Case studies - Stories of change

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We have set out some brief examples of ‘stories of change’ with therapy. These are based on themes mixed together from several real clients over the years but none are a single ‘real’ person (to protect client confidentiality). We hope they help to give a more concrete idea of what therapy can be about.

Mum with self esteem issues

I met with Pamela for 1 assessment session, after which we agreed to embark on a course of Cognitive Behaviour Therapy (CBT) for low self-esteem. By the end of the assessment, the information I had learnt from Pamela had enabled me to draw out a diagram representing a vicious circle of thoughts, feelings and actions we both agreed Pamela was stuck in. We focused also, and particuarly in Pamela’s case, on a series of ‘life rules’ she seemed to have developed which were making things very difficult for her. For example, it seemed that Pamela had, almost unconsciously, tried to compensate for her thoughts about being ‘not good enough’ by making sure she worked harder than anyone else, both at her business and at her personal relationships.

There was the implication for Pamela that ‘if I try harder to be more perfect than other people, then I might be able to make up for being not good enough’. This ‘rule’, however, actually caused Pamela no end of problems. It is actually impossible to be perfect, and certainly not in several areas of your life at the same time. Pamela would, for example, work late into the night trying to get the plans for a forthcoming event she was catering for right. This made her very tired, and as a result paradoxically more likely to make mistakes. It also meant Pamela was exhausted the next day, and more likely to snap at her husband. When Pamela did make a mistake, or when she did lose her temper, she became very angry with herself for being so ‘useless’, which brought all her thoughts about being ‘not good enough’ back up to the surface. Pamela would respond by resolving to ‘work harder’ the next day, and so the vicious circle continued.

Pamela found the assessment itself very enlightening. She told me she had not realised she was, in her words, ‘my own worst enemy’. She felt relieved because she could see that there was something she might actually be able to do to change how she felt, although she did admit to being apprehensive about whether or not she would be able to change.

I saw Pamela for a total of 9 sessions. Following some more exploration around the difficulty, we began by encouraging Pamela to start ‘breaking’ her life rules in order that she might be able to let them go, or at least to make them less extreme. Pamela understandably found this difficult at first, after all the ‘rules’ had been developed for a good reason; they protected her from having to feel that she wasn’t good enough. Pamela was frightened that she would fail if she wasn’t trying to be perfect, so we set up a series of ‘experiments’ she could try in between sessions to help build her confidence. The experiments started off gently, and became more challenging once Pamela’s confidence began to grow. One example was that Pamela worked on saying ‘no’ to members of her family more effectively.

Previously she would spend hours on the telephone to her children helping them with various ups and downs. She would take calls at any time of day, meaning other aspects of her life and business would suffer, and for as long as her children wanted to talk, sometimes for hours taking up entire evenings. Pamela was very reluctant to manage these calls differently because she worried that doing so would make her a ‘bad mother’. The first time she experimented in this area, she told her daughter, who rang in the middle of one of Pamela’s planning sessions with her business partner, that she would have to call her back in an hour but that she would only have 30 minutes to chat because she had a hair appointment. Not only was Pamela’s daughter accepting of this, they had a helpful, more focused, conversation when Pamela rang back, after which her daughter thanked her for supporting her to make a decision. Pamela was extremely surprised at this outcome.

However, it, and the results of the many other experiments we designed, began to genuinely improve her confidence. By the end of therapy Pamela told me she had realised that she couldn’t have been the failure she used to believe she was because, once she became more relaxed about how she lived her life, things began to work more not less successfully. With her ‘rules’ less extreme, Pamela also felt less stressed and more in control of all the things she had to juggle. Like other clients, she took away a blueprint of the therapy to refer to in future. Pamela told me she had stuck the now positive, rather than vicious, circle we drew out in the inside flap of her diary in order to remind her how much things had changed for the better.

