RANZCP Psychological Methods Case History

This case describes Grace, a 60-year-old woman who suffered from a long-standing history of depressive and anxiety syndrome associated with borderline, anxious and avoidant personality traits. She underwent psychotherapy to explore the source of her anxiety and low self-esteem.

RANZCP Psychological Methods Case History
“Grace Willa”: The Conversational Model of Psychotherapy Informed by Psychodynamic
Psychotherapy and Other Key Principles
Submitted under RANZCP guidelines
De-identification and Confidentiality Declaration
In accordance with RANZCP requirements, this case history has been de-identified. This
includes all data that could identify the patient, their family and other individuals, such as name,
location, names of hospitals, supervisor and dates of admission. Data that are de-identified are
initially marked with an asterisk (*) the first time they appear.
Word Count (excluding the de-identification disclaimer, cover sheet, index/table of contents
and references/bibliography): 9,574 words
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TABLE OF CONTENTS
Contents 2-4
Synopsis 5
Identifying Data 5
Referral 5
Presenting Complaint 5
History of the Presenting Illness 6-7
Extensive Past History 7-8
Medical History 9
Medications 9
Allergies 9
Alcohol and Drug History 9
Family History 10
Personal History 10-13
Spiritual Beliefs 14
Premorbid Personality 14
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Mental Status Examination 14-15
Risk Assessment 15-16
Physical Examination and Initial Investigations 16
Initial Psychodynamic Formulation 16-18
Provisional DSM 5 Diagnosis 18
Differential Diagnoses 18-21
Management 21
 Initial Agreement and Plan 21
 Decision to Employ Psychotherapy 22
 Consideration of Alternative Treatment Strategies 22
 Goals of Psychotherapy 24
 Treatment Contract 24
 Liaison with Other Professionals 25
 Supervision 25
Progress in Psychotherapy 25
 The Initial Phase 25-28
 The Middle Phase 29-33
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 The Final Phase 34
 Termination 34-35
Reformulation 35-37
Discussion and Final Reflections 37-39
Bibliography 40-41
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Synopsis
This case describes Grace, a 60-year-old woman who suffered from a long-standing history of
depressive and anxiety syndrome associated with borderline, anxious and avoidant personality
traits. She underwent psychotherapy to explore the source of her anxiety and low selfesteem.
During the therapy, it was established that ongoing interpersonal issues and social stressors
relating to money, job and accommodation, as well as a history of sexual and domestic violence
by her father, contributed to her condition.
Identifying data
Grace was a 60-year-old woman and a mother of two children. She lives in a regional town,
which is several hundreds of kilometers away from any major city. She was unemployed and
living with her male partner, Kennedy, whom was also unemployed. Grace had undergone two
divorces with her first husband, Michael, and second husband, William.
Referral
Grace was referred to me on March 10th, 2017, by Community Mental Health Team
Psychologist Ms. Smith*. Ms. Smith felt that long-term psychotherapy would help Grace
overcome her low selfesteem issues and trauma. I presented the case to my supervisor, Dr.
Erickson*, who agreed that psychotherapy sessions were necessary for Grace. Ms. Smith, who
was Grace’s Psychologist for more than two years, was also convinced that the psychotherapy
was essential for her.
Presenting Complaint
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“I feel anxious, hopeless and depressed. I need help”.
History of the presenting illness
In 2017, the Community Mental Health Team Psychologist referred Grace to me for long-term
psychotherapy.
Grace reported symptoms of sadness, anhedonia, guilt, hopelessness, energy loss, concentration
loss, appetite change, slowing of psychomotor activity, sleep change and fleeting suicidal ideas
of more than two weeks in duration – this indicated a major depressive disorder with a recurrent
nature and moderate intensity. Grace reported feeling sad most days for over two years,
manifested by sleep change, hopelessness, appetite change, low self-esteem and concentration
loss and associated with significant distress – this indicated a persistent depressive disorder.
She reported ongoing lower-back pain, which impacted on her thoughts, feelings and behavior
when severe – this demonstrated somatic symptom disorder. She reported having reading and
writing difficulties from an early age and that she struggled enormously at school and left due to
these difficulties at the age of 9 – this indicated a learning disorder.
She reported intermittent ongoing worry, concentration loss, sleep change and impairment with
functioning. She reported drinking several glasses of wine on days when she felt overwhelmed.
She reported having intermittent nightmares from previous abuse by her father. She reported
feeling emotionally deregulated sometimes, associating this with crying, feeling hopeless about
her situation, having intermittent suicidal ideas and a history of past impulsive suicide attempts
and feeling rejected in her relationships. She reported becoming anxious and avoidant
sometimes, due to her complex circumstances, a difficult upbringing and reading and writing
problems.
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She described some social anxiety. She described becoming anxious occasionally, based on the
situation. She reported that, when she was unwell, she was unable to go shopping. Grace did not
report any symptoms of eating disorders, mania or psychosis.
Extensive Past History
Grace reported a long-standing history of anxiety and depression since childhood, due to paternal
physical and sexual abuse. She was also exposed to bullying at school, which intensified her
depression and anxiety. Additionally, Grace had a learning disorder, which involved the inability
to read and write. She had to abandon school and get married to escape the bullying at school
and her abusive father. Grace has also tried to commit suicide several times: the last time, she
tried to run in front of a truck in 2013.
She reported worrying about her inability to find proper work, and that she will never be able to
do so because of her limited education and ongoing back pain. She reported fleeting nightmares
of abuse from her father. She reported a long-standing history of back pain due to a bulging disc.
She reported that her engagement in volunteer work at the hydrotherapy pool and cardiac
rehabilitation was fluctuating, although she loves this work.
She reported spending most of her time in bed, feeling depressed and anxious. It appeared to be
related to her suppressed anger with her partner not finding work and spending all day at home.
She reported initial and middle insomnia (sleeping only a few hours a day), poor energy and
anhedonia, which have been fluctuating. She reported living a life associated with shame and
guilt and reported intermittently feeling helpless, worthless and hopeless.
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She reported a long-standing history of fleeting suicidal ideation and a few suicide attempts. She
described the difficulty in regulating her moods and worrying about what others think of her. She
reported difficulty in coping with separations and losses.
