General Psychology 110

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Karen's Case

Karen Rusa was a 30-year-old married woman and the mother of four children. Although she had been having anxiety-related problems for a number of years, she had never sought professional help prior to this time. During the preceding three months, she had become increasingly depressed; her family physician finally suggested that she seek psychological services;

For the past several months Karen had been experiencing intrusive, repetitive thoughts that centered around her children's safety. She frequently found herself imagining that a serious accident had occurred; she was unable to get these thoughts out of her mind. On one such occasion she imagined that her first son, Alan, had broken his leg playing football at school. There was no reason to believe that an accident had occurred, but Karen brooded about the possibility until she finally called the school to see if Alan was all right. Even after receiving their reassurance that he had not been hurt, she described herself as being somewhat surprised when he later arrived home unharmed. Karen also noted that her daily routine was seriously hampered by an extensive series of counting rituals that she performed throughout each day. Specific numbers had come to have a special meaning to Karen; she found that her preoccupation with these numbers was interfering with tier ability to perform everyday activities. One example was grocery shopping. Karen believed that if she selected the first item (e.g., a box of cereal) on the shelf, something terrible would happen to her oldest child. If she selected the second item, some unknown disaster would befall her second child, and so on for the four children.

The children's ages were also important. The sixth item in a row, for example, was associated with her youngest child, who was six years old. Thus specific items had to be avoided to ensure the safety of her children. Obviously, the ritual required some concentration because the children's ages changed. Karen's preoccupation with numbers extended to other activities, most notably the pattern in which she smoked cigarettes and drank coffee. If she had one cigarette, she believed that she had to smoke at least four in a row or one of the children would be harmed in someway. If she drank one cup of coffee, she felt compelled to drink four. Karen acknowledged the irrationality of these rituals but, nevertheless; maintained that she felt much more comfortable when she observed them conscientiously. When she was occasionally in too great a hurry to observe the rituals. She experienced considerable anxiety, in the form of a subjective feeling of dread and apprehension. She described herself as tense, jumpy, and unable to relax during these periods. Her fears were most often confirmed because something unfortunate invariably happened to one of the children within a few days after each such "failure." The fact that minor accidents are likely to occur at a fairly high rate in any family of four children did not diminish Karen's conviction that she had been directly responsible because of her inability to observe the numerical rules. .

In addition to her obsessive ideas and compulsive behaviors. Karen reported dissatisfaction with her marriage and problems in managing her children. Her husband, Tony had been placed on a complete physical disability 11 months prior to her first visit, Although he was only 32 years old, he suffered from a very serious heart condition that made even the most routine physical exertion potentially dangerous. Since leaving his job as a clerk at a plumbing supply store, he had spent most of his time at home. He enjoyed lying on the couch watching television and did so for most of his waking hours. He had convinced Karen that she should be responsible for all of the household chores and family errands. Her days were spent getting the children dressed, fed, and transported to school; cleaning; washing; shopping; and fetching potato chips, dip, and beer whenever Tony needed a snack. He argued, of course, that the stress of walking to the refrigerator would be unhealthy, although the merits of his reasoning-as well as his nutritional judgment-might easily have been questioned; The inequity of this situation was apparent to Karen, and extremely frustrating, yet she found herself unable to handle it effectively. She fantasized about abandoning the family; but she did not feel that she could follow through on this desire. .

The children were also clearly out other control. Robert, age 6, and Alan, age 8, were very active and mischievous. Neither responded well to parental discipline, which was inconsistent at best. Both had been noted to be behavioral problems at school, and Alan was being considered for placement in a

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special classroom for particularly disruptive children. On one occasion, Karen had been called to take Alan home early after he had kicked the school principal and told him to "go to hell." His teacher described him as always being out of his seat and constantly pestering the other children during study periods. The boys were also prone to minor physical illnesses; it seemed to Karen that at least one of the boys was always sick with a cold or some kind of infection. The girls were also difficult to handle. Denise, age 9, and Jennifer, age 11, spent much of their time at home arguing with each other. Jennifer was moderately obese. Denise teased her mercilessly about her weight. After they had quarreled for some time, Jennifer would appeal tearfully to Karen, who would attempt to intervene on her behalf. Karen was becoming increasingly distressed by her inability to handle this confusing situation, and she was getting little, if any, help from Tony. During the; past several weeks, she had been spending more and more time crying and hiding alone in her bedroom.

