Introduction
Long-term psychotherapy is generally a type of psychotherapy that goes beyond the traditional time parameters allocated for the nursing of numerous psychological illnesses. In this case, Thelma is the client and was recommended for long-term psychotherapy by her caseworker. For long-term psychotherapy, there is no definite time frame allocated for the treatment. Studies show that, in most cases, individuals suffering from psychological distress often recover when nursed through short-term psychotherapy (Teyber & McClure, 2017). Nevertheless, Thelma suffers from a more debilitating or complex psychological disorder, which requires long-term psychotherapy. According to research, this form of therapy takes at least one year to treat (Wright et al., 2017). Generally, the long-term psychotherapy process usually involves both inpatient and outpatient treatment. In this instance, the psychotherapy process mostly employed outpatient treatment. The paper will study Thelma’s case, identify her diagnosis, describe how her relationship with her relatives affected her behavior, and provide recommendations for the future.
Assessment
Description of the Professional Setting
In Thelma’s case, the counseling process involved two professional settings. The first setting is referred to as the private practice, which was based on counseling sessions with the client. The second session was community-based and entailed including the family members to establish the cause of Thelma’s condition. To examine the client’s disorder, the first step is to define Thelma’s background. The client, in this case, is a woman aged 48, and she originates from a mixed race. Thelma’s mother was African American, and her father was Hispanic, thereby making her both Hispanic and African American. Thelma never knew her father; however, she had a stepfather who was an alcoholic. Additionally, Thelma had an identical twin sister, two brothers, and an older sister. According to Thelma, she was certain that her stepfather sexually abused her when she was young. Despite these claims, she was unable to recall her encounters with her stepfather because she was too young.
Children experience memory loss when they reach a particular age, and that might explain why Thelma was not able to remember being sexually molested by her father. According to Goodman et al. (2003), children usually experience what is known as childhood amnesia, and this generally occurs when they reach the age of 7 years. However, she remembers that her stepfather frequently abused her emotionally. The reason for this may be because she was already old enough to remember what was happening in her surroundings. Furthermore, Thelma could remember being sexually abused by her brothers. She further believed that her brothers abused her twin sister and could not tell anyone. Thelma believed this occurred to her sister because she described having experienced sexually abusive behavior from both her brothers. Furthermore, when she reported this sexual abuse to her mother, she could not protect her. Thelma reported that her brothers were generally treated better than everyone else.
To ensure that Thelma did everything the mother and the twin sister wanted, they took advantage of her need for closure. As a result, they usually manipulated her into giving them financial support. For instance, the twin sister was a drug addict who could not support her habits. As a result, she manipulated Thelma into providing her with money to buy drugs in exchange for her lover and care. Similarly, the mother utilized this tactic to ensure that Thelma provided her with money. Consequently, Thelma had difficulties developing relationships outside her family, particularly between her mother and her twin sister. Mostly, she stayed indoors, which made it challenging to establish new relationships.
Thelma found it difficult to identify her sexual orientation because she was sexually abused by both her brothers and stepfather. According to epidemiological research, there is a close link between sexual and physical abuse at a young age and sexual orientation (Gaesser & Karan, 2017). It is because of this reason that Thelma found it challenging to identify sexual orientation. Consequently, she dressed androgynously, kept her hair short, and had no sexual desires. Additionally, the fact that she did not have her mother’s support contributed to her confusion regarding her sexual orientation. She lacked self-confidence and, therefore, was unable to talk about her gender identity. Furthermore, besides her choice of dressing, she was unable to apply makeup because of how she felt about her gender identity.
