Chapter 1. Jennifer

1.1 Introduction

Missouri State University

1.2 Presenting Complaint

Jennifer is a 28 year-old single female. She is currently unemployed after recently losing her job Jennifer feels like her entire life is characterized by instability. She never had a stable home life as a child, and as an adult, she continued to live in a chronic state of chaos. She often felt like she was on an emotional roller coaster. The slightest event could set her mood off in any direction. She might feel happy and euphoric one moment, but her mood could plummet after a minor stressor like having someone cancel an appointment. Even as a child, Jennifer’s reactions to events were much more extreme than those of other children. She seemed incapable of experiencing any emotion in a mild manner—her good moods were incredibly positive and her bad moods were intensely negative.

Jennifer also struggled with irrational bursts of anger. For example, a co-worker in the next cubicle once asked her to try to keep her voice down when speaking on the phone. She became extremely upset and angry and confronted the co-worker after work. She obsessed about the event for the entire night and emailed a tirade about the co-worker to their joint supervisor, copying several other co-workers. Because of incidents like these, Jennifer had never held a job for more than 6 months. Her most recent position ended following another negative interaction with a co-worker, and she was finding it more and more difficult to find employment with her history of short-term positions.

Jennifer also found it difficult to maintain any relationship over an extended period of time. She desperately wanted someone who could be a “best friend” and she tended to attach to people too quickly. If someone expressed a shared interest with her or suggested an activity they might do together, she would become hopeful that their relationship might develop into something closer. She quickly became far too clingy and intrusive at the beginning of a relationship. . As a result, she experienced a long string of relationship rejections and felt incredibly lonely. . Sadly, rejection was one of her biggest fears and yet it seemed to happen to her over and over again. In high school, for example, she once gave a “best friends” necklace to a girl she had known for only a week. Predictably, the other girl responded awkwardly to the gift and began making excuses to avoid Jennifer in the cafeteria and in classes.

Jennifer had been in and out of dating relationships since the age of 14. Similar to her attempts at friendship, she often began her dating relationships feeling “on top of the world.” She always knew that her current boyfriend was going to be the “one” and she quickly idealized the relationship and imagined a future marriage and children when they had only been on a couple dates. When she managed to stay in a relationship for more than a few weeks, her constant fear of rejection would often lead her to sabotage the relationship. She found herself constantly setting up “tests” to see if her boyfriend really cared about her. For example, she would send a vague text message posing a question such as “how could anyone love someone like me?” She would then wait to see how long it would take her boyfriend to respond and whether his response would pass the “test.” If he didn’t respond immediately, she would find herself alternating between despair and anger. Even if her boyfriend informed her that he was in a meeting, she would accuse him of lying and ignoring her. After a short period of time, each boyfriend would inevitably begin to show signs of ending the relationship. When Jennifer began to pick up on any of these “signs” she would frantically attempt to avert the impending break-up. She often fabricated stories about family members dying or dire medical test results she had just received. In several cases, she threatened to hurt herself. While these efforts were often successful in the short-run, the relationships never lasted much longer in the end. When the inevitable break-up occurred, she was unable to accept the fact that the relationship was over. Following a break-up, Jennifer often spiraled into a frantic and often suicidal state. She would write suicide notes to her ex-boyfriend and then send them in an email or leave a hand-written note on his car. On one level, she knew that her behavior was irrational and unlikely to lead to reconciliation, but she found herself unable to stop.

As a young teenager, Jennifer had discovered that during her worst periods, she could occasionally obtain some relief by causing herself physical pain. She started by simply scratching herself on the arms and legs. She would find herself sitting in class using a bent paperclip to scratch her legs until they began to bleed. She soon progressed to cutting herself with a razor and burning herself with a lighter. She usually tried to hide her cuts and sores by cutting areas of her body that would be covered by her clothing. She was embarrassed about the scars that began to cover parts of her body, but she found it more and more difficult to resist the urge to hurt herself when she was feeling out of control. When she felt physical pain it seemed to provide some relief for her intense and unbearable negative emotions.

In another attempt to escape from her emotions, Jennifer would engage in other behaviors such as binge eating and drinking. For months at a time, she would engage in secretive night binges, standing at the kitchen counter consuming vast quantities of food in the middle of the night. Then she would stop binge eating for a few weeks, and begin instead to engage in binge drinking episodes. She would tell herself each day “I’ll never do that again,” but as soon as her emotions began to ramp up, she would find it impossible to resist the urge.

1.3 Social/Family History

When Jennifer was 2 years old, her parents divorced. She lived primarily with her mother as a young child but there were times when she lived with her grandmother for months at a time. Her father had sporadic contact with her throughout the years. When she was a young child, he would call and promise her that he would pick her up for the weekend and take her to the local amusement park or on a shopping trip. She vividly remembered sitting on the front porch of their house waiting for her father for hours but his promises were more often broken than upheld. She would vow never to trust her father again, but he would somehow manage to convince her that he had a valid excuse and build her hopes up for the next time.

Jennifer’s mother remarried a total of 4 different times from the time Jennifer was 3 years old until she left home at age 17. Jennifer described her step-fathers as “losers” and she never had a close relationship with any of the men her mother married. When she was 8 years old, her 2^nd step-father began to molest her. After a year of progressively worse abuse, he raped her at the age of 9. She was terrified and embarrassed to tell anyone but one day she finally found the courage to tell her mother what had happened. She had fantasized about the moment that her mother would find out about the abuse, imagining her step-father being thrown out of the house. However, her mother reacted with seeming indifference and accused Jennifer of exaggerating. She was so devastated by her mother’s reaction that she refused to tell anyone else about the abuse for many years. Until the relationship finally ended between her mother and her 2^nd step-father, Jennifer simply tried to hide from him as much as possible. She avoided being home when she knew that he would be there alone and she made excuses to stay at school late. She would tell her mother that she was involved in various school clubs and activities, when in reality she spent much of her after-school hours sitting alone in a local park.

Jennifer’s biological father did not provide any child support and her mother’s employment record was very unstable. Her mother bounced from minimum wage job to minimum wage job every few months with long periods of unemployment in between. Jennifer never had enough money to be able to dress in stylish clothes or have the latest toys or gadgets. Because of her emotional reactivity, any teasing by other children served as a crushing blow to Jennifer. She had only a handful of friends throughout school and most of her friends had significant problems of their own. The people with whom she most wanted to be friends seemed to react the most negatively to her.

At age 17, Jennifer had a violent argument with her 4^th step-father. The argument began over something fairly minor, but her anger quickly escalated and she ultimately ended up throwing a chair through a glass door. Her step-father responded by kicking her out of the house. Her mother did not intervene on her behalf, and instead took her step-father’s side once again. She briefly moved in with her boyfriend at the time but that relationship only lasted a few months. For several years, she moved from place to place and even lived in a homeless shelter for several weeks. She dropped out of high school when she was kicked out of her house, and began a long string of short periods of employment.

1.4 Multiple-Choice Questions

1.5 Treatment