CBT Treatment for Obsessive-Compulsive Disorder

1 Running Head: MACP FINAL CAPSTONE PROJECT

Final Capstone Project

Karla Y. Drew

The Chicago School of Professional Psychology


Abstract

The following is a detailed account of an interview that occurred on April 6th

, 2015. The

client, Maggie, discloses the distressing areas of her life as she searches for understanding and

self-acceptance. The paper is comprised of a case conceptualization, client history, treatment

plan and self-evaluation. A transcript of the interview is also included as a reference piece.

Identifying Information

Margaret “Maggie” Jones is a 35-year-old, single, Caucasian female who resides in a

middle-class community in the western suburbs of Chicago. For the past twelve years, Maggie

has worked as a Nurse and currently works a daytime shift at a hospital. She was married for a

little over four years and has been divorced for two years; she has not dated or been engaged in a

romantic relationship since her ex-husband. She does not have children, but desires a family and

being in an intimate heterosexual relationship. Presently, Maggie does not identify with a higher

power or spiritual affiliation, although she was raised Lutheran. She is well-dressed, articulate in

speech and has an overall pleasant demeanor.

Presenting Problem

Maggie was encouraged to speak to a therapist after confiding in a close friend about

some areas of her personal life that were considered “not normal”. She finds it very difficult to

leave her home in the morning without checking the front door, stove and coffeepot numerous

times. Maggie experiences bouts of anxiety and a panicky sensation if she does not check these

areas of her home, which takes a considerable amount of time. She gets images in her mind that a

disaster may occur and confesses that she does not trust herself. To feel secure, Maggie has not

used the stove/oven for two years and she brought her coffeepot to the therapy session.


This area of Maggie’s life is uncontrollable and she feels powerless to stop this repetitive

pattern. She has experienced these behaviors since she moved to Chicago from California and

lived alone in the city, which was twelve years ago. Her first career position as a Nurse was

during the graveyard shift, which developed a sense of distrust and fear for Maggie over time. In

California, she only learned about the negative and violent sides of Chicago from watching the

news. She did not feel safe walking through a dark parking lot at work, nor did she trust the

neighborhood she resided in at the time. Carjacking’s occurred near her apartment, which

furthered her fears and never completely felt safe during those early stages of her career in a new

city.

Today, Maggie chooses not to leave the home on weekends to participate in social

engagements to avoid these behaviors patterns, which she identifies as “it”. Her timeliness at

work has also been affected because she regularly arrives late for her morning shift. This has

caused a significant amount of distress in Maggie’s personal and professional life; her self-image

has been negatively impacted and she has a lack of self-acceptance. Maggie does not like herself

most of the time and finds it difficult to believe that others will fully accept her as a person.

History

Developmental History. Maggie did not report any development disabilities as a child or

any physical challenges as an adult. Her enthusiasm for outdoor activities, such as gardening and

hiking, assume that she is in good health as she expressed no physical limitations. Maggie shared

some concerns for being able to bear children at her age, but it was not explored as to whether or

not she has a history of hormonal imbalances or menstrual problems. A physical exam by her


primary care physician may be recommended in the future to confirm any assumptions made by

the client.

Educational and Occupational History. The highest degree Maggie possesses is a

Bachelor of Science in Nursing. When asked about her education, Maggie responded, “Just a

Bachelor’s right now”, which may have hinted at the desire to expand upon her knowledge and

career. Maggie is motivated to do “big things”, so this is an area that needs further discussion to

clarify if and how she wants to move forward.

Since college graduation, she has worked as a Nurse and established a twelve year career.

Maggie earned a smaller salary in her first position at a hospital in Chicago, and relocated to a

suburban hospital after getting married. It was not discussed if she remained at the same hospital

after the divorce. Overall, Maggie loves her career and enjoys helping others; being a Nurse

brings her a lot of personal satisfaction and fulfilment. She also defines her career success as a

path that doesn’t take her back home to California. Maggie has an extreme fear of failure and

cannot risk losing her job. In many ways, her career is similar to a safety net that secures her in

the lifestyle she wants to maintain as an adult.

Family History. Maggie was raised in a two-parent household and is the oldest of four

girls. The age difference between siblings was not discussed, but she describes that they were

able to play together and communicate clearly as children. She only references that her father

came home from work, but does not specify his profession; her mother may have been a

homemaker. Her family’s socioeconomic status was not discussed, but Maggie gives the

impression that she was raised in a close-knit community with access to healthcare, quality foods

and educational resources.


Her father was a source of fear and intimidation for the majority of her young life. He

drank on a daily basis, primarily beers and cocktails; his levels of anger would increase with

alcohol and was easily frustrated by her mother and the children. Maggie recalls picking up

empty beer cans with her younger sisters, which transformed into a playful game, and that they

were discouraged to invite friends to their home. She describes her mother as a “Nervous Nellie”

who was very tense and would shove the children into the playroom when their father came

home. Maggie did not feel safe in this environment, which is the predominant reason why she

moved her entire life to Chicago.

Maggie did not witness or experience any physical abuse in her parent’s home. However,

her father’s outbursts caused some lingering emotional trauma that still affects her as an adult. In

the interview, it was challenging for Maggie to formulate words and recall these moments of her

life without becoming saddened; her emotional reactions are still fresh many years later. She

said, “I don’t think I trusted my father” and that he was highly critical of her mother. Maggie

believes her ex-husband is the same type of man as her father, because he diminished her

character in their short marriage.

Religion/Spiritual History. Growing up, Maggie was raised Lutheran and attended

church on a regular basis with her family. She felt the Biblical messages were contradictory

toward what occurred in her home every day. Maggie describes hypocrisy behind organized

religion because her family made all the “appearances” of being well-rounded and happy. As an

adult, she does not identify with a specific belief system or higher power; she connects with

being in space of discovery to find out her individual beliefs.


Relationship History. Prior to her marriage, Maggie dated men throughout college who

she describes as “losers”. She reports that they all became inebriated on purpose when alcohol

consumption was involved; there’s no mention of long term relational goals or mutual desires as

a couple. The social qualities of being a college student may have been the larger priority for the

men she dated.

She does not mention the name of her ex-husband, but says they were married for over

four years. Her ex may work in the corporate or political arena, because she attended social

gatherings that placed a high emphasis on public image. Maggie was only seen as “the wife on

his arm” and not as her own person; she was often criticized and ridiculed by her husband in

front of his friends. His “jokes” were mean-spirited, which caused her to feel minimized and

unprotected as his wife.

Their marriage did not end amicably because Maggie chose to pack her belongings and

leave her husband without any notice. She felt lost in her marriage and needed to escape; her

views on divorce were not discussed, but she knew this was the only decision. A positive

highlight that Maggie mentions from her marriage is that she was able to leave the house first

and ask her ex to check all the kitchen appliances in the morning; this may be why she decided to

get married. In the beginning, her husband described these behaviors as “your game”, but as

time passed he became very indignant and intolerable of Maggie.

Maggie has not dated since getting a divorce two years, due to her limited social

interactions. She describes a strong desire for a romantic relationship and to have a family of her

own.


Medical and Mental Illness History. Maggie does not report a history of medical issues

within her nuclear family. Her grandparents passed away when she was a child, so she did not

know them personally or recall learning about any medical conditions. Maggie’s great-Uncle

was a war veteran (possibly World War II) and she reports that he had some mental troubles

when he returned home. Her mother did not allow Maggie and her sisters to spend much time

with the uncle due to his condition.

Suicidal History. She does not report having any suicidal ideation or attempts at

committing suicide. Maggie’s mood is significantly impacted by these uncontrollable behaviors

and she’s somewhat socially withdrawn, so this is imperative to monitor. It was not discussed if

she knew someone who had attempted or committed suicide.

Loss History. Maggie does not report having any recent or unexpected losses. The

concept of death and loss was not discussed in the initial intake interview.

Behavioral Observations

Mental Status Examination Findings. Maggie appeared to be slightly older than her

age and she referred to The Mary Tyler Moore Show, which did not sound typical for a client in

their mid-30’s. She appeared to be in the ranges of a healthy body weight, and there were no

challenges that impacted her physical range of motion. Maggie’s clothing was clean and

unwrinkled; she sat in her chair quite comfortably in a pair of blue jeans, collared short-sleeved

shirt and tennis shoes. Her hair was well groomed and evenly trimmed, and I did not notice any

significant marks or blemishes on her arms or face. . Maggie did not display any odd mannerisms

or tic-like movements throughout the session. She sat upright and was well-poised, but sulked in

her chair when referring to distressing moments of her life.


Maggie spoke clearly and somewhat carefully throughout the session; there was a caution

with the words she chose to describe her presenting problems, marriage and family history.