Grace had to see a counselor as a child because she had difficulties coping at school and home.
These difficulties were mainly due to domestic problems – abuse by her father and siblings.
However, her father found out about the counseling sessions and ended them. She also tried to
commit suicide or conceived suicidal plans at various times. The first time was when her father
victimised her through physical violence and sexual harassment. However, she didn’t act on
those thoughts. She had thought of committing suicide after her second marriage ended,
combined with difficulties concentrating, resulting in her GP prescribing sertraline. The third
suicidal attempt was the most severe because she tried to walk in front of a moving truck when
her husband had to undergo heart bypass surgery.
Grace has been reviewed by three psychiatrists, who have monitored her mental state and
progress and treated her with psychotropic medications. She is well known to the Community
Mental Health Team and she was referred by her GP in 2013. She had psychology sessions
through her GP’s mental health plan. Grace has responded poorly to sertraline. Recently she took
a combination of duloxetine and quetiapine, which has helped to reduce her anxiety and improve
her sleep. Grace has been case managed since December 2014. She received treatment from the
Community Mental Health Team Psychologist from March to July 2017 and admitted feeling
sad, rejected and abandoned when he ceased psychotherapy.
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Medical History
Grace sustained a back injury in 2012 at work. Since then, she has experienced ongoing back
pain. She also is a haemochromatosis carrier and heterozygous for both genes. She experienced
generalized osteoarthritis, GORD with oesophagitis, hypertension and asthma and calcaneal
spurs. In 2012, she had a colonic polyp removal. There is no medical history of head injury,
seizures or CVA.
Medication
 Duloxetine – 120mg, mane
 Quetiapine – 50mg, nocte
 Candesartan – 32mg ,1 daily
 Omeprazole – 20mg, 1 daily
 Meloxicam – 15mg, 1 daily
 Salbutamol CFC – free 100mcg/dose inhaler, 2-4 puffs four times per day, PRN
Allergies: No known drug allergies or adverse reactions.
Alcohol and Drug History
Grace admitted to drinking around 12-14 drinks each night. However, this was recently reduced
to 2-3 glasses throughout the weekend. She also smokes six cigarettes per day: previously, she
stopped smoking for 15 years. She denied other illicit drugs. There is no history of drug or
alcohol treatment.
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Family History
Grace reported that her mother, who currently resides at a nursing home, suffers from dementia.
Her sisters have suffered from diabetes and renal problems, and one of them has anxiety
problems. There are ongoing conflicts between Grace and her family, mainly in relation to her
being the power of attorney for her mother and in relation to money owed. She did not report any
history of drug problems or suicide in the family. However, one of her granddaughters was
sexually abused and this incident had a negative impact on Grace.
Personal History
Birth and Childhood
Grace was the third child of Ann* and Alex*. The couple had been together for 55 years. She
had five siblings; 2 older sisters, 2 younger sisters and a stepbrother. Grace admits that she was
closest to her mother and her eldest sister. The family was financially unstable, mainly because
Alex used to abuse alcohol, leaving the family to suffer without food and other basic needs.
Grace was delivered through a normal vaginal delivery. There were no reported complications.
Grace was a healthy baby, who achieved normal physical milestones.
Grace describes the relationship between her father and mother as abusive and violent. Her father
used to beat her mother, often hitting her on the head. He was resentful towards her because she
was unfaithful. Grace reported that her stepbrother was the result of her mother’s affair with her
lover Edward*. As a result, his father would physically abuse him until her grandparents took
him with them to Orange. Since then, her stepbrother, Erik* was cut off any form of
communication and relationship with his family. Grace reported that her stepbrother felt
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mistreated and that’s why he didn’t want to associate with his parents and siblings – they
reminded him of misery and pain.
Grace said that her father was also abusive toward her and her other siblings. She remorsefully
lamented that he enjoyed torturing and beating her more than her siblings. He was sexually
inappropriate and invasive, by watching the children as they took a shower and touching their
intimate parts whilst trying to apply soap in the bathroom. Grace described her father’s sexual
abuse as “unacceptable” and “disgusting”.
Despite the awful relationship between Grace and her father, she reported having good memories
of both paternal and maternal grandparents. She described them as “fantastic” and that she felt
“safer” with them. She was also close to her paternal aunt. Unfortunately, her father made every
effort to stop the children from completing school work and spending more time with their
grandparents.
Grace reported that she felt anxious at school between ages 5-6 because she had difficulties
coping with learning. She was a victim of severe teasing and bullying. Her peers bullied her for
no reason. On one occasion, she was beaten up to the extent of bleeding and had to go home.
However, her father reacted by physically assaulting her, arguing that she was to blame for her
misfortunes. Grace describes the experience as “horrible and the last thing she would expect
from a father”. Her mother felt remorseful about her daughter’s mistreatment and she was
helpless against her husband. She responded by taking Grace to the hospital. Grace described her
mother as “soft and submissive”. The child protection agency was initially involved but there
was no action taken against her father because “he is my father”, according to Grace. Grace had
difficulties in her school work, especially reading and writing. Initially, she used to ask for help
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from teachers, but she became frustrated because they did not help her enough. Eventually, she
stopped asking for assistance. Grace stopped going to school at the aged 9. She spent most of her
time indoors with few outside interactions, except for her visits to her grandparents.
Adolescence
Grace started menstruating around the ages 11-12 and she reported having poor knowledge of
her body and sex. To escape from her father’s abuse, she was married at the age of sixteen.
Unfortunately, Mike*, her husband used to frequently rape her. She said that she had multiple
painful sexual experiences. She gave birth to a girl and a boy.
Adulthood
Eventually, her children grew up and had families of their own. Her daughter had one son and
two daughters. Once, her adult son was blamed for sexually assaulting his niece and the
experience was devastating for him and the family. Grace lost contact with her son when he
moved to a regional town after the sexual-assault allegations. She was also frustrated when one
of her sisters passed away 12 years ago, because she had lost her main support and had to face an
uncertain future.
