It was felt that the following factors were playing a part in her condition: a strong family history of depression; mother committed suicide; insecure attachment to parents; lack of care, love, and emotional expression from father and stepmother; lack of discipline from maternal grandmother who often satisfied her demands, irrespective of whether they were thought to be reasonable. There was a history of being betrayed by peers in primary school, which may have further intensified her feeling of insecurity. Repeated self‐harm behaviors and suicidal threat as a kind of manipulation to induce the boyfriend's guilt whenever Ms. B considered the relationship unstable, which contributed to a vicious circle.
Consultation
JM thanked the doctor for the thorough presentation and for developing a good relationship with Ms. B. JM then asked the doctor to state what the treatment plan was. The doctor explained that the treatment plan had been discussed with Ms. B, her father, and her aunt, and it was jointly decided that she should have counseling psychotherapy by a private professional. The doctor explained that one of the factors determining treatment provision was the limitations of the health service. JM pointed out that an additional factor probably was the doctors need to have the experience of seeing patients through to the end of treatment. JM pointed out that Ms. B had not managed to improve her ability of dealing with her emotions in a more constructive way despite the years of therapeutic efforts.
JM then asked the doctor about his understanding of the reason why Ms. B finds it so difficult to manage her feelings in a more constructive way, without resorting to destructive actions. The doctor responded that her early life experience could provide an answer. He pointed out that Ms. B had lost her mother at the age of 2 and that her father was not available for her because he was preoccupied with the survival of his business. The doctor pointed out that Ms. B felt insecure in her childhood and that this feeling was accentuated with the betrayal that she experienced in primary school. Her upbringing led her not to feel secure in any environment. JM then asked the doctor if he could clarify in what way Ms. B did not feel secure at present because history is important, but the present is equally significant. The doctor pointed out that the main source of security for Ms. B was the relationship with her boyfriend, and unfortunately, his behavior had given her grounds to feel less secure with him.
JM then drew a distinction between the realistic insecurity and the “core” insecurity that Ms. B carries with her all the time. The realistic insecurity is appropriate in her case because her boyfriend does not give her grounds to feel that the relationship is stable and long term. Her perception is not a matter for treatment. In contrast, a matter for treatment is the insecurity that she carries with her and that she perceives in many other settings.
Ms. B enters relationships without expecting them to be secure. She does that at a level that is well beyond the understandable and expects uncertainty in any new relationship. By beginning a relationship with excessive suspiciousness combined with a tendency to act destructively, Ms. B plays a part in damaging the relationship and bringing about the thing that she fears (i.e., the breakup and the resulting insecurity). This was a description of the vicious circle through which one's feelings and behavior cause their worst fears to become reality. JM pointed out that the doctor had correctly identified that this was a pattern that she developed from early age and that she applies at present.
JM then moved on to the immediate therapeutic task of enabling Ms. B to move out of this vicious circle. The focus of therapy needs to be on making Ms. B stronger emotionally so that she can cope with difficult feelings in a more constructive way. JM redefined the question of “how can this Ms. B be made to feel secure enough so that she can handle her emotions more constructively?” JM suggested that the first secure attachment that this she could have is that with the therapist. A therapist can become a secure figure for her if they are able to provide a strictly professional and predictable relationship. The first parameter is being “strictly professional.” The importance of the therapeutic alliance has been adequately researched. See studies by McCabe and Priebe (2004) and Krupnick et al. (2006). There is often the temptation to become friendly, parental, or, worse, flirtatious or amorous with a patient to respond to the patient's needs for a secure attachment. Medicolegal literature is full of cases in which therapists have not been able to maintain the professional role to the detriment of their patients and themselves.
The second dimension of the professional is that the appointments are prearranged, and the patient knows when they are going to take place, how long each session will last, and that this is not a forever relationship that has to end. In that way, the conclusion of therapy will be seen as that (conclusion of a period of treatment) and not as a further rejection. Additionally, the therapist will be able to support the patient not in the sense of colluding with her but in the sense of enabling her to reflect on her feelings and adapt them so that they correspond to reality and are not determined by the early life experiences. JM gave several examples where this process happens in a healthy and constructive way in well‐functioning families and in well‐functioning schools where staff help the children who get upset by various interactions to recover as well as mend relationships.
Finally, a therapist can help the patient develop a sense of perspective. This means that the patient will be more able to see their difficulties in context and to have hope that a better future lies ahead through a resolution of the present difficulties and the ability to develop better relationships in the future. These are some of the changes that psychotherapy can bring about. They are referred to in the scientific literature as transformative factors. For those interested in group analysis, see Garland (1982, 2015).
JM then decided to divert the attention to the area of Ms. B's view of herself. JM pointed out that the relationship between one's ability to have a relationship and one's view of themselves; for example, a person with a more realistic view of their self is more likely to develop a realistic relationship with others, and a person with a damaged view of their self is more likely to handle relationships in a dysfunctional way. At this point in the consultation, the doctor gave an excellent summary of the essence of the consultation so far, and it was natural then to move on to exploring Ms. B's self‐psychology. JM pointed out the need for the therapist to retain credibility with Ms. B and that the main basis of credibility is that they should be realistic. A tendency to idealize or to be overly hopeful often reduces the therapist's credibility in the patient's view and therefore reduces their ability to be effective. In Ms. B's case, reality means that she has the future potential to develop appropriate and functional relationships, but she will need to do some work to reach that point.
The doctor pointed out that Ms. B does not like herself at present and that she does not see herself as loveable. This is made worse by her awareness that she has negative emotions. The doctor added that Ms. B does not like herself for her feelings or for her actions in the recent past. JM then pointed out that it seemed that Ms. B only defines herself on her negative characteristics and that she attends only to the negative responses that she receives from other people. JM pointed out that Ms. B may well be ignoring any positive feedback that may come her way. In search for positives, the doctor pointed out that Ms. B was happy when she was working as an assistant basketball referee. The doctor pointed out that Ms. B remembered that there was little challenge to her decisions as an assistant referee and that when she was refereeing there was little argument in the game.
The doctor was finding it difficult to define further positive aspects of Ms. B's personality. JM then clarified that he was not asking the doctor as a teacher who knows what the right answer is but as a consultant raising issues with him that he could then explore together with his patient. In this way Ms. B would begin to look for the positive and realistically positive aspects of herself, so that Ms. B will develop a more balanced and realistic view of herself. This view will replace the damaged and almost totally negative view of herself that was based on her early traumatic life experiences. The doctor then added that there were times when Ms. B was attractive and charming. JM then concluded that a good professional relationship with the therapist would enable her to be more conscious of the positive attributes of her personality