Thelma E. swept into the office carrying a large blue shopping bag from Tiffany's in one hand and an oversized alligator handbag in the other. Her petite frame was dwarfed by them. With a great sigh, she unloaded her burden. Placing the bags on the floor, she scanned the office, trying to decide which seat to claim, finally deciding on a large recliner situated across from the therapist's chair. She proceeded to push the chair closer to the therapist's, sat down, pulled the lever to extend the footrest, and began.
"Whew. I am so glad to be here. I absolutely need to talk with someone. I'm having such problems and I'm driving my daughter nuts. She was the one who told me I absolutely had to talk to someone. She's tired of listening to me. She probably thinks I'm crazy. Anyway, she can't give me the advice I really need. But I'm counting on you. I really don't know what to do. I'm like a kid, but this is really serious." She takes a breath and continues.
"I brought you pictures," pointing to the blue bag on the floor, "so you could see him. He's really a doll. And maybe you can help me understand what's going on and tell me what I should do."
Thelma is a 71-year-old woman who appears to be in her mid-50s, and dresses as if she were in her 20s. She is very pretty in a dolllike way. Her hair is an unnatural shade of red. She wears it sleek and smooth with bangs just barely touching her eyebrows. When she speaks, she often sweeps the bangs aside in a little girl gesture. She bats her eyes and giggles, especially when she becomes excited or anxious. Good genes, cosmetic surgeries, extravagant self-care, and skill with makeup enable her youthful appearance. She and her daughter, in her 40s, are typically taken to be sisters. This error is consistently pleasing to Thelma.
Thelma, growing up, was always considered a dramatic child. She was prone to tantrums, petulance, and great gushing tears at the least provocation. She was also adorable. Her high spirit and passion were expressed with hugs and kisses that would make people feel warmly toward her. As an adult, she came to give lavish gifts and to acknowledge every event with cards and flowers. She was especially fond of sending balloon bouquets when these were popular. Balloons were favorites of hers as a child.
As a young child, Thelma lost her mother suddenly in an automobile accident. One night she went to bed and awoke the next morning without a mother. Her father was overcome by grief following the loss of his wife and soothed himself by further throwing himself into his work and consuming considerable alcohol at home after work. Thelma was mostly cared for by her maternal grandmother. A nice and well-intentioned woman, she was dealing with her own grief at the loss of her daughter. While she loved her granddaughter, she was also resentful at being called on to be responsible for a child at this stage of her life.
As adorable and outgoing as Thelma appeared, underneath she was a lonely little girl who was unattached at a deep level and terribly fearful of again being abandoned by whomever she loved, as she had been by her mother. To counter this she became more endearing to engage the overt expressions of love, and more demanding, to test that love. She danced, hugged, and tantrummed her way around the hearts of others.
A second wounding abandonment came just as Thelma began adolescence. Her father became involved with and then married a divorced woman with a son 3 years older than Thelma. Bruce was a lanky adolescent. He was as quiet and careful as Thelma was outgoing and impulsive.
Thelma, hungry for the love and attention of a mother, tried to get this from her stepmother by doing what she knew best how to do: smile, prance, hug, and giggle, but to little avail. Her stepmother was indifferent to Thelma's charms, valuing instead the quiet cen-teredness and studiousness of her son. She was in no way cruel to Thelma, but mostly just tolerated her. When she did show positive regard, it was for the benefit of her husband's approval as she was determined to make this second marriage work.
Thelma's father was predictably oblivious to her presence, let alone to her maturation. He was unaware of Thelma's shift away from him and his wife toward seeking the attention of her older brother. Bruce was initially flustered by her attention and flirta-tiousness, then engaged by it, and ultimately aroused.
Thelma remains unclear about what actually transpired between her and her stepbrother. What is clear is that something did transpire. Although the duration and precise specifics of their involvement are vague in her memory, Thelma did get from Bruce the love and attention she sought. She reports she was "a happy teenager" and claims to have missed her brother very much when he went off to college, marking the end of their special relationship.
From this relationship, Thelma refined her skills at attracting the attention of boys, and later men, to reassure herself that she could procure the love she needed, and that the resources would not be depleted. She was not an apt student, but completed a junior college course in retailing. She took a position after graduation as an assistant manager of a cosmetics section in a department store. She worked for only a few years before marrying a hardworking, somewhat withdrawn, and slightly older man who thought he had won the prize of his life with Thelma's acceptance of his marriage proposal.
