Question

Deanna is an advanced practice nurse who specializes in cognitive and behavioral therapies for patients with anxiety disorders. Today she has an appointment with a new patient, Ellen, a young woman with an anxiety disorder that includes a fear of being touched.

“I need to get over this,” Ellen says, “because I’d like to meet a really nice guy and get married someday. And that’s not going to happen if I can’t let anybody touch me, is it?” She rolls her eyes, mocking herself.

“Do you have any idea how this started?” Deanna says, hoping to get a little initial history before beginning a formal assessment. She notices that Ellen is an attractive woman, who taps the arms of her chair and swings her leg nervously.

“Yes,” Ellen says. “I know precisely how this started. My suffocating mother.”

“Your mother makes you feel suffocated?” Deanna asks.

Ellen nods. “Positively suffocates me. All my life, she has hovered and tried to control even my smallest actions. She acts terrified that something will happen to me.”

“Obsessively protective, is she?” Deanna smiles sympathetically.

“Obsessive! Yes! Protective? You’d think so, wouldn’t you. I couldn’t go to sleep-overs because she was afraid someone would kidnap me. I was good at soccer but couldn’t play—ever—because she was afraid I’d break my head. It was totally abnormal. All my friends agreed. So—protective?? Yeah, you’d think I was her precious baby, wouldn’t you! “ Angry tears form in the corners of Ellen’s eyes.

“But you don’t think you are her precious baby?”

“No, exactly.” Ellen twists the tissue in her hands over and over again. “Geez, this is so gross,” she mumbles, looking out the window.

“Take your time.” Deanna waits, giving Ellen a chance to gather her thoughts.

“I hate talking about this stuff,” Ellen says.

“I can understand that,” Deanna says. “Don’t worry. This is a safe, private place.”

After a few tearful moments, Ellen blows her nose and then lifts her head to look at Deanna. She speaks more softly. “The thing is, my mother has never really liked me. She told me she married my dad out of romantic love, and for a sense of security. She says she never was interested in having kids. She hovers and protects, and when I was little, she was obsessive over how I looked. I was overgroomed, really, in ridiculous little designer dresses she constantly bought, but she was never—”

Ellen stifles tears before going on.

“She was never proud of me, or happy with me. Nothing I did elicited praise—except when she’d realize someone noticed, and then she’d gush over me in a way that was so phony it was embarrassing and just gross. And God, we never hugged.” She shudders, imitating her mother. “That would have totally freaked her out. My father was the one who’d hug me and read me bedtime stories. Once, when I was little, I tried to get a good night hug from my mother, and she turned from her computer in annoyance and squeezed me super-tight in anger, she was so frustrated I had interrupted her. When she let go, she was all smiles, and tried to pretend it was a ‘bear hug.’ She wanted me to think it was. But it wasn’t.

“Anyway, we never touched if we didn’t have to, and when we did, it was just horrible. I remember one time, Dad lined us up together in front of the fireplace and said, ‘I want a nice portrait of my two girls.’ He had us put our arms around each other’s waists, and then the whole time he was adjusting the lens, she muttered between her perfect smiling teeth, ‘Hurry up, Wade. Just hurry up and take the picture already!’ When he was done, we broke away from each other in relief. She laughed about it, but couldn’t look at me. We had both almost felt—I don’t know—violated. From having to embrace like some normal mother and daughter.”

1. Deanna’s goal, of course, is to help Ellen get over her abhorrence of touching. But in the process of beginning her history, she has learned of a mother who has contributed to her daughter’s feeling that way. What defense mechanism did Ellen’s mother demonstrate on a regular basis? What is at its root?

1. Deanna asks Ellen to describe how her dislike of her mother’s touch has carried over into other relationships, and Ellen explains that she stiffens when anyone tries to touch her, even snapping at them occasionally. This has cost her some friendships along the way, although some of her close friends understand and accept that although Ellen cares about them and values the relationship, it’s important to “not hug Ellen.” “They just say, ‘Oh, she’s just not touchy-feely!’ Which is fine with a good understanding friend—but doesn’t exactly let me get too close to boyfriends.” To help Ellen become desensitized to touch, Deanna considers two different strategies at first: She could expose Ellen to a long, extended hug until the fear of it diminishes as the hug continues. Or she might try proposing that they take initial steps together, working on relaxing first, before each brief encounter (e.g., an occasional pat during conversation or a quick, reassuring squeeze of a hand) progressing to eventually hugging good-bye at the end of each session. Deanna prefers this second approach. Identify each Behavioral Therapy approach Deanna suggested.

1. Ellen is making progress, so she and Deanna add on new assignments, in which Ellen will also verbalize and challenge her feelings with appropriate thoughts. She will explain to a trusted friend what she is trying to do and then make a plan in which she and the friend choose a light, comfortable friendly touch, such as nudging each other while teasing, and progress to squeezing each other’s hand at some point in the conversation, and hugging hello and good-bye. During this time, Ellen now also keeps a journal about how she feels before and after each brief encounter. She also talks first with Deanna and later with her supportive friend about how this feels as she engages in light, friendly touching over time. What is the first option Deanna described—the one that Ellen rejected? When Deanna is invited to present a paper about her treatment of Ellen for an upcoming conference, the form she is filling out asked her to characterize her topic as “cognitive therapy,” “behavioral therapy,” or “other.” (Naturally, there is a blank beside “other” to indicate the appropriate category.) How would you categorize her treatment sessions with Ellen? What should Deanna put on the form for the conference? Why?

Answer 1

Ellen's fear or uneasiness for physical intimacy could be traced back to her mother's cold distant behavior towards her since childhood, her mother as described by her was a woman who never intended to have kids and was married to a man for sense of security etc. She holds sense of dissatisfaction towards her life choices which stops her from forming deeper and intimate relations with her daughter, therefore she has developed defense mechanism to feel better about her insecurities. She through her overcompensating behavior {overprotective,obsessive,materialistic} tries to suppress the fact that she is not a connecting and nurturing mother when it comes to giving emotional connect to her child, hence instead she focuses on other factors to show her hold,authority,sense of contribution in her daughter's life which in turn leaves Ellen feel suffocated and confused.

the first approach suggested by Ellen's therapist Deanna suggested was exposure therapy , which includes exposing the subject to their cause of anxiety directly, making them confront the following until a considerable reduction in anxiety is observed ,in a nutshell the therapist tries to reduce the avoidance approach to anxiety provoking situations. the exposure therapy tries to reverse the behavioral conditioning and correct the errors present in the cognition regarding one's inability to confront situations causing anxiety and handling the intense response attached to it.

the second approach Deanna used and discussed with Ellen is behavioral therapy by Joseph Wolpe involving counter conditioning achieved through systematic desensitization. the process involves teaching the client relaxation techniques , to relax one's body during anxiety reactions of body when confronted to anxiety provoking situations. once he client is ready they are made to form an anxiety hierarchy that ranks events from most anxiety provoking to least. then the stimuli are systematically arranges in front of the client, making them imagine scenes and observing the changes in body due to anxiety and continuously trying to relax the same till they are able to complete a scene . overtime they can observe a considerable reduction in restlessness caused by the stimuli they are confronted to. Deanna shall discuss the same in the paper ,as to how in Ellen's case, through a process of generalization she developed anxiety towards any physical intimacy,be it with anyone as she had them conditioned to painful emotions experienced by her during her childhood and then the therapy she chose and proceeded with including effects of the same on her condition.