Identifying information and psychological observation of the patient

Susanna Kaysen is an 18-year-old female from Mechanicsburg, Pennsylvania. She recently graduated high school and is currently living with her parents with no occupation.

Reason for Referral

Susanna recently overdosed on a bottle of Aspirin and chased that with a bottle of Vodka. She was taken to the emergency hospital where they had to pump it out of her stomach. The doctors and parents believe she was trying to commit suicide, but Susanna insists she just had a headache and she took some Aspirin. Her parents were concerned with her behaviour and mental health, so they referred her to me.

Background Information

When Susanna was a baby she rolled of the bed while her mother was changing her, and she broke her leg. The doctor put her in a body cast and also strapped her down, so she couldn’t move. Her mother feels guilt that that was the reason for her behaviour today. Growing up, Susanna’s mother was very critical of her when it comes to her behaviour and her appearance. Susanna felt she was very controlling in that aspect because she never “ looked” like other girls her age. She felt that her mother wanted a daughter that would dress properly in skirts and dresses like her, but Susanna never felt comfortable in those outfits. She felt like she wanted Susanna to change the way she was, so she could impress her friends. Her mother cared more about what the people around them would say rather than listen to her daughters wishes. For example, when Susanna got out of the hospital after her recent visit she was wearing an outfit that her mother didn’t like because they had company over. She looked at Susanna and said, “ that’s what your wearing?”. She felt a bit embarrassed because her friends were there, and her daughter didn’t look presentable. Susanna felt uncomfortable being there and didn’t like that her mother was so critical of what she was wearing. Due to her mother’s critical personality and desire to constantly please the people around her, Susanna grew up with a resentment to not be like her mother. When asked about what she wanted to do with her life after high school, Susanna replied, “ I don’t know but I know I don’t want to end up like my mother”. She explains how she doesn’t want to be stuck in the typical role that society expects of women. Furthermore, her mother’s criticism of her and focus on pleasing others, led to their relationship being distant. In addition, Susanna and her mother’s relationship is not very close because of her mother being insensitive and unempathetic to Susanna’s feelings and wishes.

Her father is a business man, so he was quite busy and wasn’t there much for Susanna growing up. He missed a lot of her school activities such as her soccer games and plays. For example, when Susanna was 9-years-old she had a poetry performance at school that she was excited to show her dad, but he never showed up because he had a business meeting to attend. Susanna remembers being hurt about that because she was really excited to show him what she worked on at school. Slowly over the years of her childhood, Susanna continued to feel more distant from her father and didn’t really feel very connected due to him focusing on his work so much. She felt like her father didn’t care about what she was interested in, rather just cared about impressing his friends like her mother. He tended to brush her feelings off rather than hearing her out. Due to feeling like this and her father being emotionally not present, they too do not have a close relationship.

For most of her life Susanna had a hard time trying to figure out her identity and what she wanted to do with her life. She didn’t feel like she fit in with what other girls were into at her age like wearing dresses or worrying about her hair or appearance in general. High school was a particularly hard time for Susanna because she couldn’t figure exactly what her identity was and who she was as a person. She felt like everyone around her had some sense of who they were and what they were interested in, but she couldn’t figure out her own identity. As a result, she began her frequent alcohol and drug abuse as a way to get away from the demands of her parents and school. When everyone in her senior class was applying to colleges and jobs, she was daunted with the reminder that she didn’t have anything planned for her life or what she wanted to do. As she tried to find a sense of herself, she grew her abuse of drinking and smoking marijuana which caused her to become friends with people that were also into those activities. She never really had close friends or people she could depend on when she needed someone. The people that she had around just used her to get drugs and nothing more than that. Furthermore, Susanna had a pattern of being attracted to or lured into friendships with people that she believes are very charismatic and had a strong sense of identity. For example, she met a girl named Lisa at one of the parties she attended and was attracted to her outgoing personality. Although Lisa had her own problematic behaviours that were quite irresponsible, Susanna was attracted to her personality due to strong, fearless personality that defied against the norm. Although Susanna enjoyed this friendship, it too was one sided and didn’t last long.

The intimate relationships she had were always as a result of impulsivity. She met her current boyfriend at her senior prom after which she slept with him. Their relationship is often one sided as he doesn’t always listen to her thoughts and feels like her behaviour is completely normal. In high school, she had an affair with her father’s friend who was much older than her and had a family. That relationship was also just a sexual one and nothing more for Susanna. When these relationships ended it didn’t seem to bother Susanna and she wasn’t hurt by them.

Through the years Susanna kept a journal with her at all times to right her thoughts and feelings out since she couldn’t exactly express or understand them. She felt since she couldn’t express it out loud she could at least write it out. This is how her desire for writing began because it was a way to let her thoughts out that people around her couldn’t and didn’t care to understand. Although it’s not very popular for a writer for her time, she grew fond with the idea of becoming a writer after writing in her journal all those years. Her parents are not exactly happy about this, but it is what Susanna wishes to do with her life.