In her late 30s, Grace got into relationship with another man, Charles*, but she didn’t have any
children with him. Charles had heart problems and was difficult. For instance, he used to
sexually and physically abuse her. Grace admitted to attempting commit suicide several times
due to intolerable abuse from Charles and due to Charles undergoing heart bypass surgery. Later,
Grace and Charles divorced. In her late 30s, she started to work as a cleaner intermittently and,
then, started to work as a volunteer in a hydrotherapy pool and cardiac rehabilitation, which she
enjoys. She reported to love “knitting”.
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Grace moved onto her third male partner, Nicholas*. They have been living together for the past
five to six years. They knew each other for eighteen years. She described him as “supportive and
helpful” and not abusive. However, Nicholas was unemployed.
Grace described her personality as “alright but like a yo-yo” and said that she is always there for
her mother – this was reciprocated. Due to this closeness, she was given power of attorney over
her mother and had to place her mother in a nursing home. She said that she did not receive
much support from her family members. She mentioned ongoing relationship issues, differences
and arguments with her siblings about this. Additionally, she felt distressed and a sense of loss
after one of her bosses at the hydrotherapy and cardiac rehabilitation, with whom she was close
to, died. Grace disclosed that it is her elder sister Miriam encouraged her to seek counseling
before she passed away.
Parenting
Grace is a mother of two children, whom she bore in her first marriage. The firstborn was a boy
named Daniel* and the secondborn was a girl, Kate*. They are now adults and Kate was married
with one child, Milly*, and Daniel* was engaged to get married to Amelia*. Unfortunately,
Grace has no access to her grandchild and she does not have a strong bond with her son and
daughter, as her son is staying a distant place due to his work commitments and as Grace’s has a
strained relationship with her daughter, so does not allow access of Milly.
Forensic History
In 2012, Grace was injured whilst working as a cleaner. She engaged a solicitor to get worker’s
compensation. She has no other forensic history.
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Spiritual Beliefs
Grace denied any unusual beliefs.
Pre-morbid Personality
Grace admitted that she has always been concerned about what other people think of her. She
suffers from poor self-esteem, mainly because of her learning disorder, which has made it
difficult to read and write. She feels intermittently helpless, worthless and hopeless.
Mental Status Examination
Appearance, Behaviour and Activity
Grace was a slightly overweight woman who looked her age. She was wearing a nice dress,
jacket and glasses. There were no concerns regarding her grooming and hygiene. Rapport was
gradually established in the first session. Grace was cooperative and engaged well with direct
eye contact. However, she was tearful for most of the interview and used a lot of tissues. She
frequently took off her glasses to wipe her tears. At one point, she became very angry and
distraught when describing her day. She was shaking and wringing her hands when she was
describing her life story and traumatic past. She struggled to bring out words and complete
sentences when she became anxious. This anxiety was evident a couple of times during the
interview; anxious facial expressions, hands shaking intermittently and hands shaking hands
when trying to pull out tissues from the box. There were no observed gestures, mannerisms, tics
or dyskinesia.
Mood and Affect
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Grace described her mood as predominantly low and anxious. She reported being unsure of what
to do, due to a lot of blame, guilt and hopelessness. She also described feeling “sad and lost” and
“purposeless”. Her affect was predominantly labile in nature, associated with anxiety, depression
and dysphoria. It was congruent with her thought processes and explanations.
Speech and Language
Grace spoke softly. She struggled to speak when severely anxious. Her speech was characterised
by low volume and tone and the rate fluctuated.
Thought Process and Content
Grace’s thoughts appeared logical, linear and in relation to her experiences. There was an
extreme preoccupation with her past traumatic experiences and current problems. For instance,
she said that she trusted her oldest sister more than her partner. She reported feelings of shame,
guilt, loss, hopelessness, helpless and worthless and felt that “things will not get better”. She has
especially blamed herself for not doing enough for her oldest sister and mother. She admitted
that she was missing them. The ANZAC parade, which was about to take place, reminded her of
her oldest sister’s death, due to kidney failure, and she felt guilty for not visiting her grave.
Perception
Grace denied hearing noises or voices and did not note occurrence of other unusual phenomena.
Cognition
Grace was oriented to time, place and person and she was alert and fully conscious. She was
unable to concentrate objectively, and she had difficulties recalling ages and objects. For
instance, she could not remember the ages of her family members and she only recalled two of
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the three objects provided. This would have been contributed by her feeling extremely guilty of
her inability to read or write. She admitted getting lost twice in the past due to anxiety and
unfamiliarity of the locations. However, she was in touch with events happening in the regional
town and Australia in particular.
Insight and Judgment
Grace’s insight was intact, and her judgment was changeable, depending on her mood. She
reported being impulsive sometimes. Although ambivalent and unsure about what to do, she
sought appropriate help from different professionals, including medications and necessary
investigations.
Risk Assessment
The current risk of suicide and homicide is low in Grace’s case. Although she reported past
suicidal thoughts and attempt, she did not report any current suicidal or homicidal ideation, intent
or plan. She also denied any access to firearms or other means. She said, “Although I am feeling
miserable, I want to move forward”.
Physical Examination and Initial Investigations
I did not do a formal physical exam, as her GP was regularly monitoring her physical state. In the
referral, her GP had excluded any acute physical problems and reported recent investigations,
including full blood count, urea and electrolytes, C reactive protein, thyroid function tests, liver
function tests, lipids, glucose and HbA 1c, which were within normal limits.
Initial Psychodynamic Formulation
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Grace is a 60-year-old lady who suffered from the recurrent major depressive disorder, persistent
depressive disorder, somatic symptom disorder and a learning disorder. She suffered from awful
physical and sexual abuse from her father, which led to low self-esteem, feelings of inadequacy
and poor coping skills. In the recent crisis, her depression and anxiety heightened and resulted in
poor functioning and escalated traumatic memories.
After her birth, she was subject to horrible forms of physical and sexual abuse from her father,
and her siblings were also victims of abuse, but she was the one who received the most. Her
mother was helpless, and due to perceived lack of emotional connectedness and maternal
deprivation, an insecure attachment likely resulted – so, there was no availability for a secure
base for her. She was subject to numerous traumatic events during her earlier years. Those
terrible relationships impacted her ability to form close and stable relationships in her early life.
The neglect, lack of help and support from her mother, poor rearing environment and reading
and writing difficulties resulted in her childhood being one of poverty, emotional, physical and
sexual abuse in her home environment. In addition, she became vulnerable to bullying at school.
