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International Journal of Existential

Volume 2, Issue 1, 2008


Psychology & Psychotherapy

THE CASE OF “PAULA”: AN have a normal life." She acknowledged that


antidepressant medication assisted in reducing her
EXISTENTIALLY BASED depressive symptoms but believed that taking the
TREATMENT APPROACH TO medication made her feel like a "weak person."
CHRONIC DEPRESSION For this reason, Paula reported that a primary goal
for therapy was the discontinuation of her
Joanna Lipari psychotropic medication, but she was willing to
delay any decision until our therapeutic
Abstract relationship had matured. Additional therapeutic
The case of “Paula” presents a multi-modal goals identified by Paula included: (a) the
existentially based treatment approach as it was management and reduction of depressive and
applied to a case of chronic depression. This anxious symptoms, (b) to improve her ability to
clinical case history documented the presenting form and maintain interpersonal relationships, and
problem, case history, case formulation and (c) to “get to the point where I can do my art."
treatment. Because of Paula's ongoing depressive and
anxious symptomatology, coupled with a history
PRESENTING PROBLEM AND RELEVANT of Major Depressive Episodes, Paula was
PERSONAL HISTORY monitored for suicidal ideation and intent on an
Paula,1 a 51-year-old divorced Caucasian female, ongoing basis throughout treatment. Twice during
initially presented for therapy at a university clinic treatment with this therapist, Paula experienced
in a California city for ongoing symptoms of major depressive episodes, with each lasting
depression and anxiety related to failed career approximately two to two-and-a-half weeks.
ambitions, employment stress and difficulties with Although Paula denied suicidal ideation or intent
interpersonal relationships. Paula reported an during these periods, additional care was taken to
extensive history of previous psychological ensure safety.
treatment from 1973 through 1999. The university GOALS OF TREATMENT
clinic records indicated that Paula first sought Depressive and anxious symptomatology appears
treatment in 1997, and participated in cognitive- ubiquitous in the outpatient clinical population.
behavioral treatment (CBT) from January 1997 to Some mental health professionals suggest that
June 1998 (38 individual sessions). Her CBT cognitive approaches that have been validated
treatment was terminated when her first therapist through empirical research to reduce depression
completed her doctoral rotation and was no longer and anxiety, should be the treatment of choice
able to provide services and Paula was transferred, (Beck, 1995). While this point of view is not to
without a break in continuity, to a second clinic be discounted, existential psychotherapy suggests
therapist who saw Paula from September 1998 to that the reason for depression and anxiety differs
July 1999 for a total of 37 individual sessions. with each individual though the symptoms may
When the doctoral rotation was concluding for this appear similar (Schneider & May, 1995). Further,
second therapist, Paula expressed interest in some causes may be due less to an event or
continuing therapy. situation (e.g., death of a loved one), and more
In October 1999, Paula met with this therapist, with profound questions of identity and meaning
who would now be the third therapist Paula was (e.g., who am I and what am I meant to do?)
assigned at the university clinic. At this time, (May, 1958b). In fact, empirically based
Paula reported that she was still experiencing practitioners point to the added efficacy of
ongoing symptoms of depression and anxiety. cognitive therapy, when existentially oriented
Paula expressed a belief that therapy was questions are addressed (Addis & Jacobson, 1996).
"necessary to keep [her] together" but was losing Paula's persistent depressive and anxious
hope that she would "ever be a normal person and symptomatology, despite years of counseling and

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International Journal of Existential
Volume 2, Issue 1, 2008
Psychology & Psychotherapy

