CASE STUDY 3-I

3 Person-Centered Therapy: A Client With Postpartum Depression Laura Kelly

■ PERSONAL EXPERIENCE WITH PERSON-CENTERED THERAPY

As a fledgling therapist in the late 1980s, amid significant changes to the payer system in healthcare and a move away from long-term-ongoing psychoanalytical therapies to shorter problem-focused approaches, I set out to “find my way.” Despite my educa- tion at Rutgers University in the theoretical orientation of interpersonal psychoanalysis through the works of Hildegard Peplau and Harry Stack Sullivan, I found myself more aligned with the humanistic approach of Carl Rogers and his Person-centered therapy (PCT).

It may have been my own anxiety specific to my therapeutic skills that initially drew me toward a framework where the therapist would have a more supportive, nondirec- tive approach rather than the directive, interpretive approach of psychoanalysis. My supposition that PCT would allow me to relax and not do too much work was soon dispelled. Creating Rogers' core conditions of genuineness/congruence, unconditional positive regard, and accurate empathic understanding necessitated an extremely high level of presence and concentrated listening as well as an awareness and understanding of myself and the client, moment-to-moment during the therapy sessions. It required that I track the client’s narrative by carefully following the sequence of events and stay- ing on topic without interrupting or changing directions in order to truly understand the client’s phenomenological experience. It demanded fostering a deep client– therapist connection that allowed for an attuned responsiveness based on sensing the client’s experience. It necessitated the utilization of facilitative communication skills that carefully matched the client’s experience. And, it required the delivery of a judicious response at choice points that emerged during a session. This was not easy and required a great deal of therapeutic skill as well as my own personal self-growth work.

In the years that followed, I spent countless hours reading the works of Carl Rogers and those that followed in his footsteps. I watched numerous videos of his work and attended many conferences, workshops, and training programs in the humanistic approach. As I honed my skills, my naïve understanding of his theory matured and my utilization of his techniques, along with other types of humanistic therapies, helped a multitude of clients in relatively brief periods of time.

Copyright Springer Publishing Company. All Rights Reserved. From: Case Study Approach to Psychotherapy for Advanced Practice Psychiatric Nurses DOI: 10.1891/9780826195043.0003

42 ■ CASE STUDY APPROACH TO PSYCHOTHERAPY FOR ADVANCED PRACTICE PSYCHIATRIC NURSES

As a PhD student in nursing during the late 1980s, and the only psychiatric advanced practice nurse in the program, there was little place for qualitative research. I struggled trying to wrap my qualitative mind around the quantitative world that I had entered. Rogers, in contrast, was utilizing qualitative methods. He was one of the first scientists to test the underlying hypotheses of his theory on the process and outcome of psycho- therapy. His work helped me broaden my understanding of the possibilities for psycho- therapy research.

As an educator, Rogers' theoretical framework also guided my teaching. Rogers' publication, Freedom to Learn, based on student-centered teaching (Rogers & Freiberg, 1994) and the many modern works on the topic that were birthed from his seminal con- cepts, have assisted me in developing my teaching skills and creating person-centered learning environments.

PCT techniques are an ideal modality when working with women during their reproductive years. My practice is primarily treating women before, during, and after pregnancy. Many women seek my services while desiring to become pregnant and have been told by their current providers that psychopharmacologic treatment during preg- nancy is not possible. Other women come because they are pregnant and experienc- ing psychological symptoms that interfere with their optimal level of functioning. Still other women come in the postpartum period often experiencing anxiety and depressive symptoms that are not familiar to them, and are therefore causing significant distur- bances in their lives.

As a prescribing practitioner, some of my interventions are more directive. Nonetheless, PCT allows me to frame directives in a way that makes it clear, regardless of my input, that clients can oversee their own decision-making and I will be present and supportive regardless of the decisions they make. My stance as a clinician is non- judgmental and empathic.

I have been practicing reproductive psychiatry as an advance practice nurse for the last 15 years and have had the opportunity to work with women over time and through numerous pregnancies. This has allowed a lifelong relationship with numerous women with many points of contact and comfortable transitions as psychotherapy care was required.