There were heightened moments of enthusiasm which affected the pitch and volume of her

voice. She would normally smile during these times while maintaining a strong eye contact.

There was an alternate smile that Maggie wore when an uncomfortable topic was discussed; her

gaze also changed as her eyes shifted toward the floor and she pushed back in the chair. Her

mood and affect matched and seemed within reasonable measures. Maggie was alert and able to

stay engaged in the conversation, share thoughtful insights and sharp, witty responses. A light-

hearted, appropriate sense of humor and passion for life also highlighted the conversation topics

There was no noticeable difficulty with Maggie comprehending any questions or communicating

her thoughts and emotions..

In addition, Maggie displayed a high level of consciousness that was based in the real

world. There were no signs of a hallucination or hearing voices, and she has never had any out of

body experiences. She has a good insight on the behavioral problems she’s experiencing and is

able to recall past experiences without difficulty Maggie did not reference any thoughts of

suicidal or homicidal ideation, as well as an apparent risk of harming herself or others.

Interactions with Therapist. When the session began, Maggie smiled graciously and

shook my hand with a firm, but gentle grip. She immediately interjected that “everybody calls

Maggie” and insisted that I refer to her by this name as opposed to Margaret. Initially, she was a

bit apprehensive to disclose the full details of her presenting problem; she has little experience

sharing this area of her life with others, so there were long pauses and heavy sighs intertwined

with her speech. Maggie laughed at various times during the session, and showed signs that she

felt more relaxed discussing her concerns: smiled more frequently, spoke with greater clarity and


enthusiasm in her voice. She was also very open in sharing about her hopes for the future, such

as wanting family and fulfilling great achievements within her career. Maggie also showed signs

of vulnerability when her eyes teared up and she cried briefly as she described an internal relief

from her daily burdens.

Strengths and Limitations. Maggie holds a very positive outlook on life and how she

can interact in her surrounding community. She has several healthy activities that she enjoys

doing when possible, such as gardening, walking through nature, sewing and reading books.

Although she limits her social life, she maintains positive relationships with her coworkers who

often invite her to weekend outings. She refers to a close friend, Sonya, who encouraged her to

seek therapy after disclosing some of the problems she experiences on a daily basis. Maggie also

has a sense of humor and desires the strength to laugh about her current problems. For the most

part, it sounds like her support base is in Chicago as she does not mention a current relationship

status with her younger sisters and parents. She also supports herself financially, which places

additional stress on her to be in good standing at her job.

Case Formulation

Cultural Assessment. According to Hays, there are status levels associated with

developing a White Racial Identity (WRI); “…the word ‘status’ reflects the process by which

white individuals respond to race-based information” (Evans, 2008). As a single, Caucasian

female it is unknown how much exposure Maggie encountered with other ethnic groups as a

youth compared to when she relocated her life to Chicago. Her level of awareness about white

privilege may have been short-sighted as she is in a marginalized group, as a female, and also

experienced unhealthy relationships with men throughout her life. Maggie is also divorced and


has no children; this may create additional barriers for her to socially connect with other women

in her age group who are married with children. Although she no longer identifies with a

religious group, Maggie was raised to believe that marriage is a holy union created by God and

that divorce compromises what God designed to be permanent. She does not specify a need to

remarry, but desires an intimate relationship and children.

Psychosocial Development. Erik Erikson would define Maggie as being in the Intimacy

vs Isolation stages of development (Erikson, 1980). A healthy way of sharing our lives with

others in an intimate relationship takes precedence in this stage, whereas avoiding intimacy and

fear of commitment can lead to isolation, loneliness or, in some cases, depression. In Maggie’s

case, she married at the age of 29 and added on the life role of becoming a wife. The

diversification of identity roles and establishment of more responsibility tend to be seen in this

developmental stage. Maggie is considered to be within the normal lifespan stages because she

still wants to be intimately connected and become a mother. “A woman older than 35 has a

higher risk of miscarriage than younger women… the risk for having labor problems increases

for women over 35 and even more for women over 40 who are having their first child” (Burd,

2014). These health risks are significant and should not be taken lightly, as Maggie expressed

some concern for being able to have children.

Identity. To be labeled as a “divorced” woman can carry a slightly negative connotation;

this can be internalized by some adults. “The mental health indicators which are affected by

divorce relate to depression, anger, low self-esteem, and anxiety. The person concerned may

blame himself/herself for such a mishap. No doubt, adapting to divorce can be a strenuous

process despite seeking relief of termination of a problematic marriage” (Sharma, 2011). In the

session, Maggie shares that she “doesn’t like herself” and wants to work on self-acceptance. The


acceptance portion can relate to the problematic behavior patterns, but it can also coincide with

the emotional and financial transitions associated with her divorce. “It has been argued that

women invest more in the family, take larger responsibility for the marriage, and therefore

perceive divorce as a greater failure than do men” (Sharma, 2011). Maggie does not refer to

herself as a failure, but some of her internal belief systems may be associated with “failing” in a

future relationship.

“He wasn’t terribly concerned with who I was.” Maggie refers to this lack of

acknowledgement and interests as an individual in her marriage. From her perspective, she was

defined as a wife and seen only within her sexual identity. Her husband diminished her character

and regularly criticized her in public. Maggie shares that she “felt crushed” by her husband’s

disregard and unprotection. These unmet emotional needs in a marriage can trigger thoughts

associated with self-worthlessness, unimportance or even abandonment. “It is important to

realize what intimacy is not. It does not involve controlling a person or submitting to another

person. It’s not about power games. It is not about dependency or co-dependency; rather, it’s

about the interdependence of independent people” (Padovani, 2006). Maggie does not define

how she viewed herself in the marriage, only how her ex-husband saw and treated her. Her

description of the marriage gives the impression that she strived to be seen for who she was

internally, but felt overshadowed by the compulsive behavior patterns that she could not control.

Childhood Identity. When Maggie mentions her father for the first time it is connected

with trust issues. As the oldest sibling, Maggie took on the responsibility to look after herself and

younger sisters during his fits of rage. The only protection her mother provided from their father

was to ask them to leave the room; there appears to be no intervention in her father’s drinking

patterns or anger management. “Firstborns are described as being more deliberate, organized,


dutiful, and self-disciplined than their younger brothers and sisters, and they are also generally

considered the ‘achiever’ of the family” (Oxford University Press, 2007). Growing up with the

expectation to do and achieve more may now be creating some internal angst that conflict with

her compulsive behaviors. Maggie is not seen as dependable to arrive at work on time and does

not take on any additional accountability to spend time with friends. These dramatic changes in

her role identity over time may also be contributing to her poor self-image and lack of self-

confidence.

“If unresolved pain is left unattended, if it stays buried and denied, it develops a sort of

psychic half life, it seeps and leaches into our emotional and psychological underground and

gives root to new complexes and conditions” (Dayton, 2012). There are psychological effects

attached to children who are raised with alcoholic parents. Some of their experiences may be

traumatic and linger into adult years. In the session, Maggie describes the internal belief that she

was unsafe as a child and how she still carries this feeling as an adult. She is almost perplexed

that her memories and emotions resonate very strongly with her more than twenty years later;

this fear and unsafety also spilled over into her marriage, as she married a man with similar

characteristics as her father. “Unfortunately in alcoholic families, as in other dysfunctional

families, the negative experiences usually outweigh the positive ones. Thus your mixed feelings

occur when you remember both the good and the back. You might remember how your father

behaved when drinking or how he could be verbally abusive. Yet, this same man might have told

you how beautiful you were and called you his special daughter” (Ackerman, 2002).


Cognitive Behavioral Therapy Conceptualization

Belief Systems. Maggie’s internal beliefs are that she’s not safe and cannot trust herself

or others. From a cognitive perspective, she developed these beliefs at a young age and believes

them to be true; the foundation on how to approach life and relationships dwells in fear and lack

of self-acceptance. “Cognitive behavior therapy is based on the cognitive model, which

hypothesizes that people’s emotions, behaviors, and physiology are influenced by their

perception of events” (Beck, 2011). Maggie is afraid that she may eventually fail in her career

and that people will not fully accept her individuality. In her marriage, Maggie thinks it may

have lasted if she was able to control, or hide, her repetitive behavioral patterns. The relationship

with her father and ex-husband were consumed with trust issues and a disregard for her personal

safety. “…interactions with the world and other people, influenced by their genetic

predisposition, lead to certain understandings: their beliefs, which may vary in their accuracy and

functionality” (Beck, 2011). Although Maggie expresses her difficulty trusting others, she

developed a close relationship with a coworker, Sonya, who she confided in about her daily

rituals. She’s also maintained a career as a Nurse, which requires an academic and social skillset

to develop a rapport with patients. Maggie shows incredible strength and self-worth when she

left her ex-husband and financially supports herself in a middle-class suburban community.