Note: I did not spend time with Pamela discussing her earlier life experiences in any detail because, although relevant, doing so was not necessary in her case in order to bring about the positive changes Pamela wanted to achieve. However, work on early life experiences can often be very helpful, if not necessary, in some cases of low self-esteem. Where this is the case, I will discuss with you as the client the benefits of including such work in therapy.

Patient suffering from OCD

Mark had a total of ten sessions with me, the first of which was a detailed assessment. At the end of the assessment, Mark and I drew out a formulation diagram which explained how Mark’s thoughts about cleanliness for his family were causing him intense anxiety, leading to the cleaning behaviours (or ‘compulsions’) he described. Mark realised that by performing all his cleaning tasks, although he felt reassured in the short term, they prevented him from trusting that no harm would come to anyone in his family if he returned to the way he and Amy used to keep their house clean before OCD took over.

Mark embarked on nine sessions of CBT for OCD during which he learnt about OCD and how it manifested in him.

We used this understanding to work through a series of behavioural experiments during which Mark was supported to reduce his cleaning activities while he was at home in between his sessions. Mark learnt how to manage the anxiety he experienced at these times, and developed the skills to challenge the obsessive thoughts about cleanliness and germs in a different way. By the end of the therapy Mark felt he had reached his goal of ‘not worrying any more about cleaning and germs than my brother does’. He took away a blueprint of the sessions which summarised the skills he had learnt. Mark thought this would be useful to refer to in the months to come.

Student suffering from depression

I spoke with Alex and his parents, both together and separately, over an extended 90-minute assessment session. Alex had no history of low mood. He was a popular boy, with a good network of friends. He did well enough at school and enjoyed playing sport. Alex was a member of a local tennis club and played in a football league with a junior team. Alex’ parents wondered whether the low mood had started following a broken leg he sustained the previous term, which prevented him from playing sport for several months. Alex agreed with this idea, but he added that he also felt very worried about his future. He was anxious about his upcoming GCSEs and said that, unlike his peers at school, he had no idea what he wanted to do in terms of a career. I learnt also that Alex’ grandfather, with whom he was very close, had died the previous Christmas.

At the end of the assessment I drew a diagram detailing the last year or so of Alex’ life. The death of his grandfather had come as a shock to Alex and he had found himself trying to deal with a lot of difficult questions, such as what the purpose of one’s life should be. Not too long after the family suffered this loss, Alex broke his leg playing football. He spent several months recovering, during which time he was not spending his weekends playing sport or seeing his sport-related friends. Alex became increasingly withdrawn. It was, as Alex put it later on, a ‘double whammy’: he lost the sense of purpose and self-esteem that he now realised he gained from his sport, but also had a lot of time on his hands to ruminate difficult life questions. The diagram showed how Alex had now become stuck in a vicious circle of negative thoughts, which made him feel low, despondent and unmotivated, leading to a change in his typical behaviours: Alex no longer went out, he stopped focusing on school work, and he distanced himself from his friends. This new way of acting naturally did not help Alex to think more positively about anything, and so the vicious circle continued.

Alex said he felt like he was understood, and that the diagram helped him to make sense of what he described as the ‘mess in my head’. Alex’ parents found the assessment helpful because they had been able to have a frank discussion with their son, and learn about his perspective instead of hypothesising themselves and feeling powerless to help him. We agreed to start a course of Cognitive Behaviour Therapy (CBT) to reverse this vicious circle. I saw Alex for a total of 12 sessions, initially on a weekly basis, but then fortnightly as he felt he was making such good progress.

Some of the elements of the therapy included:

  • Helping Alex learn to identify his thoughts and his feelings, so he could gain control over them rather than feeling like his head was ‘a mess’;
  • Spending time discussing Alex’ grandfather’s death to help him move forward (Alex found it easier to talk about this to me because he was not worried about upsetting me, unlike other members of his family);
  • Activity scheduling to encourage Alex to change some of the new behaviours he had developed (i.e. going out more, getting back into sport, scheduling short periods of time into his week for academic work so it felt manageable, not overwhelming); Working with Alex to develop strategies that worked for him to think in a more balanced way;
  • Teaching Alex ways of tolerating distress and ‘getting through’ difficult days, without having to resort to doing something that made things worse;
  • Talking with Alex about his future and helping him develop a balanced approach, putting less pressure on himself to make decisions he did not actually need to make at this point in his life.