extensive treatment in both cognitive-behavioral and desires for the future, rather than a
and psychodynamic therapeutic modalities, capitulation to patterns from the past (Sahakian,
suggested that Paula's difficulties may have 1976). Specifically, in Paula's case, this meant
become chronic and part of her characterological reinforcing her artistic identity while
structure. Further, one of the most salient features simultaneously being empathic to her need to look
of her dysphoria was the anguish she experienced for work at something that was less fulfilling, but
by not being an artist, either in the eyes of the that could support her daily living needs, and,
world, or in her ability to continue creating works. ultimately, fund her artistry. In essence, the
The dissolution of such a core identity left Paula therapeutic questions became: (a) How can Paula
with little resources to handle the stresses of the merge artistry and the need to make a living, and
present, and reconcile difficulties from the past. (b) if that is not possible, how could the therapist
An existential perspective was adopted to enable her to live constructively with existential
explore issues of identity, meaning and purpose. dysphoria?
This perspective served as a base from which to CLINICAL FORMULATION
integrate other theories and techniques, primarily In deciding the best formulation for Paula's
from the domains of cognitive behavioral and treatment, this therapist considered a number of
psychodynamic therapies, in order to gain aspects of the case. At first glance, Paula would
additional understanding of core identity issues appear a good candidate for a psychodynamic
and address the management and reduction of her (Kohutian) approach. Clinic notes from previous
depressive and anxious symptomatology. While therapists suggested that Paula exhibited certain
eclecticism sometimes appears to translate as behaviors that were consistent with psychodynamic
doing whatever comes to the therapist's mind, a formulation, namely, that Paula had a fragile self-
truly eclectic approach is actually one that seeks to identity, and was vulnerable to fragmentation
utilize different approaches, such as cognitive and under stress, and suggestive of arrested emotional
existential therapies, in a coordinated manner development. In plain language, Paula often
(Ottens & Hanna, 1998). This approach appeared appeared like a 3-year-old, stuck squarely in the
particularly relevant in that Paula made progress Oedipal period, in a fierce battle with the world as
and some relief of symptomatology from her "mommy', both seeking approval (merger) and
previous therapies. Integration of other therapeutic independence (individuation). Thus, Paula did not
interventions enabled the therapist to build on experience a true sense of self, but sought others
what had previously been accomplished in therapy, to perform a mirroring self object function.
as well as put these interventions (e.g., cognitive Additionally, Paula's current social support system
assignments), within a larger context that might be was extremely limited. After her divorce and some
more meaningful to Paula. failed relationships, Paula discontinued dating and
After rapport was established, the initial goal of socializing. Her friendships were limited and often
treatment was to attempt a phenomenological strained, and her relations with her family
understanding of the inner world of the client members were difficult.
(Merleau-Ponty, 1962; Schneider & May, 1995). Although this psychodynamic conceptualization
Therapeutically, the therapist attended to three had decided merit, it did not fully capture the
aspects of existential therapy: (a) existential complete data set from this case, i.e., that Paula
neurosis, e.g., Paula's inability to see meaning in identified herself as an artist, but had been unable
life, (b) existential 'encounter', e.g., the inner to create art for over seven years. There are two
experience of the relationship between client and striking issues stemming from the data. First,
therapist, and finally, (c) kairos, or a critical Paula's core self was so fragile that it ceased
decisive point when an intervention might be more operations (not painting), becoming disowned, and
readily accepted by Paula (Ellenberger, 1958). The second, that the particular "self” with which she
overarching goal of this approach is to enable the identified is dissuaded from revival because it is a
client to make life choices that are based on hopes "self” (the artist) that is not necessarily supported
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Volume 2, Issue 1, 2008
Psychology & Psychotherapy

