Escape from Alcatraz: Finding Safety and Peace

We'll call her Amy. Amy first came to see me because her previous therapist had discontinued practice after they had worked together for about six years. She was on Social security Disability due to a chronic mental illness that had been first diagnosed at age 19, shortly after she began college. Amy had been in treatment more or less continuously in the intervening Io years and was currently taking several psychotropic medications. She wanted continuing psychotherapy and referral to a psychiatrist for medication management. She hoped to reduce the current level of medication that she was taking as well. Amy had recently moved back into her childhood home with her parents, who were now in their sixties. Her father had a long history of alcohol abuse and was showing progressive dementia; he soon was diagnosed with Alzheimer's disease. Amy's mother, a one-time Peace Corps volunteer, functioned as the primary bread-winner and head of the household. An accountant, mother was described as emotionally aloof and critical. Further, Amy complained that both parents favored her younger brother. She felt like she was unwanted and an inconvenience to them at times. To complicate her situation, about two and one half years prior to our initial contact she had fallen from the roof of the house while attempting to install Christmas lights. She landed on her face on the concrete below. The fall resulted in a fractured occipital orb and required reconstructive surgery. The facial injuries had healed, but there was a possibility of a continuing organic brain syndrome secondary to the fall. Consequently, early in treatment I referred her for a neuropsychological evaluation from a colleague. Results of the neuropsychological exam supported my initial diagnosis of depression and PTSD. Amy's current intellectual functioning was in the high average range with a Full Scale WAIS-III score of 115. However, there was evidence of significant impairment in working memory. This was attributed to emotional interference due to her mental disorder rather than traumatic brain injury, which was tentatively ruled out. The neuropsychologist also reported that she had a history of sexual abuse and suggested that there were signs of poor relationship boundaries; he cautioned that she might be seductive. These data supported our tentative plans to work on psycho-social functioning, so we agreed to move ahead in this direction. In considering my work with Amy I will provide an overview of her psychosocial assessment, case conceptualization, and some examples of my therapeutic approach and the process of treatment as it unfolded. Psychosocial Assessment Presenting Problem: Depression, hopelessness, and anxiety related to sexual abuse trauma. Amy stated that she wished to reduce her medications. Appearance and Presentation: Very casually dressed with minimal attention to grooming and self-care. Amy had a "deer in the headlights" look about her that suggested intense vigilance and tension. She requested that the lights be turned off and kept her eyes closed or looked away most of the time. Eye contact was almost entirely absent. Mental Status: Amy was fully oriented. She showed no apparent signs of hallucinations, delusions, or other serious cognitive distortions. Mood was markedly anxious and depressed. History of problem/prior mental health treatment: Mental health treatment began at about 12-13 years of age, following sexual abuse by a paternal uncle. Amy experienced her first episode of severe emotional distress as a college freshman about Io years ago. In the interim she has been hospitalized at least three times, including at least two serious suicidal episodes in which she took overdoses of medications. She had qualified for Social security Disability due to her chronic mental illness. Diagnoses included Bipolar Disorder with a possibility of schizoaffective disorder, and anorexia. More recently Attention Deficit Disorder had been added. …