■ FOUNDERS AND LEADERS OF PCT

PCT, originally known as Client-centered therapy, was developed in the 1940s by Carl Rogers (1902–1987). Rogers, considered to be the most influential psychotherapist of the 20th century (Cook, Biyanova, & Coyne, 2009), published three seminal books that are foundational in most psychotherapy programs. The first, Counseling and Psychotherapy (Rogers, 1942), challenged the authoritative role of the therapist seen in psychoanaly- sis, and focused on the necessity of creating a nondirective atmosphere during therapy using facilitative communication techniques such as reflecting, clarifying, exploring, and focusing. In this book, he presented the first verbatim transcript ever published of an entire course of therapy, which was revolutionary at a time when no one knew what actually happened during a therapy session. His second book, Client-Centered Therapy (Rogers, 1951), described the necessary conditions for effective therapy: genuineness/ congruence, unconditional positive regard, and accurate empathetic understanding. The book also focused on the importance of understanding the client’s phenomenologi- cal experience and utilizing actualization as a positive force for change. His third book, On Becoming a Person (Rogers, 1961), focused on the importance of the therapeutic rela- tionship and the therapist and client being “true to self” in order for the therapy to be successful (Knight, 2014).

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Rogers had a profound influence on psychotherapy in other ways as well. He was one of three therapists who demonstrated their psychotherapy approach in the two iconic psychological film series, Three Approaches to Psychotherapy. In these series, an actual cli- ent was filmed while engaged in therapy with three extraordinary therapists: the client Gloria received therapy from Carl Rogers, Fritz Perls, and Albert Ellis in the first series in 1964, and the client Kathy received therapy from Carl Rogers, Everett Shostrum, and Arnold Lazarus in the second series in 1977 (Shostrom, 1965, 1977). These classic films are considered to be essential viewing for students studying to become psychothera- pists (Knight, 2014).

Rogers and others have applied PCT to many other types of therapy including group therapy (Rogers, 1970), expressive arts therapy (Rogers, 1993), and play therapy (Axline, 1947/2002). PCT is also a major component in motivational interviewing (Miller & Rollnick, 2002) and emotion-focused therapy (Greenberg, 2011), two con- temporary, humanistic–existential psychotherapy approaches. Rogers' work has been applied to parenting, education, and industry (Kirschenbaum, 2009), and his facilita- tive communication skills are an integral part of undergraduate and graduate psychi- atric nursing curriculums (Knight, 2014).

In the last decade of his life, Rogers facilitated PCT workshops throughout the United States and the world. He was devoted to applying PCT concepts in areas of social con- flict and worked for peace in Northern Ireland and South Africa. He was nominated for the Nobel Peace Prize in 1987. His influence continues today, with over 200 orga- nizations and training centers worldwide (Kirschenbaum & Jourdan, 2005). Howard Kirschenbaum, an internationally known expert on Rogers, has authored his biography in the book The Life and Work of Carl Rogers as well as a documentary about Rogers' life and teachings (Kirschenbaum, 2009).

■ PHILOSOPHY AND KEY CONCEPTS OF PCT

PCT views human nature in an optimistic way and assumes that people are trustworthy and essentially good. Human development is viewed as consistent with positive growth and change and a movement toward self-actualization. Individuals are thought to have the capacity for self-awareness, the potential for self-understanding, and the ability to find personal meaning and purpose in their lives (Rogers, 1961). PCT believes that indi- viduals are capable of coping with a wide range of thoughts, feelings, and behaviors and have the ability to direct their own lives. It assumes that individuals seek to resolve their own conflicts and inner tensions that exist between the existential concepts of free- dom and responsibility (Corey, 2017).

