Case study 1- Anxiety/Low-Self Esteem
Jill came to me with weight issues, which was affecting her self-esteem. Aged twenty-seven. Jill came from a close-knit family and had started comfort eating after a long-term relationship had come to an abrupt ending. She felt she had dealt with the emotional side of things but needed practical help to address her eating habits. Despite regular exercise walking to work, Jill had put on over twenty pounds since the break up two years ago.
Jill lived alone and it was easy for her to get in the habit of binging on junk food when she couldn’t sleep or when she was alone after work. She kept to her herself most of the time and it was easy for her to maintain such a secret unhealthy life style. She ate healthily when she did get out but was in denial about the causes of her weight gain and felt ashamed especially when she became bulimic. Her family became concerned about her weight gain and Jill herself sought medical help for the bad breath that had ensued from the bulimia that could not be disguised from her work colleagues with chewing gum. Confronted by the doctor’s diagnosis of bulimia, Jill confided in a friend who recommended life style coaching since long term counseling did not fit her temperament or budget.
We agreed on four sessions and after some initial reluctance, we agreed on including her family (especially her mother)in sharing her struggle to lose weight and on being transparent about how many unhealthy calories she had been consuming. The focus on our sessions was on shifting her reliance on junk food to compensate for lack of emotional well being to positive thinking and a healthy diet and life style. She joined a gym and in our last session she mentioned that she had started to lose weight and was feeling more energetic and good about herself.
Case study 2 – Relationship Issues
Luisa, aged 30, had been in a number of dysfunctional relationships with men who abused her from the age of 14. She liked her job as a nurse but was spending too much time on sick leave due to depression. She struggled with comfort eating because food was her best friend when she felt depressed – which was often. Her GP had put her on Paroxetine which she had been on for two years prior to seeing me. She was desperate to stop taking the anti depressants but scared that she might end up worse and not coping.
Luisa wanted to address everything and said she was ready to do what it took because she was not happy and hoped to meet someone and start a family.She knew that she was possessive and that didn’t help in relationships because she always feared being abandoned. She was too scared to confront her abandonment issues but knew it impacted on her relationships – especially with men. She had been in five relationships over the years. The first one had lasted for over five years. Even though Gary was verbally abusive in that he called her names like ‘fat cow’ and told her that no other man would ever look at her, she still stayed with him convinced that she would never find another boyfriend.
We explored her childhood issues during the first few sessions and how being abandoned was still affecting her as an adult. I used a Psychodynamic approach which enabled us to link the present with the past. This was never easy because Luisa got angry and a few times had walked out before the end of a session. She had so much anger bottled inside and even though she was never a threat to me physically, I sometimes wondered if she would come back and to my surprise; she always did!
Luisa told me how she pretended to be confident at work but deep inside could not even look herself in the mirror because she believed she was ugly. Using Cognitive Behavior Therapy and some lifestyle coaching skills, I encouraged her to look herself in the mirror and to replace the negative perception with a positive one. A few months had gone by and I was encouraged that even though I knew there was still a lot of work to do, Luisa was starting to relax more and allowing silences during sessions. She still got angry but not to the extent of walking out and I encouraged her to express herself more. We decided to focus on practical issues around her self esteem and confidence. It was hard work but slowly she mastered the concept of replacing negative thought patterns with positive thinking. On occasion I would encourage her to use the mirror in my consulting room and we would explore what she saw and reflect on that.
We also worked on a exercising and diet plan that would help her in loosing weight and still enjoy her food. I noticed a shift in her confidence and in one session she even referred to herself as ‘good looking’. In our 7th month, Luisa told me that she had spoken to a work colleague and together had joined a local gym. I was pleasantly surprised to hear of this development. She had also met a potential boyfriend, Jamie, and was worried that her anxiety would drive him away.
In a matter of a few months, Luisa had lost over a stone and said her comfort eating days were behind her. She also surprised me in one session when she told me that she had gone away for a long weekend and left her anti-depressants behind by mistake. During the four nights away with Jamie, Luisa had not felt the impact of not taking them and on returning home; she decided to stop taking them. It had been over a week now and she didn’t feel depressed or moody as a result! I encouraged her to book an appointment with her GP and talk about coming off the tablets. This was a remarkable change considering that she had been taking 30 mg every day for more than two years. I was optimistic but cautious.
Luisa was a different woman and three months after meeting Jamie, she was enjoying life and although she still felt anxious; she was in a better place. We didn’t cover everything – there were still issues with her mother but she had decided to put them in a box for now. She had come a long way and was learning to like her mother as she was. If anything, she said she felt sad for her and wished she could get her to seek help in order to enjoy a much better quality of life than stay at home most of her life feeling like a victim of circumstances!