She did not understand, as a child, how to process her emotions or relationships. She had to
undergo loss of support from her grandparents, due to her father’s decision.
That period of life was formative for her, resulting in vulnerability to rejection and abandonment
and being fearful of beatings. She stayed with distant and emotionally absent parents and
helpless siblings, who did not provide a secure base to experience trust and safety. She was
unable to experience happiness or competence and, consequently, developed poor self-esteem
from a young age. She struggled to effectively learn communication skills from her parents, a
trait which affects her journey even now.
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The abuse suffered from her father and the blame she received from her father placed a deep
sense of guilt and low self-confidence. This likely evoked a sense of helplessness that she
attempted to rectify by working hard and being helpful to everyone. She frequently felt unloved
by her parents and siblings, and this likely developed what Winnicott described as “false self”.
Her “false self” was a “people pleaser” and was very different from her true self – shameful and
needy and, ultimately, she felt very much alone.
She blamed herself for not preventing the deaths of those close to her. She became very close
with one of her older sisters, who was a motherly figure in her life. The death of her older sister
likely caused repressed negative emotions, such as guilt, fear, and abandonment, to resurface.
This would have led to a reenactment of her world as it happened during her earlier years. This
resulted in her depression and pain getting worse, complicated by impaired functioning and
learning difficulties.
Without a secure base as a child, she was unable to develop a stable sense of self, because there
was a lack of a caregiver who could validate her emotions. As an adult, she was attracted
towards unhealthy relationships at several points in her life. Trying to find validation and
through the inability to see that her relationships lacked boundaries led her to be taken advantage
of by her partners. Her marriage to her current partner, however, provided the secure base where
she could try what she wanted to be, but, at times of crises, she would feel inadequate and this
would result in her vulnerabilities surfacing.
We can hypothesise, from an Eriksonian developmental perspective that she struggled to make
sense of life and navigate between polarities of generativity versus stagnation. Moreover, there
was the risk that future psychological crises could reactivate earlier struggles. For example, a
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person being too harsh on her at her workplace or losing someone close to her could cause
repressed emotions to arise and could cause a regression in her personality and functioning.
To achieve integrity, she had to make sense of her losses, fear, guilt and disappointments. For
her, psychotherapy provided a platform to resolve these lifelong conflicts and a chance to
improve her relationships, process emotions and mourn the several losses she had in her life.
Provisional DSM 5 Diagnosis (5)
Major Depressive Disorder 296.32/F33.1
Persistent Depressive Disorder 300.4/F34.1
Somatic Symptom Disorder 300.82/F45.1
Learning Disorder 315.00/F81.0 and 315.00/F81.81
Differential Diagnoses (5)
Generalised Anxiety Disorder 300.02/F41.1
Alcohol Use Disorder 305.00/F10.10
Post-Traumatic Stress Disorder 309.81/F43.10
Borderline Personality Disorder 301.83/F60.3
Avoidant Personality Disorder 301.82/F60.6
Social Anxiety disorder 300.23/F40.10
Panic Disorder 300.01/F60.6
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Agoraphobia 300.22/F40.00
Mild Neurocognitive Disorder 331.83/G31.84
Discussion of diagnosis and differential diagnoses
Grace satisfied the criteria for major depressive disorder, persistent depressive disorder, somatic
symptom disorder and a learning disorder, as described above.
Although she reported intermittent ongoing worry, concentration loss, sleep change and
impairment with functioning, she did not report any restlessness, fatigue, irritability or becoming
tense, which goes against the diagnosis of generalized anxiety disorder.
She reported drinking several glasses of wine on days when she felt overwhelmed. She did not
report any tolerance, salience, withdrawal, impairment due to alcohol or neglect of activities due
to alcohol, which excludes alcohol use disorder.
Although she reported having intermittent nightmares about the abuse by her father in the past,
she did not report having any flashbacks, hypervigilance, avoidance behavior or reliving
experiences, which excludes post-traumatic stress disorder.
She reported feeling emotionally deregulated, sometimes associated with crying, feeling hopeless
about her situation, having intermittent suicidal ideas, a history of past impulsive suicidal
attempts and feeling rejected in her relationships. However, she did not report low frustration
tolerance or self-harming behaviors and the other features that she described were not pervasive,
which excludes borderline personality disorder, even though borderline personality traits appear
to be present.
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Due to her complex circumstances, difficult upbringing and her reading and writing problems,
she had a tendency to become anxious and was avoidant of situations in which she was incapable
of managing the symptom, which excludes anxious avoidant personality disorder.
She described some social anxiety. However, she has continued to work as a volunteer at cardiac
rehabilitation and the hydrotherapy pool section for years, except when she was severely
physically or psychologically unwell, which excludes social anxiety disorder.
She described becoming anxious sometimes, depending on the situation. She did not describe
clear-cut panic attacks arising out of the blue, associated with physical and psychological
changes, which excludes panic disorder.
She reported that sometimes when she was unwell, she was unable to go shopping. She did not
describe any fear of traveling on public transport or being in huge shopping malls, which
excludes agoraphobia.
Although, some short-term memory problems were identified on initial mental state examination,
no further short-term memory problems were identified during the following sessions. No
problems with orientation were identified during any of her sessions. Her reading and writing
problems were from an early age. No marked decline in cognitive functioning and significant
impairment in cognitive performance were noted. She was able to engage, commit and go
through the psychotherapy, which would exclude mild neurocognitive disorder.
Management
 Initial Agreement and Plan
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Grace and I agreed to begin long-term psychotherapy for 40 sessions, with the possibility of
limited extension passed those.
 The decision to Employ Psychotherapy
o Indications
Given her diagnoses of major depressive disorder and persistent depressive disorder associated
with anxiety, long-term problems stemming from attachment difficulties, dealing with chronic
suicidal thoughts and borderline traits and short-term trials of CBT and supportive therapies not
working, she was most suited for the conversational model of psychotherapy, which was also
suggested by Dr. Erickson. Furthermore, her desire to be committed to the psychotherapy was
beneficial.
o Contraindications
In Grace’s case, there were no were major contraindications to psychotherapy. The major
difficulties lay in her level of alcohol consumption. Additionally, Grace had mentioned that she
felt sad, rejected and abandoned after a previous psychotherapy was unilaterally terminated. I
was concerned that she might become dependent on therapy and this may present problems with
termination.