Presenting Problem

Susanna’s parents referred her to me due to her recent incident where she overdosed on a bottle of pills and then drank a whole bottle of Vodka afterwards. This was a result of the feelings she’s been having for the past few years and her recent graduation from high school. Susanna explains that when she went into high school her feelings of consistently being unsure of herself and her identity began to get worst. It began with her feeling very angry when people would criticize her for anything that she said or did. She notes how every time her mother would criticize her, she would take it to heart and get very angry and upset. Whether it be about the way she dressed or her behaviour, she was quick to show her temper. Not only that, but she also would get angry quickly when she felt like her boyfriend tended to brush her feelings or ideas off like they weren’t important. Susanna explains she would feel like this too when someone was just doing it for her benefit, so she could become a better person, and not with bad intentions.

Her parents explain that she shows impulsive behaviour in a few large areas in her life such as abusing drugs and alcohol and promiscuousness. Susanna explains that the drug and alcohol abuse isn’t that bad, but the people around her say it’s getting out of hand. She says that she uses them when the feeling of emptiness gets unbearable and she needs something to numb her to that feeling, so she could forget about it. She has developed a smoking habit as well due to the environments she was around in high school. She explains, “ the people around me were all doing it, I thought it was something everyone just did eventually.” Susanna has grown a habit of not only smoking cigarettes, but also marijuana in addition to her alcohol abuse. As a result of these drugs, she tends to get tired a lot and would sleep for hours, to the point it has interfered with her ability to continue her daily functioning. When asked about her reason for these promiscuous relationships, she says “ It was something I just felt like doing in the moment, I didn’t care for the consequences or that the guys were older than me and they could be taking advantage.” She continues to explain that she thought perhaps they could bring some kind of sense into her life and identity, if they were attracted to something about me. She doesn’t feel like her behaviour is abnormal at all and that her reasonings seem like she is in denial of the emotions she’s been dealing with for the past few years.

Susanna explains that her emotions are not consistent, and she has a hard time understanding them. She says, “ they feel like they are constantly going up and down and I don’t know how to feel in many situations.” She has a hard time distinguishing between different feelings and the appropriate reactions for each situation. Her parents say that every time she is asked about what she liked to do with her life or about her interests, she would always be unsure, and she tries to believe like nothing bothers her. When interviewing Susanna, she seemed quite easily distracted and doesn’t always focus in on the conversation. She seems like she is in her thoughts all the time and doesn’t tune in to the reality that is in front of her.

When asked about her hobbies and interests, she explains she like writing her thoughts out because they help clear her mind. She explains that it’s hard to her to express her feelings or the reasoning for the ways she feels, so writing was a way for her to do that without any judgement from other people. When asked about what are the qualities that make her a person and who she believes she is as a person, Susanna had a hard time trying to explain herself. She tends to go back and forth her ideas when she tried explaining, such as saying she is a good person, but then she’ll change her mind and say she is a bad person. She tended to give some good qualities she possessed, but then she would undermine that and say there is nothing good to her. This back and forth shows that she doesn’t have a consistent view about herself and what she believes is her identity. Not only does she not have a consistent view of herself, she also has a hard time having a consistent view about others. Her relationships with other people will begin by being exciting and she would be happy, but something would happen where she would immediately feel like they have bad intentions and they don’t care about her. It’s been evident in her friendships and her intimate relationships.

Clinical Description, Impressions, and Observation

Although Susanna has always had this feeling of uncertainty about herself her whole life, she said it seemed to get worst once she went into high school. She explains that in high school everyone seemed to know what they wanted to do and what they wanted to pursue. This pressure of having a sense and knowing her identity kicked in which caused her to feel even more empty because she couldn’t figure out who she wanted to be. Throughout high school she seemed to use other people as a way to fill the empty void of not knowing who she is as a person. She made friendships with people that did not care to have a good friendship with her and she used promiscuous activities to try makeup for that unstable identity.

This problem has caused Susanna distress in her life and has hindered her ability to functioning in her daily life. She explains that she is constantly in her thoughts trying to answer the question of who she is as a person. Her drug and alcohol habit have added to her losing her energy to function throughout the day. She is in bed all day sleeping if she spent the night before binging on alcohol. It has caused her to not be able to look for a regular job to keep her busy in the meantime. She spent most of her high school life either at parties or following guys, so she didn’t spend enough time in her classes or on after school activities that could have helped build that confidence in herself. Now that her class has graduated and all going to different universities or colleges of their own, she feels even more distress because she doesn’t know what to do with her life. Although she has shown interest in becoming a writer because of the journals she keeps, she has not had a great deal of encouragement from her family because they don’t see that as a productive career. The has resulted in her not believing in herself to go to school and become a writer. Susanna hasn’t reported having other hobbies other than writing in her journals. Most of her forms of pleasurable experiences seem to be wither at parties where she drinks and smokes or she is asleep the other times. She can seem to handle stress very well as indicated by her incidence with the overdosing on Aspirin and Vodka. She also tends to get angry quite easily if she is criticized in any way which indicate she doesn’t have other effective ways to let out her emotions. This pattern of instability in her sense of self and impulsive behaviour has led her at times to show suicidal behaviour. Her graduation was a key trigger for her overdosing on the pills and alcohol.