Interventions Case Study

When Eric Ishitani, age 32, an automobile salesman, came home and announced to Nancy, age 30, a very successful lumber wholesale manager, that he was in love with another woman and wanted a divorce, it shattered Nancy’s world. The marriage had been going downhill for a long time, and during the pre- ceding months Eric had been staying out nights. Nevertheless, Nancy wanted to patch things up and to have a child. But Eric was adamant, and left. Nancy was extremely distraught, with feelings of grief, guilt, worthlessness, and failure. She felt her life was mean- ingless. She didn’t want to face life alone; she was stuck in grief and felt that she was doomed to live the remainder of her life unfulfilled, without a husband or a child. She felt like a complete failure and blamed herself for not succeeding in the marriage. Nancy found herself frozen in a state of grief, remorse, guilt, depression, and self-pity.

The following intervention strategies were pro- vided and issues explored with Nancy during the days and weeks immediately following Eric’s announce- ment that he wanted a divorce. Individual counseling and intervention. Assessment of Nancy’s lethality level. Assessment of her cop- ing skills and resources. Provision of a safe atmo- sphere for her to talk her grief out and ventilate her emotions. Assessment of available support people. Consideration of her feelings of worthlessness, fear, failure, guilt, anger, depression, self-pity, and lack of self-efficacy and self-confidence. Use of ra- tional-emotive behavior therapy (Ellis & Abrahms, 1978) and behavioral modalities (Williams & Long, 1983) to help Nancy identify and success- fully refute her negative and self-defeating beliefs and self-statements and start modifying her mal- adaptive behavior. Reprogramming her internal sentences and developing positive action steps that she can own, practice, and carry out independently of a helping person. Develop a new restoration nar- rative that no longer includes her ex-husband. Support group work. Identification of divorce self- help groups for Nancy to use as supports. Assess- ment of her social needs on a time continuum from the present forward for several years. Use of the self-help group to assist her in making realis- tic plans for her personal and social adjustment to her new situation.

3. Referral resources. Assessment of Nancy’s need for legal, vocational, and financial assistance. If necessary, identification of specific referral people for her to contact immediately. While interviewing her, careful assessment of statements reflecting her present autonomy and ability to attain her goals. For example, depending on her husband’s attorney, banker, or accountant may not serve her best interests. Many newly estranged wives find that they need a different attorney, banker, and accountant from the ones used by their spouses. They also may need to find employment or training to enable them to become economically self-sufficient. Often this is a sudden and difficult switch. The worker must be sensitive, supportive, realistic, and assertive, because Nancy is so vulnerable during this phase of her separation.

The abrupt termination of a relationship by sep- aration is frequently accompanied by emotional re- sponses that are as traumatic as after the death of a loved one. People who experience the loss of separa- tion may exhibit shock, disbelief, denial, anger, with- drawal, guilt, and depression. Attachment theory indicates that separation and the subsequent feelings of loss can occur in many ways (Bowlby, 1969, 1973, 1980), and emotional reactions to a divorce may be very similar to those to a death of a partner. Each per- son responds in unique ways. Some will cry for several days. Some will verbally ventilate for days on end—to anyone who will listen. Some will go into a state of withdrawal, described by one person like this: “When he came in and told me he was leaving, packed his clothes, and left, I got in the bed and didn’t move. I intended to stay there until I died.” The loss by sepa- ration may be the result of severance of a marriage, a heterosexual, gay, or lesbian love relationship, a long- term friendship, a business partnership, or any other close personal attachment.

Helping people overcome the emotional and be- havioral results of the loss of a relationship requires crisis intervention skills similar to those needed in other types of grief and bereavement. In Nancy’s case, the client presented herself for crisis intervention

