In the next part of the session, the purpose of the audiotaping was discussed. The tape was available for Marie to take home for listening. The next portion of the interview focused on buying clothes and dressing properly.
T: It has to be the exact size, color, fit?
M: Right, and if it isn't, then that means there is something wrong with me. It doesn't mean that that score doesn't have enough sizes, colors….
T: Maybe that is something you can work on.
M: It is a good candidate for dysfunctional thought analysis.
Again, the issue of perfectionism is addressed. The idea that "if the store does not have what I want, it is my fault " is raised by Marie. The next portion of the session develops the homework assignment. The goal of the homework assignment was to collect evidence that she could use to test her thoughts and to begin to dispute some of her active dysfunctional thoughts.
T: I think I agree, it would be good to really look at yourself. With a mirror.
M: Uh-huh. That's a good idea.
T: To really sit down in front of mirror and just look at yourself and write down what you see and then deal with that, and I think it might be helpful to … hmm, do you have a full length mirror?
M: Yes.
T: .. to do it in the nude. Do it dressed and do it in the nude, and write down what you are feeling about your body and the thoughts that you have. And then sit down and knock the hell out of it. Not your body but your negative thoughts.
M: Okay.
T: Then challenge that. That it is there and to really, almost, to desensitize yourself to look in the mirror until you don't have to have that feeling anymore, because the feeling clearly stems from the thoughts. So that you then can remove that one more piece of anxiety about going clothes shopping.
You can look in the mirror and…
M: That's a good idea.
T: So that is something you can work on. And then, I think, deal with some of these issues of the "ugly, awkward" speech. I guess it is always, too, a matter of a perspective. As you look towards the reserved, chiseled profile you have envied, I wonder how many reserved, chiseled types are looking for your curly hair.
M: Nowadays, a lot. They are all going and getting permanents.
T: I guess it's the perspective that they look and say, "Gee, I wish I had naturally curly hair."
M: Yeah, it is hilarious. We all want to be different than what we are. Society tells us we're not good enough the way we are, we've got to be different. Hairdressers-every hairdresser that a women goes to tells her that she ought to do this, that, and the other to her hair, no matter what kind of hair she has. Just resisting that takes a lot of self-confidence.
T: But, given what society says, it's what we say.
M: Yeah, we internalize that and say it to ourselves, yeah.
T: Okay, let's see where we have been. We've talked about the taping, we've gotten through the homework, and you've spent a good part of the session on this issue of body image and talking about how you think makeup or clothing. Then you have to deal with it in terms of "Am I doing it for society or for me?" But to change how you look on the exterior because on the inside maybe you are not so sad. That might go along with changing that negative self-image. One piece of specific homework you'll be working on is doing some dysfunctional thoughts, specifically about your body image and your body, that will deal with several of the issues here of appearance, grooming, body image. We've talked about some of the issues about money and spending it. If you buy clothes, it is going to cost you a bundle. No way around that.
(The final part of the session is a review and summary of the session content.)
M: Yes.
T: It means, I think, I'm going to spend money. That's what it is all about. And it depends whether you then want to choose to try to go and buy as much as you can cheaply as you can or buy what you are really talking about, which may cost more. To get those fine, tailored pieces, like a camel's-hair coat, you can get a Dacron and tissue-paper version or the real one, which won't go out of style. So, OK, we've running close to the end of out time. Any thoughts on the session, thoughts you have had? Anything about me today?
M: Ummm. I don't think so.
T: Anything I have said today that has upset you, annoyed you? (Marie shakes her head) OK. Any closing comments? Ok, I will see you on Thursday.
M: OK. I'm having my six-week evaluation just before the session.
T: OK.
The next session excerpt is from the session immediately following the one described above. Marie came into the session very upset.
T: Well, where do you want to pick up today?
M: The week has been OK. But this thing that I did with, you know, the mirror has really upset me.
T: Upset you in what way?
M: Well, it just confirmed all of my negative views of myself. It didn't help me. I don't know why you made me do it.
T: Before we go into that, do you want to spend the majority of the session on that? Is that why your Hopelessness Scale is so high today?
M: As upset as I am, I think so!
T: Let's get right to it. What is so upsetting?
M: (starts crying) Even since I did it last Thursday after our session, I've been upset. I did what we agreed; I stood in front of the mirror nude. I had a pad and pen with me, and I made a list of all of the parts of my body that I didn't like. Here, here's the list.(hands therapist the list).
T: (looking at it) Its quite a list.
M: It sure is. That's way I feel so hopeless. I didn't think about what the impact of the homework would be. As I wrote, I got more and more upset. Everything is wrong with me. It's jus as I have always feared. I really hate the way that I look, and I not only have the evidence, but hate myself with greater specificity.
