Let me introduce " Caroline " a young woman who entered psychotherapy with my friend and colleague Dr. Jamie Edmund many years ago, with severe problems relating to alcoholism and cocaine addiction, depression, sexual promiscuity and a long history of poor choices in love relationships. We will first hear from Dr. Edmund about the initial phone call, and the early hours of this intensive treatment. In the next segment Dr. Edmund will tell us about Caroline's pertinent family background. Three major phases of the therapy will be offered as well. In order to facilitate our discussion Dr. Edmund has included her working hypotheses of the therapy. I will join in the discussion of the case.
Caroline called for a first appointment, asking if I would be willing to see her for "just a few sessions to help decide about going to graduate school." She inquired carefully in that first phone call about whether a brief treatment would be acceptable to me, explaining that she did not want to become engaged in a long term treatment like the 3 year therapy she had left in the Midwest 10 months earlier. She began the first appointment by explaining further that, having completed 4 years at a prestigious liberal arts college with honors, she had assiduously pursued and been awarded acceptance and scholarships at a top art school, but was now feeling confused about her lack of motivation for entering graduate school in the fall, just 3 months away. Caroline went on to describe her father, a university president from an old Boston Brahmin family, as a "knowitall" who had told her all her life what to think, including that she would never amount to anything with her "artistic temperament" and her "hysterical emotionality." Her mother, Caroline told me, was a professor of psychology, an ambitious, but anxious woman who would not contradict her husband to support Caroline. My comment at this point, early in the hour, was "your confusion about the future may have something to do with a concern about whether graduate school is for you or for your parents." Caroline responded, "When I first told them I'd been accepted, My parents asked if this particular School of Art was any good, and then as if they didn't believe me they asked everyone else if it was any good and now they go around bragging to everyone that I was accepted."
As the hour unfolded, Caroline, who appeared to me to be a very intelligent, poised, witty, lovely young woman, made it quite clear that she did not see herself this way. She told me "Everyone in my family is real smart and articulate, except me. My sisters got straight A's; I got A minuses. My oldest sister is a brilliant lawyer heading up an important federal commission. My other sister was class valedictorian. I could never speak well." A disability of some type?" "No, I was the dumb one. I guess I'm the black sheep of the 3 children"(her sisters are 4 and 2 years older.)" "How did you happen to get assigned that role?" "I don't know; I was fat and everyone else was skinny, you know, ectomorphs. I worked so hard to become thin in high school; I ran crosscountry; I swam; my mother was so proud of my body when it was thin. The whole family was always commenting on what parts of my body were fat or skinny, whether I was eating too much ice cream, whether I was exercising enough."
Caroline continued, explaining that she was cast as the "bottom of the barrel" in the familycastigated for her "lack of responsibility", her "emotional outbursts" and her "self-indulgent love" of things artistic and sensual. In response, I told her very straightforwardly that I thought that her picture of herself was inaccurate; that she appeared to me very bright and articulate; that it seemed to me she had been very successful in college, and probably in many other things in her life, but that it seemed hard for her to hold a view of herself that was different from her parents' view. Immediately following this comment, Caroline revealed anxiously and tearfully that she was in the midst of a one and a half year period of promiscuous sex and alcohol and cocaine use. I expressed great concern for her wellbeing, and she continued on to describe a club scene in which she had become caught up, involving a nightly routine of the rounds of various South of Market clubs in which she was known by many of the musicians and other regulars with whom she drank, danced, and went to bed. She told me she didn't know if she "drank to have sex or vice versa," but that she knew both had gotten "out of control." She reported drinking 280z of gin nightly; regular blackouts;12 binges a month of 23 grams of cocaine, combined with dangerous, nightly walks, drives, and bus rides home from the far reaches of S.F.; hair raising car rides with drunken friends and near muggings.