several days after she had stayed in bed with the in- tention of crying and grieving herself to death. Nancy truly wanted to die after Eric told her he was leav- ing permanently. At first her denial was so profound that she thought to herself, “This can never be. I will never be a divorcee. My parents must never know. My friends must never find out.” Nancy did not talk to anyone about Eric’s leaving for several days. There was denial: “He really isn’t leaving for good. He will be back. We will work things out.” There was guilt: “What did I do to cause this? I must have been a ter- rible wife. I shouldn’t have been so blind to his needs. If I just died in an accident, he could go on and marry the other woman and no one would ever have to know.” There was anger: “I’ve got a good mind to find her and pay her back for all the misery she’s caused me.” Nancy experienced a flood of negative emotions before she brought herself to the point of present- ing her problem to the crisis worker, who was a mar- riage and family therapist. As she presents herself, her thinking is full of all-or-none, catastrophic thinking. Her sentences start and end with words like “should,” “ought,” and “must.” She believes that the activating event, Eric’s request for a divorce, is causing the conse- quences of her depressed, angry, abandoned behavior, when in fact it is her irrational beliefs and automatic thoughts about the event that are causing her distress (Dryden & Neenan, 2004; Ellis, 1973; Ellis & Dryden, 1977; Liese, 1994; Malkinson, 2007).

CW: Well, Nancy, what brings you to see me today?

Nancy: My whole life is a wreck. It’s really a mess. The main thing is that my marriage is breaking up. Well, I guess it has broken up. My husband’s gone. Been gone for over 3 weeks. I have just got to get him back. That’s all there is to it. I am noth- ing without him. We were high school sweethearts and this is supposed to be forever.

CW: You’re feeling pretty hopeless about the mar- riage, but you don’t want to give up on it. What has happened today, in relation to your marriage breakup, to impel you to come in right now?

Nancy: Well, I was tired of lying around feeling sorry for myself—thinking about killing myself or harming my husband’s girlfriend. My intuition told me that neither one of those acts would solve anything, so I’ve come in here looking for better answers. There should be an answer to this, and I have absolutely got to have some answers to this or I’ll go nuts or wind up alone in some old folks home with no one

CW: Nancy, I’m really glad you decided to come to- day. What I want to find out first is whether you are in danger of suicide or homicide now. Is your intuition still keeping you safe? Do you have a means at hand to do it? And how close are you to suicide or homicide now?

The crisis worker’s first concern was Nancy’s immediate safety. It appeared from her verbal and nonverbal cues that she was hopeful and stable enough to have some mobility. The fact that she came to present her problem was another positive factor. However, the crisis worker still checked out her lethal- ity level. Then, when Nancy told the worker that she didn’t have a definite plan or a definite means to kill herself, the worker proceeded with other steps in the crisis interview. At one point, Nancy appeared to be in a stage of “holding on,” which Schneider (1984) de- scribes as having elements of anger, bargaining, and denial, some of the primary stages of Kübler-Ross’s stage theory (1969) of loss.

Nancy: I just can’t believe this is happening to me. My whole world has caved in on me. This is sim- ply horrible. I just can’t stand it. I just don’t know what I’m going to do without him. I must be a to- tal loser. I haven’t told anybody, but I think every- body in the sales department knows because my sales are way down. Christ! I probably have LOSER tattooed on my forehead. And I am so ashamed to tell my mother, although I think she knows something’s amiss. My God! I am so pitiful, I just want to crawl in a hole and never come out.

CW: IwanttodoacouplethingsthatIthinkwillhelp you get a handle on the situation. I want to tape- record our session, and I am going to give you a homework assignment that involves some more taping. I think this is a good assignment because I want you to hear what I call automatic thoughts. In just the few minutes you have been here I have heard a dumpster load of them, and those can get you in the kind of hot water you seem to be in now. Automatic thoughts result from people’s underlying assumptions and beliefs. The most common type of automatic thoughts involve all- or-none statements like you’re making. Telling yourself that you can’t stand it and believing that it’s horrible and that you’re terrible seem to be exag- gerations that are getting in the way. If you listen to all those “musts” and “shoulds,” those are also indicators that your belief system is out of sync with what you need to do and is contributing to

what I am going to call a problem-saturated nar- rative you have been building that won’t allow you any leniency from all those self-condemning statements your belief system is making. That is d different from telling yourself that it is bad, you don’t like it, you wish it weren’t happening, but that you didn’t cause it and that it isn’t the end of the world—even though it may make your life very difficult for a while. I want you to see where your catastrophizing, exaggerating, and awfuliz- ing color your thinking and get in the way of your clearly and objectively assessing not only what has happened but also what your real options are. Don’t you?

Nancy: Well,Idon’tknowifthat’sright.Imean,Iam pretty logical and linear and rational. I didn’t get to be sales manager of one of the biggest wholesale hardwood lumber companies in the world by be- ing a witless twit. I understand that, but would it be fair to say this is a little different than a sales campaign and the outcomes are a bit different? I have a little exercise I’d like you to do. I’d like you to make a loss and grief map.

