How to Provide Positive Therapy for a Depressed Anxious Person

¶ … afternoon, light rain falling and predictions of thunder storms on the way. Client was eight minutes late to his appointment. "It doesn't matter that you're a few minutes late, I am glad to see you -- but is everything going okay this afternoon?" he was asked by therapist. Client seems defensive when no pressure at all is put on him. First he said his watch stopped, then he admitted he lost track of time because he was into playing a new video game.

He asked if video games are a bad thing and was assured that entertainment was his choice. "Oh, also," he added. "After I was in my car I went back to my apartment to get my umbrella." Client is trying to maintain a good relationship with the therapist. The client was sweating when he sat down, and it was humid in the room so we agreed the air conditioner should be turned up.

The client took quite a bit of time making the adjustment on the wall near the door where he had come in.

"I know you have new neighbors in the apartment building -- have you had a chance to meet the people that just moved in yet?" "No, I actually thought I would let them get settled before introducing myself." "What if you ran into the couple, or one of them, in the hallway? Would you introduce yourself to them? Would you talk to them if they smiled at you and spoke to you?" "Probably not," he answered. "Well, maybe I would, depending on if they seemed friendly.

What if the couple turns out to be two women? What if they are a lesbian couple? I haven't seen them. I have just seen the movers hauling their furniture to the floor just below mine. Some of the stuff seems feminine. The colors of the paintings and other stuff I saw. I will avoid meeting them; besides, what they do is none of my business.

I mean, if they are gay, or not gay, they deserve their privacy -- and so do I." Progress Note #1 - BIRP (Behavior) The therapeutic approach in this session is to begin to observe the client's thoughts, observations, main issues, and his mood. Client is anxious about the session, has little trust at this point in the therapist. (Intervention) The therapist opens the question of the client meeting new people just moving into his apartment building; client indicates a reluctance to meet new people especially if they are female.

(Response) The client opens up about his anxiety vis-a-vis meeting new neighbors, which is a starting point, and gives the therapist honest assessment of his shyness and what causes stress. (Plan) The cognitive behavioral therapy involves establishing trust between client and therapist. Process Note #2 -- Friday June 10 The intervention is moving slowly so some sense of trust can be established with the client, who is early for his therapy appointment. He is sitting in the waiting lounge reading a men's health magazine when the therapist enters and welcomes him.

"How long will our session be today?" he asks the therapist. "As long as you would like it to be," the answer comes. Inside the therapist's office the client seems more subdued than normal and clutches a Starbucks' coffee container. He slumps in his chair and doesn't make eye contact with doctor. Client seems very distracted. The therapist passes close by the client's chair to open the blinds and gets a whiff of wine on the client's breath. Client perked up for a moment.

"What is the point of this therapy? Can you tell me from a medical perspective, what is my problem? I have a good job, I do my work and come home most days, I'm not on drugs, I only drink once in a while, and I do plan to reach out to other humans in Uganda with the missionaries this summer. Is that a positive sign I'm okay?" "I am glad you are here and we are working through this together," the Doctor says.

"We can discuss the therapy, but first of all, I would like to learn more about your friends, the people you work with. Who are your closest friends?" There is no answer. "Do you feel relaxed chatting with me in this room?" Again, no answer, but eye contact is made, and the client's expression tells the therapist he may be ready to open up. Therapist gets up, takes off his formal jacket, and focuses on client's proposed trip to Uganda, using Cognitive Behavior therapy techniques.

"I researched Uganda last night so we could talk about it together," the doctor said. He suggests that just for the sake of argument, what if he and the client both went to Uganda. That way the therapist would have the client's back if there was tension. The client adjusts his position in the chair, and agrees to talk about a scenario -- purely speculative -- in which both would be going to Uganda in the next session.

Progress Note #2 -- BIRP (Behavior) The client is questioning the value and the intent of the therapy, a positive sign that meaningful dialogue can take place. The client's language skills are evident and logical. His IQ is above average. (Intervention) Therapy is focused first on trust and good communication; there are signs of commonality. (Response) Eye contact but little verbal response is noted when therapist suggests Africa is on his bucket list.

(Plan) Therapist broadly explains cognitive-behavioral model as regards anxiety, lack of self-esteem, and emphasizes trust and frank discussions in order to address client's concerns and issues. Process Note #3 -- Monday June 13 Therapeutic intervention is in its third day. Client is asked in a non-judgmental tone at the outset of the session if it's okay to discuss his Christian faith, as background to the proposed trip. Client agrees willingly to discus Christianity and his beliefs.

When did he become a Christian and how will his trip to Uganda with 20 missionaries help native peoples there? He mentions that his father suffers from depression and even though his parents took him to church as a child, when his mother had an affair and he found out about it he only attended church services (a Protestant denomination) with a male friend. He says he fears ending up "like my father.

I have these moments when I feel so sad and unwanted that I try to stay away from everyone, especially females." He accepts that the Bible and Jesus Christ refer often to forgiveness. Will he consider forgiving his mother? He looks away.