PCT posits that positive growth and change occur as a function of our relation- ships with other people. In a therapeutic context, clients experience positive growth and change when the facilitative conditions of unconditional positive regard, genuine- ness, and empathic understanding are present and when the therapeutic relationship is trusting, collaborative, and respectful. Therapists understand as much as they can about their clients, to be present and help the clients accept who they are despite their shortcomings. When clients can accept who they are, they can change (Rogers, 1961). According to Rogers (1957), there are six conditions that lead to therapeutic change:

• The therapist and client need to have psychological contact. This level is not met simply by the client and therapist being in the same room. Rather, there must be a col- laborative relationship allowing the therapist and client to work as effective partners and thus have an impact on each other.

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• The therapist needs to be congruent, genuine, and authentic. This requires that a therapist has experienced many hours of personal growth work. The therapist must be aware of self, responsive to the level of communication with the client, and spon- taneous and open in the relationship.

• The therapist must show unconditional positive regard, also known as a nonjudg- mental stance. The therapist does not establish any conditions of worth. Positive and negative judgments can be disruptive of change.

• The therapist experiences and expresses empathy to the client. The ability to dem- onstrate an emotional understanding of and sensitivity to the client’s experience is essential to effective therapy.

• The client perceives the empathy and feels accepted by the therapist. Without the cli- ent experiencing empathy and acceptance, the therapy is less likely to be successful.

• The client must be experiencing incongruence, which is defined as a lack of align- ment or a discrepancy between the real self and the ideal self. Without incongruence, change is not possible.

■ DEFINITION OF MENTAL HEALTH AND PSYCHOPATHOLOGY IN PCT

In PCT, the client is treated as an entire human being, a movement away for the medical model of psychopathology (Haugh, 2018). Rogers did not use the terms mental health or mental illness; instead, he used the terms adjustment and maladjustment. A person is considered adjusted if there is a congruence between the ideal self (what one wants to become) and the real self (what one actually is). An adjusted person is fully functioning, open to new experiences, and lives life with freedom, authenticity, and a natural move- ment toward self-actualization (Rogers, 1961).

In contrast, a person is considered maladjusted if there is an incongruency between the real self and the ideal self that leads to living an inauthentic life and an interruption to the natural flow toward self-actualization. The maladjusted person cannot be true to self, which leads to distress in daily living and impedes the self-actualizing process. The feeling of incongruence starts when a person encounters conditional worth—when worth is depen- dent upon what he or she does or does not do. These feelings often manifest as anxiety, which the person attempts to relieve through denial and defensiveness (Frankel, Johnson, & Polak, 2019). Rogers believed that the therapist must assist the client in achieving con- gruency by getting behind the masks that are worn and which develop during the process of socialization. The client comes to recognize that contact with self has been lost by using facades; during therapy, the client begins to access his or her authentic self (Corey, 2017).

■ THERAPEUTIC GOALS OF PCT

The cornerstone of PCT is the view that the client, in a relationship with a facilitat- ing therapist, has the capacity to define and clarify his or her own goals. Accordingly, goals are set by the client and the therapist has little role in goal setting (Elliott, Bohart, Watson, & Greenberg, & Watson, 2011).

There are overarching hopes that the PCT therapist has for the client that are in tune with the overall philosophy of PCT. These include having the client become a fully func- tioning and congruent person, who can live life authentically, cope well with life’s prob- lems, and be engaged in the process of self-actualization. The PCT therapist hopes that the client develops an internal evaluation of self, replaces conditional positive regard with unconditional positive regard, develops the ability to be self-directed rather than

3. PERSON-CENTERED THERAPY: A CLIENT WITH POSTPARTUM DEPRESSION ■ 45

looking to others, and be willing to continue growing even after therapy ends (Raskin, Rogers, & Witty, 2008).

■ PERSPECTIVE ON ASSESSMENT IN PCT

Therapists practicing from a PCT approach generally do not find traditional assessment procedures such as taking a psychiatric history, using psychometric tests, and formulat- ing a diagnosis useful because these procedures encourage an external and expert per- spective of the client (Elliott et al., 2011). These procedures give the client the message that the therapist is the expert who provides the solutions. In a PCT approach, the client is not considered a sick patient in need of treatment, but a person who is prevented from realizing his or her potential. Rogers believed that diagnostic constructs are inadequate, prejudicial, and often misconstrued (Rogers, 1942). If providing a diagnosis is necessary, a collaborative approach is used in which the client and therapist together formulate the diagnosis (Bohart & Watson, 2011). Rogers saw therapy as collaborative—the client and therapist working together to formulate the ongoing issues in therapy.