Automatic Thoughts. Since relocating to Chicago, Maggie experiences very distressful

thoughts and images in her mind that she may be physically harmed or that something disastrous

may occur. When she lived in a less safe neighborhood, she thought she was in danger and got

images of being attacked when leaving her apartment in the evenings. In her current living

situation, Maggie will get reoccurring thoughts that she didn’t lock the door, or turn off the stove

or coffeepot. She describes these images as being very intrusive and demanding of her time and


attention whenever she leaves her apartment. It’s understandable for her thought processes to

reflect harm and danger, because her belief systems stem from a lack of trust and security.

“Although automatic thoughts seem to pop up spontaneously, they become fairly predictable

once the patient’s underlying beliefs are identified” (Beck, 2011).

Emotions and Behaviors. Throughout the session, Maggie shares that she feels

“frazzled” and has no control over these intrusive thoughts. She will spend a considerable

amount of time rechecking areas of her home because she doesn’t trust herself. Anxiety and an

overwhelming sense of panic will overcome Maggie if she doesn’t perform her daily rituals. The

feeling is almost “paralyzing” because she can’t physically move from her front door. She

prefers to stay indoors on weekends to avoid these repetitive patterns; this is a temporary relief

for her emotionally and mentally. “…one’s underlying beliefs influence one’s perception, which

is expressed by situation-specific automatic thoughts. These thoughts, in turn; influence one’s

emotional, behavioral and physiological reaction” (Beck, 2011). For these reasons, Maggie feels

less-worthy and insecure, which limit her social interaction and prevent her from meeting

potential suitors. Her self-confidence diminishes and her overall mood can become saddened and

depressed.

Diagnostic Formulation

Diagnostic Criteria: Obsessive-Compulsive Disorder (300.3).

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

1) Recurrent and persistent thoughts, urges or images that are experienced as intrusive

and unwanted, cause marked anxiety or distress


2) The individual attempts to ignore or suppress such thoughts, urges or images, or to

neutralize them with some other thought or action

Compulsions are defined by (1) and (2):

1) Repetitive behaviors (checking, hand washing) or mental acts that the individual feels

driven to perform in response to an obsession or according to rules

2) Behaviors or mental acts are aimed at preventing or reducing anxiety or distress,

preventing some dreaded situation or event.

B. The obsessions or compulsions are time-consuming or cause clinically significant distress

or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a

substance or another condition

D. The disturbance is not better explained by the symptoms of another medical disorder

Rationale for diagnosis. In accordance to the DSM-V (APA, 2013), Maggie’s mental and

emotional state are best explained by this diagnosis. The intrusive thoughts, patterns of anxiety

and compulsive rituals are considered typical for this disorder; she has good insight because she

“recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that

they may or may not be true”. She also avoids leaving her home when possible, which is a

common trait, because this triggers a behavioral reaction. Maggie can only fulfill her work or

personal obligations after completing the compulsive rituals, which alleviates her feelings of

distress and emotional turmoil. Maggie does not take any prescription medications or over-the-

counter drugs, and she does not have a history of mental health disorders.


Differential Diagnoses. Generalized Anxiety Disorder (APA, 2013) was ruled-out

because the thoughts creating the anxiety are often connected to real-life situations, which do not

seem odd or irrational. There may be a certain fear of objects or situations; however, the rituals

are not present. Major Depressive Disorder was another possibility, primarily because of the

mood swings, disengagement from social interactions and self-wothlessness. Similar to

Generalized Anxiety Disorder, the rituals are not part of the client’s experience and the

symptoms are based on mood as opposed intrusive thoughts. Another diagnosis that was ruled-

out is Psychotic disorders. Maggie does not experience any hallucination or hear voices, which

are common for schizophrenia or schizoaffective patients. The compulsive rituals and obsessions

are the traits that distinguish Maggie from these disorders.

Treatment Plan

Specific Treatment Plan

To help Maggie regain control and minimize the anxiety, distress and compulsive

behaviors, a combination of CBT and relaxation techniques will be utilized over the course of

eleven to twenty in person sessions.

Beginning Sessions. For CBT to be effective, it is important to establish rapport with the

client and collaboratively develop a therapeutic treatment plan. Earning Maggie’s trust and

confidence as a therapist will be one of the primary focuses in the initial sessions. The ability to

show empathy and understand her problems and ideas can be done by asking thoughtful

questions, reflection of feelings and affirming statements. Applying these techniques will help

identify “distorted thinking, modifying beliefs, relating to others in different ways, and changing

behaviors” (Beck Institute for Cognitive Behavior Therapy). As these distorted thoughts and


belief systems are pinpointed, Maggie can participate in developing ways to counteract her

current thinking patterns. She has a number of positive activities that she enjoys, which are great

strengths she can incorporate into her therapy process.

Educating Maggie about OCD will help alleviate some of the distorted thoughts that

make her feel like she’s “going crazy” or “losing my mind”. It is the therapist’s duty to provide

accurate resources for the client to learn more about a mental condition; also avoid using labels

and view the client as a whole person who is not defined by their disorder. Over time, Maggie

will have a better understanding of how “normal” her symptoms are and she can regain

confidence in herself. Hopefully, this will continue to keep her engaged throughout the

collaboration process as we establish short and long term goals.

“Most patients feel more comfortable when they know what to expect from therapy,

when they clearly understand what you want them to do, when they feel that you and they are a

team, and when they have a concrete idea of how therapy will proceed, both within a session and

over the course of treatment” (Beck, 2011). Maggie will become more familiar with the CBT

structure as her sessions progress; setting an agenda, doing a mood check and reviewing

homework will be the norm. Since Maggie’s mood has reached extremely low points, it is very

important to check in with how she’s feeling on a weekly basis. A mood stabilizer may be

recommended if she becomes more distressed and show signs of depression.

Middle Sessions. After several weeks of therapy, Maggie will have results from the

homework assignments and can discuss how effective therapy has been toward goal-setting. It is

recommended for her to maintain a journal to record when intrusive thoughts occur, and how it

makes her feel or behaviorally react. Together, Maggie and the therapist can identify what


triggers certain thoughts and how they connect to her core belief system. This is an optimal way

to address how realistic Maggie’s beliefs are and challenge her with real-life situations;

reminding her of strengths and unique qualities will improve her self-acceptance and esteem. In

addition, this is also a collaborative time for areas to be re-evaluated or create new goals that

Maggie wants to incorporate; informed consent is another ongoing feature that grows with the

therapeutic process.

“You aim to obtain a clear picture of situations that are distressing to patients. You help

them clearly differentiate their thoughts from their emotions. You empathize with their emotions

throughout this process and help them evaluate the dysfunctional thinking that has influenced

their mood” (Beck, 2011). As Maggie identifies her current belief systems she can begin to

establish new ones based in more positive, realistic view of her and others. In the initial

interview, she shares on numerous occasions the lack of trust she has within herself and that she

“doesn’t like herself”. At this point, incorporating some exposure therapy techniques can assist

Maggie in gaining trust in her actions and mindset. A therapist may suggest that she leave home

without bringing the coffeepot or attempt cooking a small breakfast for her and a friend. Her

friend Sonya, who suggested she seek therapy, may help hold Maggie accountable to some of

these new tasks. A supportive community is helpful for any person who is looking to grow or

change within a certain area of their lifestyle.

This is also a great time for Maggie to explore self-care options and incorporate more

enjoyable activities into her daily life. Her connection to nature and being outdoors is a great

way for her to relax, relieve anxiety and be more involved in the community. She expresses a

sincere appreciation for her coworkers who often invite her to social gatherings after work or on

weekends; as she grows in self-confidence and acceptance, she may be more willing to


participate in these engagements that can also replace negative thought patterns that people will

not fully accept her as a person. Maggie also wants to explore the possibility of finding love

again and having a family. Openness and acceptance will have to be focused on during these

middle sessions because it has such a strong correlation to the value of her relationships.

Termination. In the final stages of Maggie’s treatment plan it will be necessary to

review how the usage of techniques and strategies helped her reach certain goals. Maggie can

distinguish between the areas of her life that have changed the most (positive growth and

development), as well as ongoing challenges. It is equally important for Maggie to share

feedback with the therapist to disclose how she felt about their relationship: describing areas that

helped the most, if she felt the therapist listened and understood, ways to improve, etc.

