Case Study 2
Major Depression - Case of Janet
Janet called the mental health centre to ask if someone could help her 5 years old son,
Adam. He had been having trouble sleeping for the past several weeks, and Janet was
becoming concerned about his health. Adam refused to go to sleep at his regular
bedtime and also woke up at irregular intervals throughout the night. Whenever he
woke up, Adam would come downstairs to be with Janet. Her initial reaction had been
sympathetic; she would give him some water, talk to him, and rock him back to sleep.
As the cycle came to repeat itself night after night, Janet's tolerance grew thin and she
became more argumentative. She found herself engaged in repeated battles that usually
ended when she agreed to let him sleep in her room. Janet felt guilt about giving in to a
5-year-old's demands, but it seemed like the only way they would ever get any sleep.
The family physician was unable to identify a physical explanation for Adam's problem;
he suggested that Janet contact a psychologist.
The therapist began by asking several questions about Janet and her family. Janet was
30 years old and had been divorced from her husband, David, for a little more than one
year. Adam was the youngest of Janet's three children; Jennifer was 10 and Claire was 8.
Janet had resumed her college education on a part-time basis when Adam was 2 years
old. She had hoped to finish her bachelor's degree at the end of the next semester and
enter law school in the fall. Unfortunately, she had withdrawn from classes about a
month ago. Her current plans were indefinite. She spent almost all of her time at home
with Adam.
Janet and the children lived in a large, comfortable house that she had received as part
of her divorce settlement. Finances were a major concern to Janet, but she managed to
make ends meet through the combination of student loans, a grant-in-aid from the
university, and child-support payments from David. David lived in a nearby town with a
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younger woman whom he had married shortly after the divorce. He visited Janet and
the children once or twice every month and took the children to spend weekends with
him once a month.
Having collected the necessary background information, the therapist asked for a
description of the circumstances surrounding the development of Adam's sleep
difficulties and the factors that currently affected the problem. This discussion covered
the sequence of a typical evening's events, beginning with dinner and progressing
through the following morning. It was clear during this discussion that Janet felt
completely overwhelmed by the situation. She was frustrated and felt that she was
completely unable to control her son. At several points during the interview, Janet
seemed to be on the verge of crying. Her eyes were watery, and her voice broke as they
discussed her response to David's occasional visits. The therapist, therefore, suggested
that they put off a further analysis of Adam's problems and spend some time discussing
Janet's situation in a broader perspective.
In the subsequent conversation it became clear that Janet's mood had been depressed
since her husband had asked for a divorce. She felt sad, discouraged, and lonely. This
feeling seemed to become even more severe just prior to her withdrawal from classes at
the university (one year after David's departure and two months before her first clinic
appointment). When David left, she remembered feeling "down in the dumps," but she
could usually cheer herself up by playing with the children or going for a walk. Now she
was nearing desperation. She cried frequently and for long periods of time. Nothing
seemed to cheer her up. She had lost interest in her friends, and the children seemed to
be more of a burden than ever. Her depression was somewhat worse in the morning,
when it seemed that she would never be able to make it through the day.
Janet was preoccupied by her divorce from David and admitted that she spent hours
each day brooding about the events that led to their separation. These worries
interfered considerably with her ability to concentrate and seemed directly related to
her withdrawal from the university. She had found that she was totally unable to study
the assigned reading or concentrate on a 45-minute lecture. Withdrawing from school
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had precipitated further problems. She was no longer eligible for student aid and would
have to begin paying back her loans within a few months. In short, one worry led to
another, and her attitude became increasingly pessimistic.
Janet blamed herself for the divorce, although she also had considerable resentment
toward David and his new wife. Among other things, she believed that her return to
school had placed additional strain on an already problematic relationship.
She wondered whether she had acted selfishly. The therapist noted that Janet's
reasoning about her marriage often seemed vague and illogical. She argued that she had
been a poor marital partner and cited several examples of her own misconduct.