The therapist begins the assessment by asking the client where to begin and what issues to work on. The client’s phenomenological experience, rather than the present- ing problem, is the focus. The therapist is genuine, empathic, and caring and sets aside preconceptions in an attempt to understand the inner world of the client. The thera- pist creates an understanding atmosphere that encourages clarification and reflection of present feelings and experience (Knight, 2014).

■ THERAPEUTIC INTERVENTIONS IN CLIENT-CENTERED THERAPY

In PCT, each session is considered fresh and unpredictable. Structured techniques and process interventions beyond facilitative listening are avoided. The therapist honors the wisdom of the client and the ability of the client to determine the direction of therapy. This encourages greater self-exploration and improves self-understanding (Knight, 2014). The therapist creates the following facilitative conditions that enhance the thera- peutic relationship (Rogers, 1961):

■ NONDIRECTIVENESS

Nondirectiveness, the primary technique used in PCT, is much different than most therapies that use directive techniques such as setting an agenda, reviewing homework, engaging in interpretation, and determining the flow of the session. With nondirective- ness, the therapist uses a discovery-oriented approach and encourages the client to talk freely and direct the session in the way he or she chooses. The therapist is an equal collab- orator, rather than someone who directs the client toward a specific goal (Rogers, 1942).

Unconditional Positive Regard

Unconditional positive regard occurs when the therapist accepts and cares for the client as the client is in the moment. This does not necessarily mean that the therapist must like the client or agree with the client, but the therapist does not judge the client. It is essential that the client feels valued by the therapist.

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Congruence

Congruence is a match between one’s inner and outer experiences manifested by genu- ineness and authenticity. The client usually enters therapy struggling with a sense of incongruence. The therapist exhibits congruence by openly expressing thoughts and feelings as well as reactions to the client in a well-timed, constructive fashion. As the client experiences the congruency of the therapist, pretenses drop, allowing the client to model the authenticity and genuineness of the therapist (Knight, 2014).

Empathy

Empathy is a very deep understanding of the client. It requires moment-to-moment attunement to the client and an accurate understanding of his or her subjective experi- ence. Showing empathy requires understanding the client’s feelings and reflecting them back to the client to help him or her understand these feelings (Elliott et al., 2011).

Affirmations

Affirmations are a form of encouragement and can be verbal or nonverbal. An open, accepting body language (e.g., nodding, leaning forward toward the client) all indicate an open, accepting, safe environment that tells the client the therapist is interested in what he or she has to say.

Active Listening

Active listening is listening with all senses and without exhibiting judgment (either through tone, body language, or verbal responses). The therapist fully concentrates on what is being said rather than just passively hearing the message of the client.

Reflection

Reflection is a restatement of what the client says, which allows the client to hear him- self or herself. It is not directive and not advice giving. When the therapist uses reflec- tion, he or she shows an understanding of the client’s situation and displays empathy (Seligman, 2014). Reflection is not simply just repeating what the client has said, but sensing the underlying thoughts and feelings as well as the deeper meanings that are communicated (Knight, 2014).

■ CASE STUDY

Background

Pseudonyms and minor changes have been made to protect the client’s identity. Rivka is a married Orthodox Jewish woman who came to see me initially at the age of 28 after the birth of her sixth child. She had been married for 9 years at that time. Her children’s ages were 8, 7, 5, and 3 years, 15 months, and 6 weeks. She came to see me for psycho- therapy. She stated, “I’ve just not bounced back to myself and I am already 6 weeks post-partum—something is just not right.”

