Case Study - Depression

Question: "...describe in some detail the effects of a depressive episode on a real person."

BACKGROUND OF FAMILY SYSTEM AND IDENTIFIED PATIENT:

Betsy Johnson, 15, is the second of three girls and a boy born to Bob and Susan Johnson. The family resides in a rural area of southeastern New York's Catskills. Mr. and Ms. Johnson have been married for approximately 20 years. The family is of Anglo-American descent, with some extended family living in the area. Mr. Johnson is employed in a machine factory about 45 miles from hone. Residing in a crowded, rundown home on a picturesque street which runs parallel to railroad tracks and a scenic river, the Johnsons appear to survive on a living well below the Federal poverty guideline. There is very little privacy in the home. Family members' contact with each other seems center mostly in the kitchen and living room. The family does have a few modern comforts (i.e., microwave oven, color TV), but recently lost title to their house, including substantial equity, to foreclosure by a private lender. That Mr. and Mrs. Johnson ignored professional financial planning advice, to refinance with a bank for fairer treatment, seems consonant with clinical depression.

Diffuse interpersonal boundaries within the Johnson family system seem to cause or contribute to a variety of functional and interpersonal problems between members and in the community, including parent-child physical abuse, school failure, hyperactive or bipolar acting out by Betsy and her youngest brother. Ms. Johnson denies she has any reason to suspect Betsy has any history of being sexually abused. However, Ms. Johnson volunteered the information that she is aware of some indications of incestuous activity between her siblings-in-law in Mr. Johnson's family of origin.

Parent reports indicate Betsy's sleep and eating patterns are erratic, on one occasion recently "pumping herself up" with sugar and caffeine overdoses on all-night binge prior to her most recent runaway episode. Despite defensive attempts to appear uncaring and sarcastic, Betsy appears emotionally fragile and lacking in positive self-esteem. Whenever she has been seen by this writer, Betsy has seemed fatigued or run down. Betsy verbalizes moral opposition to "using" any psychoactive medications or drugs. She has been psychiatrically evaluated twice in the last six months. Betsy says she believes she would be happier if only her parents would let her marry her boyfriend, which is altogether unrealistic from any adult perspective. It remains unclear whether Betsy has given up on her hopes to reunite with the boyfriend.

Until recently being placed in foster care by Child Protective Services, Betsy was involved in a dependent-compulsive relationship with a 19-year-old man. This boyfriend was particularly objectionable to Mr. and Ms. Johnson, who expressed appropriate parental anxiety and increasing anger over Betsy's increasingly defiant attitude and inappropriate attachment to Chris. Betsy seemed to delight in her parents' reaction to her boyfriend's unusual appearance and interests, which included apparent Ku Klux Klan jailhouse tatoos on his knuckles and a Mohawk haircut, while boasting of practicing "grey magic" sorcery with Betsy.

After being brought home by police from her second runaway attempt, Betsy's parents told her she was grounded and could not leave the house. Betsy, however, continued to insist on being able to go out, leading to a fight with Father who has rarely played the part of disciplinarian, usually taking instead a sugar-daddy role in which Betsy is favored (or perhaps Betsy is simply most effective at winning his attention). One night, this led to a fight in which Betsy received a large welt on the right side of her face. Betsy then stole her older sister's car and attempted to get to her boyfriend's house, only to discover that the boyfriend had been jailed on a two unrelated outstanding warrants. Mr. Johnson's admission of having bruised Betsy's face while administering corporal punishment was reported to the Central Registry on Child Abuse and Maltreatment. After spending Thanksgiving weekend with her boyfriend's mother in Pennsylvania, Betsy was placed placed in protective foster care. Court proceedings against both parents (Neglect) and against Betsy (PINS and JD) are pending. It is expected that Betsy will be returned to her natural parents at an upcoming hearing, and perhaps be placed on probation with family therapy to continue. Treatment goals will include clarifying interpersonal boundaries within the family system, elevating the father in the family hierarchy, and supporting positive sibling and parent/child contact.

The younger of Betsy's sisters appears to suffer from intermittent stress-induced sleep disturbance and enuresis, while her brother is medicated with Ritalin for ADHD. Clearly, there is more going on in this family's dysfunctional cycle with each other, but depression is an element.

Thomas S. Rue, M.A., NCC
January 18, 1993

The Universi ty of Iowa - College of Education
Psychological and Quantitative Foundations 31:163
Abnormal Psychology

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