 Consideration of Alternative Treatment Strategies
Pharmacological:
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Previously, Grace had been tried on sertraline, but this had a poor response, and the combination
of duloxetine and quetiapine had limited benefit. But, Dr. Smith continued to explore other
suitable pharmacological options.
Other Psychological Therapies:
The previous trial of cognitive behavior therapy and supportive therapies did not work and it was
unlikely that short-term interpersonal therapy would be enough, given her longstanding problems
with depressive and anxiety symptoms, chronic suicidal thoughts and clear childhood traumatic.
(1)
The final decision was for Grace to undergo long-term psychodynamic therapy. The suicidal
ideation, hopelessness, poor social skills, poor coping skills, depression and anxiety were as a
result of trauma in Grace’s life because of attachment problems. Therefore, the most suitable
option was therapy, based on the attachment-oriented framework. The therapist would act as a
“secure base”, enabling Grace to reflect on her personal experiences.
We picked a conversational model because it has evidence for the treatment of chronic suicidal
thoughts and depressive symptoms. (4, 6, 10, 11). Furthermore, this model has less focus on
insight than traditional psychodynamic therapy, which may have been difficult for someone who
is functionally illiterate. Finally, Dr. Erikson had a lot of experience treating patients with
chronic suicidal ideation using the conversational model.
Goals of Psychotherapy
Grace wanted to achieve the following goals:
a) “Get rid of" anxiety and depression;
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b) Establish more "confidence” in herself;
c) Gain help to manage her experience of her childhood trauma; and
d) Strengthen her social relationships and gain a job.
My goals were to learn how to put the theory of psychotherapy in practice and help Grace
improve her life.
Treatment Contract
Grace was aware that I was a psychiatry trainee and that I had to undertake a long-term therapy
case to qualify in my course. After the initial assessment with the help of Dr. Erickson and our
first session, Grace and I agreed on the following:
a) Grace would continue with the Conversational Model of Psychotherapy (CM) through
weekly 50-minute sessions. The sessions would be audiotaped and forwarded to Dr.
Erickson via Dropbox for supervision purposes.
b) No fee would be charged.
c) I would be supervised by Dr. Erickson on a weekly basis via video-conference sessions.
d) All the information discussed during the therapy would remain confidential with usual
exceptions – an immediate threat to Grace or others or a court subpoena.
e) I would write and submit a deidentified case report to the RANZCP College.
f) Dr. Smith would continue to monitor Grace’s physical and mental health issues. He
would also prescribe medications if need be and monitor their side effects.
g) To develop a crisis plan, Grace was to seek help in the event of a future crisis, such as an
increase in suicidal urges. If more urgent, she was to call 000 or present herself to the ED.
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She could call the community mental health centre and leave a message for me and I
would return the message within 24 hours. Alternatively, she could call Lifeline or
Beyond Blue if she needed to talk to someone outside the business hours. If a crisis could
not be contained by the above measures and psychotherapy with me, then I would
organise a review by the Community Mental Health Team Psychiatrist Dr. Will*. I
discussed this possibility with Dr. Will prior to starting therapy.
h) We discussed ways to reduce her alcohol intake and spend more time with her partner
and close friends.
 Liaison with other Professionals
Dr. Smith as Grace’s GP continued to frequently review her, while Ms. Robinson* remained her
case manager. We liaised together every month to assess her progress and for each of us to
contribute ideas that could be implemented to help Grace. However, our meetings had to be
rescheduled several times because Dr. Smith had other work commitments.
 Supervision
Besides my scheduled supervision, I was free to consult Dr Erickson in case of questions,
difficulties or doubts via telephone calls. He provided relevant references to help me understand
and implement various aspects of therapy.
Progress in Psychotherapy
 The Initial Phase (1-10)
In the first four sessions of psychotherapy, Grace talked about her personal history. She talked
about her parents, siblings, marital life, life at school and her relationship with parents and
siblings. She was hesitant at first, but she became more open after I assured her that the
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information shared between us was confidential and I prioritised building rapport in these early
sessions. The sessions with Grace became very emotional. She used to cry each time she
remembered or talked about disturbing occurrences in her life. She was very anxious as she
narrated about her father’s sexual and physical abuse. It was difficult to hear what she was
saying when she became anxious due to lack of audibility. I had to patiently help her calm down.
Trauma was present at each stage of her life and it took courage for her to talk about what she
had gone through as a child and during adulthood.
Usually, Grace had difficulty keeping time during psychotherapy sessions. Most of the time she
showed up ten or fifteen minutes late. Later, as the therapy progressed, I learned that that Grace
suffered from insomnia and it was difficult to organise her day if she failed to get enough sleep.
However, I was late by ten minutes due to unavoidable circumstances and Grace could not
contain her anger. She yelled at the secretary and caused a commotion in the office until I
arrived. Anger was also evident during the therapy sessions, especially when she had to talk
about inconveniences and difficulties in her daily life. It was evident that Grace was letting out
all the anger she had accumulated over years but had no idea where it came from. We explored
these occurrences of anger and Grace explained that she had bottled up a lot of it since childhood
because she could not express herself to her abusive father. Each time she tried to stand up for
herself, her father punished her more, claiming that she was disrespectful. As an adult, she was
aware that she needed to learn ways of expressing her anger in different settings in a safe
manner, but, up until this time, she had not realised how her early experiences had generated
such hostility. We talked about the essence of speaking about one’s mind, feelings and even
dissatisfaction. However, I explained the essence of anger management by expressing one's
disagreement and dissatisfactions in a respectful manner.
