Read the case material below. Then:
A) describe how you would conceptualize the case using psychoanalytic theory. Consider various psychoanalytic perspectives (drive, object relations, self psychology, interpersonal psychoanalysis, relational psychoanalysis etc.) in your formulation.
B) Describe the client’s presenting concerns and central themes as well as sociocultural issues that provide insight regarding her subjective experience of her symptom presentation.
C) Be sure to note the major goals of psychotherapy, transference and counter-transference issues, and the nature of the therapeutic relationship.
D) Describe how earlier life experiences may be impacting current emotional and relational functioning.
Case material:
Justina is a 32yo Puerto Rican cisgender woman presenting with depression who sought therapy to help her with symptoms of depression and anxiety. She recently took a leave of absence from her long-time position as a nurse due to the frequency of her panic attacks. She feels depressed, wakes up early in the morning (4-5am), and has little energy for work and family obligations. She reluctantly shared that one way she copes with her emotional difficulties is through eating and feels great shame that she has gained over 12 pounds in the past year. Moreover, she feels significant guilt about not fulfilling her family obligations. Most recently, her younger brother who had been living with her decided to move back to Puerto Rico. From her perspective, his decision to move back home represented her failure to resolve a dispute between him and her husband.
Justina was born and raised in Puerto Rico. She is the eldest child and has a younger sister and two younger brothers all who live in Puerto Rico. She describes her relationship with her mother as very close and idealizes her stating that she is “the perfect mother and wife”. She shares that her mother is nurturing, generous and “always there for the family” but sometimes to the detriment of her own personal needs. For example, she worries that her mother keeps putting off seeing a doctor despite some recent complaints about chronic pain because she wants to be available in case she is needed to provide childcare for her grandchildren. She describes her relationship with her father as similarly close. She notes that her father is a hard-worker and is impressed by his ability to provide for their family despite chronic instability to the Puerto Rican economy. As a young adult Justina boarded at her college institution in Puerto Rico while she earned a nursing degree. Her family expressed a lot of pride in her educational achievement and ability to live on her own. At the age of 20 she married a widower with a 12 yo son who was 10 years her senior. Following the wedding she moved to the mainland of the United States with her new family. She has tried to visit her family-of-origin once a year. While Justina is a U.S. citizen, she strongly identifies as Puerto Rican and adheres to the cultural values (respeto, familism, Marianismo, spiritualism via the Catholic faith) central to her ethnic culture. She is fluent in Spanish and English and speaks both languages at home with her husband and children.
She describes her family life in the Northeast of the U.S. as generally positive. However, the family has endured several medical crises that have left her feeling vulnerable to anxiety at certain times of the year (July through November) when one or another of her family has been ill or seriously injured. In recent years, it has been increasingly difficult for her to live so far away from her parents as she worries about their health and ability to financially take care of themselves.
Justina is beginning therapy with some ambivalence. She is at a loss for how to reduce her depression and anxiety and feels like she needs help. However, she says that she is nervous about therapy and scheduled this initial appointment with you only at the recommendation of her family physician who has seen her family through many medical crises in the past. She trusts, respects and to some extent idealizes her PCP. In this initial appointment she is extending that trust to you, stating, “If Dr. Jones says you can help then I can at least give you a try. He’s the best and I’m sure he would only recommend me to someone who is just as good”. When you ask about her presenting concerns, she says that she has become increasingly worried and even depressed. She believes that this is an important time for her to make changes to her life to improve her mood.
Four months into the work, Justina reacted in one session, when she felt that you didn’t understand her point of view. She began to feel irritated with you, and questioned whether therapy could truly help her. In this session she was sharing more about the decision to move to the Northeast part of the U.S. shortly after she got married. She said that the initial decision was made by her husband in part due to the cultural prescriiption that the husband be the primary decision-maker in the household. She remembered that he had inquired whether she supported the decision but she was very clear that this query seemed pro forma and that to disagree would be a violation of cultural gender role expectations and considered disrespectful. However, she married at a time in her life when she was independent, making her own decisions and supporting herself. She wonders if part of her current unhappiness is related to not fulfilling her own expectations for who she is as a woman, wife, mother and professional. You ask if she wishes she had taken a different approach to her husband’s initial question about her support of the move. When asked this question, Justina felt annoyed and wondered if you were criticizing her for moving away from her family. You try to understand how Justina experienced your query and aspects of your and her subjectivity that may have contributed to this misattunement. Justina explains that she doesn’t want to disappoint her husband or children by saying she is unhappy but feels confused about how to meet her own needs. She says that your question feels both like a challenge as well as an invitation to put herself first. She feels conflicted.
