Case Study 1.3
A 37-year-old married mother of three active boys has been diagnosed with fibromyalgia and rheumatoid arthritis. She is exhausted all the time, in pain, and recently resigned from her job so she could devote all of her time to taking care of herself and her family. At the recommendation of her doctor, she begins to attend weekly therapy sessions. Using the Gestalt empty-chair technique, her therapist encourages her to give her illness a name and express her anger to the chair.
Inaccurate (or no) diagnosis, inappropriate treatment, and poor clinical understanding on the part of the therapist contributed to the situations just described.
Months later, the first man went to the doctor for an annual physical examination. His wife mentioned his increasing irritability to the doctor, who recognized the end-of-day irritability as âsundowner's,â a potential symptom of Alzheimer's disease. The patient was referred to a neurologist where he received an accurate diagnosis.
The young girl with OCD was referred by her psychiatrist for individual counseling, which could have been an appropriate companion therapy to medication management, if she had received individual sessions of CBT to help reduce her obsessions and compulsions. Unfortunately, putting her in a group with other girls with anorexia provided her an opportunity to learn new obsessive and compulsive eating behaviors that she had never thought of before. It also brought out her competitive nature. Within a month, her weight became dangerously low and she was hospitalized.
The young mother had a painful medical disorder that was exacerbated by stress. She was eventually referred to a mindfulness-based stress reduction group where she learned mindfulness meditation, acceptance, and relaxation techniques. She is now able to manage her pain without medication and has learned how to treat herself with compassion.
As these stories illustrate, the primary goal of diagnosis and treatment planning is to be able to make sound therapeutic decisions that will help clients feel better about themselves and their lives, return to better functioning, and achieve their goals. Just like other medical and mental health professionals, doctors, psychiatrists, psychologists, counselors, social workers, and addictions specialists must first do no harm. But in order to follow that edict, we must be knowledgeable about what helps and what has the potential for causing our clients to get worse.
For some well-researched disorders, such as generalized anxiety disorder, major depressive disorder, and some of the eating disorders, research has found specific evidence-based treatments that are more effective than placebo conditions or no treatment at all. When these interventions are used for specific disorders they result in improvement over relatively short periods of time, and the improvements are often of a dose-by-dose nature. More importantly, treatment gains are maintained after counseling has ended.
But many times, little or no research is available on a disorder, or despite a wealth of research, not one specific treatment modality stands out as the most effective. In other cases, as with conduct disorder, bipolar disorder, and borderline personality disorder, treatment will depend on the stage of the disorder, the most troublesome symptoms at that time, and a long-term approach.
Many of the diagnoses in DSM-5 do not have evidence-based treatments. Some are too new to have an adequate research base, and some disorders are too rare to have garnered enough interest and funding for research. In those situations, case studies can often be found in the literature that can be culled from, and approaches that provide symptom relief can be recommended.
In these cases in particular, it helps to remember that psychotherapy is effective. So effective that nearly 40 years ago Smith, Glass, & Miller (1980) conducted a meta-analytic review on the effectiveness of psychotherapy. They concluded, âThe average person who received therapy is better off at the end of it than 80% of those who do notâ (p. 87).