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One of the main problems that affected Grace was the negative emotions and the pessimism that
she had towards life. (2) The constant abuse that she got from her father and marriage partners
had lowered her self-esteem and she felt “worthless”. Additionally, she reported feeling guilty,
purposeless, sad and ashamed. Lack of a stable family background also denied her the
opportunity to get a good education. It was evident that Grace was stuck in her past, which was
tragic. As a result, she suffered from depression and anxiety that made it impossible to handle the
challenges that she was currently experiencing in her life. In addition, one characteristic that was
apparent about Grace was her inability to defend herself. She blamed herself for all the negative
things that happened in her life. For instance, she criticised herself when her husband blamed her
for their divorce. She also fought with her colleagues and siblings. Grace interpreted an
interpersonal conflict with colleagues or people in her life as lack of support. (3)
For the first ten sessions, the discussed themes revolved around her emotional pain. She hardly
ever mentioned anything that was fine in her life. The one image that made her terrified is the
memory of her father abusing her sexually and physically. She was still experiencing intermittent
nightmares about her father and how he would beat her and her siblings. Grace also had a strong
connection with her mother. However, the fact that she was in a nursing home, getting weaker
each day, which made her feel down. Watching her mother being sick reminded Grace of how
her mother and Grace were helpless when Grace was a child. Her father disrespected her mother
by calling her names and beating her up. At one time, she had to be hospitalised due to the
beating. Grace’s described one incident when her father refused to give her mother food or
money to buy food for the children. They had to starve on that day because there was nothing she
could do. The guilt that Grace felt was furthered because Grace blamed herself for not doing
enough for her mother.
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Coming to terms with Grace’s trauma was difficult for me and it was probably because of my
inexperience in psychodynamic psychotherapy at the time. I felt that Grace had undergone too
many tragic events at each point in her life. I had a tough time comprehending what it was like to
be abused from childhood up to adulthood and, sometimes, felt overwhelmed.
In the subsequent supervision, Dr. Erickson helped me make the connection between the sexual
abuse by her father and her partner. Grace mentioned that she was not interested in sex and she
had always been ignorant of sex. The lack of interest was due to the sexual abuse that she
suffered from childhood. Therefore, sexual intercourse reminded her of pain, shame and
discomfort. Her disinterest in sex may be have contributed to her husband’s sexual violence.
In the next three sessions, we explored the person that Grace wanted to be, by contrasting it
against her current image. It included the positive aspects, such as caring for her mother, the love
she felt towards her partner, the effort she was making as a volunteer and her love for knitting.
At that point, Grace smiled because she began seeing the positive contribution she was making in
her life. She saw that there are people in her life who needed her, such as her mother and her
partner. So, the main task of our work was to help Grace deal with painful emotions from
multiple traumatic experiences.
Accessing and identifying Grace’s emotions
Since childhood, Grace has always been subjected to pain. She was abused at home and school.
It was very disturbing to watch her siblings and her mother being abused. Dr. Erickson, during
one of the weekly supervisions, made it clear that it was important to help Grace to stay with and
explore these painful emotions. (2, 7)
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One thing that paralyses Grace was pessimism. She had a constant feeling that things would not
get better. Her view towards life concentrated on what was wrong and painful. For instance,
Grace said, on multiple occasions, that she will not get a job because of her inability to read and
write, as well as her back pain. Lack of employment meant that she would continue struggling
financially because her partner was also unemployed. The pessimism elicited hopelessness,
which paralysed her life by causing fights between her and her partner. She also avoided social
functions because she wanted to stay by herself, mostly in bed.
Dr. Erickson pointed out a major defect in my approach towards psychotherapy: I was focusing
on helping Grace overcome her trauma and stabilise her life by changing external things, which
became a struggle between us. However, my objective could not be attained without giving her
enough time to express her emotions and process relationship difficulties, in the context of a
conversational model of psychotherapy. (10, 11) Grace, as a person who has experienced trauma
throughout her life, required a chance to express all her emotions. I heeded his advice and our
sessions became easier.
 The Middle Phase (Sessions 10-30)
At different times in the therapy, Grace experienced crises. Some occurred when she experienced
an event that reminded her of past trauma. In other instances, a crisis took place when she
suffered from severe loss. However, there is one crisis that stood out compared to all the others:
as she was leaving a grocery store, an accident involving a motorbike occurred in front of her.
The driver of the motorcycle died on the spot. Grace reported feeling terrified and anxious. She
had to be helped to get home by a stranger, who saw her stranded and asked whether she needed
help. Grace stayed in her bedroom for the better part of the day and could not sleep despite being
tired. She also had to suspend all the activities that she had planned for that day, such as visiting
29

her mother at the nursing home. She said that she was eagerly waiting for our sessions the next
day because the accident took place on Monday.
During our session on the next day, Grace described the previous day as awful. I asked Grace to
explain. She immediately became anxious and I couldn’t figure out what she was trying to say
because her speech was unclear. After calming down, she said that the accident reminded her of
the day she tried to commit suicide by walking in front of a truck. Seeing the accident take place
reminded her of the dreadful feeling that she was experiencing at that time, such as anger and
hopelessness. It also elicited the guilt and shame for having attempted commit suicide. She said
it was unfortunate that the accident had to occur at a time she was determined to rebuild her life.
A close observation of Grace revealed anxiety and guilt. Her hands were trembling as she tried to
use gestures to explain herself. Grace said, “Oh God, I hope I never find myself in such a state
again”. It was evident that she pitied the person she was back then. We tried to contain Grace’s
anxiety and fear during the sessions. I was able to help her to work through the past trauma with
compassion, rather than burying it, as she had done in the past five years. By the end of the
session, she was feeling a little better. (7)
Countertransference, Projective Identification: Containing the anxiety, grief and fear
Grace had bestowed a lot of trust on me by this point in the therapy. She freely talked about her
worries, feelings and intentions. To some extent, I didn’t feel adequate to help her get rid of the
trauma and the crisis she was undergoing. I had difficulty relating to her pain and experiences: I
could not ignore the fact that she was anxious, sad and depressed back then. I was concerned
because Grace had never been able to disclose any of her past traumatic histories to anyone
before, and she trusted me to help her with this.
30

I notified Dr. Erickson about feeling inadequate during the next weekly supervision and his
explanation took an interesting turn. He said that it was possible that Grace’s emotions were
projected on to me and I had unconsciously identified with her feelings of inadequacy. I was
startled by this identification because I had not gone through such intense emotions before.