Thelma was content being a housewife and staying at home to raise her only child, a daughter, Elaine. She had a broad circle of friends and was considered the life of parties, her own and others. Her relationship with friends was, however, notable for her often being in conflict with someone. Thelma would become furious at any slight or mildly critical comment, and fly into a rage, talking against one person to others, and calling the offending individual and letting him or her have it. When the world turned mean and ugly, Thelma turned to her husband for comfort and support, engaging him as his little girl, weeping and trembling. He would respond, soothe her panic, and, after the crisis had abated, she would return to essentially ignoring him. He would await the next crisis, which could be counted on to arise.
When her husband was in his mid-60s, he suffered a major heart attack, and spent some months recovering in Florida. Thelma felt chained to him during that period, unused to sustained proximity and not liking it. They owned a small condominium in Florida that they had used during the winter months. Thelma would spend most of the winter there, preferring the sun to the snow. Their pattern was for her husband to join her for a 2-week vacation sometime during the season. The rest of the time, they would stay in contact by phone.
Thelma quickly established herself at the center of the social life of the Florida community. Playing tennis and bridge, she was a welcome addition to the condo complex and the country club. She was younger, and appeared even younger, than many of the residents. She was attractive and dressed provocatively. Thelma aroused the jealousy of some of the women, and the attention of some of the men.
Soon after her husband had recovered and returned to work and their customary geographically separated relationship, Thelma began an affair with a recently widowed man that continued over several winter seasons. This was a secret from her husband, but not from most others. When her lover found a new partner, and became engaged to be married, he broke off the relationship with Thelma. She became absolutely enraged, feeling at once both abandoned and humiliated by the rejection. She had never considered that her lover might, in time, want something more than a winter affair. Thelma had her first major depressive episode around that time. She was treated by her internist who prescribed initially a tricyclic anti-depressant. As the episode resolved, she was prescribed an anxi-olytic (described by Thelma as a "mother's little helper") that was popular at the time. Psychotherapy or counseling was not suggested to Thelma.
Other brief affairs followed. None were serious, but collectively they served to reestablish Thelma's confidence in her ability to attract the attention of men and to heal her wounded self-esteem. When her husband suffered a second heart attack, which he did not survive, Thelma found herself a grieving wife and an available widow. She sold the family home in the suburbs and bought a small condo in the city. She sold the small condo in Florida and bought a larger unit in the same community. At this point, she began to live in Florida for 9 months of the year, and in the city for 3 months, using it also for occasional weekends to visit her daughter, now married and the mother of two children. Thelma did not envision herself as a grandmother, but frequently sent the children gifts and cute cards signed, "With love from Thelma."
Life was easy. Thelma was sparkly and popular and had lots of activity. Between tennis and bridge and dinner parties, she was busy and content. Then she met a man at the club who, as she recounts, "Just blew me away. He was so handsome. I got tongue-tied just making small talk with him. I felt like a kid all over again."
His name was Mark, and he and his wife owned a condo in a nearby community and had recently joined the country club. His wife never appeared at the club. Thelma pursued Mark vigorously, and soon they would be playing mixed doubles tennis and having postgame and predinner drinks at the club bar.
In time, Thelma learned that Mark's wife was seriously ill. She was homebound and required 24-hour care. Mark had hired care for her during the days and cared for her himself at night. Soon a sexual affair developed. They would meet at Thelma's home during the day. As Mark was unavailable in the evening, Thelma maintained her usual social network and activities. She says about Mark, "He's the love of my life. I waited all my life to really fall in love. He is so sexy, and we like the same things. We even have the same favorite restaurant. We're so perfect together. I just don't get it."
They kept in touch by phone during the summer months when each lived in a different city, an airplane trip distance apart. During the second summer, Mark's wife died. Thelma says, "This put me in a strange spot. I tried to be supportive. I sent him nice cards with sweet messages, but he didn't seem to want to talk to me. I started having trouble even reaching him. I'd get the damn machine, and he wouldn't return some of my calls; most of my calls, really. First when I heard she died, I thought that after a decent period we could come out as a real couple. I knew we were perfect together. I thought we'd get married. I'm not sure about that, but at least we'd be a couple. We never talked about it, of course, because his wife was still alive. But I knew he felt the same way I did. So I couldn't understand why he didn't seem to want my support. I figured he needed time. So I damn well gave him time, and then I really got mad. So I left a few messages on the answering machine that I shouldn't have. He called me once and said for me to back off, please. If I really cared, I would leave him alone for now. So I hung on to that, for now like it was a lifeline." At this point she broke into tears and curled herself into a ball in the big recliner.