Although Maggie has developed her strengths, it’s useful for her to have current

resources and accurate information about her disorder. There may be support groups in her area

or hotlines she can call if her mood swings changes and she feels out of control; minimizing the

potential for her to revert back into old core beliefs and negative thinking patterns is the goal.

Maintaining an accountability partner, such as Sonya, can also help Maggie as she transitions out

of meeting with her therapist weekly. Maggie has the awareness and understanding to educate

others on her symptoms, triggers, and behavior patterns; ongoing support and collaboration may

be the best tools for Maggie to succeed.

Self-Evaluation

The Beginning of the Hour. From the initial moments of our session, I immediately felt

a sense of rapport with Maggie. There was an openness and hopeful demeanor that I sensed

while shaking her hand; more specifically, when I called her ‘Margaret’ and she insisted that I


refer to her as ‘Maggie’. By sharing her nickname, I felt connected to her personal space and

identity. I thought it was also significant that she applied her friend’s advice to talk with a

therapist. To me, that signifies that there’s some level of awareness that her issues are causing

concern for those around her. Maggie is not in denial about the reasons why she came to therapy,

but there are some challenges in how she expresses her present problems.

As Maggie describes her symptoms, I sense that she is cautious and somewhat nervous to

share her thoughts and feelings. She took several deep inhales and exhales throughout her

speech, as well as long pauses; I sensed that she wanted to protect herself and not feel judged by

me. I appreciated how well she could describe her automatic thoughts and the compulsive

behaviors. She allowed me to explore and ask close-ended questions to further understand and

empathize with her situation. I knew Maggie appreciated when I confirmed that she wasn’t

“crazy” and that it took courage for her to share this private area of her life. Eventually, she

shared that I seemed non-judgmental and she was able to smile about that; there was an overall

relief that she welcomed and I appreciated her willingness to be vulnerable. Our conversations

did not feel superficial or inflated with expert opinions. There was a mutual bond being explored

and shared, which flowed at a comfortable pace for two people who recently met.

Five Helpful Interactions. One of the first helpful interactions was establishing her

preference to be called Maggie. I thanked her for sharing this with me because I wanted to

develop a bond of trust and show competence as a graduate student. Since this was more

comfortable for her, I tried to be consistent by addressing her by this nickname. Once again,

bringing our conversations to a more personal level and connecting with her identity. Another

helpful interaction was telling her she wasn’t “crazy”, because she had used similar words to


describe her thoughts and behaviors up to this point. It was beneficial for me to normalize her

situation so that she knew I wasn’t judging or labeling her persona.

When I asked Maggie how she feels after unplugging the coffeepot it gave me a very

clear perspective on the gratification she receives from these rituals. This interaction was similar

to witnessing someone unload a heavy bag from their back; Maggie carries the weight of these

concerns with her, and I continued to watch her body language and listen to her express the

“absurdity” with the compulsive behaviors. A fourth interaction was listening to Maggie describe

her daily routine and how “hysterical” she became at work on one occasion. I felt this was a very

informative way of viewing Maggie’s life through her eyes because her voice, facial expressions

and body movements all adjusted to share this particular moment. I could tell this was very

private and difficult for her to share with me, which I thanked her for and empathize with her

experience.

Maggie appreciated me thanking her for being open and sharing her authentic self. By

this point, I sensed there was a lack of self-acceptance and need to be validated as a human

being. She needed to know that I valued her time, thoughts and emotional energy being shared

with me in the present moment. Since I was fully engaged, I think it helped her to open up more

about what was causing her distress.

5 Problematic Interactions. Throughout the opening session, I notice I do a lot of head-

nodding and non-verbal communication responses. Watching this interaction encourages me to

find other ways of communicating that I understand without using as many “mmm-hmm”

reactions. Extending beyond the beginning session, one problematic area I wished I pinpointed is

when we discuss the relationship with her father. When Maggie shares that his father made her


mother feel diminished, this could’ve been an opportune area to inquire more about how she

views her mother. This could’ve led into discussion on how Maggie views women and life roles;

I’m curious to know if she ever lost respect for her mother or harbors any negative feelings

because she grew up feeling unsafe.

Early in the session, I assumed Maggie had OCD and I began using words that related to

the DSM-V criteria. I think it’s important to use the same language as the client to see the world

from their perspective. It is wrong to assume that clients will identify with the same word

choices used by their therapist. This continues to ensure that there’s a mutual understanding and

the client is being heard. A fourth interaction is when I showed my surprise when Maggie said

she drinks an entire pot of coffee every morning. My inner-thoughts showed through my facial

expression and voice tone, which could’ve meant I was judging or ridiculing her for drinking

large amounts of caffeine every day. Thankfully, Maggie did not frown upon my reaction;

instead, we were able to laugh about how much coffee she drinks because we refer back to her

bringing the coffeepot to session on several occasions. Another interaction that could’ve been

problematic is when I told Maggie she can still have children at 35-years-old. I did not inquire if

she had any deeper concerns, other than her age, that may be contributing to her self-doubt. She

may have tried to get pregnant when she was married, or even had a miscarriage. These

would’ve been important areas to discuss and not make assumptions.

My overall opinion of the interview is that it was more comfortable than I originally

thought. It was much easier to incorporate the MSE toward the end of the interview, because I

gathered pertinent information that related to those questions. As a black female, Maggie did not

show any signs of discomfort toward my race or gender; we were both close in age, so I think it

made it somewhat easier speaking to me since we’re from the same generation. We are both


heterosexual and desire families of our own in the near future. Maggie and I do have spiritual

differences, but I respect that she shared her views on organized religion and how this affected

her during childhood. For Maggie, I think she appreciated that I was open to listen to her life

experience and not cast judgement. My genuine concern for her livelihood and safety were felt

during our discussions, and I was thankful she was encouraged to share private details of her life.

To me, there was a special bond established early on in the session, which made all the

difference toward empathizing with Maggie and seeing her uniqueness. This interview helped

me feel more confident in my interviewing skills and show areas where there’s room to grow.

By signing this form we are both agreeing not to use any of my therapeutic intervention records

or testimony in any future court proceedings.

Signed: ____Maggie Jones

_______________________________________________Date________4/20/15________

Signed: ___Karla Drew

________________________________________________Date_______4/20/05_________


Works Cited

Ackerman, R. (2002). Perfect Daughters: Adult Daughters of Alcoholics. Deerfield Beach: Health

Communications, Inc. .

APA. (2013). Diagnostic and Statiscal Manual of Mental Disorders Fifth Edition. Arlington: American

Psychiatric Asssociation.

Beck Institute for Cognitive Behavior Therapy. (n.d.). What is CBT? Retrieved April 19, 2014, from Beck

Institute for Cognitive Behavior Therapy: http://www.beckinstitute.org/cognitive-behavioral-

therapy/

Beck, J. (2011). Cognitive Behavior Therapy, Second Edition. New York: The Guilford Press.

Burd, I. (2014, April 14). University of Maryland Medical Center. Retrieved April 17, 2015, from Later Age

Pregnancy : http://umm.edu/health/medical/pregnancy/specialcare-pregnancies/later-age-

pregnancy

Dayton, D. T. (2012, August 28). Adult Children of Alcoholics. Retrieved April 17, 2015, from The

Huffington Post: http://www.huffingtonpost.com/dr-tian-dayton/adult-children-of-

alcoholics_b_1835677.html

Erikson, E. (1980). Identity and the Life Cycle. New York: W.W. Norton & Company, Inc.

Evans, K. (2008). Gaining Cultural Competence in Career Counseling. Lahaska: Houghton Mifflin

Company.

Oxford University Press. (2007). Oxford Handbook of Evolutionary Pscyhology. New York: Oxford

University Press Inc.

Padovani, M. (2006). Healing Wounded Relationships. New London: Twenty-Third Publications.

Sharma, B. (2011). Mental and Emotional Impact of Divorce on Women. Journal of the Indian Academy

of Applied Psychology, 1.


Interview Transcription

T1: Hello, Margaret.

CL1: Hi.

T2: I’m Karla

CL2: Hi, nice to meet you.

T3: Nice to meet you.

CL3: Everybody calls me Maggie

T4: Oh…

CL4:… please call me Maggie.

T5: I certainly will. Thank you for sharing that with me, Maggie. And thank you for coming in

today, I appreciate you taking the time to come and meet with me today. Umm… and I definitely

want to hear about what’s brought you here. I just want to go over a few informalities that we

have to..

CL5: Sure.

T6: Just so you know, I am a graduate student and our session is being recorded, and it will be

shared with our professor, so just know that. Uh, but anything that is discussed within our

session it will, uh, you know, anything pertaining to any type of abuse that might be happening

within your life or if I feel that there are any areas where harm might be inflicted upon you or

someone else those are areas where I would have to inform the right authorities. Um..