However, I learned that projection does not necessarily reflect what has happened to me and I
began making sense of what Dr. Erickson said. Previously, I had worked with patients with
trauma, but none had affected me like Grace. Understanding the concept of projective
identification and how it played out on Grace was an important lesson. (6, 7, 9, 10, 11)
I had watched Grace stabilise in the previous weeks. She was more positive and showed the
enthusiasm to move on with her life. However, seeing her breakdown caused me distress. I felt
the need to help her get out of her distress. I constantly tried to offer comfort and reassure her
whenever she began crying. However, Dr. Erickson helped me realise that my role was to
continue providing a safe therapeutic relationship, and this would be all that would be needed for
Grace to overcome distress. (12) Additionally, I had to trust her to work through her emotions as
I had seen her do in the previous weeks. At this point, I struggled with feeling helpless as I
thought that I could not shield Grace from her difficulties. I knew that she was fragile and
anything that reminded her of past trauma would definitely lead to a crisis. The awareness of
projective identification and my countertransference were essential because it helped me to
contain Grace’s emotions and not rush to reassure or redirect her away from those feelings. (10,
11)
Imagery
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Grace had difficulties understanding some of the psychological terms and concepts. At first, I
used to have a difficult time trying to explain the psychological terms and I had to explain one
concept about three times. However, I learned that we communicated better by using imagery. I
identified this method because Grace frequently used imagery when describing how she felt or
how an event took place. For example, she was able to visually recall the torment she went
through when she was a child when her dad used to beat her and sexually invade her in the
bathroom. Since then, I would offer imagery to demonstrate what I was saying.
Absence: Rupture and Repair
On the 30th week, I had to leave for a short time. By this time, Grace had begun reconstructing
her life. Grace also had a job and she reported that her employer had been good to her.
Additionally, her reactions to the events in her life were more stable. For instance, she didn’t
experience any form of crisis during her sister’s funeral, which had taken place within the
therapy period. There were still conflicts in her life, especially with family. However, she was
able to handle these problems without being reactive, even though that was the case before. The
relationship with her partner was much better. Her social life had also improved, since she
reached out to her children, sisters and grandchildren. In fact, Grace informed me that she was
making plans for Christmas with her family during our last session. When I had to leave, I
personally called her because I didn’t want another person to inform her on my behalf. At the
time, Grace sounded fine and she even wished me well.
As soon as I came back, I was shocked to hear that Grace became sick the day after I informed
her about my sudden leave. She had diarrhea and nausea. She was also anxious because her
mother was getting worse. Her anxiety revolved around her mother’s health deterioration. Grace
32

was anxious and stressed to the extent that she was unable to work because she could not
concentrate. Her mothers’ deterioration had brought back the awful memories of her father’s
beating her and the sense of powerlessness as a child.
In our next session, I tried to find out what Grace was feeling. She didn’t look too happy to see
me, even though she had asked to see me because she was having a difficult time. Further
discussion revealed that Grace was feeling guilty. She felt that she had grown dependent on the
therapy. Grace had reported feeling rejected by a previous psychologist when their therapy
sessions ended. These feelings of abandonment and rejection had been elicited when I was on
leave. (9) She said that she had no control over what she felt but she was deeply affected. Later,
in the session, I explained that experiencing rejection and being able to talk about it is a step
towards healing. The aim was to show Grace that expressing how she felt was appropriate
because it gave us an opportunity to repair things. Grace seemed to agree with me towards the
end of the session.
Grace was in a jovial mood during the next session. She mentioned that she had been reflecting
on the concept of rupture and repair throughout the week. It had dawned on her that she had
adopted a “rupture and avoid” approach rather than a “rupture and repair” approach throughout
her life. (12, 13) The approach had hurt her immensely because she accumulated painful
emotions instead of mending them. She feels that the approach of “rupture and avoid” had played
a huge role in destroying her relationships with friends, friends and even simple social
interactions. For instance, each time that she was criticised, she responded by avoiding that
person or group. As a result, she ended up without an effective social life. I was impressed when
Grace told me that she had started applying the principle of rupture and repair in her life. For
33

example, she apologised to her partner when she realised she was wrong, instead of avoiding
him. At one point, he hugged her just for saying sorry because he had never heard her say that.
I didn’t lay much emphasis on the importance of repairing ruptured relationships. However,
listening to Grace made me realise how essential the concept was. Grace needed to move on with
her life and that meant repairing past relationships and building new ones and keeping them.
Grace was keen to put this into action. At this point, the therapy seemed to be helping because
Grace was improving.
 The Final Phase (Sessions 30-40)
In the final sessions, Grace’s life continued to improve. Her relationship with her partner had
improved significantly. She was more comfortable with meeting her friends. Grace also tried to
reach out to her family, including her children and siblings. She was making more contact with
her adult son and his fiancée and was having meaningful conversations with them, as well as
going out with them on outings when they were in town. One of the significant steps is that
Grace also got a part-time job to work at a motel.
The therapy had shifted from discussing Grace’s misery and past trauma. At this point, her
anxiety and fear revolved around the challenges she faced while trying to get out of her comfort
zone and change her life. I could also see her determination to solve the problems from the past,
especially with her siblings and children.
Empathy
During our therapy, I began to have high expectations for Grace because she had already shown
impressive progressive. It was like I expected her life to fall back into perfection. However, there
were days when Grace broke down because she had recalled her father’s beatings. Towards our
34

final sessions, Grace would lament about the abuse. However, I felt like we had dealt with the
issue so many times that she should be over it.
In the next supervision, Dr. Erickson was trying to help me understand that psychotherapy is not
necessarily a linear process of improvement (meaning there are often temporary setbacks) and
that not everything will be necessarily be resolved in 40 sessions. He also pointed out that I
should avoid having unrealistic expectations for Grace. Tinsley (1994) also pointed out that a
therapist can develop unrealistic expectations towards their patients. However, I learned to
contain my emotions, to avoid getting in the way of Grace’s recovery. I also wondered about the
effect of countertransference of her disappointment, where I had absorbed her disappointment
unconsciously.
 Termination: The inevitability of loss
My sessions with Grace were nearly coming to an end and I had the responsibility of reminding
her of this. Her mood suddenly changed, and she responded by saying that she didn’t feel ready.
She needed more time and said that I was unfair and that I was about to abandon her just as she
was starting to get better. I can still recall her expression, “Why would you build me and then
leave to me to fall apart?” However, I reminded her that she and I would come up with a plan
and she was calm.
