A Case Example
Earlier in my career as a psychologist, I had a client, let's call him R, who was a 32 year old student referred to me for symptoms of depression. He was pleasant, friendly and seemed to develop a good bond with me from the get go. Soon after we began each session, his cheerful attitude would shift into distress as he complained about people who had done him wrong, his low self esteem, not feeling good enough, not being able to motivate himself to study or work and so on. And this would spiral into self blame. He would express suicidal thoughts from time to time. His presentation was textbook depressive symptoms. I diagnosed him with Major Depressive Disorder and began treatment accordingly. I felt like the progress was okay. Treatment was focused on the obvious: Improving his self image, challenging his guilt, self blame and fear of disappointing others. I thought we were going well. But there were a few things that started to concern me:
Firstly progress was slow. As R unpacked his emotions about being hurt by others, his thinking and speech would become unorganised and rapid and he found it difficult to concentrate due to his heightened emotional states. He displayed lack of interest in or commitment to any of the the treatment strategies applied throughout our sessions. His self esteem or general mood were not responding to treatment. A variety of antidepressants were also prescribed to him during this period, without significant success. Simply put, progress was minimal.
My second concern was that R kept dropping in and out of therapy. After every session I would think to myself that with the amount of genuine care I was giving him and the healthy therapeutic connection that I felt we had developed, even if he had trouble concentrating on the exercises, he should surely be making a progress. We know the impact that a healthy therapeutic connection makes to client healing, and I felt that at least that aspect of therapy was going well. Except time and time again, I was genuinely surprised by R disconnecting from therapy, only to be coaxed back by his roommate who was concerned about his mental health. He would once in a while drop me a hint that R had been offended by something that I had done or said. This was a surprise to me every time. He had interpreted benign innocent things, such as me being a little less warm than usual when I had a small headache at the end of a long workday, or explaining our cancellation policy to him when he had canceled a session last minute, as a sign of me not caring. Each time I would reassure R and managed to mend the relationship but the pattern kept repeating time and time again.
So I did that thing that I told you about earlier. I held a case conference with myself to review my work with R. Was there something I was missing? Yes there was. Here’s what I had missed. Throughout my work with R, he gave me a few hints that I have since learned to pay special attention to. He kept telling me that he felt lonely, alone and not cared for. He felt like if he didn’t match up to people’s expectations, they would easily abandon him. He clearly felt that his important connections, including the connection he had made with me, had no strong legs to stand on. To him these relationships were fragile and not very trustworthy. There were several times throughout our interactions where I became aware of a strange feeling within myself as if R and I were living in alternate universes where I believed the therapeutic rapport and trust was strong enough to handle small hick ups like normal ups and downs to my mannerism from one day to another, or communicating a need to give us more notice when cancelling. But for R that rapport or trust was completely non-existent. Almost like he wasn’t able to notice or believe my genuine care.
He had also told me about his relationship with his parents since a young age. His dad was absent and his mum was cold, distant, critical and callous. There were no warm or loving connections that he could recall in his childhood. It became clear to me that I was looking at the wrong part of the triangle. I was trying to treat his self esteem and self image, but the section below that, the attachment and connection section, was in deficit.
As we previously learned, clients with attachment and connection problems will also show deficits in the area of self esteem and self image, just like R did. But focusing on self esteem prematurely will not yield to much success. It was important that I moved the focus to treating R’s sense of loneliness, lack of connection and poor attachment issues first.