CL6: Okay.

T7: Does that make sense?

CL7: Sure.

T8: Okay, okay. Just a few house rules, just so you know, but everything else would be kept

confidential

CL8: Okay..

T9: Um, just wanted to share that with you.

CL9: Good, good. Okay.

T10: Okay. So, um, Maggie what brings you in today?


CL10: (sighs) A friend of mine recommended that I come see you…

T11: Okay.

CL11: A friend, coworker, umm… (sighs) it’s really hard to even describe. I feel like Im going

completely crazy.

T12: Hmm…

CL12: Um… I feel like ive (exhales) I don’t know, somedays I just (exhales) I just have no

control over my life. I love my job. I’m a nurse.

T13: You’re a nurse, okay.

CL13: I’ve been doing this for a number of years. Um.. and, I like going to work. Love my

coworkers, love my job, but (pause) it just sounds so silly.

T14: Mmm.. Take your time

CL14: (exhales) I really have a hard time getting to work in that I have hard getting out of my

apartment. It takes me a very, very long time. Umm… it’s (pause) I get up and I get ready.

Everything’s going great, I’m having my coffee, feed the cat, you know, it’s a normal day.

Everything’ s going smooth. The weather channel’s going in the background and, and then as im

trying to get out the door I cant seem to make that move. Umm…

T15: Can you describe what that feels like? Is it almost like, umm, paralyzing when you say you

cant..

CL15: Oh, paralyzing! Ohmigosh, it is so paralyzing.

T16: Mmm-hmm.

CL16: Umm. Because, and, and I feel a lot of panic. I feel out of control and very panicky. I lock

the door, turn the thing and I close it and I turn to go down the stairs, but then in that instant I

have this image in my head that says ‘you didn’t lock the door!’ so, I have to turn back and I

have to try the doorknob to check and see if it got locked and, of course it is because I did. But

then I turn away I immediately feel this rush of panic that I didn’t lock the door. And then in…

while all this is going on, it suddenly pops into my head ‘well, you didn’t shut the stove off’

T17: Okay

CL17: Not thinking that I haven’t turned my stove on in two years.

T18: Mmm. Mmm-hmm.


CL18: Because I never know if it’s off or not. Um, but I have to go back and I have to touch and

feel all of the burners. Does that sound completely crazy? It does to me. Umm.. I feel like I’m

going nuts.

T19: Well, I can tell you that it does not sound crazy. You don’t sound crazy. I want to affirm

that…

CL19: Thank you.

T20: It sounds like you took some great steps just to get here today, just based on what occurs on

a day to day basis with the locking and rechecking of the doors and the stove

CL20: Oh, and the coffeepot

T21: The coffeepot…

CL21: I know it’s absurd. I know it is and… it has an automatic shut-off, but I still have to

unplug it before I can leave in the morning.

T22: Okay. When you unplug the coffeepot, does that make you feel more relieved? Does that

help you in anyway? Or…

CL22: When I, when I unplug, yea, I get this rush of relief…

T23: Okay

CL23: Okay, great. I’m looking at it and I know I’ve done this and I know I’ve unplugged it.

T24: Okay.

CL24: Then I go out the door. Close that door and I know that I did not unplug that.

T25: Okay.

CL25: So… even though I, ohmigosh, even though I know I didn’t lock the door and I have to

keep reaffirming that, I have to unlock the door to go in to check the coffeepot htat I unplugged

and it just starts this whole cycle that I do every single day. It’s exhausting… umm, absolutely

exhausting. (pause) A copuple of days ago, I finally told one of my coworkers about this, about

three months ago, I mean I literally took that stupid coffeepot with me to work that day. I

couldn’t get past not knowing if was unplugged or not.

T26: Mmm. Mmm-hmm.

CL26: And, and I was in the stairwell at the apartment and I was crying. Umm, I was, I was like

hysterical. But I couldn’t make it stop, couldn’t make it stop.


T27: Well, I certainly thank you Maggie for sharing these very deep feelings and emotions with

me. And, and I … Know that I really appreciate that, umm, you bringing your full authentic self

here today. I can tell this causes some discomfort for you. And, umm, you know, thinking that

this is ‘absurd’ as you say, (mmm-hmm) but I, I want you to know there are some ways we can

help.. help you get to, it sounds like a more peaceful place that doesn’t involve some of the day

to day rituals, I would say…

CL27: So there’s some hope?

T28: There is hope.

CL28: Okay, good.

T29: There is hope. Um.. what would you say, umm, ‘hope’ looks or feels like for you?

CL29: To be able to (laughs) just walk out that door and just walk right down the stairs and out

of the building and off to work without that stress, panic, hysteria. You know, all those things

that just churn up.

T30: I see a smile there.

CL30: Well, umm, if you feel very non-judgmental. I feel very safe to talk about this fear. So,

thank you for that, umm. You know, ‘hope’ also looks like, you know, maybe being with

somebody again. I am divorced…

T31: Okay, okay.

CL31: Uh, I got divorced about two, two years ago. Umm.. was married for a little over four

years, maybe?

T32: Okay

CL32: And. So… I feel like this is something that, you know, I’ve always sort of done. It’s just

kind of a part of who I am, but, even though it’s really uncomfortable. Doesn’t that sound crazy?

It feels normal but it’s not normal all at the same time.

T33: Mmm- hmm.

CL33: It’s just kind of my thing. And, umm, but I would, uh.. it made it easier to get out the

house when we left to go to our different jobs at the same time of day.

T134: Oh. I see..

CL34: So, um.. cleverly, I would be the first one out. And, uh, and then I would say, ‘oh, by the

way, are you sure you go the coffeepot turned off?’ You know? ‘Did you remember to lock the

door, dear?’


T35: Mmm-hmm.

CL35: And, the first while he didn’t think anything of it. But then it really started to annoy. You

know, he was like, he called it my ‘game’…

T36: Okay.

CL36: He was onto my game and he didn’t know what that was. But, he was really annoyed with

it. And, he wasn’t in hindsight, maybe not a real nice person. But, he would.. it got to the point

where he would laugh at me, he would ridicule me. I would be the butt of his jokes to his friends.

T37: What was that like for you for him to make those comments and say that this was ‘your

game’? What did that do to you inside?

CL37: Oh, I felt crushed. It was awful, I… and the way he said it it was mean.

T38: Mmm-hmm.

CL38: And it was, like, like, I felt like, a dog that had urinated on the carpet and he was going to

rub my nose in it.

T39: Hmm…

CL39: And you know, I’m gonna make fun of you and, and criticize you and and tell people

how odd you are. And… it was awful.

T40: That’s a very strong image. It umm.. It puts you in a place where you’re not completely

seen as his equal. Almost as a child who’s made a mistake and, umm, it sounds like a part of you

wished he would have protected you and accepted you.

CL40: Accepted me, umm.. Yea, he.. umm, I don’t know if he was ever terribly concerned with

who I was. It was just, he wanted a wife and that was the role I was supposed to play and.. and,

you know, smile at his business functions

T41: Okay..

CL41: and support him, but it felt.. I, I never felt so lonely in my life.

T42: In the four years?

CL42: In four years. Umm.. so finally one day I just packed up what I could put in my car and,

and left.

T43: Do you, um, still carry around some of those feelings from your marriage and the umm,

ending of a marriage with the divorce?


CL43: Yea. (sighs) I, I do. Uh, you know, if I wasn’t like this, you know, it probably would’ve

been okay. Umm.. you know, I just, wished I’d done things differently. I should’ve covered it up

more.

T44: Well, I’ll say Maggie, it’s… we can olnly be ourselves. And it can be challenging for others

to sometimes to accept or embrace the full truth of someone else. Umm, I think sometimes when

we can’t always accept it within ourselves. So, having that self-acceptance can sometimes make

a bigger difference as well. Umm… so, from what I’ve heard you share it sounds like the, umm,

rituals you’ve had you had them before your marriage (mmm-hmm) and they continued

throughout your marriage and would you say they increased after your divorce, as well? Or did

they pretty much stay the same?

CL44: It fluctuates, umm… being pressured kills me. Like, if he was to say, uh ‘hurry up you’re

taking too long to get ready’ in the morning. You know? ‘Hurry up, hurry up!’ Then I, I, i.. it

makes it worse. Umm, and, and stress makes it worse, so now that I’m on my own… trying to

meet rent, you know, worried about finances and.. and, I know it makes it worse. Umm.. but I

just feel so powerless to do anything about it.

T45: Mmm… when you say powerless how does that look to you?

