The Case of "Sonia": Psychotherapy With a Complex, Difficult Patient Grounded in the Integrated Psychotherapy Model of Hector Fernandez-Alvarez

Abstract

Sonia was part of a clinical, naturalistic, and longitudinal research project I developed that began in 1998, with patients who consulted at the well-known AIGLE center in Buenos Aires, Argentina. In the project I selected patients with severe and complex psychological symptoms for whom previous treatments were reported by the patients to have been ineffective. The goal of the project was to employ Dr. Héctor Fernández-Álvarez's Integrative Psychotherapy Model to design a new treatment approach involving combined strategies that could successfully work with such individuals. At the time of intake, Sonia was a 44-year-old, divorced, morbidly obese woman living with her 18-year-old mildly retarded son in an apartment purchased for her by her affluent parents. When Sonia came for treatment, she could not manage her son or her own basic needs and finances and had frequent angry outbursts with her family members. She was diagnosed as having bipolar disorder or cyclothymia, trichotillomania, borderline personality disorder, borderline intellectual functioning, and was on medication for these conditions. This case study describes 10 years of treatment,including over 900 sessions, working on the development of Sonia's coping and interpersonal skills and on restructuring her most basic cognitions about herself and her relationships to others, particularly her family members. During the 10 years, the therapy was gradually reduced in intensity as Sonia made gradual but dramatic changes in her self-concept, her obesity, her relationship to her family, and her ability to work and independently manage her life. While because of her long history of previous treatments, Sonia did not consent to take any standardized assessment measures, she did agree to a collaboratively developed, individualized, 27-item List of Problems and Behaviors Questionnaire (LOPBQ). With a scoring range of 0 ("problem not solved at all") to 5 (problem "totally solved") on each item, Sonia went from an average item score of .33 to one of 4.19 over the course of the first 8 years; that is, from a score of 6.7% of a maximum score to 83.8% of a maximum score. The process by which this impressive change took place is detailed.