SOCIAL HISTORY

Karen was raised in New York City by Italian immigrant parents. She was the first of four children. Her family was deeply religious, and she was raised to be a devout Roman Catholic. She attended parochial schools from the first grade through high school and was a reasonably good student. Her memories of the severe practices of the church and school authorities were vivid. The formal rituals of the church played an important role in her life, as they did for the other members of her family. Beginning at a very early age, Karen was taught that she had to observe many specific guidelines that governed social behavior within the church (not eating meat on Fridays. going to confession regularly, etc:). She was told that her strict adherence to these norms would ensure the safety of her immortal soul and, conversely, that transgressions would be severely punished.

The depth of her belief and the severity of its consequences can be> seen in the following story, which Karen recalled during an early session. When she was eight years old, Karen and her classmates at school were to receive their first communion in the church. This is a particularly important and solemn occasion for Roman Catholics that signifies the child's advancement to adult status in the church community. Before the child is allowed to partake in communion, however, a complete confession must be made of all prior sins. Karen was told that she was to confess all of her sins, regardless of their severity or the time of their occurrence to her priest, who would prescribe an appropriate penance for her sins. She remembered her parents' and teachers' warnings that if she failed to mention any of her sins, her soul would be banished to hell for eternity. This threat was still vivid in Karen's mind many years later. Despite the terror aroused by these circumstances, Karen intentionally failed to tell the priest about one of her sins; she had stolen a small picture book from her classroom and was now afraid either to return it or to tell anyone about the crime. She lived with intense guilt about this omission for several years and could remember having occasional terrifying nightmares that centered around imagined punishments for not providing a complete confession. In subsequent years, Karen intensified her efforts to abide by even the most minute details of church regulations, but she continued to harbor the conviction that she could never atone for this mortal sin.

Karen remembered her parents as having been very strict disciplinarians. Her mother was apparently a cold, rigid person who had insisted on the maintenance of order and cleanliness in their household. Beyond her unerring adherence to religious rules and regulations., Karen's mother had kept the family on a very tight schedule with regard to meals and other routine activities. When the children deviated from these guidelines, they were severely punished. Karen's most positive recollections of interaction with her mother centered around their mutual participation in prescribed church functions. She did not remember her parents ever demonstrating affection for each other in front of their children.

Shortly after she graduated from high school, Karen married Tony. He was two years older than Karen and had been working as a stockboy at a department store. Their courtship was hurried. In retrospect, Karen wondered whether her interest in Tony had been motivated by a desire td escape from the confines of her parents' home.

Karen became pregnant two months after their marriage. During this pregnancy, she witnessed an unfortunate accident at her neighbor's apartment. While Karen was chatting with her friend, the woman's one-year-old daughter crawled off the porch arid was run over by another child riding a bicycle. The girl was seriously injured and remained in the hospital for several weeks. Shortly after this accident, Karen began experiencing repetitive, intrusive thoughts about injuring herself. At unpredictable but frequent intervals throughout the day, she would find herself thinking about jumping out of windows, walking in front of cars, and other similar dangerous behaviors. These thoughts were, of course, frightening to her, but she could not prevent their occurrence. When one of the thoughts did come into her mind, she attempted to get rid of it by quickly repeating a short prayer that she had learned as a child and then asking God for forgiveness for having entertained such a sinful impulse. This procedure was moderately successful as a temporary source of distraction, but it did not prevent the reappearance of a similar intrusive thought several hours later. These thoughts of self injury gradually disappeared after the birth of her first child, Jennifer.