These included events and circumstances that struck the therapist as being very
common and perhaps expected differences between men and women. She spent more
money than he did on clothes, did not share his enthusiasm for sports, and frequently
tried to engage David in discussions about his personal habits that annoyed her and the
imperfections of their relationship. Of course, one could easily argue that David had not
been sufficiently concerned about his own appearance (spending too little effort on
buying good clothes), that he had been too preoccupied with sports, and that he had
avoided her sincere efforts to work on their marital difficulties. But Janet blamed
herself. Rather than viewing these things as simple differences in their interests and
personalities, Janet saw them as evidence of her own failures. She blew these matters
totally out of proportion until they appeared to her to be terrible sins. Janet also
generalized from her marriage to other relationships in her life. If her first marriage had
failed, how could she ever expect to develop a satisfactory relationship with another
man? Furthermore, Janet had begun to question her value as a friend and parent. The
collapse of her marriage seemed to affect the manner in which she viewed all of her
social relationships. The future looked bleak from her current perspective, but she had
not given up all hope. Her interest in solving Adam's problem, for example, was an
encouraging sign. Although she was not optimistic about the chances of success, she was
willing to try to develop new skills that would help her become a more effective parent.
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Social History
Janet's early childhood had been ordinary and boring. Not having any siblings, she spent
most of her time with adults, particularly her mother. She remembered her parents'
relationship as being warm and pleasant. The family took frequent outings together and,
despite the usual number of quarrels and disagreements, everyone seemed to enjoy
being together.
When Janet was 10 years old, her mother died in an automobile accident. Janet could
remember the events of that day with terrible clarity. When she arrived home from
school, her mother's best friend was there to meet her. She explained that Janet's
mother had been in an accident and that her father had gone to the hospital. He arrived
home several hours later and told Janet that her mother had died. The following months
were very difficult for Janet and her father. Janet's father was overcome with grief, but
he managed to continue working and arranged for neighbourhood friends to care for
Janet when he was not home. Janet struggled through her normal schedule of activities.
Her performance at school was not markedly affected, and she continued to play with
her small circle of friends. She did remember, however, that she often spent long hours
sitting in her mother's room gazing at old photographs and crying softly to herself. On
one occasion, her father found her wearing some of her mother's clothes and makeup.
His response seemed to be appropriate and sympathetic. They had a long talk about
how much they both missed Janet's mother and how they could help each other through
this difficult time. Shortly after this incident, Janet's father donated her mother's clothes
to the charity.
Even prior to her mother's death, Janet had been reserved socially. She tended to have
one or two special friends with whom she spent much of her time outside of school, but
she felt awkward and self-conscious in larger groups of children. Although her friends
were important to her and she enjoyed spending time with them, Janet usually waited
for them to contact her. She did not initiate activities and hesitated to express her own
preferences when they were trying to decide what to do. In retrospect, Janet attributed
this lack of assertiveness to her fear that her friends would abandon her or ridicule her
interests. She was also self-conscious about her weight. She was not really fat, but she
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tended to be a bit plump and was therefore afraid that the others would tease her if she
drew attention to herself.
This friendship pattern persisted throughout high school and into her college years.
She was interested in boys and dated intermittently until her junior year in high school,
when she began to date one boy on a regular basis. Janet was certain that she was in
love with him and soon lost all contact with the few girlfriends with whom she had been
close. She and her boyfriend, John, spent all of their time together, both after school and
on the weekends. Janet remembered that the other kids seemed to make fun of her
relationship with John and admitted that it did seem silly from her current perspective.
Whether they were alone or in a group, Janet always sat next to John, holding his hand
and giggling at his dreary jokes. The others teased Janet and John about acting as if they
were married. This criticism troubled Janet, even though she fully expected that she and
John would be married shortly after they graduated from high school.
Her marriage plans did not work out, however. She and John broke up during Janet's
first year in college. He announced suddenly that he wanted to date other women and
that their relationship was over. Janet met David a few weeks afterward, and they were
married the following summer. Janet later wondered whether she had rushed into her
relationship with David primarily to avoid the vacuum created by John's sudden exit.