Nancy: Well, yes, but . . . OK, I guess that’ll be interesting.

CW: Draw a circle in the middle of the page and put your primary loss in it. Think of all your thoughts and feelings associated with it and write them down around the circle. [See Figure 12.1.] Focus on the thoughts, the billboards that pop up when you think about the word D-I-V-O-R-C-E. Once you have the thoughts down, put the feelings down that go with it. Go back and look at feelings. As you think about them, see if others don’t bub- ble up. Lots of times we have a feeling about a feel- ing. For example, “stupid” might lead to “regret.”

Nancy: Yes. I see it. That’s pretty bad. I guess I have come down harder on myself and on the problem than is necessary. I know it isn’t the end of the world, but I feel, at the time, that it’s horrible and awful. CW: Then your believing it’s horrible and awful is the real culprit, isn’t it? There is a difference between your beliefs and how things really are.

Nancy: You’re right! It helps just to look at it differ- ently, even though it doesn’t solve my big mess.

CW: You’re right. It doesn’t solve it. But we can objec- tively examine it and together begin to figure out options you can choose if we know on the front end.

even though you’re grieving over your hurt, that we are not dealing with a world-shattering catastrophe.

The crisis worker was intervening by using ele- ments of rational-emotive behavior therapy (REBT) (Ellis, 1973) and cognitive-behavioral therapy (Meichenbaum, 1977). The worker was attempting to dispute the client’s irrational beliefs about the separa- tion and help her begin to direct her emotional energy toward the real issues. Nancy was an intelligent per- son who quickly responded to the rational ideas pre- sented. But, as is typical in such cases dealing with the emotional state during loss, the worker knew that rep- etition, practice, support, and encouragement would be needed. A person in Nancy’s state must have far more than just a one-shot session using REBT to get her beyond crisis and back to a state of equilibrium.

In addition to using REBT as a crisis intervention strategy, the crisis worker also used a self-managed behavioral technique (Williams & Long, 1983) to help Nancy expend her grief energy over a period of several weeks. What Nancy did was to make a series of audio- tapes—alone, at home—in a sequential and system- atic manner. The purposes for making the tapes were (1) to serve as a mechanism for self-catharsis; (2) to present to both her and the crisis worker her full story and form the basis for changing it from a problem- saturated story line to a restoration narrative; (3) to clarify, in her own mind, the loss and movement to- ward restoration she was going through; and (4) to document her progress in controlling her automatic thoughts and catching her “shoulds,” “oughts,” and other mustrabatory statements about love, marriage, and her self-concept.

The loss and grief map (Greenspan, 2003) is a concrete representation of all the absolutist, nega- tive, irrational beliefs she has about herself and the divorce. Once she has those in conscious awareness, she and the worker will start working on positive counterinjunctions that cool these hot cognitions off. The worker will also set up a self-managed behavior model with her that will allow frequency counts of the number of times she makes those statement to herself in a day. He will use a thought-stopping procedure and cueing (Dr. James’s magical rubber band-on-the-wrist- thought-stopper) to cue her to shift from those all- or-none irrational thoughts to cooler, more positive, self-enhancing counterinjunctions that are designed to start changing her narrative to one of restoration.

The audio recordings were quite useful to the crisis worker in verbally journaling her changing narrative as she worked her cognitive-behavioral plan. But the main value of the behavioral plan was providing Nancy the purpose and the experience of doing it. She described in detail her thoughts, feelings, and actions throughout several stages: shock and disbelief, denial, anger, with- drawal, guilt, depression, searching, and resolution. Nancy made eight recordings. She reported that the most valuable and helpful aspect of the activity was lis- tening to her own recordings, which she found herself doing over and over. Nancy kept the recordings with the stated intention of continuing to listen to them. But she later reported that after her crisis subsided, she didn’t need to listen to them anymore.

Nancy also contracted with the worker to go to a divorce support group at a local church. Such groups provide crisis support, role models for survival, adap- tation pathways, and new social networks (Raphael & Dobson, 2000). You will note that over and over we advocate the use of these groups as part of a compre- hensive crisis and transcrisis intervention treatment model. They are an important part of the response to bereavement, and there is evidence that they are effective as a social and healing process (Kitzman & Gaylord, 2001; Raphael & Dobson, 2000).