Case study 3 – Couples Therapy (Finding an amicable way to divorce)
After ten years of marriage, two children and hectic careers, Edward and Fiona contacted me about counseling. Their relationship had become increasingly dominated by quarrels, miscommunication and lack of respect for each other as appropriate parental role models. Making love had become such a difficult part of their relationship and only happened when Edward begged –something he had started to resent Fiona for. Oblivious to Edward, Fiona had been having an affair with a neighborfor nearly eight months and was planning an exit strategy.
Edward and Fiona’s decision to enter joint counseling was not an easy one,therefore. Using a variety of techniques, predominately psychodynamic, over a period of 20 sessions, Edward and Fiona were able to put their personal emotions aside and the focus on the children’s future. During therapy they realized there were irreconcilable differences based on Fiona’s attachment to the new lover and was not willing to let go. Despite Edward’s willingness to forgive, therapy in this case allowed them to air their differences in a constructive fashionand plan what was best for the children.
Psychotherapydid not put their relationship back on track but it did enable the couple to come to terms with their respective goals and plan what was best for the children thus avoiding years of acrimonious dispute to the detriment of the children.
Case Study 4 – (Written by a client for Closure)
I will never forget the morning of September (0520am to be precise), switching my mobile on and hearing a text message alert that had just come through. ‘Andrea passed away around midnight’, it read and I stared at it waiting for another message to come through and say it was the cruellest joke to wake up to. Half an hour later, I was to get the confirmation that my sister had indeed died. My younger sister had sent the message from her mobile after several attempts to call me had failed. Part of me understands the need to get the message to me somehow although I have never got over the shock of learning of such news through a text message. I have grown to dislike communicating via text messaging and on a bad day I still get goose pimples when a text arrives – especially from my family who live abroad.
That was seven years ago, yet on sometimes it still feels like only yesterday. I have had nightmares and a deep sense of sadness that I think I will live with for the rest of my life. I have lost a few family members and relatives over the years yet not one of those deaths hit me as hard as losing my sister. I felt like a part of me had died with her and even wished it was me instead of her. Why her? She was such a bubbly spirited young person who could light up a room with her laughter and positive energy. For her to die so suddenly left me not only in shock, but for many years after that refusing to accept that I would never see her or hear her infectious laughter ever again. I also became secretly afraid of going to sleep at night and could not understand why life had to be so cruel. I should say through it all, I was never suicidal but very angry at the world.
After losing a few loved ones, you would imagine that one could more readily accept the notion of death. I became withdrawn and suffered quietly yet I kept going until things got so out of control that I consulted with my GP. She recommended that I saw a professional therapist to deal with my reaction to the bereavement. Two months later, I walked into a large, clean room beautifully decorated and furnished with two huge couches and I nervously asked if I could lie down on one. To my surprise, the therapist did not mind. I didn’t know where to begin. After a few minutes of trying to make myself comfortable on the old couch, I decided to sit up and face the therapist who was watching me with some curiously at the same time with gentle eyes that were reassuring.
This was to be the beginning of a new chapter in my life. Once I opened my mouth, it was as if a tap of water had been turned on and left to run. I felt like I could go on talking but before long it was time to go. Memory was gentle and made me feel at ease.
Over the course of time, she never changed her sympathetic demeanour even when I would vent my anger at her (something I regret) but at the time it felt like the pain was too much. I think being a professional, she understood what I was going through. Hence, she never gave up on me. She used a psychodynamic approach mostly which I found useful although at times difficult and together we explored my upbringing and family history. Sometimes, I found the sessions painful yet I knew it was a systematic process and no one had promised that it would be easy. I was convinced deep inside that I was doing the right thing. Some days she challenged me and other days she would sit back and use a person-centred approach (non-challenging and more empathetic). On a few occasions, she would use self-disclosure and it helped knowing that she was not just relying on theory but had been through grief too. The more I opened up and shared my heartbreaks, the more I started to let go of the feelings of anger I had towards some members of my family.
I had been carrying more anger, sadness and fear of death over the years than I had realised. Fortunately for me, I do not drink much nor do I smoke but I had turned to self-harming which took the form of overeating and forcing myself to throw up. This had started about six months after losing my sister. I was overwhelmed with grief and would cook my sister’s favourite meals and eat until I could not move. Then I would go to the bathroom and pretend to others to be on the toilet while I secretly threw up. This was the beginning of my Bulimia which lasted for a couple of years and I became addicted to. At the time, I felt like I had no control and became more secretive so that no one would find out that I had become an addict. I had never shared that side of my life with anyone because of feelings of shame. Once I revealed it to Memory, I felt a sense of relief as we explored my emotions further. She reassured me over time that I was not to be ashamed but perhaps I needed to find other things to distract me. Before seeing her, I only associated self-harm with harming oneself physically. Yet, for years I had been psychologically inflicting pain upon myself to relieve the overwhelming sadness and anger that I carried with me.