Rivka is a client that I saw initially for 18 sessions. She worked on identifying and expressing her feelings, finding her voice, and validating herself rather than punished

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herself for having these feelings. She returned to therapy 4 years later to work on asser- tiveness skills in decision-making. Rivka was someone who did not feel safe in identify- ing or sharing her feelings for fear of being judged. She worked very hard and made significant strides in her work in therapy.

She recently reentered therapy and is currently pregnant with her 11th child. She has weathered many difficulties since her first entrance into therapy, but has been able to accept and express her feelings and not judge herself too critically. Last year, her sixth child, the one whom she had right before entering therapy the first time, was diagnosed with neuroblastoma. The 10th child was 8 months and when she reentered therapy, she had just found out she was pregnant with her 11th baby.

Transcripts of PCT Sessions

The transcripts selected here were selected from segments from the beginning phase, middle phase, and final phase of therapy. Also, there is a reentry into therapy phase.

Beginning Phase

APPN: Hi Rivka. Welcome, please make yourself comfortable. Tell me, what brings you here?

Rivka: Gosh. I’m not sure where to begin. I just know something is off—not right. I have not bounced back the way I usually do after a baby (quiet and looking down at her hands).

APPN: Umh, hmm (sits quietly waiting).

Rivka: Well, I mean I don’t feel present. I feel like I am looking at myself out- side of myself (looks up). Does that make any sense to you? Have you ever heard of such a thing?

APPN: Tell me more, I want to understand.

Rivka: (Long pause) My baby, he is just delicious, I mean the other children they are crazy over him, and he is such a good baby. He only cries when he wants to eat (looks up at me and down again). But something is wrong. I don't feel like he is mine, like I am not bonding with him like I did my other babies. I just feel not present, that's the only way I can explain it (cries softly).

APPN: (Hands client a box of tissues) And this makes you sad. Does it bring up other feelings as well?

Rivka: Scared. I think I may be going crazy. Or that maybe, I don’t know, maybe because of how I was feeling while I was pregnant, I caused this, this terrible disconnection.

APPN: Umh, hmm.

Rivka: (Long pause) I’m afraid to even say out loud how I was feeling during the pregnancy. I am afraid to utter the words. But the baby on top of him, my 15-month-old, he was, ah is, such a hard, demanding baby. Gosh, he is an infant himself, and he has all sorts of gastrointestinal (GI) problems. He is allergic to everything, he has tube feedings to supple- ment so he gains weight. He is a terrible sleeper (cries, dabs tears, and looks at me). I am a horrible mother, I can't believe that I thought during

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this pregnancy that I wished I would miscarry and now God has given me a perfect child—I don’t deserve him (cries more), especially since I didn’t even want him, and now he is so good and I don’t think he is mine. And no one knows how I felt, not even Moishe (her husband), because a mother should never feel that way about a child (cries more). I feel so alone and now I am going crazy. I can't connect with him. I am going through the motions day by day, but I don’t feel anything.

APPN: It seems like you are saying these negative feelings during your preg- nancy had been so hard for you and that you have had to keep it to yourself because you don’t think any mother would feel this way about her unborn child.

Rivka: Yes, right, exactly. What kind of a mother wants her baby to die?

APPN: If you’d like we can explore that. Tell me about yourself as a mother. Perhaps if you would like, describe how you are feeling on a typical day.

