CASE STUDY: HARPREET AND

MOHAMMED

Harpreet and Mohammed, a newly-married professional

Indian couple in their early 40s, sought marital counseling

to help with their increasing conflict. Mohammed's family

wanted him to be a doctor, but he became a medical device

salesman instead. He had explored becoming a doctor in his

early 20s but didn't enjoy the classes. He had no plans to go

to medical school, ostensibly because he couldn't afford it

now that he was married and in his 40s, but really because

deep down he didn't want to-even though he believed

strongly that he should. Almost every time something went

wrong in their life, Mohammed would chalk it up to him not

being a doctor. They were short on money? Wouldn't be hap-

pening if he had become a doctor. Treated disrespectfully by

the waiter? If only he had become a doctor, he'd get more

respect. Life feeling meaningless and flat? Probably because

he hadn't become a doctor. He realized that this belief was

illogical, but he couldn't shake it. Perseverating on his fail-

ure to become a doctor would often send him into a dark

mood that would last for a week or longer, during which

time his work would suffer and he would neglect his house-

hold responsibilities, leaving Harpreet to pick up the slack. His

recent aloominess, which had brought them into therapy, had

lasted almost two months.

At first Harpreet was supportive and compassionate,

but she eventually grew frustrated with Mohammed's extreme

response to what seemed to her an illogical belief. She didn't

care if he was a doctor. She accused him of using his disap-

pointment as an excuse to not help around the house and

dreaded the pall his gloominess cast over their family. Over

time, she started responding to Mohammed's dark moods

with anger, and when that didn't work, she'd grow distant and

cold. She resented the extra work that came her way--she had

a full-time professional job as well, and she was losing respect for Mohammed. "Suck it up and be a man," was becoming a common refrain

which didn't help Mohammed's sense of inferiority.

Outside of Mohammed's "doctor spirals" as they called them, their marriage was in good shape. They enjoyed spending time together, communicated well, had good sex, and were attentive to each other's needs. Consequently, their therapist hypothesized that if she could help Mohammed stop his doctor spirals, they would be okay. At first she tried a cognitive-behavior (CT) approach; since Mohammed worked with doctors all day (something he likened to an alcoholic working in a bar), she had him ask his doctor colleagues whether they would choose to be a doctor if they could do it all over again. Even though over 90% of them said " no," and Mohammed acknowledged that most of them seemed miserable, he still was obsessed with being a doctor.

undeterred, she next had him ask his parents whether they were truly disappointed in him for not being a doctor. Harpreet assured her that they didn't care. Mohammed asked, and even though they said "no," Mohammed was sure they were just patronizing him. Clearly the direct CBT

approach wasn't working.

Reflect and Reply

1. If you were a strategic therapist, what type of paradoxical intervention(s) might you try? Why?
2. Which of the three types of problem-maintaining solution loops is Mohammed stuck in? Consider cybernetics, positive and negative feedback loops. Consequently, what should be the treatment goal?
3. How might a Milan therapist approach this case?