Francine is a 70-year-old, Irish Catholic female. She worked for 40 years as a librarian in an institution of higher education and retired at age 65. Francine has lived alone for the past year, after her partner, Joan, died of cancer. Joan and Francine had been together for 30 years, and while Francine personally identifies as a lesbian, she never came out to her family or to her colleagues. When speaking to all but her closest confidantes, Francine referred to Joan as her “best friend” or her “roommate.” Francine’s bereavement was therefore complicated because she did not feel she could discuss the true nature of her partnership with Joan. She felt that there was little recognition from her family, and even some of her close associates, of the impact and meaning of Joan’s death to Francine. There is a history of alcohol abuse in Francine’s family, and Francine abused alcohol from late adolescence into her mid-30s. However, Francine has been in recovery for several decades. Francine has no known sexual abuse history and no criminal history.
Francine sought counseling with me for several reasons, including an ongoing depressed mood, a lack of pleasure or enjoyment in her life, and loneliness and isolation since Joan’s death. She also reported that she had begun to drink again and that while her drinking was not yet at the level it had been earlier in her life, she was concerned that she could return to a dependence upon alcohol. Francine came to counseling with several considerable strengths, including a capacity to form intimate relationships, a successful work history, a history of having maintained her sobriety in the past for many years, as well as insight into the factors that had contributed to her current difficulties.
During our initial meetings, Francine stated that her goals were to feel less depressed, to reduce or stop drinking, and to feel less isolated. In order to ensure that no medical issues were contributing to her depression symptoms, I referred Francine to her primary care physician for an evaluation. Francine’s physician did not find any medical cause of her symptoms, diagnosing Francine with moderate clinical depression and recommending that Francine begin a course of antidepressant medication. Francine was reluctant to take medication and first wanted to try a course of counseling.
In order to help Francine meet her goal of reducing her depression symptoms, I employed a technique called behavioral activation (BA), which is drawn from principles of cognitive behavioral therapy and helps to reengage people in pleasant physical, social, and recreational activities. We began with a small initial goal of having Francine dedicate at least 5 minutes of each day to an activity she found pleasant or rewarding. Over the following weeks, we increased the time. Francine’s treatment progress was monitored through weekly completion of the Patient Health Questionnaire (PHQ-9) in order to determine whether or not her depressive symptoms were improving.
I helped Francine address her drinking by reconnecting her with effective coping strategies she had used in the past to achieve and maintain her sobriety. These included identifying triggers for the urge to drink and exploring her motivations for both continuing to drink and for stopping her use of alcohol. Francine began attending regular meetings of Alcoholics Anonymous™ (AA) and found several meetings that were specifically for older women and for lesbians. In addition, Francine spoke regularly with a sponsor who helped her to remain abstinent during particularly stressful moments during her reengagement in sobriety.
Finally, in order to address Francine’s goal of feeling less lonely and isolated, we explored potential avenues to increase her social networks. In addition to spending time with her family, friends, and her AA sponsor, Francine began to visit the local lesbian, gay, bisexual, and transgender (LGBT), center for the first time in her life and attended a support group for women who had lost their partners. Francine also began spending time at her local senior center and went there at least three times a week for exercise classes, other recreational activities, and lunch. She also began to do volunteer work at her local library once a week.
Over several months of counseling, Francine stopped drinking; significantly increased her daily involvement in pleasant and rewarding activities, including social and recreational activities; and reported feeling less lonely, despite still missing her partner a great deal. Francine’s scores on the PHQ-9 gradually decreased over time, and after 16 weeks of counseling, Francine reported that she no longer felt she needed the session to move on with her life. In addition, Francine visited her primary care physician, who found upon evaluation that her depression had lifted considerably and that an antidepressant was no longer indicated. By the end of counseling, Francine’s focused work on identifying her depression symptoms and her triggers for drinking equipped her to better recognize when she might need support in the future and to whom she could reach out for help if she needed it.