Rivka: OK. Yesterday, for instance. Let’s see. I got up to feed my baby at 6. Then he went back down and I showered. My husband was already getting the three oldest ready and giving them breakfast. I went in to take care of Yehuda. He’s my baby that needs to be tube-fed. I usually have to bathe him again in the morning because sometimes the tube feedings give him diarrhea. So, I was busy with him. He also is not walking yet, so I must carry him everywhere. Once he is all dressed my husband takes the three oldest and Yehuda out the door and then goes directly to the Yeshiva where he learns all day. I quickly got some breakfast and then fed my newborn, Zvi, again. My 3-year-old is generally awake and hungry by now so I feed her, dress her, and then the three of us set off. We only have one car, so I bundle the newborn and my Chana and we walk to the sitter to drop off Zvi. Then Chana and I walk to my work. I am an assistant in a day care. I teach in a 3-year-old class so she can come with me. At 3:30 I leave the day care, pick up Zvi, and walk home. By then it is 4:00 and my husband arrives home with the four children. He has to leave to go back to Yeshiva, so I am now needing to take care of all six kids. This is the hardest time because usually Zvi needs to eat and Yehuda is cranky because he is also hungry. They won't tube-feed him at the babysitter and he is a terrible eater. My 3-year-old is also kvetchy because she is tired, but my 8-year-old is so good with her, and she will usually color with her so I can take care of Yehuda. And little Zvi swings patiently in his swing (long pause, looks down). After I get caught up, I make dinner for the others, and then baths and more time with Yehuda. He gets OT so I am working with him on his exercises; he is making good progress and he should be walking soon! He almost stands on his own. And that Zvi is swinging or sleeping, never a peep. Sometimes I almost forget he is there (looking down, tearful). By 7:30 my husband gets back home and gets the older kids to bed. He then leaves again by 9 and is home for the night by midnight. We try to eat a quick dinner before he goes back out. Once all six kids are quiet, I then throw in laundry, make lunches, call in a grocery order, and clean up. I am not a neat nick—my house is lived in, but I don't like dirt. I usually feed Zvi one more time and get to bed by 1 a.m. Yehuda usually gets up twice, but my husband and I take turns soothing him or giving him a little food. Then before you know it, time to do it all over again!

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APPN: You described a very busy day. However, I didn’t hear you describe too much about how you were feeling, only what you were doing.

Rivka: (After a pause) Hmmm, I didn’t even hear you ask me how I felt, I thought you wanted to know what I did. Hmm. How was I feeling? (Cries and long pause)

APPN: Yes.

Rivka: I am afraid to feel. I am afraid that if I let the feelings come in, I will lose control and how will I care for my family? What if this causes me to go crazy?

APPN: Crazy? Tell me more about what you mean.

Rivka: I mean crazy. Like I will need to be locked up in a hospital. Like my children will be taken away. I’m not sure I can do this. Is there a pill to help me? Get rid of this feeling? This disconnection. Or maybe I am being punished. God knows what I thought (crying).

Middle Phase

Rivka and I saw each other 18 times over 10 months. This session was a little more than midway through the 18 sessions. She just found out she was pregnant with her seventh child. While she had become much better at owning her feelings and sharing them with her husband, this session illuminated the work she still needed to do in understanding where her feelings came from.

Rivka: I know I told you last time that I thought I might be pregnant again— well I am, only a few weeks but the pregnancy test was positive last Sunday. Funny you know, since I decided against an intrauterine device (IUD) I knew it would happen. And I can honestly say that I am not feeling ready and I am scared and disappointed. I was hoping it would take a little longer (to get pregnant) but I know we will all manage (long pause). Much different than the dread and anger I felt while pregnant with Zvi (laughs). Listen to me admitting out loud that I was angry! So angry I wanted a miscarriage!

APPN: In the beginning you carried the feelings within you, such a secret. A dark place for you.

Rivka: It was amazing. Once I started saying how I was feeling out loud, that disconnected feeling went away. Slowly at first. I told Moishe about the pregnancy and how I was disappointed that it happened so fast. I asked how he felt and he said he felt the same. He also told me he appreciated that I could be honest with him about how I felt. I am still sad about Zvi. I was so absent in his first months of life—I mean absent emotionally. I wonder how this will affect him in the long run, especially now that we are adding another baby—seems like Zvi has not gotten what the others had—a happy, present mother from the beginning.

APPN: I know I didn’t know you before Zvi was born, but I think what I am hearing from you is that when you look back you perceive a very dif- ferent mother before Zvi. I am wondering if the birth of Zvi just illumi- nated what was already going on with you in a way you couldn’t see prior to that. Just curious what you think about that?

