The following is an intake assessment of Dr. Martin Ellingham completed as if he were a new patient seeking therapy. It was written by Santa, a retired counselor, with input and advice from Abby, currently practicing as a therapist. I contributed to some degree, mostly by asking questions and getting clarifications. I think you will all find this quite enlightening. Santa exposes many insightful details about ME as her assessment summarizes all that we have learned about Martin Ellingham relevant to what a therapist would want to know. As she has told me, she is impressed with how many personal details the show writers have provided from Martin’s life throughout the 6 series. I am convinced that her efforts will inspire much discussion. I invite any other readers of this blog to add observations of their own.
This initial analysis is meant to provide a basis upon which to elicit various treatment protocols and approaches to therapy for this “patient” from any of you who might venture to recommend them. We are interested in any treatment plans you might like to suggest.
As you will notice, we have included medication in his care. We figured Ruth would be likely to refer Martin to a psychiatrist and that he would prefer to be seen by an MD. Most psychiatrists would recommend medicines. On the other hand, we consider it important that therapy include establishing a relationship with someone who is competent in many sorts of therapeutic methods. Santa and Abby believe Martin would benefit from individual therapy as well as couples therapy with Louisa. Of course, we have no idea how the show will handle therapy in series 7, but since there are only 8 episodes in each series, we expect that couples counseling may be all we see.
Presenting Problem: Martin Ellingham, M.D. was referred by Ruth Ellingham, M.D. (his aunt). Dr. Ellingham says that he has sought help because his wife of 6 months has recently told him that she is not happy in their marriage and needs to take “a break.” She told him this shortly after she had a serious accident, which patient believes he was instrumental in causing. She was in fact on her way to Spain with their 9 month old son, to visit her mother for an undetermined period of time, when she was forced to return to Truro for emergency surgery to correct a potentially life threatening arteriovenous malformation. The threat of losing his marriage is a source of deep distress for Dr. Ellingham. He acknowledges that he must “change” in order for their marriage to succeed. However, his desire to change is not very specific and he is uncertain about how to proceed and what he needs to do in order to be “a better husband.”
He further states that for some time before his wife indicated her unhappiness with the marriage, he had been preoccupied with worries about his health, precipitated by a return of a hemophobia. He had lost his appetite and was sleeping poorly. He tried to self-diagnose a physical disorder that might be causing these somatic symptoms; he did not consult a physician. He also reports increased irritability and decreased libido during this period. He states that he “shut out” his wife from these concerns, although he can’t explain why he did so. He believes this to be one source of his wife’s unhappiness and frustration with him. Furthermore, he states that he has never understood why she was attracted to “someone like me.” He now acknowledges that these somatic issues may have an emotional origin and is interested in exploring issues in his family of origin that may relate to his present difficulties, especially as they may relate to his wife’s decision to take a break from their marriage. He denies that the return of his phobia has anything to do with his marriage, stating that he loves his wife and son very much. He reluctantly admits, however, that the chaos and disorder attendant upon life with an infant, as well as sharing his living space for the first time, and with someone who doesn’t share his habits of tidiness, sometimes have been difficult to deal with. He says that he has been eating and sleeping a little better since he made the conscious decision to seek help in order to “change.” He admits to being “very sad” from time to time at the prospect of being separated from his wife and son.
Mental Status, Affect and Mood: Dr. Ellingham is a tall, immaculately groomed Caucasian man, formally dressed, in his late 40s, who appears to be his stated age. His clothes are somewhat loose and he says that he has lost weight. His affect is restricted, and his mood is somewhat dysphoric. He denies suicidal ideation. He shows no evidence of a thought disorder; he is oriented and his judgment is unimpaired. He makes good eye contact and is responsive. His answers are concise and to the point. His insight into his difficulties is somewhat limited. During the interview, he occasionally appeared anxious or irritated, or sad, but these emotions were quickly suppressed.
Substance Use: Patient states that he disapproves of liquor and never drinks. He has never smoked, or used any banned substances.