T: It's a long list. (counting items) 27 different things that you hate [see Table 12-2].
M: Yes. From the top of my head to the tips of my toes.
T: What do you think of … let me back up. What did you think of as you were doing it?
M: I'm ugly, I've always been ugly, it will always be the same.
T: As you look at the list right now, what do you think?
M: I feel lousy.
T: What thoughts go through your mind?
M: That's is. I feel lousy.
T: You're saying what to yourself?
M: I'm what I've always been and will always be. I have been cheated. Others have good looks, and look at my list.
T: Hmm. So the list is really bugging you. You've been cheated, and there's nothing, absolutely nothing you might do?
Table12-2 Things I Hate About Myself (Marie)
My hair is cut poorly
My hair is a mousy color
I have gray hairs, which make me look old
My hair is too curly
My hair is thinning
My forehead is too high
My glasses make my eyes look beady
My poor eyesight makes me wear thick glasses
I have squint wrinkles near my eyes
My nose is too wide
My lips are too full
My face is too broad
My shoulders are too wide
My breasts are too small
My stomach sticks out
My hips ate too wide
My thighs are heavy
My ass is huge
My knees are bony
My calves are too heavy
I have ugly ankles
My toes are too long and ugly
My skin is a sallow color
My skin is too grainy
I'm too short
I have a thick waist
I have saddlebags on my hipsM: Sure, I can always kill myself.
T: Anything else?
M: Not that I can think of.
T: I wonder… I wonder what would happen if we looked at this list in some different ways.
M: Such as?
T: Well, what if we divided this list into three list? List one would be things that you might easily change. Lest two would be things that you could change with difficulty, and finally list three would be those things that you could not change.
M: What would that do? This list would be as long.
T: The overall list would be as long, but we might have some things you could work on. Would you be agreeable to trying it?
M: Sure.
T: How about if I read the list, and you assign it to one of the three categories? Let's try it.
M: OK. My hair is cut poorly. I could always have it recut. But it's so short now, what are they going to cut? It will just look worse. I'm getting bald as it is…
T: Whoa! You're going too fast for me. Let's separate things. Can you get your hair recut?
M: I guess so.
T: Will having your hair recut be something easy, some difficulty, or impossible?
M: Easy. But …
T: Hold the "but" for a moment until I write down the first hair issue in the easy column. (writes it down) Now, what thoughts did you have?
M: This won't work, it won't make any difference. My hair is awful, and this won't make it any better.
T: Lots of thoughts! Can we do two different things here? Fist, can we do the columns, and then can we deal with the thought? I've written them down so that we won't lose them.
M: OK. It's just that this seems like a waste of time.
T: A barber?
M: Yes. The closest shop to my apartment, and also the one that's open late, is a barber shop. I have always avoided women's beauty shops as places to advance one's narcissism. All of that primping and women's stuff is awful.
T: Between a men's barber shop and a women's beauty parlor, there must be other choices. Possibly ones that are more inconvenient, but will better meet you needs in this regard.
M: I suppose there must be.
Marie's all-or-nothing thinking once again governs her choices. She must either go to a barber who cuts her hair poorly or to a beauty parlor that represents an image she hates. The assignment of each of the various body part concerns to one of the three columns proceeded throughout the session. The following excerpt picks up the session at the end.
T: We're almost out of time, and we have several more of these to go. How do you want to handle that?
M: I could do it for homework. I feel much better. I see where you were going with this. Its obvious that the longest list is composed of things that I can do rather easily. There are far fewer on the next list [with difficulty]. I'm not going to have my nose done!
T: How about the last list?
M: (laughts) No. You've made that all-or-nothing point enough. I can do something.
T: When you cane in, you were not feeling good about the homework, and about me. How are you feeling now as we end?
M: Better. I believe that I can do something. I'm not sure what, and when it will all get done …
T: All?
M: OK, OK.
T: Good luck with this. I'll see you next week.
The sexual issue was addressed in sessions 14 though 19. mare's husband refused to come in for any therapy sessions. His position was the therapy did not help their sex life, so he saw no reason to start therapy again. Marie wanted to change the sexual situation, so the sexual issue became a focus in her individual therapy. An assessment of Marie's sexual problems in addition to her early sexual learnings and experience.
What emerged was that Marie had often experienced painful intercourses. The issue was that she did not generate vaginal lubrication; when penile penetration was attempted, the result was painful. Oral stimulation was enjoyable but not her preferred sexual activity. When questioned as to why she did not enjoy the oral sex, inasmuch as she enjoyed it and was gratified by it, Marie said, "It's not the right way." Once again, her schema become manifest in her sexual activities. The schematic issue was tested when she was questioned about the possibility of using a vaginal lubricant prior the intercourse (e.g., K-Y Jelly). Marie responded, "I want to do it the right way. These jellies are not natural. I should be able to do it the way that everyone does it."