I told her I felt she was in immediate and very real danger and that I thought we needed to begin immediately to work together to protect her from being mugged, raped or killed, to stop the alcohol and drug addiction and to help her feel that she deserved a much better life. She began to cry and said that she found herself wondering each day if she might die in one way or another. She said, "I don't want to continue this way but I don't know how to stop." I responded, "We know a good deal about alcohol and drug addiction and how to help people get off this stuff and stay sober; you can do it; along with therapy the key to recovery is learning about the disease of addiction, and setting up an active, daily support network of AA and NA meetings. She sat thoughtfully for a moment and then responded, "O.K., I guess it's time to do it; I didn't want to admit I was in trouble, I guess. I never thought I would become this pathetic." I discussed the alternative of an inpatient detox program as well, but she chose to try an outpatient recovery plan and I felt she was a good candidate for outpatient treatment; she agreed to begin that day attending 12 step meetings, with the goal of finding a meeting for each day of the week; we also set up a 3 time a week schedule for her to see me, with the option of increasing appointments if needed.
By this point toward the end of the first hour, She seemed very relieved. She volunteered that she wanted to stay away from the clubs, but that if she did go, she would try not to go home with anyone, and if she did go home with a man, she thought she could at the very least protect herself by practicing safe sex and taking a cab home. I set up an appointment for the next day and asked her to call me each evening for the next few days for a brief phone call to let me know how she was doing. That was the first hour. Over the next three weeks, Caroline made progress both in building an alliance with me, as well as establishing AA and NA as strong supports.
Initially Caroline insisted upon handling all the negotiations with her parents, saying she did not want them telling me "bad things" about her; but her father called me 8 or 9 times the first two weeks of treatment, questioning my credentials, questioning the treatment plan, questioning the decision not to hospitalize. In order to reassure and contain this extremely controlling and anxious man, I suggested getting a second opinion from a nationally known psychiatrist (of whom this father had heard), who has expertise in a number of relevant areas including the treatment of chemical dependency. The parents flew out to meet with him, and were reassured by his confidence in the treatment plan Caroline and I had made. A plan was agreed upon: the psychiatrist would handle medications for Caroline (he prescribed Prozac for the subsequent year and a half) and would meet or speak by phone with the parents as often as they wished. In addition, he suggested they get into therapy in their home town "to get the support they deserved, as well as to try to see things from Caroline's perspective." Following 4 weeks of intensive communications between the parents, the psychiatrist, and myself,(the intensity and pressure of which would be hard to convey easily to you,) the parents agreed to pay for treatment, and tolerated, under protest, Caroline's decision to cut off contact with them at least temporarily.
In our discussions leading up to Caroline's decision to cut off contact with her parents, she articulated a tormenting belief that she deserved to be punished for going against her parents; I have seen this as her deepest pathogenic beliefthe belief that wanting to have a life of her own, separate from them, harmed them profoundly. Visible in these early hours were key goals in disconfirming aspects of this core pathogenic belief. These goals included: 1)A deep desire to stop abusing her body by using alcohol and cocaine and unsafe sex. 2) The wish to free herself from worry and overresponsibility for her parents and sisters. 3) the desire to change her belief that she deserved to be punished for making her parents unhappy. 4) freedom from selfblame so that she could not only protect her life but enjoy it. 5) A profound motivation to love herself including the things about herself which her parents criticized.
Early testing of me included: 1) Caroline's presentation of herself as the loser and problemchild in the family to see if I would agree with her; Immediately following my challenge to this negative view of herself, she revealed the very serious danger she was in. 2)Secondly, she presented me with very serious selfabuse to see if I would leave her unprotected as her mother had or move to confront the addictions and self endangering behaviors. 3)In addition, there were many early tests in which Caroline attempted to ascertain whether I needed to be propped up like her father as an authority having all the answers. Could I allow her to think and feel for herself. Could I tolerate her disagreeing with me? In an increasingly bold style she challenged my views, for example, "Maybe you don't know what's right about sex; maybe sex for fun is good; it feels good; maybe you're trying to brainwash me like my father did." 4) Other tests about protection were also crucial; Caroline was sometimes very emphatic about wanting to make her own decisions; at certain points, however, Caroline needed protection rather than "support" for her autonomy, for example, by the second week of treatment her parents were overwhelming her with controlling and guiltinducing contact, at which point I told Caroline I wanted to call them and recommend that they not contact her directly for a time, which I did, but not before we had two hard sessions in which she objected to my "acting like her father and taking things out of her hands." All of these early testsmy persistence in helping her deal with her parents, my going up against them to protect her from contact, my asking them to pay for treatment even though they couldn't see her, my dealing clearly with her addictionsall these made it clear that I did not want her to be selfdestructive, in danger, or unprotected. These tests were critical in creating the sense of safety which allowed her to progress.