Relevant Psycho-Social History: Dr. Ellingham is currently a General Practitioner in Portwenn, Cornwall. Formerly, he was a surgeon in London, for 12 years head of Vascular Surgery at St. Thomas. About 5 years ago, he suddenly developed hemophobia, disabling him from the practice of surgery. He reports that the phobia developed when operating on a patient who he had recently seen interacting with concerned family members. Their concern and affection for the patient suddenly struck him in a way that was unusual for him. He was unable to finish the operation or to perform any subsequent operations. He retrained as a general practitioner, and relocated in Portwenn, a place where he had family (an aunt, since deceased) and had spent time as a boy. It is unclear why he chose to retrain and relocate rather than to seek treatment for his condition. About a year ago, he utilized cognitive-behavioral techniques to desensitize himself to the sight and smell of blood. This succeeded enough that he felt able to apply for and accept a position as surgeon at Imperial Hospital in London. This position was not taken up, as he decided instead to marry the mother of his child and remain in Portwenn, where she was most comfortable. He states that he detests Portwenn, and finds dealing with his patients frustrating on account of their unwillingness to follow advice or sound hygienic principles. He denies, however, that foregoing the opportunity to resume his career as a surgeon, and living in a place that he dislikes, have anything to do with his dysphoric mood or the return of his phobia.
He reports that he did not expect to marry or to have a child, and his relationship with his current wife has been tumultuous, marked by missteps, separations and miscommunication throughout their courtship and in their marriage. Nevertheless, he states that he is deeply in love with her, and has been since their initial encounter several years ago. (She is head teacher at the primary school in Portwenn.) They did not begin living together until after their son was born, and the decision to marry was not made until 3 months after that.
Patient states that this is his first marriage and his first serious relationship since he was in medical school. His first real relationship ended when the woman, a fellow student, chose to leave England to study abroad. He reports that he was devastated by this. With few and brief exceptions, he has neither sought nor welcomed female companionship thereafter. At the same time, he is clear that his orientation is heterosexual.
Social Supports. He has lived alone all his adult life. He reports few friendships of any significance, with the exception of a former classmate from medical school, who is now the head of the Cornwall NHS, and who helped him to relocate and later in his effort to find a job in London. He does admit to being friendly with one or two inhabitants of Portwenn. He was fond of his aunt, now deceased, who was living in Portwenn when he relocated, and she was a source of support to him both when he moved to Portwenn and as a child. He is close to another aunt who now lives in Portwenn, and she is perhaps the only person in whom he feels he can confide. He reports that he has little time for social niceties, which he considers “rubbish,” and always speaks his mind. He admits that some may find his manner abrasive. In any case, he feels that finding a friend among the inhabitants of Portwenn is highly unlikely, as he finds most of them extremely irritating. He has no church affiliation. His sole hobby is repairing antique clocks, an activity that he does alone. His wife does not share this interest.
Family of Origin Issues: Patient reports a long-standing estrangement from both parents. He had no communication with them at all for seven years, until a couple of years ago, when they showed up to ask for money and announce their separation. During this visit, his mother made clear how much she had always resented and disliked him, to the point of saying that she wished he had never been born. Predictably, the visit ended badly, and he had no further communication with them until a few weeks ago. At that point, his mother arrived unannounced, and told him that his father had recently died and she had come to re-establish a relationship with him as her sole remaining family. It developed that she was without financial resources and that her real goal in contacting him was to obtain from him enough money to support herself. Upon realizing the extent of her duplicity, Dr. Ellingham asked her to leave his house and indicated that he desired to sever all further relations with her.
Patient’s childhood was marked by bedwetting, social isolation, ridicule and shaming from both parents, little affection, and harsh punishments, including spanking with a belt and enforced enclosure in small spaces for seemingly trivial infractions. His aunt recently told him that between the ages of 4 and 6, his behavior underwent a change and he became significantly more defended. He was sent to boarding school from age six on, where he notes that his bedwetting and social isolation continued and he was the object of considerable bullying. Uncoordinated and physically clumsy, he did not participate in team sports. He was, however, good at chess and derived some pleasure from winning competitions.
