Counseling approach for Lars: emotional withdrawal, depression, and commitment concerns

Lars

Heart Issues

Lars appears to have strong issues of the heart. He is emotionally closed off and distant at the current time with his fiancee, Jennifer. This may be due to his conservative upbringing. It will be important to find out what type of environment he grew up in and what his role in the family was. His ambivalence about his upcoming marriage and his withdrawal from Jennifer may be due to actual or perceived disapproval from his conservative Lutheran parents about marrying a woman who is divorced. This rift, whether true or not, would cause a great strain for Lars' heart well-being. It may also be Lars' own disapproval of his pending marriage to a divorced woman. If this is the case, he may or may not actively realize it at this time.

Relational Issues

Lars appeared to function with relative ease and comfort in his relationship with Jennifer while it was long-distance and casual. It seems that Lars enjoys the benefits of his friendship with Jennifer but is fearful of and reluctant to make a more formal, serious commitment such as marriage. He describes his childhood as a relatively easy childhood growing up in the mountains of Germany but he does not go into details. He does mention his periodic struggles with depression and his parents' refusal to take him for medical or psychological help. This may cause him some anger and/or resentment surrounding this. Lars does not talk about his relationship with his parents in any way; it will be important to probe into this issue during his treatment.

Physical Issues

Lars does not seem to have any physical issues that need to be addressed medically at this time other than his depression. He mentions incidents of depression going as far back as he can remember. This suggests that his depression is a medical issue. It will be of utmost importance to determine if his depression is chemically induced or situational or possibly both, and to treat his depression with the proper medication.

Potential Problems

There are several areas in Lars' background that have a potential to cause problems in his treatment. His strict Lutheran upbringing and the way his parents responded to his depression as a child - i.e. refusing to take him for treatment, ostensibly for religious reasons - may cause Lars to resist the treatment process. Any clinician or treatment provider may have to reassure Lars that psychiatric treatment is a valid medical process and that his issues with depression are not sinful nor do these issues represent a punishment from God. The second area of concern is his profession as a social worker. Many people in this profession tend to approach and participate in treatment in an overly intellectualized manner. Lars most likely has had some, if not extensive, psychiatric training, and it will be important for him to learn how to approach his own treatment process as a patient instead of a professional social worker.

DSMIV Diagnostic Information

Lars' ongoing history of depressive episodes since childhood and his fiancee Jennifer's description of him - very withdrawn, walking slowly with a stooped posture, having a persistent pessimistic attitude, responding to her with only one- or two-word answers and refusing to eat, take walks with her, or even come out of the bedroom - indicate an Axis I diagnosis of one of the Major Depressive Disorders, Recurrent, most likely moderate to severe. Lars did not revealed any psychotic episodes. It is possible that he may also fit the diagnostic criteria for 309 Adjustment Disorder with Depressed Mood or 309.4 Adjustment Disorder with Mixed Disturbance of Emotions and Conduct, due to the fact that this depressed mood, argument with and reluctance to marry Jennifer began when he moved to America from Germany. He states that he has had a difficult time adjusting to his new home and that he is very self-conscious about his ability to speak and read English. An Axis III diagnosis of 301.82 Avoidant Personality Disorder may also be made, due to the way that Lars seems to want to end his engagement to Jennifer instead of discussing and working out their problems while treating his depression; more specific details would have to be provided to make this diagnosis.

Formal Counseling Agenda

Suicide Risk Level

Lars is at a moderate to high risk level for suicide. He just moved to a foreign country and does not mention any friends or support group within his new community. His fiancee Jennifer's description of him indicates a severely depressed mood. He should be strongly questioned about any suicidal ideation, and may need to be hospitalized if he is unable to convincingly deny thoughts of suicide. He should be put on a contract to prevent suicide and monitored frequently until his depression begins to dissipate. Any further symptoms of or increased severity in depression may warrant hospitalization in the future to prevent Lars from harming himself.

Suggested Biblical Passages

"Come to me, all of you who are weary and carry heavy burdens, and I will give you rest. Take my yoke upon you. Let me teach you, because I am humble and gentle at heart, and you will find rest for your souls. For my yoke is easy to bear, and the burden I give you is light." Matthew 11:28-30. This passage relates to Lars' weariness in experiencing persistent depression throughout his life. It will help to remind Lars that he is a beloved child of God and that his God will never give him burdens that he cannot handle. Our Lord and Savior Jesus Christ, who spoke these words to His disciples, also meant them to give strength to all of those who follow Him. This passage will remind Lars that when his burdens feel too heavy for him to carry alone, Jesus is walking beside him.

"All praise to God, the Father of our Lord Jesus Christ. God is our merciful Father and the source of all comfort. He comforts us in all our troubles so that we can comfort others...For the more we suffer for Christ, the more God will shower us with His comfort through Christ." 2 Corinthians 1:3-4, 5. This passage relates to Lars' suffering through depression. It will help Lars to view his suffering as an opportunity to turn to prayer and ask God to comfort him in his time of great sorrow. It will help Lars to remember that our Father God is always ready to comfort His children, and that the more we suffer the more comfort we will receive from Him.

Homework Assignments

Lars should:

1. Make a gratitude list with at least ten things that he is grateful for and thank the Lord each night in prayer for all the things on this list. This assignment will help him to remember that even though he is in the midst of a depression, he has been blessed in many ways. The reminder of things that make him grateful may help to lift Lars out of his depression.

2. Keep a Feelings Journal. Set aside a specific time each day and rate his mood on a scale of 1-100, then spend at least fifteen minutes writing about his moods and feelings, what he is thinking when he is experiencing these moods and feelings, and any events that may have contributed to his thoughts, moods, or feelings for that day. This exercise will help him to explore his depression and allow him to see if there is a pattern to his depressed mood.