When Marie was asked about her sexual fantasies, she responded that she did not have any. Given that sexual arousal is largely a cognitive event, it would seem antisexual to not have (or be able to generate) sexual fantasies in the office, she seemed flustered. She finally said, "I'm having sex with a man." Given her intelligence, this seemed a rather sparse response. When asked to elaborate on the fantasy, Marie responded, "I'm having sex with two men."
The sexual focus involved Marie agreeing to a six-session program. In her first homework assignment, she was asked to read My Secret Garden, a volume of women's sexual fantasies, by Nancy Friday. The next series of excerpts are from the sexual-focus sessions.
M: (commenting on the homework) I never have fantasies like that. I have always written off these kinds of stories or fantasies as pornography. But I must say that I found them to be rather exciting. It made it easier when you assigned this book, but I noticed a certain, um, tickle.
T: A tickle?
M: Must I say it?
T: Yes.
M: I felt excited. It was fun.
T: Were there any particular stories that tickled you more than others?
M: I haven't finished the book yet, but there are several that I found especially exciting. Some didn't appeal to me at all.
T: Did you share the book with Alan?
M: No. I read it during the week at my apartment.
T: Were there any special images that you enjoyed?
M: Yes. There was one about a women … do you want me to tell you the one that I found sexy?
T: Would you be comfortable in doing that?
M: No.
T: Then it's not necessary. Let's deal with it without your having to tell me the details. What could you do to make the fantasy more "you"?
M: What do you mean?
T: Well, what you read was somebody else's fantasy. What should you do to place yourself into the fantasy? You know, make it more Marie.
At this point, Marie described the fantasy and tried to rework the images to place herself into the picture. The next parts of the treatment strategy would include having Marie image the arousal scene and then masturbate in response to the scene. In the second session, the arousal practice was altered to include practice imaging the arousal scene and then using a nonsexual image to de crease arousal. This homework came from the session material where Marie discussed the problem of trying to maintain her arousal. She described her sexual states as so tenuous that any interruption would cause her to lose her arousal. Once the arousal was gone, it could not be recaptured. Marie then practiced arousal, masturbation, interruption of the image, and then trying to regain the arousal. She reported in the third session that she had been successful at regaining arousal after losing the image.
Her homework for the fourth session was a result of the third session material. Marie reported that if she became aroused, she could achieve an orgasm, but only once each time that she was aroused. Her homework involved trying to stimulate herself mentally and then to masturbate to orgasm. After a brief period of time, she was to try to become aroused again and to reach a second orgasm. During the fifth session, she reported having multiple orgasms. She seemed surprised that it was so simple.
M: I have an orgasm, and then another … and another.
T: You seem surprised.
M: I am. I've never had several orgasms in a row. I've read about it, but, well …
T: So the equipment works. What do you make of that?
M: I can't believe all of the orgasms that I've missed over the years.
T: What are you doing right now?
M: I'm not sure.
T: Let's look at it. You start by being surprised and happy about the orgasms, but then do something to yourself.
M: I focused on what I didn't have. The many years of missed orgasms.
T: Exactly.
In this exchange, the schematic issue of all-or-nothing is once again a focus. In the sixth session, Marie discussed the antisexual images and thoughts she had; when she could focus on the sexual images, she was easily aroused. A final test was the weekend when she went home. She left My Secret Garden on the kitchen counter. Her husband found the book and was quite interested. They decided to take the book to the bedroom and to read the fantasies to each other. The result was sexual intercourse without difficulty.
Conclusion
In the course of the therapy with Marie, sexual issues were dealt with. The goal of the therapy was not to achieve a cure of her long-term depression. In the short-term treatment model of cognitive therapy, Marie was taught several basic skills. By looking at her negative thoughts, identifying the nature of her distortions, and then testing the thoughts using the format of the Daily Record of Dysfunctional Thoughts (DRDT), Marie learned that she could take control of her life by controlling her depression. The schematic focus of pointing out several of her prominent life rules was helpful in helping her to generalize her gains in one area to other life areas. Marie's self0esteem was enhanced by her taking control. Her depression lifted and, at follow-up, remained under control. The focus on her sexual behavior allowed greater success and for Marie to increase her sexual behavior with her husband.
As Marie felt better, she began exploring the possibilities of jobs closer to home. She eventually accepted a position commensurate with her education, experience, and salary requirements. Homework was emphasized with Marie; as a lifelong academic, she understood its importance. The therapist stressed that the therapy in the session was akin to the lecture part of a course, while the homework was the laboratory part of the course. Without the opportunity to try out the various ideas and behaviors in real life, the material from the sessions would have remained an abstraction for Marie.
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