Memory suggested some Mindfulness techniques that she felt might help me on a day-to-day basis. As sessions continued, we explored my lack of confidence and seven months later, I pushed myself, cut back on a few luxury items so that I could join the gym. By now I was starting to feel a lot better as I slept well on most nights and the nightmares I had become accustomed to seemed to have gone or I would have one, only occasionally. I started to feel alive again and besides enjoying my work and being more focused, I really liked working out in the gym and doing yoga. I don’t really know how, but within weeks, I found no place for Bulimia and stopped my habit of overeating. Now when I cook foods for comfort (which I don’t do often), I make sure I eat sensibly and it’s true that Bulimia is always at the back of my mind. What I have learnt to do through mindfulness is to manage the triggers and confide in someone when I feel overwhelmed. Now I am coping well I still reach out to Memory (only done twice since ending therapy). It is helpful to know that I have professional support. There are days when I miss my sister – especially at birthdays and Christmas. Memory told me that it’s okay to remember my loved ones in ways that may seem bizarre to some because it’s about me and the memories that I treasure. I sometimes look up to the sky at night and happily whisper something to the universe and it gives me comfort.
As I reflect, it’s been six months since my last session with Memory. When the moment came, we both knew it was time to move on but saying goodbye after nearly two years was not easy. I worried that I might relapse. She was as reassuring as ever and said I could come back if I needed to see her again. That was good to hear and today I am in a much happier place than I have been for years. I still miss my sister as well as other relatives I have lost. When I do, I allow myself to feel sad for a while and cry if I get emotional. Its nearly a year since I last experienced Bulimia. The urge still comes up occasionally and because I am in a better place and feeling a lot healthier than I have felt in years, I refuse to go back to my old ways. I am still going to the gym and have become more confident in myself and in social circles than before. I really think that I could not have come this far without the help of Memory and my GP.
Written for closure and in loving memory of Bev.
By Vicky (January 2017)
Case Study 5 – Depression/Grieving
Jane was referred to me through her GP surgery. She was on Prozac for depression and was grieving the loss of her mother who had passed away five months earlier. During the assessment, I explained to Jane that I would be taking a few notes for my personal use and she was ok with that. I gave her a contract form to take away and bring the following week if she wanted to carry on with me. She spoke a lot about her mother and how she wanted her back. She told me how she often woke up in the middle of the night wishing that she could die and join her. I gently reflected on her death wishes and she said although she would not consider herself suicidal, she spent a lot of time thinking of her own death. That led me to ponder about her child whom she had only mentioned once. Jane looked at me and said I would probably think that she was a bad mother but her daughter had a loving father who could take good care of her.
With her mother gone, she felt that she had no one else in the world to love her. She told me how her father had abused her as a child and often called her fat cow and ugly. She did not think much of him and wondered why God had taken her mother who was a gentle and loving person and left her father who was evil. She was convinced that he was responsible for the heart attack which led to her death. Probing her to expand on this, I sensed deep rooted anger towards her father and she said she would toast to his death because he had made her life miserable. She told me how he called her daughter fat cow as well and what kind of a grandparent would do that. Towards the end of our first session, Jane asked if she could see my notes and I willingly passed the notebook on to her. She spoke out loud as she browsed through it and pointed to where I had referred to her mother as deceased and asked me if I could change that.
I took it back and she went on to explain that she gets angry when people refer to her mother using the D (dead) word. I had recognized initially that she was in denial but now I sensed paralysing fear of letting go. Mind you, this was only five months since she passed away. Grief is like a string of indeterminate length. It is difficult to tell how long it will take for each individual to get to a more accepting place and allow themselves to move on. Moving on does not mean forgetting or stop loving, it simply means allowing yourself to carry on with life once again while treasuring the memories of the loved one who has passed away. During the course of our six months, we explored the anger she had for her father and the possibility that it was necessary in her grief to acknowledge it but perhaps to think of what would happen if she forgave him. I saw her cry a few times and in this session she said she was afraid that she would be overwhelmed with guilt, and instead, direct the anger at her mother for leaving.
