“The Case of Mrs. C” is excerpted from Systems of Psycotherapy: A Transtheoretical Analysis, 9th Edition, by James O. Prochaska and John C. Norcross, and does not reflect a clinical assessment of the client and the family members’ experiences.

THE CASE OF MRS. C

Psychotherapy systems are not merely static combinations of change processes, theoretical contents, and research studies. The systems are, first and foremost, concerned with serious disorders afflicting fellow humans. In comparing systems, it is essential to picture how the psychotherapies conceptualize and treat the presenting problems of an actual client. The client selected for comparative purposes is Mrs. C.

Mrs. C is a 47-year-old mother of six children: Arlene, 17; Barry, 15; Charles, 13; Debra, 11; Ellen, 9; and Frederick, 7. Without reading further, and astute observer might discern Mrs. C‘s personality configuration. The orderliness of children named alphabetically and of childbirths every 2 years are consistent with obsessive-compulsive disorder (OCD).

For the past 10 years, Mrs. C has been plagued by compulsive washing. Her baseline charts, in which she recorded her behavior each day before treatment began, indicated that she washed her hands 25 to 30 times a day, 5 to 10 minutes at a time. Her daily morning shower lasted about 2 hours with rituals involving each part of her body, beginning with her rectum. If she lost track of where she was in her ritual, then she would have to start all over. A couple of times this had resulted in her husband, George, going off to work while his wife was in the shower only to return 8 hours later to find her still involved in the lengthy ritual.

To avoid extended showers, George had begun helping his wife keep track of her ritual, so that at times she would yell out, “Which arm, George?” and he would yell back, “Left arm, Martha.” His participation in the shower ritual required George to rise at 5:00 A.M. in order to have his wife out of the shower before he left for work at 7:00 A.M. After 2 years of this schedule, George was ready to explode.

George was, understandably, becoming increasingly impatient with many of his wife’s related symptoms. She would not let anyone wear a pair of underwear more than once and often wouldn’t even let the underwear be washed. There were piles of dirty underwear in each bedroom corner. When we asked her husband to gather up the underwear for the laundry, we asked him to count them, but he quit counting after the thousandth pair. He was depressed to realize that he had more than $2,000 invested in once-worn underwear.

Other objects were scattered around the house because a fork or a can of food dropped on the floor could not be retrieved in Mrs. C‘s presence. She felt it was contaminated. Mrs. C had been doing no housework—no cooking, cleaning, or washing—for years. One of her children described the house as a “state dump,” and my (JOP) visit to the home confirmed this impression.

Mrs. C did work part -time. What would be a likely job for her? Something to do with washing, of course. In fact, she was a dental technician, which involves washing and sterilizing all the dentist’s equipment.

As if these were not sufficient concerns, Mrs. C had become unappealing in appearance. She had not purchased new clothes in 7 years, and her existing clothes were becoming ragged. Never in her life had she been to a beautician and now she seldom combed her own hair. Her incessant washing of her body and hair led to a presentation somewhere between a prune and a boiled lobster with the frizzies.

Mrs. C‘s washing ritual also entailed walking around the house nude from the waist up as she went from her bedroom bath to the downstairs bath to complete her washing. This was especially upsetting to Mr. C because of the embarrassment it was producing in their teenage sons. The children were also upset by Mrs. C‘s frequent nagging to wash their hands and change their underwear, and she would not allow them to entertain friends in the house.

Consistent with OCD features, Mrs. C was a hoarder: she had two closets filled with hundreds of towels and sheets, dozens of unused earrings, and her entire wardrobe from the past 20 years. She did not consider this hoarding a problem because it was a family characteristic, which she believes she inherited from her mother and from her mother’s mother.

Mrs. C also suffered from a sexual arousal disorder; in common parlance, she was “frigid.” She said she had never been sexually excited in her life, but at least for the first 13 years of her marriage she engaged in sexual relations to satisfy her husband. However, in the past 2 years they had intercourse just twice, because sex and become increasingly unpleasant for her.

To complete the list, Mrs. C was clinically depressed. She had made a suicide gesture by swallowing a bottle of aspirin since she had an inkling that her psychotherapist was giving up on her and her husband was probably going to commit her to a psychiatric hospital.

Mrs. C‘s compulsive rituals revolved around and obsession with pinworms. Her oldest daughter had come home with pinworms 10 years earlier during a severe flu epidemic. Mrs. C had to care for a sick family while pregnant, sick with the flu herself, and caring for a demanding 1-year-old child. Her physician told her that, to avoid having the pinworms spread throughout the family, Mrs. C would need to be extremely careful about the children’s underwear, clothes, and sheets and that she should boil all of these articles to kill any pinworm eggs. Mrs. C confirmed that both she and her husband were rather anxious about a pinworm epidemic in the home and were both preoccupied with cleanliness during this time. However, Mrs. C’s preoccupation with cleanliness and pinworms continued even after it was confirmed that her daughter’s pinworms were eliminated.

The C couple acknowledged a relatively good marriage before the pinworm episode. They had both wanted a sizable family, and Mr. C‘s income as a business executive had allowed them to afford a large family and comfortable home without financial strain. During the first 13 years of their marriage, Mrs. C had demonstrated some of her obsessive-compulsive traits, but never to such a degree that Mr. C considered them a problem. Mr. C and the older children recalled many happy times with Mrs. C, and they kept alive the warmth and love that they had once shared with this now preoccupied person.

Mrs. C hailed from a strict, authoritarian, and sexually repressed Catholic family. She was the middle of three girls, all of whom were dominated by a father who was 6 feet, 4 inches tall and weighed 250 pounds. When Mrs. C was a teenager, her father would wait up for her after dates to question her about what she had done; he once went so far is to follow her on a date. He tolerated absolutely no expression of anger, especially toward himself, and when she would try to explain her point of view politely, he would have to tell her to shut up. Mrs. C‘s mother was a cold, compulsive woman who repeatedly regaled her daughters about her disgust with sex. She also frequently warned her daughters about diseases and the centrality of cleanliness.

In developing a psychotherapy plan for Mrs. C, one of the differential diagnostic questions was whether Mrs. C was plagued with a severe obsessive-compulsive disorder or whether her symptoms were masking a latent schizophrenic process. A full battery of psychological testing was completed, and the test results were consistent with those from previous evaluations that had found no evidence of a thought disorder or other signs of psychotic processes.

Mrs. C had previously undergone a total of six years of mental health treatment, and throughout that time the clinicians had uniformly considered her problems to be severe but nonpsychotic in nature. The only time schizophrenia was offered as a diagnosis was after some extensive individual psychotherapy failed to lead to any improvement. The consensus in our clinic was that Mrs. C was demonstrating severe OCD that was going to be extremely difficult to treat.

CREDIT LINE: SYSTEMS OF PYSCHOTHERAPY: A Transtheoretical Analysis, 9th Edition, by James O. Prochaska and John C. Norcross. Copyright 2018 by Oxford University Press. Reprinted by permission of Oxford University Press via the Copyright Clearance Center.