In terms of family composition, Thelma’s family had different types of people. To begin with, Thelma’s father was not available, and it is recorded that she never met him. However, Thelma had a stepfather, and according to her narration, she was not a father figure. She believes that the stepfather molested her while she was young. Nevertheless, she could not remember anything about her molestation, but she could remember that the stepfather was emotionally abusive. In addition to this, Thelma had two brothers who she recalls sexually abusing her. Furthermore, after her twin sister described her relationship with the two brothers, she deduces that her twin was sexually molested by her two brothers. Thelma’s mother adores the brothers compared to Thelma and her sisters. As a result, when Thelma reports incidents of sexual abuse from the brothers, the mother blames Thelma for their actions. In the end, due to their guilt, Thelma’s eldest brother and sister separate from the family.
As a person originating from mixed ethnicity, specifically from an African American and Hispanic ethnicity, Thelma’s condition may be exacerbated. Thelma originates from communities that are classified as minorities, and these often experience depression or mental illnesses differently. Studies state that mental health illnesses among Hispanic and African American communities are frequently stigmatized, and as a result, these individuals suffer for a long time (Holden et al., 2017). In Thelma’s case, this could explain why she has been treating her condition for 18 years. Despite being a patient and having her own caseworker, Thelma was unable to associate with different people. In most cases, this means that Thelma was silent about her condition, and only a few people knew about it. Studies state that this type of silence contains a type of experience that may result in mental health disorders, including trauma, depression, and antisocial behavior. Furthermore, individuals from mixed racial ethnicities face unique systemic and institutional barriers that may negatively affect their access to mental health services.
How Membership in an Oppressed Group Might Contribute to or Exacerbate the Problem
In Thelma’s situation, she was experiencing mental health issues common to the Hispanic community. One of the characteristics she went through involved long-term treatment. In her case, she was recommended for long-term psychotherapy, which is a common treatment among her community. Additionally, she was silent about her condition, which was a contributing factor to mental disorders among the Latino community. The primary reason she was quiet about her condition was that she desperately needed her mother’s and twin sister’s affection. Her twin sister and mother knew that she craved their love and used it against her. They never considered what effect their action could do on Thelma. Despite all this, Thelma had a stable income, which she used to support herself and her family.
Family Issues and/or Stressful/Traumatic/Developmental Experiences Have Contributed to the Client’s Current Problem
One of the traumatic experiences that contributed to Thelma’s situation was the lack of a father figure. According to research, children who grow up without a father figure are more likely to be depressed compared to those who grow up with father figures (Otte et al., 2016). Additionally, children who suffer from sexual abuse from their caregivers generally have gender identity issues and lack self-esteem (Davenport, 2016). In Thelma’s case, she did not know her father, and she suspected that her stepfather sexually abused her. The other factor that contributed to her mental state was the relationship between her twin sister and the mother. Research states that manipulative behaviors from close relatives negatively impact the development of a child, especially when it comes to forming external relationships (Dir et al., 2013). For instance, Thelma was unable to form outside relationships and was mostly indoors. The reason was that she did not trust anyone because her closest relatives, the mother and the twin sister, manipulated her when they needed financial support.
Psychiatric Diagnosis According to DSM-5
According to the fifth edition of the Diagnostic and Statistical Manual (DSM-5) of Mental Disorders, Ms. Thelma meets the criteria for major depressive disorder (Roehr, 2013). The reason for this is because the client experiences persistent feelings of hopelessness, sadness and has no interest in a lot of activities. According to the DSM-5 criterion, a person must experience at least five signs within a period of two weeks (Hasin et al., 2018). In addition to this, among the five symptoms, at least one must be loss of pleasure or interest or depressed mood. Other symptoms include weight gain or loss due to increased appetite. According to the case study, Thelma used engaged herself in binge eating. Furthermore, reduced physical movements and when an individual experiences slow thinking are other symptoms of major depressive disorder. Fatigue and inappropriate guilt or feelings of worthlessness also demonstrate that an individual may be suffering from a major depressive disorder.