She could not be angry at her mother as that would make her feel guilty. Her father was abusive to her as a child hence it was easy for her to feel bitter towards him. As the first anniversary of her mother’s death approached, Jane was struggling to deal with the idea of getting together with her father and siblings. She told me how one of her brothers had asked her to stop crying and behaving like she was the only one feeling the pain. That had hurt her deeply. She thought her father was getting unnecessary attention from the family and was using her mother’s death to control the children as he did when they were young. We explored the possibility that her agreeing to take part in choosing her mother’s headstone could also be interpreted as a sign that she was slowly coming round to accept the difficult reality that she was indeed gone. The anniversary of her mother’s death was fast approaching and she asked me if we could extend our programme of sessions. I agreed because I felt that together we were getting somewhere. She told me how she had cried one night and her daughter had stayed in bed with her.
Jane said for the first time in a long time, she realized that her daughter was growing fast and she needed her mother. This was later confirmed by a dream she had. We had explored a few dreams previously and in this one, Jane told me how she was out enjoying a shopping spree with her mother when suddenly her daughter appeared. Her mother had immediately disappeared and she woke up. I asked her what she thought of the dream. She told me that her mother was spiritual and it was a sign that for a long time she had neglected her daughter and it was time to put her daughter first. We explored how that felt and by the end of the session she told me how she had used the word ‘dead’ herself for the first time and she had cried profusely. This was a major step for Jane to take. She told me that as long as the word was used sensitively, she did not mind because she believed that her mother was watching over her in spirit. She told me the anniversary had gone smoothly than she had thought it would and everyone seemed to get on better than at the funeral.
As for her father, she said she was starting to feel sorry for him that he was an old man too stuck in his old ways to change now. She said she hugged him for the first time and he told the family how much he loved their mother and missed her. Jane knew that she still had a lot of issues to deal with and had enrolled at a local gym to try and get herself into an exercise routine. She also spoke of how much fun she had had with her daughter when they went shopping for food and made sure they stick to healthy shopping. After all, she realized that her mother would still want her to be happy and she was going to take each day at a time. I saw Jane for thirty sessions in total excluding two holidays. Grief was a huge theme and we covered as much as we could during the sessions. I mainly used a humanistic approach during the sessions. As I have illustrated above, I also tried to give her tools to use in order to build her self confidence using CBT. Hence she took some steps towards joining a gym and changing some of her old shopping habits. I think we managed to do a lot of work around her grief including the anger she was directing at her father. Jane is now happier and better adjusted to her situation. She has a healthier lifestyle and is more confident than she was previously.
Case Study 6 – Mindfulness CBT
Tina was referred to me by a colleague. She had been made redundant from work two years previously and her normal pattern had become ‘chaotic’ to quote her own words. She was on a light dose of Citalopram which her GP had prescribed for depression. She had become increasingly anxious and dreaded going for job interviews because she had stayed in the same job for sixteen years and felt that she was no longer ‘good enough’. Her long term partner had recently left her and this only compounded her situation. We first spoke briefly on the telephone and agreed to meet for an assessment. Through observation, I could tell that she was anxious and I offered her a glass of water which she accepted with a smile. I spent a lot of time during our first session taking notes of her history and things in her life that had led to her feeling overwhelmed by anxiety.
I also managed to formulate a diagram of her feelings, behavior, physical state and thoughts which she helped me to fill in by illustrating on each in her own words. This was useful for me to understand how her life revolved in this cycle which had become increasingly unhealthy for her.
Behavior – drinking too much, eating junk, easily getting angry
Physical state – not sleeping well at night, tired most of the time, Obese, Constipation
Thoughts – unattractive, low self esteem, always worrying about bills, not good enough, hated men and hated herself even more.
We agreed to meet for twelve sessions. There was a lot on my diagram to work with, most of which could not be achieved within six sessions. We agreed to focus on change in behavior as this was realistically achievable. During the next sessions, I would give Tina homework which she reluctantly agreed to try. She started preparing fresh food and eating home cooked meals to fast foods every day. In our fourth session she was pleased that by eating freshly cooked meals, not only had she rediscovered her love of spices but she was saving money which had become tight and had also lost a stone in weight. She was starting to slowly tell herself that with self discipline and determination, she was good enough to find another job.I have worked with other clients before but not like Tina, she was driven to make a change and had decided to stop drinking at home.
She reluctantly agreed to contact one or two old friends to meet for some social activities. When she did, she said she did not realize what she was missing because she had such a great time. One other thing she had started doing was walking to the shops which were about fifteen minutes walk from her house. She said she had become so lazy that she would use the bus all the time.