Thelma has presented with a lifelong pattern of thinking, feeling, and behaving consistent with a diagnosis of Histrionic Personality Disorder (HPD). Her presentation, while reflecting the unique contexts and relations of different life stages, continues to reflect the pathology and causes her and others with whom she in relationship considerable distress. Consider the following diagnostic criteria for HPD, and how these are expressed by Thelma.
She is melodramatic and requires being the center of attention. Only when all eyes are on her, can she connect with others and, even then, it is often for the purpose of attracting attention to herself or endearing them to her.
Although not grossly inappropriate, her physical presentation and clothing choices are patently seductive. As she has aged, her sense of style, fashion, and makeup have not kept up. She continues to dress and present herself in a flirtatious, overly youthful manner.
She is emotionally labile, shifting rapidly in her emotional expressions. Her face and body are hyperexpressive, continually in motion exhibiting joy, sadness, disbelief, emotions easily read like shifting sands. This is mirrored by her speech and language—colorful and notable for hyperbole.
Most relevant perhaps to her current crisis is a propensity to imbue relationships with much greater intimacy and value than is warranted.
The psychotherapy treatment plan needs to focus on consideration of the specific stressor, or precipitant. In this case it is her perceived rejection by Mark. The realities are that Thelma and Mark have been in a sexual relationship for 2 years and that Mark's wife of more than 45 years has recently died. His relationship with Thelma, while meeting his needs for companionship during this trying stage of his own life, held no promises of future plans. He enjoyed Thelma, they were easy and comfortable with each other and enjoyed good times. However, Mark could not envision life beyond his wife's death, and certainly not what he might want in a life partner at some future time.
Although never discussed directly with Mark, Thelma adopted her fantasy as reality, and planned for the two of them to emerge as a committed couple following a reasonable period after his wife's death. Until that time, Thelma envisioned herself as his life support; waiting patiently in the wings until he was ready to come forth to proclaim his love and fidelity. However, Mark did not behave in accordance with her fantasy script. His grief for his wife was real and deep. Their relationship had been far more intimate than the one he believed he could develop with Thelma.
Thelma responded to his rejection initially with anger and then depression. She developed neurovegetative symptoms including loss of appetite and weight, trouble sleeping, and loss of pleasure and ini tiative. She was also tearful, and alternated between periods of agitation and lethargy.
The treatment incorporated psychopharmacology. Her anxi-olytic was gradually discontinued and an antidepressant medication was introduced. Thelma was also prescribed a nonbenzodiazepine to help her sleep. The aim of the talking therapy included four sequential segments.
The therapist would serve as a reliable presence for comfort and support, and to diminish her sense of helplessness. This would enable Thelma to restore her self-esteem through reviewing past competencies, strengths, and successful relationships.
To revisit the events leading to and comprising this crisis, as both a specific occurrence and as an exemplar of a pattern, Thelma would be encouraged to consider how she shifts fantasy to reality and to achieve some appreciation of another's phenomenology, in this instance, Mark's. She would be led to understand that while another's experience could affect her, it was not about her, and usually not intended to hurt her.
Thelma would be coached around recognizing the different depths and qualities of relationships, and how she might distinguish between them. She would also be coached to recognize her escalating affect and check it against the reality of experience.
Another essential aspect of the treatment would be to help Thelma achieve a sense of control when she feels her feelings are controlling her behaviors. To that end, stress management techniques would be introduced into the sessions and as lifestyle change homework between sessions.
The frequency of the therapy sessions was established in accordance with Thelma's clinical needs, but the frame of the therapeutic contract was held firm. This is especially important in work with patients with personality disorders. As her feelings of helplessness and anxiety receded, her sense of self-cohesion and efficacy became restored, and the between-session intervals were extended. In time, she planned to return to Florida and a last session was scheduled. Rather than a good-bye, a check-in visit was scheduled for during the summer when she would next be in the area. At this time, she would be able to report back to the therapist about how she was faring and how she was using her new learning. At this time, she appeared well and fit and said "I'm feeling like myself again, only better. Maybe a little more grown up. Anyway, thanks for your help. You've been a doll."
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