When Jennifer was nine months old, Karen once again became pregnant. She and Tony decided to move to the suburbs, where they would be able to afford a house with a yard in which the children could play. Tony found a job as a clerk at a plumbing supply store. Karen stayed at home with Jennifer and tended to household responsibilities. Although she was proud of their new home, Karen became somewhat depressed during this period because she missed her old friends.

It was at this time that Karen began t6 be disillusioned with the church. Her distress centered around a number of reforms that had been introduced by Pope John XXIII and the Ecumenical Council. The Mass, for example, was no longer said in Latin, and non-clerical persons were allowed to administer various rites of the church. Similarly, church members were no longer admonished to give up meat on Fridays and other rituals were modified or completely eliminated. Most people found these changes refreshing, but Karen was horrified. The church's rituals had come to play a central role in her life. In de-emphasizing the importance of traditional rituals, the church was depriving Karen of her principal means of controlling her own destiny. She was extremely uncomfortable with these new practices and soon stopped going to church all together.

Karen's situation showed very little change throughout the next few years. By the time she was 25 years old, she had four children. She found this responsibility overwhelming and was generally unhappy most of the time. Her relationship with Tony had essentially reached a stalemate; they were not satisfied with their marriage, but they agreed to stay together for the children. Although they did not fight with each other openly, a sense of covert tension and estrangement pervaded their relationship. Tony refused to participate in what he considered to be unnecessarily rigid and complicated household regulations, particularly those dealing with the children's behavior. Karen had established very specific guidelines for meals, bedtime, and so on, but found that she was unable to enforce these rules by herself. She remained distant from Tony and resisted most of his attempts to display physical affection. They did maintain a sexual relationship but it lacked spontaneity and genuine warmth.

Karen believed that sex was her marital responsibility, so she was willing to perform or acquiesce as necessary. Since the birth of their fourth child. Karen had been particularly anxious about becoming pregnant again. She refused to use any form of artificial birth control, which was, of course, contrary to the teachings of the church. Their sexual encounters were therefore very carefully scheduled to avoid the days surrounding ovulation. This scheduling became increasingly complex until Karen finally settled on two four-day periods pre-ceding and following menstruation during which she was willing to have inter-course with Tony. When they did engage in sexual activity, it came to follow a careful, routine sequence that was usually limited to that minimum physical stimulation necessary for Tony to achieve orgasm. On most occasions, Karen described herself as being tense and anxious at these times; she did not view herself as an active participant. She was not, however, totally inorgasmic; she did occasionally experience an orgasm during intercourse and was able to reach orgasm through self-stimulation. Masturbation made her feel quite guilty, and she did not discuss this activity with Tony. Thus, overall, Karen was chronically unhappy and generally dissatisfied with her life, but she nevertheless clung to her miserable surroundings and established patterns of behavior out of fear that any change would be for the worse.

This unhappy yet tolerable equilibrium was disturbed by Tony's deteriorating health. One day, while he was working at the store, he experienced sudden chest pains and numbness in his extremities. Recognizing these symptoms as serious in nature (he had had high blood pressure for years and was therefore well informed in this regard), Tony asked a friend to drive him to the hospital. His experience was diagnosed as a mild heart attack. Further testing revealed serious structural abnormalities in his heart. He was eventually discharged from the hospital given a complete medical disability, and laid off from his job.

Karen became more and more depressed after Tony began staying home during the day. It was during this time that her fears about the children's safety became clearly unreasonable and she started performing her counting rituals. Karen could not remember when she first began checking the order of items on a shelf or counting the number of cigarettes she smoked in sequence. She did realize that her situation was desperate because she felt that she had lost control of her own behavior and experienced considerable anxiety whenever she attempted to resist performing the rituals. At this point she finally decided to seek professional help.