I am a licensed Clinical Psychologist with an office in Bloomington. I received my Ph.D. in Clinical Psychology from the University of Minnesota Psychology Department in 1990. I have a general psychology practice in a 3-person group called Hoosier Counseling Center. My practice concentrates on marital, family and couples therapy, counseling for personality disorders, and women's issues such as rape trauma.
I do not keep specific notes or tape recordings of any individual sessions. I have found that they are not helpful. I keep my practice limited to a fairly small number of patients, and I find that I do a better job of therapy if I simply get to know them as people. I see an average of 30 patients per week. Of those, twenty are frequent patients (one or two visits per week). Another ten patients come once every two weeks. I see another twenty patients infrequently to monitor their progress.
Marianne Moore was a patient of mine in 1999 through 2000. She came to me in September 1999, complaining of depressed mood and loss of interest in her usual activities and pastimes. She used words like depressed, sad, and feeling blue. She told me she had been irritable. In a series of sessions over her first three or four weeks of counseling, it was revealed that she had undergone weight loss, and loss of appetite. She had been experiencing significant insomnia, self-reported as two or three completely sleepless nights a week, and an average of three to four hours of sleep on other nights. She said she had a loss of sexual drive. She testified to general malaise, loss of energy and fatigue. During our conversations, it was clear that she felt worthless and had excessive and inappropriate levels of self-doubt and self-reproach. She expressed fear because she was having thoughts of suicide. She thought she would have to leave her husband and live alone. These symptoms were not accompanied by any self-reports of unusual behavior, hallucinations or delusions. My observation was that she was in a depressed mood. By varying the time of day at which she came for her sessions, it was clear that the depression was worst early in the morning. These symptoms had been present since early summer, and had been steady or getting worse. The insomnia seemed to be the major problem. She said that use of tranquilizers did not alleviate the insomnia or improve her mood. She did not show any previous manic episodes, so I diagnosed her condition as a major depressive episode accompanied by melancholia, or 296.23 using the DSM numbering system.
Based on my clinical treatment of her beginning in late September, 1999, I did not see enough symptoms to diagnose her as suffering PTSD. This is not unusual given the circumstances. PTSD usually begins soon after a traumatic event and in almost all cases not involving repressed memory, within three months. In cases where the stressor was mild and did not involve rape, severe injury or death of a loved one, it has been my clinical experience that recovery from PTSD takes only three to four months. Marianne was attacked by her boss in a hotel room in March and did not begin therapy with me until six months later. If she had experienced PTSD, it probably would have subsided by the time we began our therapeutic relationship.
That being said, I believe based on her self-report of the six months right after the assault that her behavior and symptoms indicate PTSD consistent with having been sexually attacked.
Moore's initial response to the assault evidenced fear, confusion and helplessness. These are the usual initial symptoms of PTSD. She was afraid to continue attending the conference or stay overnight in her hotel room, and was afraid to return to work for several days. She displayed some degree of confusion and helplessness by insisting on driving home to be with her husband. She also expressed feelings of helplessness at having no alternative but to return to work because of the family financial situation.
In the weeks following the assault, Moore displayed persistent avoidance behavior typical of PTSD. She did not talk about the incident, stopped associating socially with other people in her department, expressed feelings that other people were avoiding or isolating her because of the event, ceased sexual relations with her husband, and expressed feelings this incident had permanently affected her future, especially that she was being "blackballed" by senior city administrators and would be unable to ever find work again. The feelings of loss of a future persisted well into the beginning of our therapeutic relationship. She frequently expressed the fear that she would have to leave her husband and live alone because of the assault.
Throughout the three to four month period when Moore's PTSD would be most predominant, she expressed persistent symptoms of abnormal arousal. She told me she had been irritable and had undergone unusual appetite change involving significant weight loss. She had been experiencing significant insomnia, self-reported as two or three completely sleepless nights a week, and an average of three to four hours of sleep on other nights. She said she had a loss of sexual drive. These symptoms had been present since shortly after she was fired and had been steady or getting worse for several months. The insomnia especially seemed to be the major problem. She said that use of tranquilizers did not alleviate the insomnia. All these symptoms and the length of time she experienced them are consistent with PTSD.
Many people who suffer PTSD experience persistent flashbacks, recollections or dreams about the event. Moore did not experience abnormal or morbid recollections of the event; however, in my experience not all patients experience such flashbacks.
I felt that by the time she came to see me, no treatment for PTSD was warranted, but the depression had to be treated. Because she had been on a tranquilizer without effect, I prescribed Prozac, 20 mg. per day to be administered in the morning. After several weeks, I increased the dosage to 30 mg. per day taken in the morning. Within a month, the drug appeared to be effective in stabilizing her moods, improving her sleep, and improving her self-esteem. After seven or eight months of therapy with me, Ms. Moore left the Bloomington area and moved to Iowa City. At that point, she had made considerable psychological improvement, but further counseling and monitoring of the Prozac was necessary.
In Moore's case, the important task was to diagnose the problem, and stabilize her moods. I was not especially concerned with the reasons for the onset of the depressive episode at first. When we did begin to explore the reasons for the onset of the episode, it became clear that Marianne's perception that she had been the victim of sexual harassment was the triggering event. This paralleled a previous self-reported episode of major depression that had occurred over 10 years earlier in college, when she had similarly been the victim of sexual harassment. We were exploring in depth her attitudes towards sexuality and self, and whether she was especially thin-skinned when it came to male sexual advances, including the possibility of repressed lesbianism, when she moved with her husband to Iowa City. My therapeutic sessions with her were only partially successful, because she could not attend as often as was therapeutically desirable. She had been fired from her job, and did not have the money to attend two session per week, which would have been ideal. Instead, she came only once every 14 days.
Marianne started seeing me in early September 1999, and saw me through May, 2000. I would estimate that we had 20 sessions during that period, but I do not keep specific records. The sessions were 45 minutes each, and I charge $75.00 per session, which is supposed to be paid at the conclusion of the session. Marianne still owes me approximately $1,000 for unpaid sessions, which she is paying over time. I felt it was unfair to charge her at the time because she had no income. I am not a Freudian, after all.