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Rivka: Gosh I have thought about that. You are right. I never expressed my feelings out loud, unless I thought the feelings were what others expected. When I think back to my first babies, they were all good— just like Zvi. It was not until Yehuda that things became more dif- ficult—he needed so much. He still does. You know he is making progress, but it is so slow. He is still needing supplemental feedings. And he is still not walking (long pause, then she became tearful). Oh no, I just realized something, it's not that I am angry and disappointed and afraid about being pregnant—I am mad that Yehuda isn't better. And somehow having more babies is a reminder that he is not progressing and I do resent that he needs so much from me. Why can't he just be normal? (crying)

Final Phase

This was Rivka’s 18th session, her last of her first time in therapy prior to reentering 4 years later. Here she reviews the connections she has made and speaks about the deeper understanding that she has about herself and how she is able to cope better with her feelings now that she has an understanding about where they come from.

Rivka: Remember how I told you that I was thinking about my mother and her expectations of me? You know, she was really good at not stating directly, “Rivka I expect that as the oldest you will do so and so . . . .” Instead she would say things like, “You are so good at getting yourself and your sisters breakfast, it’s amazing that you don’t need me to help you.” By that time, I probably had three sisters and I was only 6! One of my sisters was just a real picky eater and I remember giving her candy for breakfast, just so I could tell my mother everyone ate. I knew this was not a good idea, but I could not imagine my mother being disappointed in me. And now I am thinking how clever she was—she was probably feeling completely overwhelmed herself, she had 15 children—so she needed me to be a helper. If she convinced me that I was doing a great job, I guess it would be highly unlikely I wouldn’t strive for perfection. I certainly don’t blame her, but gosh I was 6 . . . and I have been thinking a lot about myself as a mother—do I do that to my oldest kids? (pause) I mean, I was only 6.

APPN: Am I hearing a little resentment toward your mother? You did an awful lot to please her.

Rivka: Yes, for sure. Boy I would never have admitted that in the beginning. I didn’t even realize it in the beginning. I love my mother so much, but now I realize, much of the way I respond to others—especially those that I perceive may judge my skills as a mother, wife, friend, whatever, I just respond in a way that I think I should. It never mattered how I actu- ally felt, only how I thought I should feel. And now I see why I used to be so mean to my sister right below me—she was always easy going, never a care, never a worry, the perfect kid . . . (pause).

APPN: Perfect like Zvi?

Rivka: Yes exactly. Easier to be angry toward someone who could take it. Now I see when Yehuda was born, with all his problems, he messed up the flow. Not his fault of course, so how could I possibly be mad at him? So, I recognize now that feelings I often have may be misdirected—so they

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don’t feel “right,” they are, well, prohibited. So, I think the disconnec- tion that I was feeling when I started was a defense mechanism against feeling these prohibited feelings (pauses).

APPN: And instead carrying them deep inside you?

Rivka: Yes, yes. Because I could not trust myself. I didn’t even know how to feel and once I let myself feel then I started to realize that the feelings I was having were often misguided. Targeted often at the wrong person or situation. Oh my . . . what a mess this is!

APPN: You’ve been meeting other peoples’ expectations of you for your entire life. It’s a lot to unpack in less than a year. What do you think of your progress?

Rivka: Hmmm . . . well, I have an awareness now that I never had before. I don’t need to feel happy and carefree all the time. I can feel angry, frustrated, anxious, sad, or any other feeling. I now also take the time to look at the situations and try to figure out what I am really feeling about. I have become so reflective! Moishe teases, he says, “I know you need time to think about how you feel and then we can talk about it!” He has been a blessing, such an understanding husband. We are all works in progress.

Commentary

We did not have a formal termination, but instead had discussed the difficulties we had in meeting regularly as she had a very busy schedule. However, no matter how many weeks had gone between sessions, Rivka always came back, having given a lot of thought to her feelings and behaviors, and making a lot of connections. She truly wanted congruence. At the end of this session, we had decided to wait until after the fall holidays to set up another appointment. I did not hear from her again for 4 years. However, as I ended every session with “I am here for you whenever you need to come back,” she felt comfortable in reaching out and returning to a place where she felt safe and not judged.