All our appointments were conducted with just Alex and myself. However, at the end of many of the sessions, Alex and I would decide to invite either one or both of his parents (depending on who had accompanied him to the clinic) in for the last 10 minutes. We agreed what we would share and why it might be helpful to do so. Alex admitted he was nervous about doing this initially, but after a few weeks he told me that he felt it made a big difference to his parents’ level of understanding. This in turn made it easier for him to be at home and to ask for back up from his parents if he needed it. Alex’ parents were very pleased to be involved as it meant they could do something to help him, and, as Alex’ mother put it one day ‘at least I don’t put my foot in it anymore’! The whole family reported they felt closer to one another and were able, finally, to regain a shared sense of humour.

By the end of the therapy, Alex had returned to playing football although he had decided to stop tennis for the time being so he had fewer pressures placed on his time. He found it much easier to strike a balance between study and other aspects of his now growing social life, and less worried about his future. Alex told me he felt ‘like myself’ again. Although he admitted there were times (e.g. when something went wrong at school) when he noticed negative thoughts arising, Alex now felt able to stop any ensuing vicious circles in their tracks. He took away a blueprint of all the work we had covered together which he said he might refer to at these times in order to get an ‘extra boost’. Alex said he felt in control of his life and looked forward to a positive, if not totally defined future.

a graduate with eating difficulties

She had pursued a demanding degree at a prestigious university, but spent her three years there doing little other than work. She admitted that, by focusing on her work, she had managed to ignore other underlying worries about her weight, appearance and the way she was viewed by her peers. Having returned home, Laura felt some of her old anxieties resurfacing. She described an increasing sense of insecurity about her future and her relationships with others, an urge to return to restricted eating, and a general sense of low self-esteem.

Laura came to see me for two assessment sessions, during which we discovered the feelings she described had been with her for many years. I hypothesised with Laura that the original underlying reasons for the eating disorder as a teenager were very much unresolved. Laura agreed she did not know why she felt the way she did, and that her original treatment had focused mainly on weight gain. She had been discharged very shortly after restoring her weight. Laura felt stuck in negative patterns of thinking and feeling which did not seem to change despite her knowing some psychological techniques to improve them. We agreed to pursue a course of schema therapy, a type of cognitive therapy, which is more holistic in its approach.

Therapy began with exploring Laura’s earlier life, identifying the self-defeating patterns she had developed over the years. Highlighting these and identifying the reasons they arose gave Laura a huge sense of relief. She explained she no longer felt ‘wrong’ or ‘bad’ for feeling the way she did, and since she could now see the reasons for her feelings and thoughts, she felt excited and able to explore the process of change. Laura and I continued the therapy, supporting her to make real changes in her life, trying out new patterns and waiting to see the results. For example, she began to act ‘as though’ her deep seated beliefs about being unlikable were false (even though deep down she believed them to be true). Instead of shunning social situations, she began to accept invitations, starting initially in a small way, by going out for a drink with colleagues after work. Laura was amazed to see that people did appear to value her company, a realisation that boosted her confidence and slowly began to change the way she felt about herself. We maintained a second focus in each session on Laura’s thoughts and feelings towards her body and eating, until gradually these became interwoven with the schema work. With the other improvements in her life, her feelings and her thoughts, Laura began to worry much less about how she looked, and certainly about how much she weighed or what she ate.

I saw Laura for a total of 21 sessions, although later sessions were spaced out with long gaps, given Laura had made so much progress in her life at that point. The final few sessions were designed merely to confirm to Laura that she could trust in her sense that things had really changed. They also focused on summarising the schema therapy and preparing Laura for an exciting future using all the skills and knowledge she had gained to maintain the positive changes for years to come.

