15 Clinical Applications With People in Poverty Debbie-Ann Chambers, Lucinda Bratini, and Laura Smith THE WHITE PICKET FENCE LIFE: THE STORY OF MARISOL Case Description year Marisol was a 19-year-old, heterosexual, Latina female in her freshman at a predominantly White university in the south-central United States. She appeared somewhat older than her stated age and was dressed in fashion- able clothing with neatly coiffed, long, straight hair. She presented to the university counseling center with suicidal ideation after the breakup of a five-month-long romantic relationship. However, her affect was restricted, betraying no evidence of depressed feelings. Dr. Josefina Montalvo, a young Latina psychologist in her first year of working at the university counseling center, was assigned to work with her. Marisol's chief complaint in the initial session was the loss of her ro- mantic relationship. Marisol tearfully reported that she was at fault for the breakup, as her boyfriend walked off after she had angrily lashed out at him for rejecting her. Dr. Montalvo wondered whether the breakup had possibly triggered deep and old wounds of loss and rejection. Marisol expressed deep 217 218 CASE STUDIES IN MULTICULTURAL COUNSELING AND THERAPY or famil of the po e only chil numerous health care guilt and shame about her display of anger to her boyfriend. Dr. Montalvo's belief was that the experience of these emotions had likely overwhelmed Marisol and triggered her suicidal ideation. Her first concern, however, was to assess Marisol's level of risk for suicide and facilitate safety planning. During the assessment, Dr. Montalvo was struck by Marisol's restricted af- fect and the way in which she minimized the importance of her emotional concerns. At the same time, Marisol's minimizations helped her to stave off intent to commit suicide. Prens mes or fan o care for meals. Be by a fami reponde began en As M ings of In their initial meetings, Marisol shared her history with depression, persistent isolation, and suicidal ideation and attempts. Marisol explained that she had sought treatment for her depression previously. Her psychiatric history included two hospitalizations associated with suicide attempts and deliberate self-harm, the first taking place when she was 16 years old. During her second hospitalization, at 18 years old, Marisol was diagnosed with borderline personality disorder at which point her mother reprimanded her harshly for being "weak-minded." Marisol expressed feelings of anger toward her mother, describing her as a "bad parent"; she rejected her only daughter by sending Marisol to live with her grandmother after the first hospitalization. At the same time, she "understood" her mother's decision to send her to live with her grand- mother. Marisol believed that her mother had "enough" on her plate and so could not also care for a daughter with a mental illness. Her grandmother, in contrast, had cared for more than 25 foster children in the past 10 years, so her mother saw her grandmother as someone who could deal with problem behavior. Marisol then reported in a low, hushed voice that her grandmoth- er's fostering of children was not due to a love for children but because the funding she received as a foster parent provided her with the financial means to care for her own four children. Whenever Dr. Montalvo validated the complex feelings associated with these experiences, Marisol quickly moved to a new topic. She attributed her continued struggle with depression to the fact that treatment had not and could not help her. As a result she no longer sought a "cure" for her depres- sion. She had grown to see her symptoms as something she was "doomed" to have to live with for the rest of her life. In subsequent sessions, Dr. Montalvo explored Marisol's developmental history and its influence on her experience with depression. Recollections of her childhood were not often expressed, but when they were they conveyed particu thizing talk w secon exper such stead resp She Com ha th THERAPY y overwhelme Dr. Montalve cern, howeve afety planning s restricted her emotiona er to stave of one Clinical Applications With People in Poverty 219 her family's struggle with poverty. Marisol grew up and continued to live in e of the poorest communities in the south-central United States. She was the only child of a single immigrant mother whose financial struggles led to numerous evictions, blackouts due to unpaid electric bills, and limited care or child care. Marisol's mother also worked as an overnight secu- rity guard. For that reason, Marisol was often left unattended or with rela- family friends. By the time Marisol was 7 years old, she had learned to care for herself by walking home from school alone and cooking her own meals. Beginning at the age of 9, Marisol was repeatedly sexually abused by a family friend. Marisol revealed this information to her mother, who responded by angrily calling her a liar. It was around this time that Marisol began engaging in deliberate self-harm behavior by cutting. health tives or depression sol explained er psychiatric attempts and old. During gnosed with manded her cribing her Marisol to same time her grand ate and so mother, in years, so problem ndmoth As Marisol described her experiences, she reported having intense feel- ings of anger toward her mother yet her affect remained restricted. In one particular session, Dr. Montalvo attempted to join Marisol's anger, empa- thizing with how painful this must have been for her and how hard it is to talk with her about these experiences. Dr. Montalvo wondered aloud about secondary feelings of hurt and pain related to the rejection and neglect she experienced from her mother, the pressure of having to care for herself at such a young age, and the dangers she encountered as result. Marisol, in- stead of being comforted by Dr. Montalvo's joining, became irritated. She responded by stating that it was useless to sit with or explore her feelings. She further said that what she wanted was to do was to learn skills to better communicate with her romantic partners. By the end of this