Psychological Methods Case History: Grace Willa - RANZCP Submission

This comprehensive case history details the psychotherapy of Grace Willa, a 60-year-old woman with a long history of depression, anxiety, and personality traits. The case study, submitted under RANZCP guidelines, outlines Grace's referral, presenting complaints, extensive past history, medical background, and mental status examination. It explores her initial psychodynamic formulation, provisional DSM-5 diagnosis, differential diagnoses, and the management strategies employed, including the initial agreement, goals of psychotherapy, and treatment contract. The report further details the progress of the psychotherapy across initial, middle, and final phases, including termination and reformulation. The case highlights the conversational model of psychotherapy informed by psychodynamic principles, addressing interpersonal issues, social stressors, and a history of trauma. The case is de-identified in accordance with RANZCP requirements, emphasizing confidentiality and providing a detailed analysis of the patient's treatment journey.

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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