CL45: (exhales) Gosh, like I’m this puppet on a, on a string. That, that it’s like this whole big

joke that everybody else is in on. And, and I just keep having this same experience over and over

and over again (mmm-hmm) Annd, yea, it feels like I don’t have power or control over, over that

piece of my life.

T46: So this piece of your life, which it sounds like it occurs everyday, has control over you in

many ways.

CL46: Oh, it does! Very much so.

T47: And how long would you say this has been happening?

CL47: Umm.. I really noticed it since I got out of college. And… um, moved into my first

apartment.

T48: Mmm-hmm.

CL48: (pause) I was.. I had, I mean, I had a good job lined up. Good grades and… so I was really

excited about the hospital I got in on. And I was glad to be out on my own. Feeling confident and

that I could do this! Glad that I was out of college.. was happy to be away from my family.

Umm.. you know things were going to be different now.

T49: Hmm. Can you tell me what that means ‘different now’?


CL49: (pause) Oh, I was gonna start new, you know? You see Mary Tyler Moore in whatever

show that was and she throws her little hat up in the air.

T50: Right, right.

CL50: Um, gonna start fresh. In a new town, was gonna be a new me. Um, I was gonna… be

successful in my career.. find a nice man, have kids. You know, the whole nine yards.

T51: Okay, okay.

CL51: Um. Yea, I thought I was leaving junk behind.. Um, guys I dated in college were losers.

Oh, such losers. Umm.. (laughs) I always managed to connect myself with the ones who drank a

lot.

T52: Hmmm..

CL52: And drink to get drunk, I kind of, fell into that for a bit… for awhile.

T53: Do you, do you like to drink?

CL53: Not anymore.

T54: Not anymore

CL54: I did it for a time in college uh, just trying to fit in, and be like everybody else. Umm, yea,

and when I decided I wanted to move away that was one of the things I wanted to leave behind.

T55: Mmm-hmm. So, it sounds like the move, in a way, was also escaping from parts of your

past that you no longer wanted to be connected to or reminded of. Umm.. where did you move

from?

CL55: I moved from California.

T56: Okay.

CL56: Um, you know, halfway across the country.

T57: Yea.

CL57: I thought that was a pretty good escape.

T58: It’s a long way. Yea, it’s quite a journey to take by yourself.

CL58: Yes!


T59: Especially. So, once you moved from California you were done with college, you had

found a job here in Chicago. And, you would describe that as time when this area of your life

started to come into play?

CL59: Yea,

T60: Okay. .

CL60: Yea, uh.. it was definitely there before I got married.

T61: Mmm-hmm.

CL61: Um, you know. as we’re talking about it, it makes me wonder if I got married to escape

that too.

T62: Hmm… can you tell me some more about that?

CL62: You know, I had a great job when I came out here, but it didn’t pay a lot.

T63: Mmm-hmm.

CL63: Um, so the apartment I got was in… I didn’t , I didn’t know the neighborhoods and the

suburbs here before I came out and, umm, so the apartment I could afford was in a neighborhood

that wasn’t horrible, but it wasn’t great. Uh, horrible (laughs) there were carjackings in the

parking lot.

T64: Okay.

CL64: Umm, so I… and I, I worked the graveyard shift so I had to leave my apartment and be at

the hospital at 11 o’clock at night. So I was going out to the big parking lot by myself at night..

T65: Okay, okay.

CL65: Um (pause)

T66: How was that,.it sounds like this is even a little uncomfortable to talk about. Just those

memories of walking through a dark parking lot at night.

CL66: mm-hjmm. Umm, I.. I was determined. I felt determined, I was going to do this and I did.

But, I just had this horrible knot in my stomach. You know, each time that I went. Um, nothing

ever happened.. eventually I (inaudible) and got married (laughs). But, yea, it never really felt

safe.

T67: So, you think the knot in your stomach was caused by the feelings of being unprotected?

When you made that walk from your apartment to your car, to your car to the hospital and back

again


CL67: Yea..

T68: … all at night.

CL68: Right..

T69: In Chicago..

CL69: .. In Chicago. That’s all they show on the TV in California are the gangs, and crime rate is

horrible. So, yea, I guess those are images that come into my mind.

T70: Well, I appreciate you sharing that with me. I can sense the discomfort that it, it causes you

even right now as if it’s still happening. Um, hopefully you work on a different shift. You still

work as a nurse?

CL70: Yes.

T71: And are you still at that same hospital?

CL71: I’m at a different hospital.

T72: Okay.

CL72: Um, I’m out in the suburbs now.

T73: Okay.

CL73: And, um, I have the dayshift, so I don’t need to be there until 7 o’clock in the morning.

So, except for the very dead of winter it’s light out.

T74: Okay. Right, right.

CL74: And, it’s a safe neighborhood. So, yea, so I know this isn’t normal ‘cause there’s nothing

there to be afraid of.

T75: Mmm… Well, do you, uh, do you feel that fear is moreso internal or do you feel that

sometimes it’s moreso caused by our external surroundings? Or maybe both?

(pause) external.

More external? Ok, so, it sounds like the environment you were in it was unfamiliar to you.

Being in Chicago and the neighborhood was maybe a little questionable. Um, especially based

on what you’d seen living in Califronia..

CL75: Right.


T76: And, so, there were these thoughts that caused this distress and, um, does that sound about

right?

CL76: Yeah.

T77: Okay. Um, so would you say that there’s a question between the thoughts and the fear and

this area of your life tha tyou’re hoping to change or transform?

CL77: Yes. Umm (pause) is that possible to get there?

T78: Well, I believe it is. You made it here today, which is one big step. So, uh, this, this sounds

like this may be the first time you’ve come to speak with a therapist about this. So, I would say

that’s a big accomplishment.

CL78: Yea, in my whole life this is the first time I was able to vocalize and give words to it.

T79: Okay. Um, and this it what would you call it?

CL79: Hmm.. (pause) I just… the word that comes is odd. I mean, when you say that ‘it’, the

word that popped into my head was trust.

T80: Hmm, okay.

CL80: And, I don’t have a lot of trust.

T81: Can you share more of that with me?

CL81: (pause) Um, like with my ex-husband. I couldn’t trust that he had my back. Um, um

(pause) this is really hard, really hard.

T82: Okay, you can take your time.

CL82: Umm… I feel terrible saying this, um, I don’t think I trusted my father. (pause) It wasn’t

safe. It didn’t feel safe always.

T83: Can you share that with me? The feelings of not being safe with your father as a child..?

CL83: (exhales) He was angry a lot of the time. Always angry… I just remember him always

being angry.

T84: Mmm-hmm.

CL84: Um, he drank a lot and the more he drank it seemed like the angrier he got and, um, less

tolerant he got of us kids.

T85: Hmm..


CL85: Um, so my mom when he got like that, which was often, she would quick-feed us dinner

and shove us off into the playroom. Encourage us to just play quietly.

T86: Okay.

CL86: Um, and until things… until he mellowed out.

T87: Can I ask you more of a difficult question?

T87: Sure.

T88: Did you ever see any, um, abuse growing up between your parents or with your other

siblings?

CL88: No, not with me and my sisters ‘cause mom had a way of corralling us and sort of keeping

us out of harms way. Um, and he, but he, he wasn’t physically violent toward her. I mean, he

never hit her, but it was the anger. And I remember one night, one night we were all having

dinner together. Of course, he had had a few cocktails when he got home from work. And, mom

had tried this new recipe, um, some kind of a casserole or hot dish.. it wasn’t that bad. Um, he

didn’t like it and he took the whole plate of food and just threw it against the wall. Past her, he

didn’t throw it at her, but past her and it, it landed on the wall behind her. Um.. he was just

saying he worked hard all day long and deserved better than that.

T89: How old were you when this happened?

CL89: Maybe about twelve.

T90: Okay. So, that was about 24 years ago and it still sounds like a very fresh memory.

CL90: Yea, I remember not feeling safe.

T91: Mmm-hmm.

CL91: Um, my sisters and I we never talked about it..

T92: Mmm-hmm.

CL92: I think they were scared. Yea, I just was never sure, you know? What was, what was

gonna be there everyday.

T93: Are you the oldest of your sisters?

CL93: I am the oldest.

T94: Okay. How many sisters?

CL94: Three.


T95: Three younger sisters?

CL95: Mmm-hmm.

T96: Okay. So, It sounds like you were, somewhat of the ring leader and the protector for them?

CL96: Um, yea, yea… especially the youngest one… When mom told us to go in the playroom

upstairs, if somebody protested (inaudible) let’s go play, Yea.. help them come along.

T97: Maggie, that’s, um, with how you’ve described your father I can see tjhat it still causes you

a lot of pain. You know, just seeing how your facial expressions have changed since we’ve been

talking, It’s something that’s very difficult and..