by the American culture of which Paula is part. framework with which to approach the therapeutic
Existential theory is heuristic and aptly addresses situation.
this issue of personal meaning, as well as the COURSE OF TREATMENT
responsibility of the individual to make choices Paula participated in 65 weekly psychotherapy
and exercise personal freedom to create the life sessions from 1999 through 2001 at the university
she or he deems worth living (Yalom, 1980). In counseling center. Diagnostically, Paula met
essence, the individual is torn between ontological criteria for Dysthymic Disorder, Early Onset
anxiety (fear of the future and the unknown), and (300.4) and Generalized Anxiety Disorder (300.2)
ontological guilt (regret at what might have been) within the Diagnostic and Statistical Manual of
in her or his struggle to become fully authentic Mental Disorder, 4th ed. (DSM-IV). Paula also
(true to her or his own being) (Heidegger, 1962). had a history of Major Depressive Disorder, but
From this theoretical perspective, the inauthentic did not meet DSM-N criteria at the time of intake
person is one who runs away from personal and with this therapist.
individuating choices, eschews personal freedom In the first two sessions, Paula discussed her
and responsibility, and capitulates to a world view disappointment that "years of therapy" had not
that may or may not be in accord with her or his "fixed" her psychologically. She expressed
own personal ideals (Heidegger, 1962). The discouragement regarding the therapeutic process,
aptness of this conceptualization for Paula is especially because she felt she had "tried so hard"
highlighted by her own continued report in clinical to learn through the process. This therapist
records that she felt "out of step" with the world suggested to Paula that there might be another
around her, particularly her family, that never way to look at therapy, rather than as being solely
supported her artistic passions. Therefore, it was remedial, that is, trying to correct problems and
hypothesized that Paula’s depressive and anxious "fix neuroses". Instead, this work might better be
symptomatology stemmed from Paula's conceptualized as being exploratory, creative, and
accentuated sense of ontological guilt for what life enhancing. In essence, it was suggested that
might have been, but was now too afraid to Paula consider therapy as chronicling the progress
choose, resulting in an inability to tolerate of becoming a "hero" in her own life.2 Paula
ontological anxiety. responded to this conceptualization by stating that
This formulation in no way negated the it gave her a sense of renewed hope, and made
substantive psychodynamic formulation outlined her feel like she was not "damaged goods."
above. In fact, an existential conceptualization This initial positive response to an overarching
only deepened the meaning and understanding of existential concept suggested that this approach
the psychodynamic one. That the two might benefit Paula. In the next two sessions, the
conceptualizations could operate simultaneously therapist assisted Paula in exploring her thoughts
and be integrated into a singular approach is and feelings about her artwork and the possible
supported by the work of Otto Rank, who connection to her present state. Paula reported her
interpreted psychodynamic concepts such as problems stemmed from her mother, who never
attachment and individuation as being in part approved of her artistic ambitions and who "only
existential dilemmas, namely fear of death prepared [Paula] to be somebody's wife." Paula
(limitedness through merger) and fear of life believed that her relationship with her mother
(anxiety about separating and individuating) contributed to an ongoing Weltschmerz,3 in that
(Becker, 1973). Thus, formulating Paula's case by she believed what she desperately wanted most in
using an existential approach, appeared to be the life as an artist was impossible in a world that
most appropriate because it could capture the expected her to be "a good working stiff and
richness of Paula's difficulties as well as her somebody's wife." An exploration of Paula's sense
phenomenological experience, while affording the of personal meaning (i.e., Paula was an artist
therapist a flexible, structural theoretical living in America), Paula revealed that she had not

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Volume 2, Issue 1, 2008
Psychology & Psychotherapy

