicidal ideation, sleep disturbance, tearfulness, feelings of failure and feelings of worthlessness.
   
6. Post-traumatic symptomatology secondary to being attacked – D. reported that 7 years prior to the start of her therapy with me, another sister, who ‘was mentally ill’, had tried to kill the patient by strangulation. D. obviously had managed to get away, but she stated that she still experienced flashbacks reminiscent of when D.’s mother had threatened to kill the patient when she was psychotic. D. also reported that she often feared for her safety. Again, the patient complained of a ‘lack of response from [her] superiors’, when she complained about her safety.
   
7. Sadness in response to the loss of D.’s previous community – These losses included not only the loss of ‘really good friends’ but also the loss of opportunities for career advancement (e.g. ‘getting to work at the college level’).
   
8. Job dissatisfaction – D. reported that even though she really liked the children that she taught, she was feeling very bored as a sixth grade teacher. She further complained that she ’did not feel challenged at all and had to make an effort not to be bored’.
   
9. Extreme sensitivity to criticism – Even though this problem area can be easily understood given all the traumatic criticism, verbal abuse and physical beatings D. experienced growing up, D. complained that this was a particularly difficult problem for her. And, as I witnessed multiple times over the course of D.’s therapy with me, perceived criticism by me often set off severe PTSD reactions for the patient (e.g. flashbacks, severe anxiety, dissociation and migraine headaches).
   
10. ‘Emotional eating’ – Again, clearly traceable to traumatic experiences growing up, the patient coped with feelings of abandonment and deprivation by bingeing on large amounts of candy and other sweets.
    
11. ‘Misophonia’ – D. reported that she experienced an unbearable agitation and anxiety in response to others gulping their drinks or the sounds of others chewing their food. This reaction was so severe for the patient that she either dissociated at the dinner table or had to leave the room where others were eating.
    
12. Fear of flying – This was especially significant for D. because it prevented her from experiencing many special vacation opportunities that her younger brother could provide for D. because of a perk of his job. The feelings of loss secondary to this flying phobia were compounded by all of the traumatic loss associated with special occasions for D. when she was growing up (e.g. holidays and birthdays when her mother was hospitalized).

D.’s Goals for Therapy

At the beginning of her fourth session, D. provided a written account of her goals for therapy. They were as follows:

• ‘Look at my past experiences and identify where healing/integration is still needed and work on accomplishing that.
  
• Establish alternative and healthier ways to handle my anxiety.
  
• Grieve the loss of my mother and the loss that comes from leaving my former congregation’.

In addition to the previously stated goals, D. spoke of how frustrated she was with all of the protocols of religious life and how she’d like to work better within that system. She also wished to pursue a more stimulating profession and to ‘understand the whole OCD thing better’.