REENTRY INTO THERAPY AGAIN: Rivka returned to therapy 4 years after our last session.

APPN: I am so happy to see you again.

Rivka: You remember me? (laughs)

APPN: Of course, I remember you. I remember a woman who worked very hard identifying and expressing her feelings. Tell me, what brings you back?

Rivka: Well, my 10th baby is now 8 months old. Remember Yehuda? He is big and gaining weight and eating on his own—no more feeding tube for years! I hardly remember those times. And I just found out yesterday I am pregnant again. I made this appointment before I knew. Lots of stuff going on—which is expected when managing a big family. I was hoping when I made this appointment that I could work on my asser- tiveness skills—I really want to have an IUD put in—obviously it will be after this pregnancy, but I think my family is big enough (pauses). Zvi was diagnosed last year with neuroblastoma. He is doing well.

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Just finished his sixth round of chemo. Moishe and I realized when he was diagnosed that we needed to divide and conquer and Moishe has been wonderful. He oversees Zvi and getting him into and out of the city for care. Moishe also handles all the doctor’s appointments and then he and I review the plans and options and make decisions. Oh, so I am here because I realized that while owning and expressing my feelings are very important—and I am no longer afraid to feel them—I also need to be able to assert myself in situations that in the past I felt like I had no control over. One of these areas is spacing my kids.

APPN: Mhm . . . hmm. So, are you saying that understanding how you feel and being able to express that to others in your life doesn’t necessarily change situations that you would like to change? That you would like to have some control over changing?

Rivka: Yes exactly. I need to be able to do both. If something makes me mad or overwhelmed or unhappy or happy or angry or resentful or whatever, just feeling it isn’t enough. Neither is just expressing it! It’s been like “thanks for sharing but this is how it is.” Now I realize that it is only step one. I need to be heard, yes, but I also need to be able to make changes. And up until now, I have not, I still feel afraid. I feel like a little child who let’s big decisions get made by others.

APPN: Because making big decisions might make others unhappy or make them judge you?

Rivka: Yes, I think so. I guess I was also thinking that if I explained to my husband or the rabbi or my mother how I was feeling then they would make the decisions needed to make me feel better. This is crazy, isn’t it? I am still not taking responsibility for myself. It took me 4 years to figure this out? Really?

APPN: You sound surprised. But you spent your entire life until 4 years ago never even letting yourself feel. Change does come in steps. The fact that you have made this recognition and now want to do something about it is a big step.

Commentary

I continue to work with Rivka. She is at the end of her 11th pregnancy. Her son Zvi is not doing well and will likely succumb to his disease as his treatments have not stopped the progression. Dealing with the anticipatory grief and all the feelings she is discover- ing through this ordeal has been a lot, but she is asserting herself in some ways—one example was choosing not to continue treatments that are not working and giving Zvi some time to “just enjoy” without the side effects of the chemo that have been very difficult for him. She and her husband agreed with this decision, but she did receive some negative responses from the community. She stated that in the past this would have probably made her change her mind, but she and her husband have stuck by their decision and although it is very painful to deal with a dying child, she is content that this is the right decision for him. As the therapist, being an active listener, providing unconditional positive regard, and providing Rivka a safe place to explore her emotions in depth with no consequences to outside relationships were the key components in my

3. PERSON-CENTERED THERAPY: A CLIENT WITH POSTPARTUM DEPRESSION ■ 53

role. Rivka is the driving force of each session. My key role is to do my very best to be present, nonjudgmental, and understanding.

DISCUSSION QUESTIONS

1. Would you be able to be present with Rivka without being more directive or active in your techniques?

2. What do you mainly hear Rivka saying throughout the sessions? 3. Are you able to empathize with Rivka and enter her experiential world? 4. What are your personal reactions to Rivka? 5. Are you able to accept the decisions that Rivka has chosen for her son Zvi? Do you

accept her decision of doing nothing to avoid pregnancy?

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