A man recovering from stroke and managing chronic pain

He had significant weakness in his right arm which affected many things from being able to write, to driving a car. David also had pain in his right shoulder and a right ‘foot drop’. He found the foot drop particularly difficult to handle psychologically as he felt people looked at him when he walked and thought he was ‘weird’. David was comparing himself to his contemporaries who had not suffered strokes and were busy enjoying newfound freedoms in retirement or continuing to work. Due to the limitations of the weakness and pain, David had stopped doing many of the things he had previously valued such as taking care of DIY and gardening, fishing and looking after his grandchildren. Although he was continuing to sit on the board of governors for the local primary school, he had started to avoid some of the meetings as he felt too embarrassed for others to see how he walked.

David and I used an Acceptance and Commitment Therapy (ACT)-based approach. Together we came to understand that David was driven by a belief that he was somehow ‘broken’ and that life therefore retained very little positive meaning for him. David, understandably, had a lot of strong and difficult emotions in response to the stroke and the challenges he was now facing. Anything he did that made those emotions stronger (e.g. being out in public where others might see his foot drop) he wanted to avoid. David’s understanding of what makes a ‘meaningful life’ was linked to being well, without the symptoms he now had to face. He felt well and truly stuck with this belief that what he was experiencing was ‘abnormal’.

I explained to David that, unlike many other therapies, ACT does not try to ‘get rid of symptoms’. Trying to banish the difficult emotions he was experiencing (as David had been trying to do) actually makes things worse. At first David challenged this idea saying “the whole point of me coming to see you was to get rid of this depression!”. We talked about how – generally – human beings get on in life by solving problems (or avoiding them). But what happens when something comes your way that you can’t change – or avoid? Our usual skill set that we will have come to depend on so far – fails. We feel lost, hopeless and downright depressed.

David and I worked on two main areas in therapy (which are cornerstones of the ACT approach) – helping him develop acceptance of his personal reality which was out of his control (both his physical symptoms from the stroke and his feelings about them) AND developing a commitment and action towards living a valued life alongside them.

We began by examining together the things David had been doing to try to help himself. For example, stopping taking care of his garden. David explained that he could actually still garden, but not in the same way he did before. Every time he had tried, he had felt sad about his right-side weakness and frustrated that he could no longer use the large spade. He became angry and would go back inside, distracting himself by watching TV instead. I asked David how this was working out for him. He reflected that it helped in the moment, but soon after he started to feel more depressed. He would look out at his garden that was increasingly unkempt which would make him feel useless and low. We agreed the outcome of the avoidance did not seem particularly helpful for David overall. David, however, raised a key point: “So basically I am doomed – if I try to garden, I feel depressed, and if I avoid doing it – I still feel depressed!”. David and I used an analogy to understand just how trapped he felt in trying to avoid all these difficult feelings – it was like David was stuck in quicksand (his difficult feelings) that he was desperately trying to free himself from, but the more he struggled to get away from it (from the emotions), the more stuck he became (and the more additional struggle he was creating for himself). We explored together – over several sessions – what it would be like to stop struggling, and to start accepting what he was thinking and feeling instead (to stand still in the quicksand and observe it). David expressed reservations about this idea believing it would make him feel worse, and certainly more hopeless. Instead of challenging that, I invited him to join me to test it out together.

