COGNITIVE AND BEHAVIORAL PRACTICE 5, 331-334, 1 9 9 8

Freeman's Response to the Case of Joe

Arthur Freeman Philadelphia College of Osteopathic Medicme

Presenting Problems

Joe presents with what I would term "symptom profusion," that Is, a broad range of symptoms. His presenting problems constitute a "formal list" (i.e., what he directly states as problems) and an informal list (i.e., those problems that are imbedded in his ongoing concerns). What is most obvious is that what Joe pre- sents as problems are, in fact, complaints. The problem list is far lengthier, con- sdtuting the problems that are part of his complaints.

Diagnosis

(Given that there is no opportunity to interview the patient and to test diag- nostic hypotheses, all diagnostic statements are extrapolations.)

Axis I: Generahzed Anxiety Disorder, Dysthymia, and Obsessive-Compulsive Disorder.

Axis II: Avoldant Personality Disorder, Dependen t Personality Disorder, Ob- sessive-Compulsive Personality Disorder, and Passive-Aggressive Personality Disorder.

AxIS V: GAF = 45

Assessment Plan

The additional measures that I would use for assessment would include the MCMI-III, to confirm the Axis II diagnoses, and the MMPI.II. While both of

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these instruments will help gather additional data, the testing procedure itself will, I think, have a salutary effect on Joe. He wants to gather and share data so that the therapist can really understand him.

Summary of Unique Features of the Case That Deviate From Prototype Cases

I do not see any umque features of this case. Joe is a fairly consistent sample of a patient with Cluster C problems.

Case Conceptualization

Joe is consistent with the Axis II diagnoses in Cluster C. I see the narcissistic traits as, more likely, evidence of his acute dependence coupled with his passive- aggressive style. As individuals are generally "true to their cluster," Joe appears to meet criteria for all of the Cluster C (anxious, fearful) disorders. These dis- orders are also consistent with anxiety disorders, which Joe also manifests. In fact, it is not clear how the anxiety disorders and the personality disorders are juxtaposed.

Joe meets several clinical criteria for the Axis II diagnosis:

• enduring patterns of cognition, affect, interpersonal functioning, and im- pulse control

• pattern is inflexible and pervasive • personal distress and social occupational dysfunction • stable and long duration • not accounted for by another mental disorder • not due to physiological effect.

Further, his problems are more ego-syntomc than -dystonlc: he goes from crisis to crisis, the pat tern originates in early adolescence (and possibly in child- hood) , he has problems in self- and other monitoring, he sees his problems as outside himself, and there is a lack of an internal point of reference for more adaptive thnctioning. This is how he has always been.

I see the major t reatment issue to be the passive-aggressive component . For example: Carol wants ch i ld ren- - Joe is not interested. Carol works as a res ident - - Joe stays up all night playang computer games and sleeps late into the day. Carol cannot invite her friends or relatives to their apar tment because of Joe's accumulated debris and his concern that they will see him as "a dirty person." Joe does no t complete the requirements for an M.B.A. and considers going back and getting another undergraduate degree. Joe puts off tasks and is late for appointments. He hit the brakes suddenly and his mother went into the windshield. Overall, I see Joe as unable to assert himself directly; he has devel-

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oped a style of maintaining indirect control, power, and an aggressive stance to- ward those around him.

Finally, I question his wife's acceptance of his style. She takes medication to control her anger at him but seemingly is powerless to change his behavior. She has allowed herself to be controlled by his symptoms. If psychopathology, like water, seeks its own level, she has significant problems in assertion and self- esteem. She is being abused by Joe's style of behaving.

Treatment Plan

I am first unsure of Joe's commi tment to change. A major focus of the therapy would have to be Joe's willingness to risk-take and confront the anxio- genic situations. For example, would he be willing to start to reduce the volumes of the saved papers? An in vivo approach that involved the therapist being with him to record the thoughts about and a round the discarding of the materials would be helpful. Alternatively, having Carol as an adjunct to the therapy would be useful to help to do homework.

A second factor would be to help Joe to unders tand how he developed his passive-aggressive style. As a child he could not directly face up to his mother so he learned to be more circumspect. Now, as an adult, this style is, in many ways, not working.

Third, Joe can be viewed as being m early ret irement or on perpetual vaca- tion. He plays games, watches TV, presumably reads, sleeps late, has few require- merits or restrictions on his time, "plays" at life tasks (i.e., going to school). Is he willing to give this up in favor of a more productive lifestyle? This would need to be addressed.

Fourth, Joe needs to learn the differences among aggressive, passive-depen- dent, passive-aggressive, and assertive behaviors. Two approaches might involve (a) having him look at the assertiveness book by Bower and Bower (1976) and discussing it in therapy or (b) reading Eric Berne's (1964) Games People Play and discussing this in therapy.

Fifth, given Joe's extreme dependence, I would try to use the pathology in the service of the the rapy- -po in t ing out to Joe that the more he acts the way he does, the less of what he wants (love, care, support) he may get. He will have to be willing to try new and different ways of getting what he needs.

Sixth, I would want to evaluate Carol's need to be a supportive enabler of Joe 's behavior. She will need to be educated as to alternate ways of behaving. I would structure therapy (which I think would be fine with Joe re: his obsessive style) to work in 5-session modules. This would help to keep both me and Joe "honest." We would be able to stay on target and avoid the "talking ad nauseam" potential .Joe might not want this focus, as he believes that therapy should be an opportuni ty to talk away all of his problems. It also might be likened to working

334 FREEMAN

8 hours and feehng trapped. The agenda-setting must be flexible to allow for an exchange of his rigidity to a more adaptive structure.

Adjunctive Interventions

At some later point in therapy, a couples group might be useful to support both Carol and Joe m the need to change and skills to effect change.

Potential or Anticipated Problems

I believe that the major issue in therapy will be his passive-aggressive style combined with his high level o f anxiety and arousal. I would expect that Joe will constantly test the therapist by being just a little bit late for sessions, doing s o m e

of the homework, trying parts of new behaviors, avoiding anxiety, or becoming anxious about the possibility of becoming anxious. Of special note will be my countertransference to Joe 's ongoing passive-aggressive style and behaviors. I will need to keep my own reactions under careful watch and control.

Expected Outcome

Given the chronic nature of the problems and the fact that he exhibits so many of the criteria for Axis II disorders, this will be a difficult therapy. Small gains will be the goal. The marital work will be very important.

References

Berne, E (1964) Games people play The psychology of human relatzonsh~ps NewYork: Grove Press Bower, S. A., & Bower, G H (1976). Assertmgyou~self A practzcalguzdeforposztwe change Readmg,

MA Addison-Wesley

Address correspondence to Arthur Freeman, Ed D, ABPP, Philadelphia College of Osteopathic Medicine, Department of Psychology, 4190 City Ave., Philadelphia, PA 19131

RECEIVED' July 24, 1998 ACCEPTED. July 24, 1998