Applying the Framework
For three years, Sara, a case manager in a mental health agency, worked with Anne, a thirty-five year old single white female diagnosed with major depressive disorder with psychotic features and a history of anorexia. They met twice each week and spent most of the time discussing the intensely painful feelings Anne experienced (rage, disappointment, and abandonment), her difficulties managing family relationships, and her plans for coping with these issues without self-injuring.
These sessions were emotionally draining for Sara, who, through supervision, developed a number of strategies to let go of the impact of the negativity and rage expressed by Anne. These strategies worked well until Anne's rage became focused on Sara over several months and she became increasingly agitated and psychotic. Anne now sought daily contact with Sara, requiring Sara to drop whatever she was doing to attend to her. Despite her demands for extra support and assistance, Anne insisted she was not getting "sick" and refused to consider a medication change or hospitalization. Anne became rageful and verbally abusive toward Sara on an increasing personal level, cursing her and calling her names on a number of occasions. Sara began feeling defensive and angry, yet felt she needed to hide those feelings and instead be all the more patient and consistent in her work with Anne. Sara found her patience and energy for her other clients waning and she had trouble sleeping well: she was dreaming about conflict with Anne. She felt too tired to see friends. After helping Anne finally agree to be hospitalized and consider a change in medication to help her restabilize, Sara had to confront her personal sense of exhaustion and evaluate the toll that working with Anne, in the way in which she was, was having her own health.
(Arledge & Wolfson, 2001)