session, Marisol had become distant and requested to end the session early. cause the al means It was after this session that Dr. Montalvo recognized she had dominated their sessions with her interpretations of Marisol's depression. Dr. Montalvo realized that she failed to co-construct treatment goals with Marisol. In the session that followed, she invited Marisol to discuss her reactions to their work thus far. Marisol was not hesitant to share that she felt misunderstood. She spoke of feeing perceived as unfortunate, poor, and neglected and that, like her previous White therapists, Dr. Montalvo associated her with people ed with ted ber hot and depres pour Rental ns of pal from "the ghetto." Marisol was adamant that she was not like other people from the ghetto and spoke with confidence of her experiences as a high-achieving student. She had been bused to middle school and high school in an affluent middle- class community about an hour outside of the city. She proudly emphasized 220 CASE STUDIES IN MULTICULTURAL COUNSELING AND THERAPY the clothing and shoes that her mother managed to buy her so that she looked as much like the other kids as possible. Her mother also relaxed her hair for this purpose. "She taught me to always fit in like that," she said, adding "I'm really middle class-we just live near the hood." At this point, it struck Dr. Montalvo that she had not explored with Marisol what it was like for her to be in a predominantly White school or how she felt about work- ing with a Latina therapist. Marisol briefly talked about her current struggle making friends but denied the importance of race to her struggle. After several months of therapy, when entering her second year in college, Marisol established a "sort of" romantic relationship with a male classmate. She had developed an acquaintance with a popular, academically accomplished White student named Matthew. She described the bright future she could enjoy with this young man, specifying the neighborhood they could live in, the house they could own, and the trips they could take together. When discussing Michael, she appeared much brighter and hap- pier than Dr. Montalvo had ever seen her. She also disclosed that she had always wished to have biracial children. Dr. Montalvo was struck with how enthusiastic she appeared while discussing what Marisol called her "white picket fence life." Over subsequent sessions, it appeared that the young man was not inter- ested in a relationship with Marisol, avoided her, rejected her advances, and distanced himself from the group of friends they shared. Marisol suggested that she was at fault for his distancing; she pathologized her interpersonal style by attributing his rejection to her lack of self-control and her inability to behave like "a lady" in his presence. Marisol wondered whether she was good enough for this young man, whether she spoke well enough, dressed well enough, or acted well enough for him. In one session, Dr. Montalvo shared with Marisol her own feeling of sadness with how hard it must be for Marisol to constantly feel at fault, "It's like you're always doing something wrong, and like you always have to change." Marisol seemed deflated and quietly reiterated that she was "at fault." She shared that she could not imag- ine it being any different. This was the first time Marisol openly expressed vulnerable feelings without jumping to the next topic. They spent much of the session sitting in silence as they considered where this negative self-image could have come from. Marisol continued to struggle to identify the roots of her experiences. She did not want to blame others for her faults or weaknesses, and she began 3. 2. L W d she share her relatio attempts at wondered w Marisol s Montalvo relationshi er dreams o She recogn tionship stuck at the co e woman looking o has alread da for a s Fregressio somed to present as Clinical Applications With People in Poverty 221 sguarded and withdrawn. She seemed tense and avoided contact, and she shared that she felt hopeless when she thought of lack of progress ness eye in her relationship with Matthew. He had continued to ignore her calls and attempts at connection. Dr. Montalvo empathized with her sad- s and wondered what it was like to share these feelings with her, a Latina therapist. Marisol simply shrugged her shoulders and returned to talking about her dreams of a life with Matthew. Dr. Montalvo was left wondering to herself about the meaning of this fantasy relationship with Matthew as well as the dynamics of their relation- ship. She recognized that the session in which she and Marisol processed their relationship and their shared identities had proved difficult for Marisol. Feeling stuck, Dr. Montalvo sought consultation from a peer supervision group at the counseling center. One of the senior clinicians, Dr. James, a White woman, listened to a description of the case and said, "I think you are overlooking one of the more obvious explanations. The client is borderline and has already had two hospitalizations. She seems to have pulled things to- gether for a short time but is now becoming delusional and is showing signs Let's this client set up of regression into a more decompensated state. get with someone for an extended assessment, and then we can Reflection and Discussion Questions go from there." I. What is the role of poverty in the client's presenting problem? 2. How does the client's social class status directly and indirectly affect her presenting concern and her ability to heal from it? think it 3. Dr. Montalvo sensed that something was going on in her relationship with Marisol that was impacting their work. What do might be? you 4. What was the meaning of Marisol's self-reported middle-class identification? 5. Dr. James accurately made reference to Marisol's case history. What thoughts do you have about her recommendations? 6. Do you think the diagnosis of borderline personality disorder applies to Marisol? How can social class, race-ethnicity, and gender affect the diagnosis? 7. What meanings could be attributed to Marisol's fantasies about her college acquaintance? new