The therapist (a male) obtains a complete history, paying particular attention to Ms. B's
interpersonal relationships. He uses open-ended questions in the first session to find out about her goals for treatment and her expectations of the therapist. It quickly becomes clear that she doesn't feel comfortable taking the initiative but rather expects the therapist to tell her what to do. This early manifestation of transference informs the therapist about patterns of compliance and pleasing behavior in relation to male authority figures.
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In the second session, Ms. B reveals that her husband complains about feeling neglected and unappreciated. He spends a lot of time on the Internet, on eBay, and usually doesn't come to bed until after she is asleep. Ms. B rationalizes this by saying that he has a stressful job and deserves to relax after work. The therapist decides to utilize Sifneos's STAPP approach to confront Ms. B's avoidance of the problems in her marriage. He now combines open-ended with forced-choice questions, which arouses Ms. B's anxiety but also reveals Ms. B as "Daddy's little girl" who consults her father on all decisions, which leaves her husband feeling sidelined and unimportant.
Ms. B's mother is submissive and passive-aggressive, reacting against her husband's dominance with back pain that leaves her periodically bedridden. Ms. B's father habitually turns to Ms. B for companionship, complaining bitterly about her mother's inadequacies as a wife. When Ms. B talked to her father about her husband's excessive Internet use, her father replied that he never thought that her husband was good enough for her—after all, dentists aren't real doctors—but that she shouldn't complain because she has a good life. Ms. B's father had worked long hours in a blue-collar job and always felt envious of her husband's success.
From very early on, Ms. B deployed defenses such as repression, reaction formation, isolation of affect, and rationalization to avoid her negative feelings in order to maintain her parent's positive regard, especially her father's. The therapist's persistent exploration of Ms. B's feelings about her husband's nighttime Internet activity is actively defended against as she continues to maintain that her husband is a good provider and that she is content even as their sex life dwindles to nothing:
Therapist: How do you feel about competing with eBay for your husband's attention?
Ms. B: Well (laughs nervously, somewhat taken aback), I wouldn't say I am competing! He collects antique toy soldiers, something he enjoys a lot, and he works hard—he should have some fun, too.
Therapist: I agree, but it seems that this fun is coming at your expense—you're working extra hard at your job, taking care of your parents and your sons out of your own paycheck, and he's staying up late buying expensive toys while you go to bed alone.
Ms. B: It's not that bad . . . I have a good life, nothing to complain about really . . . not like some people who have real problems.
Therapist: I'd say having no sex life is a "real" problem, wouldn't you?
Ms. B: Well . . . maybe that's normal . . . after all, we're not young anymore. He's a good, hard-working man . . . at least he's home and not out like some husbands.
Therapist: Sex is a normal part of a healthy marriage throughout the life cycle. Are you really satisfied that while he's home he ignores you?
Ms. B (looking tearful): We used to be closer that way, I guess, but . . . I spend most evenings taking care of my mother when she's not feeling well—I feel so horrible when I feel angry and resentful of her. Or I'm out to dinner with my father, who's miserable with her. Then there are the boys, who always need something. I feel wrung out at the end of the day and exhausted. (She breaks down and cries.) I feel so lonely . . . I don't blame him for not wanting to be with me . . . I look like a wreck and I feel that way, too.
The therapist recognizes the oedipal dynamic and summarizes it for Ms. B:
Therapist: All your life, you have had to distance yourself from your mother in order to protect your special status with your father. Now you distance yourself from your husband—whom your father does not like, just as he does not like your mother—perhaps as a way to maintain closeness with your father.
She is startled when she realizes that she is repeating the relationship that she has with her
parents with her sons, in whom she confides and to whom she complains about her husband. Ms. B
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and the therapist agree that the problems in her marriage stem from her overly close relationship with her father. They agree that the task is to help Ms. B distance herself from her father and limit her involvement with her sons so that she has more time and energy to work on her marriage.
Initially, Ms. B appears compliant with the treatment goal, although she postpones talking to her husband. The therapist sees the positive paternal transference as a resistance, as Ms. B pressures the therapist to reassure her that everything will turn out well, while rationalizing waiting to talk to her husband until he is less stressed at work.
Therapist: I think you want me to be like your father, telling you what to do and how to feel, instead of paying attention to your own thoughts and feelings.
Ms. B (flustered): I just want to know that things are going to be OK.
Therapist: I think how things turn out depends on your being able to take a risk in asking for the affection and attention you need from your husband.
Ms. B (crying helplessly): But what if he says he's too tired from work to spend time with me at night?
The therapist persistently confronts her resistance while monitoring his countertransference for sadistic impulses or sexual arousal in response to her crying.
Soon, Ms. B begins to interact more with her husband, initiating dinner dates and other activities outside of church attendance, and feels more optimistic about the marriage; the therapist
understands this as a reaction formation and a "flight into health" given that she has not initiated a discussion about the Internet activity and their sex life is still nonexistent. The therapist actively confronts Ms. B's avoidance of conflict with her husband and with her father, who continues to make inordinate demands on her time.
Therapist: Have you talked to your husband yet?
Ms. B: Not yet, he's so stressed out . . . Therapist: And you're not?
Ms. B: Well, yes, but it's better now that we've been going out to dinner . . .
Therapist: I think what you've been saying is that you need more—more love and affection, not just dinners out.
Ms. B (after a long moment of reflection): That's true . . . maybe I can come home earlier from work today, just call my parents instead of stopping by, turn off the phone, and make a nice dinner at home . . . candles and nice music might put us both in a more relaxed mood to talk.
Ms. B's husband reacts warmly. He acknowledges that he has been frustrated by her indifference to him, which makes him feel old and lonely. He tells her that he has enjoyed the extra time they now spend together and is pleasantly surprised that they are talking openly for the first time in their marriage.
As treatment intensifies, Ms. B gets in touch with her anger, first at the therapist and then at her husband, not only for his Internet activity but also for not helping her more with their children and her parents. She then also feels anger at her father for demeaning her husband, for inappropriate demands on her time, and for criticizing her mother. Successfully working through these feelings helps Ms. B create more mature relationships with her parents and husband.
After 5 months of treatment, Ms. B is ready for termination as her attention shifts to her renewed, and increasingly healthy, relationship with her husband. A flexible date for termination is set. The therapist addresses Ms. B's feelings of separation and loss. Ms. B seesaws between feeling ready
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to go and needing reassurance from her therapist when she experiences conflict with her husband.
The therapist encourages her to take on the role he has been playing in questioning her behavior and gives her time to feel ready to terminate treatment. Ms. B resolves her ambivalence and decides that she can handle things on her own. She ends therapy with sadness and gratitude.