Patient’s father and grandfather were surgeons, and patient seems to have internalized their belief that a surgical career was the top of the medical profession, and that being a GP was far inferior. His father was contemptuous of his position in Portwenn.
Patient reports that he had only very recently come to understand that he did not deserve his parents’ treatment of him and that, in fact, it was abusive. He notes the contrast between his childhood, and his wife’s and his own loving interactions with their son. He wonders if he might possibly have developed a sense that he does not deserve to be treated lovingly.
Summary and Clinical Assessment: It should be noted that Dr. Ellingham has recently experienced multiple significant stressors, including recent marriage and fatherhood, marital difficulties, death of a parent, and the severing of ties with his mother. At this point, he certainly meets criteria for a diagnosis of Major Depressive Disorder, with periods of sadness, loss of appetite, difficulty sleeping, loss of interest in usual activities, increased irritability, and feelings of worthlessness, and guilt. He has agreed to a trial of anti-depressant medication, and medication to help him sleep.
Dr. Ellingham has a specific anxiety disorder, i.e., hemophobia. The hemophobia is of secondary clinical concern, although it should be addressed at some point, ideally by returning to a course of desensitization, supervised by a cognitive-behavioral therapist to make sure he reaches a point of “overtraining.”
Dr. Ellingham has few interpersonal skills, and little understanding of their utility. He tends to have little empathy with others, and has lived as a social isolate for most of his life. He makes good eye contact, however, and his lack of empathy may well be a result of suppressing emotions he considers “soft” rather than an inability to sense the feelings of others. While a diagnosis on the autism spectrum, i.e., Asperger’s, can be kept in mind, this interviewer does not currently find much support for such a diagnosis
The clinical impression of this interviewer is that Dr. Ellingham is a man of formidable intelligence, who learned very early in his life to formulate a defensive structure that protected his deep sense of vulnerability and defectiveness. This was necessitated by emotional and physical abuse, but more significantly, a profound failure of maternal attachment. This defensive structure includes an insistence on order and control, on minimizing affective reactions, and on a degree of autonomy and lack of entanglement in relationships that might expose his neediness and vulnerability. In short, intimacy presents serious difficulties for him. He is unable to seek help from others, and because this “counter-dependent” structure emerged so early – certainly by the age of 6 or 7 – he has been unable to manage or integrate emotional responses that occur in later life. Another way to say this is that much of his emotional development has been frozen at the “child” level. Thus, “falling in love” was an experience which essentially blind-sided him, and for which he was in no way prepared. Ultimately, this impulse was too strong for his defensive structure, and he acted on it. The burden, however, of living intimately with a wife and child and surrendering much of his sense of control, has been another major stressor, under which, this interviewer believes, his anxiety disorder, as well as other somatizing symptoms, re-emerged.
It is this interviewer’s impression also that his feelings about his loss of his surgical career, both from his hemophobia and the decision to remain in Portwenn, are unresolved and probably contribute to his depression.
Last, there is a hint of some traumatic event between the ages of 4 and 6, which should be explored as the therapeutic alliance becomes stronger and the patient’s symptoms of depression are resolving.
Recommendations: Dr. Ellingham’s wife, Louisa, should participate in some sessions with the treating therapist. He has never been able to share much of his inner self with her, and may need support and assistance in doing so. Helping her to understand his difficulties may go a long way toward healing their marital problems. Couples counseling is also recommended, if his wife will agree to it.
Nevertheless, Dr. Ellingham could benefit from individual therapy. He has many losses to grieve, among them the loss of his career (and identification) as a surgeon, and the loss of his parents, both now and as a child. He needs to repair a sense of himself as defective and undeserving of love. He certainly needs to develop better access to his own emotional life. A cognitive-behavioral strategy or “restructuring” negative thoughts would be a good place to start. The experience of a therapeutic alliance with a treating therapist would be of significant benefit to him.
Originally posted 2014-12-07 14:34:19.