Thelma’s Strengths
Despite suffering from a mental disorder, Thelma had some positive attributes (strengths). In a family that seemed dysfunctional, she was the common factor that united a part of their family. One of the strengths she had is that she cared for her sister. She stated that her sister described being molested by her two brothers. For this reason, her twin sister was engaged in drug abuse and had little money to support her habit. Despite Thelma feeling manipulated by her sister, she still provided financial support to her twin sister. Similarly, her mother manipulated her into giving her money, which she provided. The other strength that Thelma had was the courage to enroll herself in therapy. The first step to recovery is accepting that an individual has a problem. As a result, Thelma went into psychotherapy treatment, and despite the process taking a long time, it helped her address her disorder.
Thelma’s Treatment Goals
To ensure that a psychotherapy session is successful, a client must have specific and measurable goals. In this case, the client’s goal involves improving social or family relationships. Thelma’s family was one of the contributing factors to her mental disorder. Ensuring that the family members are supportive and provide everything that Thelma needs in her psychotherapy treatment would help improve her situation. A psychotherapist would know whether the client’s goal has been achieved by observing the relationship between Thelma and her family members. The other treatment goal for Thelma involves increasing positive health behaviors after her psychotherapy. One of the unhealthy behaviors that Thelma had was binge eating. Through psychotherapy, Thelma could learn ways to avoid distractive search habits. A psychotherapist could identify whether the session provided positive outcomes when Thelma stops binge eating.
Interpersonal Interaction
Successful therapy sessions depend on an individual being honest when sharing their behavior and experiences. Through such elements as the client’s body language and their interaction with the therapist, a specialist can identify how the client relates with other people. In this situation, Thelma was not reluctant when it came to seeking treatment. She pursued treatment because she wanted to and not on behalf of another person. From this type of relationship, one can perceive Thelma as confident, especially around her family members. Thelma was most anxious, which could have affected her therapy session. From this, a therapist might establish that she was antisocial. For instance, the client was mostly indoors and was unable to form new relationships outside her family. Furthermore, the client should sign of trauma, which made it hard for her to trust others.
Engagement
Role of the Holding Environment
The therapeutic holding environment concept was created during the 20th century by Donald Winnicott. From Winnicott’s perspective, the holding environment is based on the relationship between the mother and the child. A loving mother must provide emotional and physical support based on the child’s needs (Warren, 2017). Therefore, psychotherapists must create a holding environment suitable for their psychotherapy clients. Currently, numerous psychotherapists utilize the holding environment because it offers crucial tools during the therapy session. In Thelma’s case, the holding environment is especially important because it provides an empathetic and compassionate surrounding. These attributes were lacking from her mother and from other family members. The holding environment means that the client receives help from a consistent and reliable therapist. By maintaining these attributes, the therapist remains consistent, meaning that the caseworker will be able to maintain boundaries that are appropriate with Thelma. Since the client comes from an erratic and abusive family, these characteristics of a holding environment may be advantageous to her.
Cognitive Behavioral Therapy
Uncovering Automatic Thoughts
The first cognitive intervention that may be used to help the client achieve her goals involves looking at her negative thought pattern. The intervention is found under the cognitive reframing or restructuring theory. The intervention helps the client in managing her thought patterns. Thelma had difficulties establishing relationships with other people because she did not trust them. What can explain this behavioral condition is that the client generally assumed the worst would occur. Consequently, her thought patterns affect what she did because she mainly stayed indoors. The intervention allows a therapist to ask a client about her thought process in particular circumstances to determine negative patterns. In Thelma’s case, the caseworker can decide to question her about what she feels when around other people. These will help the therapist identify negative patterns, which the caseworker would utilize to reframe or restructure her thought patterns.
Thelma also is unable to create sexual relationships and has never been engaged in consensual sexual behavior. The reason for this is that Thelma was sexually abused by her brothers, and since then, she has developed negative thoughts when it comes to sexual relationships. Through the negative thought intervention method of cognitive-behavior intervention, a therapist is able to identify such negative thoughts. By identifying these negative patterns, the therapist may restructure her thoughts. By doing so, Thelma will be able to achieve her goal of forming relationships with others. Additionally, she would be able to think positively concerning others, thereby improving her association with others. She would be able to make more friends, thereby improving her general health and wellbeing.
