A case study

To give you some idea of what our work can look like, here’s a case study. Please note that all personal information, including names, has been screened from this study.

Jim came to our first session reporting symptoms of depression including thoughts of harming himself, with feelings of being overwhelmed and with a pattern of self-medication that was beginning to trouble him. We spent the first sessions establishing his safety and our therapeutic alliance. During this time I proved that I was trustworthy, which for Jim meant being non-judgmental, attentive without telling him what to do and yet willing to set and observe boundaries.

He described being troubled by his self-medication practices first. As I listened to him I paid attention to what drugs did for him. I referred him to consult with his doctor about safe ways to decrease his use. Meanwhile we identified triggers for depression, which included spending time with a friend for whom he had romantic feelings but who did not reciprocate. We worked out some ways to decrease his exposure to this trigger, and to accept that his feelings weren’t returned.

As his depressive symptoms decreased we were able to look at his thoughts about depression itself. This included a fear that he would become caught in the mood permanently and not be able to free himself from it. He described depression as being like quicksand. We looked at when and where the depression showed up, charting it in his daily experience as if it was a literal pit of quicksand. Where were its edges? How close to it could he get without danger?

For Jim the worst aspect of depression was its feeling of emptiness. He originally described this as unbearable. Over several sessions and taking it in slow easy steps I interviewed him on the unbearable feeling. The imagery he used changed from quicksand to a deep hole in the ground. This suggested that that the situation had become more stable. We discussed things he had tried unsuccessfully to fill the hole with, including self-medication, sex and trying to please others. We looked at issues in his childhood, including abandonment, that might have led to feelings of emptiness.

As we continued our work we noticed together that we seemed to be building a stairway around the sides of the hole. He was able to go into the feeling in order to observe it more closely and to describe it in our sessions, but come up out of it when he chose to. He remarked that the hole seemed smaller. We agreed that this made sense, and worked out why it did. The hole occurred in Jim’s sense of self, so what would fill it better than Jim’s own awareness of it?

Jim had by this time largely ceased self-medication and was able to discuss events that earlier in treatment would have been catastrophic. Our sessions which had originally been weekly switched to every two weeks, then once a month and finally check-ins every three months. Jim gradually shifted from relying on therapy as his main source of support to participation in a community social network.