CL97: It is..

T98:… it’s something that’s carried with you through adulthood.

CL98: I mean, oh… I had some good friends growing up, but I, I couldn’t bring them to the

house. And if I did I had to check and make sure that all the beer cans had been put away. Umm,

ugh, Mom didn’t want anybody in town to know, so we weren’t allowed to talk about it at

school.

T99: Okay.

CL99: Um, I had to remind my sisters, you know, to pick up their stuff. You know? So, picking

up the random beer can kind of became part of the game for them.

T100: Mmm-hmm. Wow.. as children?

CL100Yea. I don’t know. Yea.

T101: Well I can see the, umm, discomfort that this has caused for you. Um, Just with your

father’s drinking and the anger that came with it, um, and you being in a position to have to

really protect your younger siblings, as well. Um, and it sounds like there’s that theme of being

unsafe with your father and then also with your ex-husband. Umm… Do you feel safe now?

CL101: (exhales) Um, I should feel safe now. Um, (pause) but when.. something happens at

work.. the head nurse she, you know, gets upset with me coming in late and getting a little

intolerant of that since I’ve lost concentration when I get there. You know, she needs a staff that

she can rely on

T102: Mmm-hmm.

CL102And, um, (pause) so, then I get scared ‘cause if I fail at this then I’ll have to move home.

T103: So the fear of failure?


CL103: It scares the hell out of me.

T104: And, and from what I hear ‘home’ translatesinto being a place that’s not safe.

CL104: Yea. Yea, but I’m a grown woman.

T105: Well, as adults we can tend to carry a lot of our childhood with us and a lot of belief

systems as well. And our parennt’s relationships and their dynamics, we can sometimes see hints

of it in our relationships. As you’ve described.

CL105: Yea.,

T106: Which happens very often. It does..

CL106: I married my father.

T107: Well, uh, it that how you feel?

CL107: Yea, I do actually. Um, his criticalness… and I guess that reminds me of how my father

treated my mother. He treated her… he made her feel ashamed of who she was. And, um,

diminished her I guess.

T108: It sounds like a very, um, lonely feeling. Not being seen for who you are.

CL108: Yea.

T109: Maggie, what would you, umm… if you could paint a picture for me of your ideal life

and how it would look and feel, what would that, could you describe that for me?

CL109: Yea, being with someone, I guess I don’t know that I’d have to be married, but have a

close relationship with somebody that can know these details about me. Um, more of, what I told

my friend Sonya, and I, I felt her caring and I, I felt that trust. I, I didn’t feel like she was gonna

run and tell everybody at work that I’m a nut, um, you know, she guided me into coming here.

So, yea, I want to be surrounded by people who, umm… yea, can just accept me for me, um, and

you know whatever this is. Cause yea, I, I guess I don’t like myself very much right now. I guess

my ideal life would be, umm, you know maybe being able to laugh at it someday.

T110: So, I hear a lot about acceptance. Not just from others, but from yourself

CL110: Mmm-hmm.

T111: As well as the possibility of having love in your life again or a partner. Umm, and perhaps

even finding a peace with ‘home’?

CL111: That feels a little scary.


T112: Okay.

CL112: Yea, I don’t know if I can go there right now.

T113: Okay, okay. Thank you for telling me. You know, we can focus on what’s most needed

and right now the biggest thing right now I hear is acceptance and relationships, quality

relationships, where you feel nonjudgments from other people and people embrace you for who

you are.

CL113: Yea, yea. I’d like to like myself too.

T114: You’d like to like yourself.. And, so that, umm, with the liking of yourself does that mean

it doesn’t include the ‘it’ in your life? This, this area…

CL114: See, alright, see I’m already starting to laugh about ‘it’.

T115: Mmm-hmm…

CL115: Umm, I mean I do already have the coffeepot in my car

T116: Okay, okay…

CL116: Umm..

T117: You should’ve brought it in, we could’ve made some coffee.. .

CL117: (laughs aloud)Um, I would like ‘it’ to, uh, take a back seat. Yea, I don’t, I don’t want ‘it’

controlling me… I want… I want control for ‘it’. Or at least come to peace with ‘it’.

T118: Okay, okay. So definitely minimizing what ‘it’ controls over your life on a day to day. So

that would mean not having the coffee pot with you…

CL118: Yes!

T119: Even though I do enjoy coffee if you were to bring it in..

CL119: (laughter)

T120: So, I can understand you don’t want to always bring your coffeepot everywhere with you.

CL120: Yes.

T121: Okay, okay. And just even the comfortability of talking about it, you know?

CL121: It feels silly, but, thank you for letting me share that.

T122: Yes. Yea, and just even to laugh about it and not beat yourself about it. Okay?


CL122: Yea.

T123: Well, I know there are some goals we can focus on together. If that sounds alright to you?

CL123: Yes, most definitely.

T124: Okay, great. Um, I definitely want to ask you just a few more questions. Just to find out

more about how you’re feeling and just a little bit to find out how your memory is doing..

CL124: Sure.

T125: So do you mind if I ask you some questions? Maybe take a few notes?

CL125: Oh, yes, please.

T126: Okay. Um, your mood today.,. if you had to say on a scale of one to ten, one being ‘sad,

extremely down, maybe close to depression’ ten being ‘I’m so happy and joyous I just can’t

contain myself’ where would you say you’re at?

CL126: Um, I think if you’d ask me that when I walked in I would’ve said about a two.

T127: Okay.

CL127: Um, just kind of anxious and not knowing how this was gonna go

T128: Okay..

CL128: I was very apprehensive about coming in. Um, you know, but as we talk.. feeling a little

bit better. So I’d go a four.

T129: A four! Okay! That’s definitely an improvement within such a short amount of time.

CL129: Yea

T130: So, it sounds like the more com.. um, the more you’re able to talk about how you feel and

expressing those areas that you haven’t felt so safe in and how you’d like to feel safe. You

know, getting that picture of ‘hope’ is able to bring you some joy.

CL130: This is uh, uh, it’s like a relief.

T131: Yea, and I can see that in you. Okay, well that’s wonderful to hear. Just to see where your

memory is, I’m going to give you three words and I’m just going to ask you to repeat those back

to me. And then I’m gonna ask you to repeat them to me again a little bit later.

CL131: Okay.

T132: Okay. Bird, cat, telephone.


CL132: Bird, cat telephone.

T133: Ok. Just remember those three words. Are you, um, do you drink? I know I asked you

before about alcohol, but you don’t drink currently?

CL133: No.

T134: Alright. Do you smoke at all?

CL134: No.

T135: Okay. I know you have a coffee pot, but do you drink coffee?

CL135: (laughs) I do! I love coffee!

T136: You love coffee!

CL136: Yes. I have a whole pot of it every morning.

T137: Oh, okay. Oh! A whole pot. Okay.. any other caffeine products?

CL137: No.

T138: Okay. Are you on any types of prescription medications or do you use any recreational

drugs?

CL138: No.

T139: No, okay. Even over the counter? Tylenol?

CL139: No.

T140: No, okay. Great. Um, from what you described to me about your father, um, his drinking

… it sounds like there was a problem with alcohol and substance use. Would you say that’s in

other areas of your family, as well?

CL140: Um, I mean, my ex-husband’s brother is an alcoholic.

T141: Oh, okay, okay.

CL141: But, um.. in my immediate blood fam.. blood line family, no. That I know of… but, uh,

my grandparent’s died while I was young, so… I didn’t, I met them, but I didn’t know them well.

T142: You didn’t know them. Okay.

CL142: You know, there was… you know, when everybody was together there was always

drinking..


T143: Mmm-hmm.

CL143: Um, you know, other people didn’t seem to get to that level though.

T144: Okay. As your father did?

CL144: Mmm-hmm..

T145: With your family as a whole it was social, but with your father it was more on an everyday

basis.

CL145: Right.

T146: Okay. Okay. Um, just to know a bit more about how you feel day-to-day or throughout the

week, would you say you still have an interest in things you like to do? Any activities?

CL146: (sighs)

T147: Or has anything been impacted that you’d like?

CL147: (laughs) I used to like to cook…

T148: Mmm. Mmm-hmm.

CL148: Um, I loved breakfast.

T149: Okay.

CL149: But I can’t make break… I can’t make a hot breakfast, unless it’s in a microwave.

T150: Okay.

CL150: ‘Cause I don’t trust myself.

T151: Mmm-hmm. Okay. With turning off and on the stove or the oven?

CL151: Exactly.

T152: Okay. Has your, um, appetite been affected by this in any way? Or your sleep been

disturbed?