drawn, or painted, or created any piece of art for she was seeking previously. She reported that
over seven years. She stated that when she thought before embarking on an understanding of personal
of getting her art supplies out of the closet, she meaning vis-à-vis her art, she had felt like "an
felt intensely "nauseous." amoeba swimming aimlessly in a sea of
At this point, while the focus remained depression." Now, however, she understood her
existential in that the existential issues of identity, symptoms as part of a larger existential crisis.
personal meaning, freedom and choice were This understanding gave her a feeling of hope for
central in the session, a multi-theoretical technique the future, although she acknowledged feeling
approach was employed to guide Paula on this "very scared" about the challenges facing her.
journey. For example, cognitive restructuring During the middle phase of treatment, Paula
(Meichenbaum, 1977) was introduced as a continued creating art, although inconsistently.
technique to actively challenge and re-orient When experiencing anxiety and/or depression
Paula's defeating self-talk. Further, because Paula's regarding the stress of work situations or
sense of self was tenuous at this juncture, interpersonal relationships, Paula would cease
techniques from Kohutian theory, such as doing her artwork. At this point, the therapist
mirroring and monitoring of disintegration anxiety introduced therapeutic techniques from other
and fragmentation (Wolf, 1988) provided the disciplines that were more aggressive inasmuch as
therapist concrete tools to assist in strengthening Paula's sense of identity was growing in
Paula's sense of self and enable her to forge ahead definition, strength and resiliency. The first added
with our existential explorations. In other words, technique was the disputation of irrational beliefs,
when the intensity of the existential issues made it which is a cognitive technique from Ellis' REBT
difficult for Paula to "stay in the room" therapy (Dryden & Ellis, 1988). This technique
psychologically, these additional techniques and encourages the therapist to actively dispute and
theoretical concepts would assist the therapist in challenge the client's "irrational" beliefs about
providing concrete respite, as well as an herself or himself, the environment, and the future.
opportunity to increase resiliency. Invariably, This technique was especially useful when Paula's
Paula would re-orient through these techniques and anxiety would be stimulated and she would
then be willing, and indeed, curious to proceed devolve into ever increasing fear and worry.
with deeper discussions. In subsequent sessions, Introducing the disputation of irrational beliefs
Paula expressed feeling stronger, more resilient assisted Paula in understanding her tendency to
and eager, and "less like a loser;" although she catastrophize beyond what was most likely going
still experienced ongoing anxiety and depression to happen. Additionally, Paula would utilize
related to work and interpersonal relationships. catastrophizing to regress into repressive affect as
As the sessions progressed, small art a defense against the real issue. In other words,
assignments, such as sketching on plain paper with when the issue became meaningful within the
a pencil, were initiated. During this phase of session, Paula might become anxious and fearful.
treatment, her anxiety and depressive symptoms Because this anxiety was uncomfortable, Paula
would vary in intensity, in part due to situations would defend against it by "giving up" and being
regarding employment searches. By Session # 10, reduced to uncontrollable crying. Certainly, Paula
Paula had created her first piece of art, a pen and was experiencing pain in those moments, but that
pencil drawing. This creation represented a turning pain was also in service of defending against
point in therapy, a kairos. From this point forward facing the meaningful issues that she sought to
(approximately mid-December 1999), Paula began resolve.
to explore her feelings of depression and anxiety The second added technique comes from short-
within the context of her renewing identity as an term psychodynamic therapy (Davanloo, 1988).
artist. This context provided Paula with the "root" This technique places consistent pressure on a

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Psychology & Psychotherapy

client's defenses (e.g., anything that gets in the throughout the day. She has continued taking this
way of the client saying what she or he is thinking medication at this dosage to the present.
and feeling), until the client's defenses are At this time, Paula moved into an important new
exhausted and relinquished to the authentic phase of existential development. She began
thoughts and feelings. This technique was regularly producing art. Paula also outlined hopes,
especially useful with Paula in this phase of dreams and goals for the future, and began to
therapy because of her tendency to digress when acknowledge her role as creator of her life, by
the therapy moved into uncomfortable areas. This accepting the role of responsibility, freedom and
deflection served to derail the emotionally laden choice as determinants of one's life (May, 1958a).
therapeutic process. By utilizing Davanloo's (1988) She initiated interpersonal relationships with
technique of pressuring the defenses, Paula would members of her family with whom she had not
be able to access the meaningful material. spoken, most notably with a nephew. This new
In October of 2000, Paula experienced a major relationship with her nephew, his wife, and their
depressive episode, which was precipitated by small toddler-age child resulted in Paula
difficulties at one of her free-lance assignments, experiencing a new role as "aunt" which gave her
which resulted in her being terminated. Following immense joy. Although Paula would experience
that job, Paula found it difficult to continue anxiety about this deepening involvement with
seeking employment opportunities. Despite the family members, she nevertheless continued to
severity of her depressive symptoms, Paula pursue the relationships, which have grown
continued to work vigorously in therapy. This considerably over the past year.
depressive episode was a second kairos in the In the summer of 2001, Paula experienced her
therapeutic course. Since Paula had experienced a second major depressive episode while in
relatively long period of approximately one year of treatment with this therapist. Again, the precipitant
feeling like she was making "progress" and had was work related. Paula felt defeated by the stress
renewed hope for the future, the intensity of of a deadline-laden free-lance job, and she
depression from this episode made Paula even devolved into depression. This depression lasted
more determined to change. Therefore, she was exactly two weeks and was markedly different
more open both to the depth and breadth of the from her previous depressive episodes. Paula
existential exploration, as well as to entertaining related in therapy that she was aware that it was
alterations in her medication, a previously resistant an "episode" while it was happening, that it was
topic for Paula. finite, and that she could "bounce back". These
Prior to the onset of this depressive episode, the realizations were a major shift in Paula's previous
therapist had been concerned that Paula's views of herself.
complaints of gastrointestinal distress might be During the 25 months of treatment, Paula has
related to the type of anti-depressant medication increasingly become more confident with her
she was taking. After the severity of depressive identification as an artist, as well as feeling more
symptoms abated, Paula agreed to a consultation able to handle her ongoing dysphoria and, at
and ongoing pro bono treatment with a psychiatrist times, major depressive episodes. Ultimately,
arranged by the therapist. This psychiatrist therapy has been about Paula learning to accept,
performed a complete psychiatric evaluation on like, and live with who she is and the world as it
Paula and determined that in fact, the Zoloft might is, rather than remediating flawed aspects of
have been the cause of her stomach upset. Her herself to fit some imagined profile of "normal."
medication was switched at that time to Prozac Paula reports understanding that, though she has a
(20 mg). Within 3 weeks, Paula's stomach tendency to become anxious and depressed, these
problems disappeared. In addition, Paula reported feelings are only a facet of who she is, an attribute
feeling "better," with improved mood consistently with which she can learn to adjust and actually