"Is that why you want to go to Uganda? To maybe have a fresh start? I would like to go there too because I've always been fascinated with Africa." The client reminds the therapist that this is a Christian mission, and the therapist explains that he is a "PK" (preacher's kid) and he regularly attends local Lutheran services. After that remark the client smiles. Some sense of trust may be beginning to emerge. An intervention can achieve some initial success when both client and therapist have the same spiritual values.

The client is asked if he would invite the therapist to church on a future Sunday, and the client agrees. Clearly Christianity's strong symbolism of resurrection and renewal -- and empathy for those less fortunate and/or struggling to fit in -- could play a role in this intervention. The therapist is cautious about opening the door to interactions with the client outside the sense of safety in the controlled office environment.

But the idea of sharing thoughts on spiritual and religious topics is bringing the two men into a kind of bonding vis-a-vis a new outside topic both share deep feelings about. The client has begun to open up more fully to questions asked and comments made about his depression, his anxiety, his difficulty in his involvement with other people he does not know. Progress Note #3 -- BIRP (Behavior) Client openly discusses anxiety stemming from his upbringing experiences with parents that were less than fulfilling psychologically and physically.

Social judgment is otherwise intact. (Intervention) Client understands the need to work with a professional to make his life fuller. He is a Christian and a person who believes in forgiveness but has not learned how to forgive and move past unpleasant relationships with family. (Response) When Christianity comes into play in the discussion client is fully engaged in this dialogue. Client is thoroughly realistic and appropriate.

(Plan) The idea of better social life as an alternative to being a loner and fearing new friendships or associations is linked with his Christianity. Process Note #4 -- Friday June 17 Therapist goes into the fourth session with a commitment to engage the client in conversation directed specifically and pointedly towards solutions as regards his avoidant personality disorder. Therapist seeks a shared understanding of the problems client struggles with.

There is thunder, lightning and steady rain outside the therapy facility as the session begins and the client -- who brought his umbrella into the room -- seems excited and happy because there have been drought conditions in the state and rain is a welcome dynamic. "I have some succulents and other plants on the deck outside my apartment and the rain will be better for them then me pouring tap water on them," he explains.

This is a new side of the client, to offer information about his personal living situation. It is time to set goals with the client and construct a list of problems we need to work on. He is asked to imagine how helpful it would be if solutions to his behavioral issues could come gently flowing from the sky like the rain that is nourishing his succulents and other plants. "Life doesn't happen that way; we don't live in a fantasy world" he said.

"So, okay, this is real: let's make a list of what you want to get out of this, what you hope to accomplish. You come here twice a week, faithfully, and we sit in this room together with the goal of making adjustments in the kinds of life experiences that you have shared with me." The two agree on several things to address specifically that may be helpful to the client.

His anxiety when he encounters new people and when he relates to his girlfriend cheating on him five years ago (agreed); why is he unwilling to meet women and how can he come to terms with the truth that not every girlfriend in his future will be unfaithful to him (agreed); Why he prefers to go directly home after work rather than socializing with colleagues; and how will a sojourn to Uganda help him make the adjustments he knows that he needs to make? (agreed) The truth is: he is handsome, intelligent, educated, wears attractive clothing which he buys at a discount from the store where he is employed so people see him as attractive and professional (agreed) Progress Note #4 -- BIRP (Behavior) Problem solving based on an agreed-upon list of important bullet points is conducted.

The agenda was set and client agreed building a bridge from one session to the next is the key to accomplishing what both men set out to do. (Intervention) Therapist believes client understands the treatment plan; today's session went over the hour as progress was being made towards an understanding of what behavioral changes are imperative in order for client to enjoy a life without depression, anxiety, fear of strangers and prejudice.

(Plan) Client agrees to role-playing within the therapy sessions; therapist will bring in people client has never met and engage client in conversation to overcome shyness and anxiety. Process Note #5 -- Monday June 20 The last bullet point is discussed first. Client is shown photos of men in clothing advertisements -- well-groomed men with happy facial expressions. Do these male sales professionals look very different from him? He agrees that he is an attractive person but senses that he is different and not worthy for a woman to like him.

Does he attend to women who come into his store to buy clothing for their husbands, or sons, or boyfriends? Yes he does, and he says he has "learned to handle my anxiety by hiding my real feelings." What are those real feelings that the client explained in the last session? "I am a product of a dysfunctional family and I'm afraid I will never be a normal person unafraid to meet new people, especially women.

Every woman I see, every time I see an attractive woman, I wonder if she has affairs with men other than her husband or boyfriend." Can the client perceive in a woman's eyes and her expressions whether or not she cheats on her male companion? "Sometimes, yes, I can tell if she is a cheater," he says. How so, he is asked. "She just has that look in her eyes like she knows something nobody else knows," he says.

Therapist notes that in a challenging environment with new people in the mix the client falls back on his old rationalizations and fears. Client promises to socialize with his clothing store colleagues next time he is invited to go for a glass of wine after work. "Do it for yourself, to counter your anxiety -- but you're not doing it for me," the therapist explains. Client is not.