Description
Karen Rusa was a 30-year-old married woman and the mother of four children. Although she had been having anxiety-related problems for a number of years, she had never sought professional help prior to this time. During the preceding 3 months, she had become increasingly depressed; her family physician fi nally suggested that she seek psychological services.
For the past several months, Karen had been experiencing intrusive, repeti-tive thoughts that centered on her children’s safety. She frequently found her-self imagining that a serious accident had occurred, and she was unable to put these thoughts out of her mind. On one such occasion, she imagined that her son, Alan, had broken his leg playing football at school. There was no reason to believe that an accident had occurred, but Karen brooded about the possibility until she fi nally called the school to see if Alan was all right. Even after receiv-ing reassurance that he had not been hurt, she was somewhat surprised when he later arrived home unharmed.
Karen also noted that her daily routine was seriously hampered by an exten-sive series of counting rituals that she performed throughout each day. Specifi c numbers had come to have a special meaning to Karen; she found that her preoc-cupation with these numbers was interfering with her ability to perform every-day activities. One example was grocery shopping. Karen believed that if she selected the fi rst item (e.g., a box of cereal) on the shelf, something terrible would happen to her oldest child. If she selected the second item, some unknown disaster would befall her second child, and so on for the four children. The chil-dren’s ages were also important. The sixth item in a row, for example, was asso-ciated with her youngest child, who was 6 years old. Thus, specifi c items had to be avoided to ensure the safety of her children. Obviously, the rituals required continuing attention because the children’s ages changed. Karen’s preoccupation with numbers extended to other activities, most notably the pattern in which she smoked cigarettes and drank coffee. If she had one cigarette, she believed that she had to smoke at least four in a row or one of the children would be harmed in some way. If she drank one cup of coffee, she felt compelled to drink four.
Karen acknowledged the irrationality of these rituals but, nevertheless, maintained that she felt much more comfortable when she observed them con-scientiously. When she was occasionally in too great a hurry to perform the ritu-als, she experienced considerable anxiety in the form of a subjective feeling of dread and apprehension. She described herself as tense, jumpy, and unable to relax during these periods. Her fears were most often confi rmed because some-thing unfortunate invariably happened to one of the children within a few days after each such “failure.” The fact that minor accidents are likely to occur at a fairly high rate in any family of four children did not diminish Karen’s convic-tion that she had been directly responsible because of her inability to observe the numerical rules.
In addition to her obsessive ideas and compulsive behaviors, Karen reported dissatisfaction with her marriage and problems in managing her children. Her husband, Tony, had been placed on complete physical disability 11 months prior to her fi rst visit to the mental health center. Although he was only 32 years old, Tony suffered from a serious heart condition that made even the most routine physical exertion potentially dangerous. Since leaving his job as a clerk at a plumbing supply store, he had spent most of his time at home. He enjoyed lying on the couch watching television and did so for most of his waking hours. He had convinced Karen that she should be responsible for all the household chores and family errands. Her days were spent getting the children dressed, fed, and transported to school; cleaning; washing; shopping; and fetching potato chips, dip, and beer whenever Tony needed a snack. The inequity of this situation was apparent to Karen and was extremely frustrating, yet she found herself unable to handle it effectively.
The children were also clearly out of her control. Robert, age 6, and Alan, age 8, were very active and mischievous. Neither responded well to parental dis-cipline, which was inconsistent at best. Both experienced behavioral problems at school, and Alan was being considered for placement in a special classroom for particularly disruptive children. The girls were also diffi cult to handle. Denise, age 9, and Jennifer, age 11, spent much of their time at home arguing with each other. Jennifer was moderately obese. Denise teased her mercilessly about her weight. After they had quarreled for some time, Jennifer would appeal tearfully to Karen, who would attempt to intervene on her behalf. Karen was becoming increasingly distressed by her inability to handle this confusing situation, and she was getting little, if any, help from Tony. During the past several weeks, she had been spending more and more time crying and hiding alone in her bedroom.