International Journal of Existential Volume 2, Issue 1, 2008 Psychology & Psychotherapy THE CASE OF “PAULA”: AN have a normal life." She acknowledged that antidepressant medication assisted in reducing her EXISTENTIALLY BASED depressive symptoms but believed that taking the TREATMENT APPROACH TO medication made her feel like a "weak person." CHRONIC DEPRESSION For this reason, Paula reported that a primary goal for therapy was the discontinuation of her Joanna Lipari psychotropic medication, but she was willing to delay any decision until our therapeutic Abstract relationship had matured. Additional therapeutic The case of “Paula” presents a multi-modal goals identified by Paula included: (a) the existentially based treatment approach as it was management and reduction of depressive and applied to a case of chronic depression. This anxious symptoms, (b) to improve her ability to clinical case history documented the presenting form and maintain interpersonal relationships, and problem, case history, case formulation and (c) to “get to the point where I can do my art." treatment. Because of Paula's ongoing depressive and anxious symptomatology, coupled with a history PRESENTING PROBLEM AND RELEVANT of Major Depressive Episodes, Paula was PERSONAL HISTORY monitored for suicidal ideation and intent on an Paula,1 a 51-year-old divorced Caucasian female, ongoing basis throughout treatment. Twice during initially presented for therapy at a university clinic treatment with this therapist, Paula experienced in a California city for ongoing symptoms of major depressive episodes, with each lasting depression and anxiety related to failed career approximately two to two-and-a-half weeks. ambitions, employment stress and difficulties with Although Paula denied suicidal ideation or intent interpersonal relationships. Paula reported an during these periods, additional care was taken to extensive history of previous psychological ensure safety. treatment from 1973 through 1999. The university GOALS OF TREATMENT clinic records indicated that Paula first sought Depressive and anxious symptomatology appears treatment in 1997, and participated in cognitive- ubiquitous in the outpatient clinical population. behavioral treatment (CBT) from January 1997 to Some mental health professionals suggest that June 1998 (38 individual sessions). Her CBT cognitive approaches that have been validated treatment was terminated when her first therapist through empirical research to reduce depression completed her doctoral rotation and was no longer and anxiety, should be the treatment of choice able to provide services and Paula was transferred, (Beck, 1995). While this point of view is not to without a break in continuity, to a second clinic be discounted, existential psychotherapy suggests therapist who saw Paula from September 1998 to that the reason for depression and anxiety differs July 1999 for a total of 37 individual sessions. with each individual though the symptoms may When the doctoral rotation was concluding for this appear similar (Schneider & May, 1995). Further, second therapist, Paula expressed interest in some causes may be due less to an event or continuing therapy. situation (e.g., death of a loved one), and more In October 1999, Paula met with this therapist, with profound questions of identity and meaning who would now be the third therapist Paula was (e.g., who am I and what am I meant to do?) assigned at the university clinic. At this time, (May, 1958b). In fact, empirically based Paula reported that she was still experiencing practitioners point to the added efficacy of ongoing symptoms of depression and anxiety. cognitive therapy, when existentially oriented Paula expressed a belief that therapy was questions are addressed (Addis & Jacobson, 1996). "necessary to keep [her] together" but was losing Paula's persistent depressive and anxious hope that she would "ever be a normal person and symptomatology, despite years of counseling and 1 International Journal of Existential Volume 2, Issue 1, 2008 Psychology & Psychotherapy extensive treatment in both cognitive-behavioral and desires for the future, rather than a and psychodynamic therapeutic modalities, capitulation to patterns from the past (Sahakian, suggested that Paula's difficulties may have 1976). Specifically, in Paula's case, this meant become chronic and part of her characterological reinforcing her artistic identity while structure. Further, one of the most salient features simultaneously being empathic to her need to look of her dysphoria was the anguish she experienced for work at something that was less fulfilling, but by not being an artist, either in the eyes of the that could support her daily living needs, and, world, or in her ability to continue creating works. ultimately, fund her artistry. In essence, the The dissolution of such a core identity left Paula therapeutic questions became: (a) How can Paula with little resources to handle the stresses of the merge artistry and the need to make a living, and present, and reconcile difficulties from the past. (b) if that is not possible, how could the therapist An existential perspective was adopted to enable her to live constructively with existential explore issues of identity, meaning and purpose. dysphoria? This perspective served as a base from which to CLINICAL FORMULATION integrate other theories and techniques, primarily In deciding the best formulation for Paula's from the domains of cognitive behavioral and treatment, this therapist considered a number of psychodynamic therapies, in order to gain aspects of the case. At first glance, Paula would additional understanding of core identity issues appear a good candidate for a psychodynamic and address the management and reduction of her (Kohutian) approach. Clinic notes from previous depressive and anxious symptomatology. While therapists suggested that Paula exhibited certain eclecticism sometimes appears to translate as behaviors that were consistent with psychodynamic doing whatever comes to the therapist's mind, a formulation, namely, that Paula had a fragile self- truly eclectic approach is actually one that seeks to identity, and was vulnerable to fragmentation utilize different approaches, such as cognitive and under stress, and suggestive of arrested emotional existential therapies, in a coordinated manner development. In plain language, Paula often (Ottens & Hanna, 1998). This approach appeared appeared like a 3-year-old, stuck squarely in the particularly relevant in that Paula made progress Oedipal period, in a fierce battle with the world as and some relief of symptomatology from her "mommy', both seeking approval (merger) and previous therapies. Integration of other therapeutic independence (individuation). Thus, Paula did not interventions enabled the therapist to build on experience a true sense of self, but sought others what had previously been accomplished in therapy, to perform a mirroring self object function. as well as put these interventions (e.g., cognitive Additionally, Paula's current social support system assignments), within a larger context that might be was extremely limited. After her divorce and some more meaningful to Paula. failed relationships, Paula discontinued dating and After rapport was established, the initial goal of socializing. Her friendships were limited and often treatment was to attempt a phenomenological strained, and her relations with her family understanding of the inner world of the client members were difficult. (Merleau-Ponty, 1962; Schneider & May, 1995). Although this psychodynamic conceptualization Therapeutically, the therapist attended to three had decided merit, it did not fully capture the aspects of existential therapy: (a) existential complete data set from this case, i.e., that Paula neurosis, e.g., Paula's inability to see meaning in identified herself as an artist, but had been unable life, (b) existential 'encounter', e.g., the inner to create art for over seven years. There are two experience of the relationship between client and striking issues stemming from the data. First, therapist, and finally, (c) kairos, or a critical Paula's core self was so fragile that it ceased decisive point when an intervention might be more operations (not painting), becoming disowned, and readily accepted by Paula (Ellenberger, 1958). The second, that the particular "self” with which she overarching goal of this approach is to enable the identified is dissuaded from revival because it is a client to make life choices that are based on hopes "self” (the artist) that is not necessarily supported 2 International Journal of Existential Volume 2, Issue 1, 2008 Psychology & Psychotherapy by the American culture of which Paula is part. framework with which to approach the therapeutic Existential theory is heuristic and aptly addresses situation. this issue of personal meaning, as well as the COURSE OF TREATMENT responsibility of the individual to make choices Paula participated in 65 weekly psychotherapy and exercise personal freedom to create the life sessions from 1999 through 2001 at the university she or he deems worth living (Yalom, 1980). In counseling center. Diagnostically, Paula met essence, the individual is torn between ontological criteria for Dysthymic Disorder, Early Onset anxiety (fear of the future and the unknown), and (300.4) and Generalized Anxiety Disorder (300.2) ontological guilt (regret at what might have been) within the Diagnostic and Statistical Manual of in her or his struggle to become fully