Assignment: The Case of Mary

Assignment: The Case of Mary

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Mary is a 47-year-old, single, heterosexual Caucasian female. She lives with her 52-year-old sister and 87-year-old father in the home in which she was raised. She also has a 45-year-old sister who lives 10 minutes away and a 23-year-old daughter living on her own. Mary and her family members do not maintain friendships outside the family. Mary has been unable to work for the past 3 years because she says she has felt too frightened to go too far from her home. As a result, she has been financially reliant on her family members for these last few years. Prior to this lapse in employment, she had been a school bus driver and an administrative assistant at a warehouse distribution center. Mary has no history of drug or alcohol abuse. She is well groomed and physically fit with a diagnosis of hypoactive thyroid, for which she is treated with Synthroid^®. Mary was diagnosed with post-traumatic stress disorder (PTSD) and adjustment disorder, not otherwise specified (NOS) by the clinic psychiatrist. Assignment: The Case of Mary

Before meeting with me, Mary saw a social worker in a private practice for 2 years. She entered treatment with that clinician because she said she was traumatized by a romantic relationship with a married African American man she had met at work. Her trauma symptoms began 6 months after she ended the yearlong romantic relationship. Mary said the romance occurred because he had “brainwashed” her, as there could be no other reason she would have slept with him. Mary believes that bad people are capable of “brainwashing” good people to perform bad deeds. Mary was raised in a home that espoused racism, and she and her family members believe that African Americans and other people of color are untrustworthy and bad. She said, “I take after my father, and he thinks black people are just evil.” Mary said she understands her feelings about race are not right.

Mary considered her initial attempt at treatment unsuccessful for two reasons. First, she felt the therapist (a Caucasian woman) judged her and her family harshly for their racial beliefs and this got in the way of the two of them building a trusting working relationship. Second, she did not feel relief from her PTSD symptoms. Mary ended the relationship with that social worker 6 months ago. Mary then approached her primary care physician about her symptoms, and the doctor prescribed an antidepressant. When, after 3 months, Mary asked to have her dosage increased, the doctor suggested that she get a psychiatric evaluation and consider returning to therapy. Mary’s insurance company suggested our agency for the psychiatric evaluation and approved 10 sessions.

Mary said she felt sad, frightened, and anxious most of the time. She had no appetite, slept most of the day, had no interest in dressing, and rarely left the house. When she did go out, she felt the need to be accompanied by of one of her sisters.

Mary presented as angry during our initial sessions. She requested that one of her sisters attend the sessions with her, to which I agreed. My intent in agreeing to have her sister in the room was to help Mary feel safe and create a strong rapport. During the early sessions, most of what Mary said began as half sentences that she asked her sister to complete. Mary referred to her sisters as her “caretakers and minders” who “know me better than I know myself so you should talk to them.” Mary said that if she talked for herself she would get “it wrong.” The “it” and the “wrong” remained elusive in meaning when I asked her what that meant.

Mary agreed, after two sessions, to meet with me alone. We used our first individual session to establish Mary’s goals for therapy. Among her goals was developing ways she could feel safer about going outside alone. Over the next eight sessions, I used cognitive behavioral therapy interventions to help Mary build coping strategies for recognizing triggers to frightening thoughts and to help her manage her anxiety symptoms. I also used psychoeducational interventions to help Mary develop routines for proper sleep hygiene, healthy eating, and regular exercise.

After several sessions, Mary shared insight into her feelings about dating an African American man. Mary said that being attracted to an African American man frightened her and that there was no future for her relationship with this man because he was married. Mary believed that she had jeopardized her secure position in the family because being with an African American man challenged the family’s ideas about race and their view of themselves as separate and unique from non-family members. Once the family discovered Mary’s relationship with this man, she believed her only way back into their lives was to accept the role of a “crazy sister” in need of protection and whose judgment about people was faulty. By forming a relationship with an African American man, Mary had shown her judgment to be outside of the norm in the conventions of her family.

In our final two sessions, Mary said that she no longer felt like she was the “crazy woman in the family” and she felt safe going to the grocery store alone. It was my impression that Mary may have been the identified patient in her family but exploring this idea would require family therapy.