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use in a positive sense. As she has jokingly than I could have, and benefited the client more
explained in a session, "You [the therapist] are than I would have, had I not undertaken an
short, and I'm depressed. So what." aggressive, integrative approach. Although I would
CRITICAL EVALUATION like to take credit for the immense progress this
This was a challenging, rewarding and client has made, I cannot. It solely has been
instructive case. My overall evaluation of my through her own willingness and determination to
handling of this case is that I have made more construct a life of her own choosing.
mistakes than I should have, less interventions

References

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Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press.
Becker, E. (1973). Denial of death. New York: Free Press.
Campbell, J. (1971). A hero with a thousand faces. Princeton, NJ: Princeton University Press.
Davanloo, H. (1988). The technique of unlocking the unconscious, Part I. International Journal of Short-
Term Psychotherapy, 3, 123-159.
Dryden, W., & Ellis, A. (1988). Rational-emotive therapy. In K. S. Dobson (Ed.), Handbook of cognitive-
behavioral therapies (pp. 214-272). New York: Guilford Press.
Ellenberger, H. (1958). A clinical introduction to psychiatric phenomenology and existential analysis. In
R. May, E. Angel, & H. Ellenberger (Eds.), Existence: A new dimension in psychiatry and psychology
(pp. 92-126). New York: Basic Books.
Heidegger, M. (1962). Being and time (J. Macquarrie & E. Robinson, Trans.). New York: Harper & Row.
Kohut, H. (1984). How does analysis cure? Chicago: University of Chicago Press.
May, R. (1958a). Contributions of existential psychotherapy. In R. May, E. Angel, & H. Ellenberger
(Eds.), Existence: A new dimension in psychiatry and psychology (pp. 3791). New York: Basic Books.
May, R. (1958b). The origins and significance of the existential movement in psychology. In R. May, E.
Angel, & H. Ellenberger (Eds.), Existence: A new dimension in psychiatry and psychology (pp. 3-
36). New York: Basic Books.
Meichenbaum, D. (1977). Cognitive behavior modification: An integrative approach. New York:
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Endnotes
1.For purposes of confidentiality and anonymity, the name of the client has been changed, with “Paula”
serving as the pseudonym. Further, identifying facts in this case have also been changed to ensure
confidentially.
2.The allusion is to the work of Joseph Campbell (1971), author of Hero with a Thousand Faces and
other works regarding the use of myth. His work was made generally popular by the PBS Bill Moyer's
series on television.
3.The term Weltschmerz was coined by Jean Paul Sartre in 1827, meaning “world pain.”