During our last session, Tina looked different from the shy, reserved woman who had walked through my door a few weeks earlier. She still had a long way to go, but she was taking control of her life and slowly changing her negative thought patterns which had kept her stuck in an unhealthy cycle for nearly two years. She said overall she felt less anxious and was preparing for a job interview to go to in a few weeks time. Having asked her how she felt about it, she smiled and said for the first time she was excited but still a bit anxious.
Case stydy 7- Confused Sexuality
Gerry was a shy and soft spoken young man when we first met. He admitted that it was his first time in therapy and needed me to encourage him to talk. He was medium built with huge striking eyes and always dressed immaculately. He had come to therapy because he felt stuck inside as he struggled with his sexuality. He had been brought up in a strict catholic Italian family and was religious himself which added to his inner turmoil when it came to his own conflict of being attracted to both sexes.
By the age of 28, he had had two girlfriends and five male partners. His parents were liberal Catholics which helped in that they supported him in what he termed his ‘confusion state’ as they would tell him from time to time. He said his mother always said one day she saw him married to a woman with a house full of screaming kids. He had one sibling and his upbringing was generally a happy one. Gerry was easy going and also engaging once he got used to me and felt safe to to reveal his deep sense of shame.
He was hoping that by talking to me, it would help him reach some clarity and overcome the shame which weighed him down. This was exacerbated by the fact that he did not believe that anyone could be born bisexual as well given that the Bible did not encourage homosexuality. A few times he had lost his temper when someone had referred to him as bisexual but he had no problems if someone called him gay. What was most challenging in working with Gerry was that in other sessions he would be forthcoming while in others he would regress to the extent that some of the silences became awkward and I addressed this with my supervisor. My supervisor thought it could be down to some counter-transferences in the room which I needed to explore further. It took us a good few months to understand the dynamics which were at play in the room at different times.
Work progressed slowly and he felt great when he thought I had been helpful but there were a few times when I felt that it had stalled. He could become defensive that I doubted myself – to the point where I felt that perhaps we had explored as much as we could together and needed to refer him on. About four months into our work, it was the second time we were going to reflect on his progress or lack of it and what we could do differently going forward. Gerry was open enough to admit that he felt like therapy had stalled and thought it was mainly due to the fact that he had recently started seeing a man he met in a nightclub and somehow felt reluctant to tell me. Having explored more about his feelings of shame, he was not proud to share that they had gone back to his flat and ended up having sex on that same night.
He had sex liaisons with Alan about ten times since they got together (been together for three weeks). A few days before our session, Alan had told him that he wanted to have an open relationship which was a shock to Gerry as he had not anticipated that. They had ended their short relationship over the telephone and quite abruptly which had left him feeling used. It led him to opening up about how his family (extended family in particular) and some friends in general were prone to judging gay men as promiscuous. He had fallen for Alan easily and too fast because Alan was gregarious and always made him laugh. They had been meeting regularly in that short time and Alan had encouraged Gerry to loosen up and enjoy life more. I challenged him as to whether he also felt judged by me. He sighed, this was followed by a reflective silence before looking up and saying, ‘Yes’.
We were able to explore that further and I reassured him that I would not judge him but I was simply curious as well as interested in helping him reach a level of awareness which could help him manage his life better. He had not had much success with his male partners as Alan had been the forth one to let him down. This conflicted with Gerry’s belief of exclusive relationships and left him with more shame and sad given the progress he felt that he had made in therapy to that point.
In sessions that followed, we focused our work on building his self esteem (confidence) which had been affected largely by his own sexual ambivalence. His sister had also given birth to a baby boy and it became increasingly clear that Gerry yearned to settle down and raise a family with a woman. He went back to Italy to attend his nephew’s christening ceremony. Over the course of the week that followed, he had felt drawn to his nephew in a natural sense that all the doubts he might have had in becoming a parent had vanished. He was still attracted to both men and women yet the yearning to become a father seemed to draw his attention more towards the opposite sex.
We finished our work after 18 months and towards the end, Gerry had met an Australian girl whom he had been steadily seeing for three months and was very fond of. As a result of his employment contract coming to an end, he was moving back home to Italy and did not know if this relationship was going to last but nevertheless, he was eager to try and make it work. He also promised to write to me and jokingly said he would send me a wedding invitation if it all worked out.
It had been both refreshing and challenging. Seven months went by and I did not hear from Gerry although he crossed my mind from time to time. I did not expect to hear from him yet he had left me often wondering whether he had settled down and where he might be. One day I received a hand written letter in the post and to my pleasant surprise, it was from Gerry. He was doing fine and had proposed to Clare the previous month and she had agreed to marry him. They were planning on a church wedding in six months time and a formal invitation was on its way.
This news made my day and all I wished for Gerry was happiness – whether with a man or woman and it seems he had found it.