Today is a first for Walking the Black Dog. We have a guest post by Tim Desmond, MFTI. Tim has an MA in Clinical Psychology and works in private practice in Oakland, CA. He offers phone counseling through his website as well as consultation for therapists.

For those of you thinking about getting into (or going back to) therapy this case study should give you some idea of what is possible.

I wondered why her self-talk was so unkind, so I asked her to imagine what it would be like to really know that she was a good person and deserved love. She tried, but could not even imagine what it would be like. She said, “I just can’t go there. It’s just not real.” I sat with her for a minute or so just connecting with what she had said. Then I asked her to try saying, “I am unwilling to even imagine seeing myself as a good person because…” and to finish that sentence without pre-thinking the ending.

Just then, she told me that she had a flash of what she was like in high school. She said that she was miserable at home with her verbally abusive parents, but that as soon as she arrived at school, she was happy and filled with confidence. I was interested in how this connected to the sentence I had given her, but more interested in why she experienced such a difference in self-esteem between home and school. When I asked how she made sense of the difference she told me that she was getting excellent grades in high school and was the editor of her year book. She said it was the only time in her life she had felt confident, and that her confidence had led to having lots of friends. When I asked when she had lost her confidence, she said that she had always felt horrible at home but it got much worse when she went to college. There she had visited a counselor to try to work out some of her issues with her family and he had put her on a serious psychiatric drug. She had very bad side effects from it and was no longer able to excel in her classes, which had a strong impact on her confidence. We paused for a while to grieve that terrible mistake.

I then brought us back to her purpose in calling me — relieving her depression. I asked her to remember what it was like to arrive at high school and go from feeling depressed to confident. I asked her to try to picture herself just as the change was happening in the morning and waited for her to do so. When she was there, I asked her to say, “The thing that’s different now is…” and to finish that sentence. She said, “The difference here is that people think I’m special.” and started to cry. At this point, I felt like I was beginning to understand. It seemed to me that when people were treating her like she was special, she felt good about herself, and when they were not she felt bad. I wondered if that was still true.

I asked to try imagining herself in high school and saying, “When I feel bad about myself, it is because people are treating me like I don’t matter. When I feel good, it is because they are treating me like I’m special.” When she repeated those sentences, she said they felt powerfully true. I asked her to try saying them again as her adult self. She did and cried more, realizing how rarely people ever treat her like she was special any more. With just a few minutes left, I asked her to write down those sentences and spend at least five minutes with them twice a day. When scheduled our next session for three weeks later to give her time to process what we had uncovered.

At the beginning of our next session, Mary told me she was feeling much better than she had in a long time, but she was very adamant that she was not entirely better. She said that she was now able to make sense out of her low self esteem, and that it no longer felt like something that was intrinsic to who she was. She said that her depression was much better but that it was definitely still there.

That made sense to me, because I still didn’t understand exactly why she would feel bad about herself when other people were uncaring to her, as opposed to getting angry, trying to please them, or any of the other possible responses people have. I find that it is important to discover the sense to all of these questions for the deepest kind of change to happen.

I asked her to picture her first memory of feeling depressed, and asked how old she was. She was seven, and I asked if she could try to become that little girl for a while so I could talk to her. When she was ready I said hello and asked the little girl if she gets depressed. She said she does because her mom is really mean and calls her names. I told her I was sorry that her mom did that. Then I asked if she knows grown-up Mary (connecting her child self with her adult self), and she said she did. I asked her to tell grown-up Mary what she should do when people are mean to her. She said, “What should she do when people aren’t being mean to her?” and fell silent for a few moments. She said, “If you get depressed, you don’t have to do anything.” and paused a long time. She continued, “If you get depressed, you can just sit around and you don’t have to do anything.” Judging by her tone of voice and the long drawn out pauses, I knew that she was in a deep place and I let her have as much time there as she needed. We spend the rest of the session saying those sentences and letting them feel true. When we ended, she thought she would need a month to process what had happened. However, she called a few days prior to her next appointment and canceled saying that she had fully recovered and was working again.

You might be wondering how exactly that worked. Mary had two distinct purposes for being depressed, and each of them only needed to be partially discovered in order to for her to change. First, she learned that she felt bad about herself not because she was a defective person, but that she felt depressed when people were being unkind to her — a normal response. When she realized that it changed depending on how she was being treated, she realized that it did not mean she was inherently defective, and she began feeling better. In the next session, she realized that since childhood being depressed had been her way to avoid “having to do anything.” I never learned exactly why it was important for her to have a way to escape from

This entry was posted on Thursday, August 28th, 2008 at 10:46 am and is filed under therapy.