Over time David developed an ability to notice his experiences and to accept them for what they were, instead of trying to argue with them or change them. He became aware of thoughts he was having such as “I am doomed if I can’t do what I did before”, “people will think I’m useless and feel sorry for me if they see my foot drop”. We didn’t try to change these thoughts, we just noticed them and allowed them to be there. We did the same with David’s emotions, using various techniques to allow them to be as they were, rather than trying to get rid of them. David practiced these tasks in-between sessions. He began to notice that he was a person who experienced all sorts of thoughts and feelings (some of which were difficult), but that he himself was more than those thoughts and feelings. The more he allowed himself to be with his experiences (rather than trying to change them) the more David realised they changed anyway. A particular exercise David liked was ‘the thought clipboard’. I asked him to write one of his difficult thoughts down on a clipboard in front of him. David wrote “my life is over now that I’ve had a stroke”. He then said to me “I assume you now want me to write down all the reasons why me life isn’t over?”. But I said no. I asked him to hold up the clipboard close to his face so that he could see only the thought and asked him how it felt. “Claustrophobic…I hate it”, said David. “Ok”, I said, “where do you notice that hate in your body?” David described it. We continued in this way for a few minutes and then I asked David to extend the clipboard a little further away from his face. I asked him what he was now thinking and feeling. David said “I can still see that thought and feel the hate, they’re not gone, but I am a bit tired of them and I am becoming a bit more interested in what is now coming into my field of vision, like that new plant you’ve got on the bookshelf”. David found it very surprising that without getting rid of the thought or the feelings (in fact by doing the opposite and deliberately bringing them closer), they naturally became less overpowering, and he started to become more aware of other things.

David’s mention of my new house plant illustrated his natural interest in plants coming through – something that he had always valued. In the next phase of the therapy, having helped David to accept his thoughts and emotions and allow them to be present, we began working on developing a commitment to living a valued life alongside the changes brought about by the stroke. We spent time identifying what was most important to David, what sort of person he wanted to be, what was meaningful to him and what he wanted to stand for in his life. Even posing those questions was quite an emotional experience for David; he commented that he’d never really thought about life in these terms and considering his answers actually made him feel in touch with himself and hopeful for the first time in ages. Using various exercises in our sessions, David identified that he valued making a difference to other people, building meaningful friendships, spending time in nature and being close with his family. It was interesting to David that he realised he’d been avoiding many activities that were in line with these values such as seeing his grandchildren, attending the governors’ meetings, being in his garden and so on – “no wonder I’ve been feeling down’ he said. We explored together that to act on these values would likely also bring up difficult feelings (which is why David had avoided them in the first place) but David now said “I know that, and I can accept that I will feel these things – I’ve had a big change in my life; but I will let them be there and I know they will just be one part of what my life is about”. This was a very different approach to the one David had held at the start of therapy.

David worked hard on his goals and on adapting the way he lived his life to be true to the values he held – he returned to the board of governors and addressed the foot drop head on. “Apart from that first conversation – when I did feel anxious and embarrassed – nobody has even mentioned it since and instead they’ve asked me to lead a school action plan with the Head around green spaces”. David felt he was really contributing again. He also decided to accept some help from his neighbour in the garden to do the jobs he couldn’t manage himself, freeing him up to spend time doing what he could do – his garden looked different, but beautiful again. In our last session David brought with him a thank-you card he had made. He explained he had initially ordered a card online as he did not want me to see his shaky handwriting. He had been unwrapping the card the day before when his grandson was with him. His grandson had asked him who the card was for and David explained. On hearing this, the little boy suggested David should make his own card as that was what people did when they really wanted to say thank you! David said his immediate reaction was that that was ‘silly’ and that “I won’t be able to do it”. But he saw his grandson’s spirit in the idea and set to work with the idea of drawing a garden. The first mark David made coincided with a spasm and the pen jerked on the paper. David felt frustrated. David’s grandson saw the mark and said it looked like a sun so, instead of throwing the card in the bin, they worked together on a different drawing accepting the ‘out of place’ mark in the middle. David handed the card to me and said “I would never have even drawn that before therapy, much less let anyone else see it. When I look at it I feel some sadness that I can’t draw as I would have done before, but also a lot of pride that I’ve done it at all and that I did it with my grandson”. It was a poignant analogy of accepting feelings and committing to a meaningful life.

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