In the subsequent sessions, we discussed the inevitability of loss and the essence of a good bond.
I made it clear that her recovery depended not only on therapy but also investing in other
relationships. Her work and relationship with colleagues had also become a source of fulfillment.
Grace began to see that progress depended on her ability to shift her attention from the therapy
and, then, focus on the important relationships in her life.
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In the next sessions, we reviewed the milestones that we had achieved during the therapy. I
wanted Grace to see the progress that she had made. It took some effort to instill confidence in
herself as a person, instead of relying on the therapy. The reflection, therefore, was an attempt to
change her attitude, as she thought she couldn’t do this without the therapy sessions. Grace was
amazed to see the immense change in her life within the 40 sessions. She was grateful that I had
seen her through such a tough time in her life. It was decided to give her some extra sessions,
with a view to help her to overcome dependence with therapy and with a view to create a gradual
cessation of therapy, as she had experienced feelings of rejection and abandonment in the past.
Moreover, it was decided to increase her independent behavior and use what she had learned in
therapy to overcome dependence with therapy. In addition, given her experience in the past of
the feelings of rejection and abandonment, her current preferences and my commitments were
considered and a plan was formulated – sessions were continued with a view to gradually
tapering them down and cease the therapy in six months.
Reformulation
Grace came to therapy with primary complaints of feeling anxious, hopeless and depressed, in
the setting of awful physical and sexual abuse from her father, which was further enhanced by
poor self-esteem, feelings of inadequacy, negative emotions, pessimism, internalising anger,
interpreting interpersonal relationships as lack of support and guilt feelings for not looking after
her mother: this was complicated by decreased functioning and reactivation of traumatic memory
systems at times of crises.
Grace’s family included a history of poor attachments, drug abuse, alcohol abuse in father and
the inability to regulate emotions and intergenerational developmental trauma, which led to an
36

early childhood environment manifested by neglect, lack of help and support from her mother,
reading and writing difficulties and poverty, where her needs were not met and she had problems
understanding how to process her emotions: this was complicated by distance from her
grandparents, which was created by her father and an inability to work through trauma.
Most importantly, this resulted in vulnerability to rejection and abandonment, no creation of a
secure base and poor self-esteem and she continued to struggle with communicating effectively
with significant others. The abuse she suffered from her father resulted in a deep sense of guilt
and low self-confidence, and, so, developed “false self”. She became a “people pleaser”, rather
than feeling shameful and needy and eventually felt “alone”.
Given her traumatic experiences, the death of people close to her triggered further abandonment
and guilt: and, notably, the death of her older sister caused repressed negative emotions, such as
guilt, fear and abandonment to resurface. She was unable to develop a stable sense of self
without a “secure base” or validate her emotions and she made herself vulnerable to be drawn
towards unhealthy relationships and to being taken advantage by her previous partners.
Furthermore, complicated by unbearable guilt and shame, she has tried to commit suicide a few
times in the past.
She was stuck in Erikson’s developmental stage of generativity versus stagnation associated with
the struggle to make sense of life and navigate through various situations, which was further
complicated by deterioration in her personality and functioning.
The conversational model of psychotherapy gave the platform to Grace to resolve these lifelong
and distressing conflicts. Furthermore, it gave her the opportunity of to improve her
37

relationships, process emotions naturally and grieve and mourn the several losses she had in her
life.
Grace continues to be in a stable relationship with her current partner; she appears to be more
confident in resolving any arising interpersonal difficulties; she is gradually gaining a better
understanding of herself and she has started to engage in quality alone time; she has gained better
control in regards to alcohol and, now, only drinks on social occasions; and she is working to
improve relationships with her family. She continues to enjoy her volunteer work. She has
become proactive and has developed the capacity to escalate a situation where someone has been
harsh to her. She has started to process her emotions in a meaningful way, by identifying the
links between the traumatic past and the present and between her pain and her emotions. She
continues to regularly follow up with her GP and take care of her physical health whilst
maintaining good sleep hygiene.
Discussion and Final Reflections
Working with Grace on such a close basis over a year was a personally rewarding experience.
Supervision helped me enormously. Dr. Erickson helped me to understand the effect of sexual
abuse from her father and her previous partners on Grace. Grace projecting inadequate feelings
on to me was difficult and Dr. Erickson made me understand the important concepts of
projective identification and countertransference. I also learned from Dr. Erickson that giving
Grace the time to process her emotions and process her relationships was essential. Containing
her emotions, by not rushing to reassure or redirect her away from them and not having
unrealistic expectations for her, helped me enhance my understanding and confidence during the
course of a conversational model of psychotherapy. I understand psychodynamic therapy is a
38

platform for a patient to explore their emotions with the intent of finding a meaningful and
fulfilling life. (1, 2) Also, my confidence, in terms of applying underlying principles of a
conversational model of psychotherapy, increased.
I learned the importance of finding a suitable patient with the help of Dr. Erickson, who is
willing to commit to the long-term therapy. In addition, I learned about containing her anxiety,
grief and fear by having conversations with her and by predominantly listening to her with a
view to allow her to process emotions and traumatic memory systems in a secure and safe space,
whilst being empathic throughout the therapy. Furthermore, I learned about the benefits of
rupture and repair, in comparison to rupture and avoid, both in the recovery process and in
therapy.
As for Grace, a bond was created between us in a safe, therapeutic environment, which led to
togetherness and created a “secure base” for Grace to express her emotions and overcome
unconscious conflicts. She was more organised to deal with day-to-day activities and
demonstrated better coping mechanisms with various situations. She was better able to process
her trauma and was identified less with negative emotions. She was more assertive in her
approach and interactions with her family. She was able to find more meaning and purpose in her
life, with her gradually increasing the ability to identify the links between a traumatic past and
her current present, with a view to resolve unconscious conflicts. Creating awareness about the
past and the present is the underlying principle in psychodynamic therapy and a crucial step
towards recovery. (3) She had a better sense of self.
Eventually, the appropriateness of using the conversational model of psychotherapy will become
more apparent, which will be further demonstrated by Grace. All in all, the process appears to
39

have been a mutually helpful one and I feel grateful for the opportunity, which has already had a
huge impact on my day-to-day clinical practice and encounters.
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