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Special Section: In the Field
Students and New Professionals working in Collaborative Care Contexts
By Mary Kelleher, M.S. Cand. & Christina Tanner, M.D.
(4/10/2004) -
The case presented in this account was conducted at the University of Washington Medical Center Family Medicine Clinic, which is a large practice affiliated with the UW School of Medicine. This training site is staffed by interns, medical residents, attending physicians, physician assistants, a medical social worker, and three behavioral scientists. Patients are referred by their primary care providers to the clinic’s behavioral scientists, and collaborative care is carried out through a variety of formal and informal means (e.g., hallway conferences, a computerized charting system).
Case Example
Sarah* is a 48 year old Middle Eastern female. She fled to the United States 20 years ago with her extended family to escape a repressive regime and possible imprisonment and torture for her activities in women’s education. She divorced after a 3 year marriage to a fellow émigré (the marriage having caused considerable conflict within her extended family) and has no children. Since the death of her father approximately 10 years ago, this previously well-to-do family has experienced significant financial hardships and Sarah became largely responsible for the economic support of her mother and other family members. She currently resides with her mother, brother, sister and nephew.
Sarah was referred to therapy by her primary care physician, Christina Tanner, MD, for the treatment of anxiety and assistance with pain control. A further psychological and psychosocial assessment revealed that Sarah had developed frequent severe and chronic headaches (consisting of a mix of migraine and tension headaches) in comorbidity with anxiety at the age of 9. By age 18, the frequency of Sarah’s headaches was daily (with severity scores of 10/10), and this continued until just a few years ago. Sarah developed depression during adolescence, which had worsened since the death of her father. Except for one brief instance of suicidal ideation a decade ago, Sarah has not been suicidal. In 1990, Sarah had a motor vehicle accident resulting in cervical strain and since then, her pain has generalized. Other medical issues include hypercholesterolemia, occasionally elevated blood pressure, chronically itchy skin, and irritable bowel syndrome.
Almost all of the Sarah’s first degree relatives suffer from some form of anxiety. Sarah’s mother also had developed severe chronic headache, panic disorder, anxiety, and depression from the age of 13, and according to Sarah’s report, the family was organized around the mother’s health issues and the father’s frequent absences (as a highly successful professional) and his mercurial and sometimes violent outbursts directed at his wife and children when at home.
Sarah reports that she responded poorly to medical and psychological treatments in her country of origin. She has been treated with a variety of antidepressants over the last ten years, including Amitriptyline, Zoloft, and Effexor. Sarah began to enjoy some pain control during the last few years from a regimen of Celebrex, Celexa, Imipramine, and Clonazepam; she also responded well to relaxation and cognitive behavioral techniques for pain management.
Presenting Problems and Attempted Solutions
From childhood until the last few years, Sarah was able to stay highly productive despite daily pain and frequent anxiety. However, as stressors increased in her life during her marriage, divorce, and the death of her father, Sarah’s depression and anxiety increased. Normal activities would trigger fear of failure, which led to a cycle of anxiety, pain, and long periods of depression. Sarah was frequently angry and grieving at the loss of a normal life and failure to fulfill her dreams because of her chronic illness. Previously, she had managed her illness by hiding or ignoring symptoms, avoiding triggers, gaining personal and family approval through high achievement, and soothing herself with creative endeavors. The worsening of her depression and her ability to function daily, as well as the loss of the ability to pursue previously satisfying creative pursuits and an increasing feeling of personal failure, motivated Sarah to pursue psychotherapy.
Sarah has a rich array of internal resources. She is highly educated, creatively gifted, pleasant, insightful, and maintains an excellent command of the English language. Sarah is highly motivated to make treatment progress. She practices a form of logotherapy, searching for existential meaning to her life struggles. She is a devout Sufi (a form of Islamic mysticism), and her personal relationship with God has sustained her throughout her life’s experiences. She draws pride from her rich cultural heritage. Despite her family’s personal struggles and internal conflicts, they are close and supportive of Sarah and each other.