CL152: No, um… no, I sleep okay. Um, I mean I actually, you know, I don’t think about this

until that exact moment.

T153: Mmm-hmm, mmm-hmmm.

CL153: You know, so, once I’m out the door then it’s out of my head.

T154: Mmm-hmm.


CL154: You know, For twenty four hours.

T155: Right. I see, okay. So it doesn’t disrupt you ..

CL155: Yea, but, you know, in saying that… I don’t.. on a weekend or something I don’t go out

as much with friends ‘cuase I have to get up and leave the ouse. So, it’s kind of two days when,

you know, I don’t have to go anywhere, so I don’t have to go through that.

T156: I see. So, it, uh.. just so I understand correctly, so the… it sounds like some of your social

interactcion has been impacted, but it kind of relieves you to know you don’t have to go

through..

CL156: Yea.

T157: … the rituals or patterns with, with ‘it’.

CL157: Yea, you know. Sonya always wants me to get out and do more… and others coworkers

and stuff. You know, so I feel bad turning them down, it seems like a lot of fun. But, Yea…

T158: Is that something that you would like to changes? As far as getting out more with your

friends and having more of that social...?

CL158: Yea.

T159: Okay.

CL159: Pretty much so.

T160: Great. It sounds like you have some wonderful friends.

CL160: Mmm-hmm.

T161: So, I’m sure they would love to have you along when they go out. So…

CL161: So far, it’s.. I guess I do. I guess I hadn’t thought about it that much before

T162: Okay.

CL162: Yea, they keep asking.

T163: Okay, okay. Well… that’s a good thing.

CL163: Mmm-hmm.

T164: Well, great. Umm.. Where would you say your energy level has been? Umm… are you

able to… do you feel really motivated throughout the day? Or your concentration levels effected

at all?


CL164: You know, when I first get to work.. Head Nurse is right. I’m flustered. Frazzled.

T165: Okay.

CL165: My concentration’s down, but… for the most part I’m able to kick it in gear then.

T166: Mmm-hmmm.

CL166: And, uh, perform at the level I need to.

T167: Okay, okay. As a nurse do you work, umm, twelve hour shirts or, umm..?

CL167: No, I’m fortunate to be just on an eight hour…

T168: Oh, that’s very nice. Very nice. And, umm, I’m gonna ask maybe umm… I just have to

ask, just to find out. Have you ever had any thoughts about harming yourself or hurting yourself?

CL168: No.

T169: Okay. Pretty, uh, optimistic about life and wanting to enjoy life?

CL169: I wanna do big things. I know I want that…

T170: Okay, okay.

CL170: Umm,

T171: That’s a very affirming statement.

CL171: Um, Yea.. I, I want to move up. Umm, and a lot of days I guess I’m pretty confident that

I can and then other days I feel like I start all over again.

T172: Okay. Well, thankfully we can take every day a day a day at a time. We don’t have to do

Monday and Tuesday all at once. Um, now this may be somewhat of an unusual question, umm,

but just so I know do you ever have any, ugh, hallucinations or hear any voices or f eel like you

see things?

CL172: No.

T173: Okay. Any out of body experiences that you’ve ever had or encountered.

CL173: No.

T174: Okay. Great… um, I know you said you were married, do you have any children?

CL174: No.

T175: No children. Would you like children one day?


CL175: I would!

T176: Okay!

CL176: I’m getting kind of old now, I guess.. I don’t know, can you still have kids at thirty-five?

T177: Of course! Of course you can.. absolutely.

CL177: But then again if that doesn’t happen… you know, I’m not… it’s not like my life would

be over if I didn’t.

T178: But, it sounds like you want to?

CL178: Mmm-hmm.

T179: Okay. So we can put that on the ideal picture list.

CL179: Okay.

T180: Okay. We’re not gonna leave anything off, okay?

CL180: Okay. Alright.

T181: Umm, so you said you work as a Nurse. Do you have a Bachelors degree or a Masters

degree?

CL181: Just a Bachelors right now.

T182: Okay. And you said you love what you do?

CL182: Mmm-hmm.

T183: Okay. So, that’s good to know that your work brings you a lot of joy and the people..

CL183: Mmm-hmm. It does.

T184: And you’re in a position where you serve others, so…

CL184: Yea.

T185: Yea, okay. Uh, what are some things you like to do for fun?

CL185: (sighs) I like to sew.

T186: Okay.

CL186: Umm, I like to read. When I do get out I like to go to the park… just kind of be out, out

in nature.


T187: Okay.

CL187: It calms me a little bit maybe.

T188: It sounds like it. Your voice got a little calmer even when you said that or just thought

about being in the park.

CL188: Yea… there’s a big garden across from my apartment.

T189: Oh really? Okay, okay…

CL189: It’s next to the Starbucks. You can tell I like coffee.

T190: (laughs)

CL190: But, yea, it’s a beautiful rose garden.

T191: Oh, very lovely. Okay. So when you mentioned, umm, feeling anxious at times do you

ever turn to a few of these things to maybe help you not feel as anxious? Or panicky? Or..

CL191: Um, yea, like on a Saturday morning when I’m up… and I like to look out my window

and look onto the park. And, um, I like that.

T192: Okay.

CL192: Or.. sometimes if I, when I get home I’ll actually go sit on a swing a little bit before I go

up.

T193: Okay, that’s good. It’s good to hear that you’re already using some relaxing and enjoyable

moments, you know.. to help to not feel controlled by ‘it’.

CL193: Right.

T194: You know, whether you’re indoors or outdoors.

CL194: Yea..

T195: So. That’s good. Those are some great things we can work with together. Great and Just,

uh, a few more questions for you. Are you feeling okay?

CL195: I am.

T196: You are? Okay, good… Do you have any, umm, any family history with psychiat, CL196:

psychiatric illness or mental history in your family? Or..

CL196: Um. My mom’s a bit of a Nervous Nellie.

T197: Okay, okay. Can you describe that for me?


CL197: Umm. You know, um, well.. I suppose that.. for her it seemed normal, but she knew

when it was about that time of day, when dad was coming home

T198: Mmm-hhmm.

CL198: You know, they’re still married, but when I was living there she’d just get nervous. And,

you know, a little anxious and.. and some things started feeling a little tense.

T199: Okay, okay. They started feeling tense in the home?

CL199: Mmm-hmm. Mmm-hmm.

T200: Okay.

CL200: I think her uncle had some issues coming out of the war.

T201: Mmm-hmm.

CL201: She doesn’t talk about him much.

T202: This was her brother? Her uncle?

CL202: Her uncle.

T203: Okay. That’s good to know, thanks for sharing that. Are you connected to any type of

religion or identify with a certain spiritual group?

CL203: I was raised Lutheran.

T204: mm-hmm.

CL204: And, uh, I don’t practice that now.

T205: Okay. Do you have any idea of a higher power? What is your belief system?

CL205: I don’t know what that is now!

T206: Mmm-hmm.

CL 206: Um, yea, I don’t, I don’t know. I guess I kinda look at organized religion as being, you

know, the place wehre people hid.

T207: Hmm…

CL207: You know, we’d go to church as kids with, uh, both parents. And everybody looks

happy, you know like we’re the well-rounded family.

T208: Mmm-hmm.


CL208: You know it was a show, almost… and, yea, it seemed really hypocritical.

T209: Okay.

CL209: And, yea, so I.. it just seemed to be in conflict with the teachings. So, yea, I don’t know

where I’m at with that right now.

T210: Okay, and that’s completely fine. It’s good for me to know where you’re coming from,

um, but it sounds like you have a strong support system with your friends and some other great,

um, recreational activities that you like to enjoy where you get your peace and comfort from.

CL210: Yea..

T211: So that’s good… I feel, I feel hopeful that we can work on a lot of things together to get

you to that big picture that you want to reach.

CL211: Good. And about how long does that take? Is that a long process?

T212: Well, you know, it kind of depends on the person, but I feel you are a very highly

motivated individual. And, so, that definitely helps with the process.

CL212: Okay.

T213: So, you know, you coming here and you maintaining a wonderful career and you having

still very ideal long term goals for your life really says a lot. So, I think we have a very strong

foundation to start with and we’ll continue from there.

CL213: Okay.

T214: Okay.

CL214: Very good.

T215: Well, thank you Maggie for coming in today. Um, just in closing I guess we’ll focus on

some of these goals a bit more next week and we can talk about some ideas that you have and

ways to work towards them.

CL215: Okay.

T216: Okay.

CL216: Thank you.

T217: Well, thank you.

CBT Treatment for Obsessive-Compulsive Disorder

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Transcript of CBT Treatment for Obsessive-Compulsive Disorder