Thought Recording and Journaling
The other cognitive behavior therapy involves thought and journaling records. One of the mental disorders Thelma had was binge eating. Furthermore, when Thelma could not control her thoughts, she engaged in self-mutilating behaviors. One of her goals was to stop unhealthy, destructive behaviors. To ensure that a client achieves such a goal, a therapist can encourage them to journal and record their thoughts (Gibbons et al., 2019). According to research, the intervention method helps a client get in touch with their thoughts. A therapy session utilizing this form of intervention also involves asking questions. The therapist may ask the client to identify both negative and positive thoughts that she experiences in the course of the therapy. The therapy session involves the client identifying the thoughts that led to the self-manipulative behavior. In Thelma’s case, it may have been thoughts associated with self-esteem and the manipulative behavior from the mother and the twin sister. Writing them down would help her identify new thoughts, thereby leading to positive outcomes from the psychotherapy process.
Thelma further experiences episodes of depression, which result from her relationship with her family members. According to research, abusive behaviors from family members negatively impact a child’s psychological and mental development (Roxburgh, 2009). In Thelma’s situation, she felt that, at times, she was being misunderstood. The result of this behavior is that Thelma wanted to commit suicide most of the time. Journaling as a therapeutic intervention offers a means of self-expression to the client. Some of the health advantages that this technique has been that it helps manage depression, anxiety and reduces stress. Furthermore, the client experiences mood fluctuations resulting from stress. Through journaling, she would be able to prioritize concerns, fears, and problems. Since the client is writing her thoughts every day, she would be able to recognize what triggers her situation and find better ways to control them.
Professional Use of Self
Countertransference
Several factors may influence the development and maintenance of a therapeutic relationship between a therapist and a client. One of these factors is countertransference, which occurs when a therapist transfers emotions to a client. Psychologists who experience this phenomenon may find it challenging to correct behavior in clients (Davenport, 2016). Problematic countertransference stems from situations where the doctor transfers personal issues to the client. However, countertransference may be used to the advantage of the client, especially one who finds it challenging to share information with the psychologist. In this case, the doctor may decide to direct the conversation and offer additional prompts to the individual to improve the discussion process. Countertransference further occurs when a client has specific beliefs and special preferences that differ from that of a psychologist. For instance, a client may have different views concerning the sexual orientation of others or might have different racial views. To correct this behavior, a psychologist can establish the origin of such views and discuss them with the client.
Personal Bias
The other element that influences the development and maintenance of a therapeutic relationship between a therapist and a client is personal bias. In psychology, personal bias is defined as an idea, emotion, attitude, or perception that limits a psychologist’s ability to associate with their clients (Kinavey & Cool, 2019). These emotions may further cause a psychologist to develop tendencies that marginalize elements of a client’s experiences. If personal bias is not corrected, it can negatively affect an individual by replicating the bias and stigma the client faces in society. Additionally, if personal bias is not changed, it may trigger internalized oppression, thereby resulting in the sense of self-damage. Personal bias can further be used to study both the client and the psychologist. The result could be used to transform, deepen and enlighten the relationship and connection between the therapist and the client.
How I Modified My Practice
In some way, I needed to adjust my practice because I realized that there are some methods I utilized that did not produce a result. For instance, in some situations, I experienced countertransference in my therapy sessions. I would transfer emotions to the client without knowing it could harm a client. Therefore, in the future, I will attempt to ensure that I change my methods to ensure that the sessions achieve positive results. Secondly, I believe that I have had instances of personal bias, especially when dealing with a client who had racist views. Initially, I would ignore this issue and continue with the main therapy session. To change this method, my therapy sessions would involve interviewing the client to establish the origin of such racist views.
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