A particularly relevant issue in Sarah’s treatment was that of culture. It became important early on that this issue be acknowledged and addressed in therapy because it is integral in Sarah’s worldview and coping skills. Sarah was eager to explain cultural differences and assisted the therapist in understanding how Islamic culture deals with illness, family, and grief and loss. These conversations allowed the therapist to gain greater insight into Sarah’s experience and to frame interventions in a culturally acceptable manner; this was particularly relevant in issues pertaining to Sarah’s relationships with parents and older male siblings, where limited life choices (as defined by Western culture) were respected and supported, rather than challenged, within the therapeutic relationship.
Treatment and Outcome
Long-term chronic pain patients often experience the avoidance or outright refusal of intimate friends, family, and even healthcare providers to listen to and validate their suffering. This had been Sarah’s experience with her family, one which was accentuated by culturally- and family-directed ways of dealing with physical suffering. At the same time, depression in the Middle East is perceived as grief and sadness, and the cultural experience of grief is one rich with social connection, verbal processing, and ritual. Because Sarah’s experiences of loss and depression were intimately connected with her physical suffering, she had been denied the ability to grieve her personal losses in a way most natural to her. Active employment of a narrative approach helped to restore this ability.
The recounting of trauma is also an intervention used in the treatment of PTSD, and this was indicated in the therapy with Sarah. Treatment initially consisted of a narrative by Sarah regarding her life story with frequent questions to clarify experiences and feelings and externalize problems. This was supplemented with education on the biopsychosocial aspects of pain and the exploration of ways to improve Sarah’s quality of life.
Within one month of therapy’s onset, Sarah began to experience a lifting of depression. Within 3 months, Sarah reported that the cycle of trigger-anxiety-pain-depression had shortened from months to days, and she had begun to experience increasingly prolonged periods of reduced pain with less anxiety and depression. She began to feel hopeful and became more assertive in her interactions with her family. In response, Sarah reported that her family had begun to reorganize in a healthier manner and her mother was taking increasing responsibility for her own medical issues (which was of significant concern). Sarah also became more assertive in the workplace, and reports that she has been promised a promotion. She has begun to engage in creative activities such as painting and music which had previously triggered anxiety, and she is also actively pursuing a social life.
Collaboration
Therapist’s Reflections
This case has been challenging insofar as I have had to choose therapeutic interventions that compliment the patient’s cultural background and multiple diagnoses. In particular, Narrative Therapy techniques offered Sarah the opportunity to reframe her depression as grief, to process her losses (health and homeland) through the use of story, and to revise key portions of her story to acknowledge her strengths and accomplishments.
This case was also notable in terms of the patient’s level of motivation and personal courage vis-à-vis a lifetime that encompassed considerable trauma and pain. I found myself constantly inspired by her as she recounted her experiences at each session.
Finally, Sarah was one of the first patients I saw as a Medical Family Therapy intern, and I had consequently approached this complex case with some anxiety. I found that my initial consultation with Dr. Tanner was very valuable in orienting my approach to Sarah and my choice of treatment; Dr. Tanner’s sensitivity to the patient’s cultural background and experience of chronic pain served to alert me to the importance of these issues, and they were pivotal in the successful treatment of Sarah’s depression and anxiety.
Physician’s Reflections
Psychological factors are almost always very important in patients’ suffering from chronic pain and anxiety. However, an individual patient’s ability to recognize, accept and deal with these issues is variable and sometimes quite limited. I believed that this particular patient would make a good candidate for therapy because she is intelligent, remarkably articulate, psychologically-minded, had already benefited to some degree from prior behavioral therapy, and had specific academic, work-related and artistic goals. The therapeutic intervention in fact resulted in the patient reporting subjectively-decreased levels of depression and anxiety, decreased reliance on and use of medication, improved work performance (and consequent improvement in her financial situation), and a general sense of better control of her life. The patient emphasized that cultural sensitivity, respect and genuine caring from her physician and therapist were crucial to her therapeutic improvement.
*Patients’ names have been changed to protect confidentiality.
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