GrandScienceAlpaca5Diana Miller, age 25, entered a long-term treatment unit of a…Diana Miller, age 25, entered a long-term treatment unit of a psychiatric hospital after a serious suicide attempt. Alone in her enormous suburban house, with her parents away on vacation, depressed and desperately lonely, she made herself a diazepam and scotch cocktail, drank it, and then called her psychiatrist.
Ms. Miller had been a tractable child, with a mediocre school record until she was age 12. Her disposition, which had been cheerful and outgoing, changed drastically: she became demanding, sullen, and rebellious, shifting precipitously from a giddy euphoria to tearfulness and depression. She took up with a “fast” crowd, became sexually promiscuous, abused marijuana and hallucinogens, and ran away from home at age 15 with a 17-year-old boy: Two weeks later, having eluded the private investigators her parents had hired, they both returned. She reentered school, but dropped out for good in her junior year of high school. Her relationships with men were stormy, full of passion, unbearable longing and violent arguments. She craved excitement. She would get drunk and dance wildly on tabletops in discos and then leave with strange men and have sex in their cars. If she refused, she was sometimes put out on the street.
After one such incident, at age 17, she made her first suicide attempt, cutting her wrist severely, leading to her first hospitalization.
After her first hospitalization, Ms. Miller was referred to a therapist for intensive, twice-weekly dynamic psychotherapy, for which she had little aptitude. She filled up most of her sessions with a litany of complaints against her family, from whom she expected “100% attention.” She called her therapist several times a day about one “crisis” or another.
During her long period of unsuccessful outpatient treatment, punctuated by several brief hospitalizations, Ms. Miller had many symptoms. She was afraid to travel even to her doctor’s office without one of her parents. She was depressed, with suicidal preoccupations and feelings of hopelessness. She drank excessively and used u to 40mg/ day of diazepam. She had eating binges, followed by crash diets to get back to her normal weight. She was obsessed with calories and with the need to have her foods cut into particular shapes and arranged on her plate in a particular manner. If her mother failed to comply with these rules, Ms. Miller had tantrums, sometimes so extreme that she broke dishes and had to be physically restrained by her father.
Ms. Miller has never worked except for a few months as a receptionist in her father’s company. She never had an idea of what she wanted to do with her life, apart from being with a “romantic man.” She has never had female friends, and her only source of solace was her dog. She was often “eaten alive” with boredom. Efforts by her therapists to set limits had little effect. She refused to join Alcoholics Anonymous or to attend a day program or vocational rehabilitation center, regarding these as “beneath ” her.. Instead she languished at home, grew more depressed and agoraphobic, and escalated her diazepam use to 80 mg/day. It was a serious suicide attempt that led to her current (seventh) psychiatric hospitalization.
In the hospital, Ms. Miller complained that the nurses were “cruel” to her and that other patients “hated” her. Her parents attended many of their own therapy sessions, where they were counseled to resist their daughter’s pleas to return home. She was exquisitely sensitive to the slightest decrement in her diazepam level, such that she could be weaned only 1 mg at a time. It took 3 months before she was “off” the drug. Afterward, her progress was unexpectedly good. Her disposition became cheerful. She grew cooperative toward the staff and friendly toward other patients. She learned secretarial skills in a hospital rehabilitation program, and she became less fearful of going outside and less fussy about food. By the end of her 10-month stay, she developed a friendship with another convalescing patient, and the two arranged to share an apartment. Both found part-time work, and Ms. Miller continued therapy once a week as an outpatient.
Ms. Miller responded primarily to a supportive mode of psychotherapy, one that emphasized education, exhortation, encouragement, and limit setting. She was too anxious and too action prone to benefit from a psychodynamic approach that required introspection and reflection. Brief hospitalizations could not stem the tide of her multiple and intense symptoms, of which her substance abuse was the most threatening. For Ms. Miller, what seemed to work best was a long-term hospitalization, where the substance abuse could be properly dealt with, and where vocational rehabilitation could take hold. The enforced separation from her parents helped her and her mother realize that each could survive without the other. During 7 years of follow-up, Ms. Miller has held her ground, continues to work, lives with the same roommate, and is able to visit her parents with regularity, and without falling back into the old pattern of mother-daughter interdependence. Sensation-seeking remains a noticeable part of her adaptation she likes flashy clothes, clubs, and rock concerts but she is less impulsive, abstains from alcohol and other drugs, and no longer places herself in jeopardy with strange men
Discuss the therapeutic goals for your client.
Discuss the psychotherapeutic treatment you believe is appropriate for your client.
Discuss any pharmacological treatment options you believe is appropriate for your client.
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