Whatever her motivation might have been, her marriage was followed shortly by her
first pregnancy, which precipitated her withdrawal from the university. For the next
seven years, Janet was occupied as a fulltime mother and housekeeper.
When Adam was two years old and able to attend a day-care centre, Janet decided to
resume her college education. She and David had discussed her desire to complete her
degree and pursue a profession on several occasions. He was less than excited about
this prospect and preferred that Janet continue in her present role. She disagreed but
admitted that the children were too young and they could not afford both tuition and
day care. Now that Adam was older, the circumstances were finally in Janet's favour,
and David agreed to take a more active role in various responsibilities that had
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previously been assumed by Janet alone. Adam was enrolled at a daycare centre on a
half-time basis, and Janet began taking two courses each semester.
Following Janet's return to school, her relationship with David became increasingly
strained. They had even less time than usual to spend with each other. David resented
his increased household responsibilities. Janet was no longer able to prepare meals for
the family every night of the week, so David had to learn to cook. He also had to share
the cleaning and drive the children to many of their lessons and social activities.
A more balanced and stable relationship would have been able to withstand the stress
associated with these changes, but Janet and David were unable to adjust. Instead of
working to improve their communications, they bickered continuously. They found it
impossible to negotiate a mutually acceptable exchange of responsibilities. The final
blow came when David met another woman to whom he was attracted and who offered
him an alternative to the escalating hostility with Janet. He asked for a divorce and
moved to an apartment.
Janet was shaken by David's departure, in spite of the fact that they had not been happy
together. Fortunately, she did have a few friends to whom she could turn for support.
The most important one was a neighbour who had children of approximately the same
ages as Janet's daughters. There were also two couples with whom she and David had
socialized. They were all helpful for the first few weeks, but she quickly lost contact with
the couples. It was awkward to get together as a threesome, and Janet had never been
close enough with the women to preserve their relationships on an individual basis.
That left the neighbour, Susan, as her sole adviser and confidante.
Susan was the only person with whom Janet felt she could discuss her feelings openly.
They spent hours talking about the recent events in Janet's life and her plans for the
coming months. For the next few months, Janet was able to continue her studies. With
the children's help she managed the household chores and kept up with her work. She
even found time for some brief social activities. She agreed to go out on two blind dates
arranged by people with whom she and David had been friends. These were generally
unpleasant encounters; one of her dates was boring and unattractive, and the other was
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obnoxiously aggressive. After the latter experience, she discontinued the minimal
efforts she had made to develop new friendships. The process seemed too difficult and
threatening. Janet referred to single-parent clubs as "meat markets" where people
paired off for casual sexual encounters. She might have become acquainted with other
people in her classes at the university, but she was uncomfortable initiating
conversations with her classmates.
As time wore on, Janet found herself brooding more and more about the divorce. She
was gaining weight at the rate of three or four pounds a month. The first few pounds
had been easy to ignore and were more a nuisance than anything else. But soon her
clothes no longer fit, and the children began to comment on her appearance. To make
matters worse, Claire developed a serious ear infection just prior to Janet's midterm
exams. The added worry of Claire's health and her concern about missed classes and
lost studying time contributed substantially to a decline in Janet's mood. She finally
realized that she would have to withdraw from her classes to avoid receiving failing
grades.
By this point, one month prior to her appointment at the mental health centre, she had
lost interest in most of her previous activities. Even casual reading had come to be a
tedious chore. She did not have any hobbies because she never had enough time. She
also found that her friend Susan was becoming markedly aloof. When Janet called, Susan
seldom talked for more than a few minutes before finding an excuse to hang up. Their
contacts gradually diminished to an occasional wave across the street or a quick, polite
conversation when they picked up their children from school. It seemed that Susan had
grown tired of Janet's company.
This was Janet's situation when she contacted the mental health centre. Her mood was
depressed and anxious. She was preoccupied with financial concerns and her lack of
social relationships. Adam's sleeping problem, which had begun about one week after
she withdrew from her classes, was the last straw. She felt that she could no longer
control her difficult situation and recognized that she needed help.
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