Presenting the Problem
The client is a 43-year-old male who reported struggles in remaining faithful to his wife, and is also suffering from alcohol dependency.
Appearance and Behaviour:
The client is meticulously groomed. His behavior is very controlled, reserved and composed. The client presents himself as respectful and direct.
Family and Origin
The client described himself as an orphan raised in a whore house. His mother was a 22 year old prostitute who died during the client’s childbirth. His father was a ‘client’ of the mother, indicating that there was no relationship between the father and mother. The client’s father, along with his wife, raised the client until the age of 10, at which time his father was kicked in the face by a horse and passed away from his injuries. The client reported that his father was a drunk and abusive. After the passing of his father, the client then lived with his stepmother and stepmother’s boyfriend, ‘Uncle Mack’, who owned a brothel in which the client lived. ‘Uncle Mack’ was reportedly kind to him, but his stepmother was mentally and physically abusive towards the client. This abuse included constant reminders that he was a ‘whore’s child’. The client also reported being raped at age 10 when he was sick and was nursed to health by a prostitute.
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During his late teens, the client ran away from home and joined the army. He served in the Korean War and switched identities with a dead, unrecognized soldier. The client assumed the dead soldier’s name, cut off contact from his family and created a new life and identity for himself.
Present Family Relations
The client is married to his second wife. He described his wife as caring, loving, and the only person he ever confided in about his true identity and past. However, the client reported having had several affairs. The client has three children with his ex-wife. The divorce was due to his extramarital affairs and due to his wife finding out about his true identity. The client only communicates with his ex-wife regarding matters concerning their children. He feels disconnected from his children, but cares for them and loves the unconditionally. He sees his children every other weekend.
The client did not complete high school or attend any further schooling; however, he reported being an avid reader.
Physical Health and Psychological Antecedents
The client is in good physical health, and reports having no physical illnesses. However, he admitted to drinking and smoking excessively, indicating he smoke and drank consistently throughout the day.
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The client works in the advertisement and marketing industry where he is a senior partner and creative director for an ad agency called Sterling Cooper and Partners. He reported that although work can be very stressful and demanding, he could not imagine doing anything else. The client mentioned that he excels at his job and is considered by his colleagues and clientele as the ‘best ever pitchman’.
The client did not report having any close friends, stating he mostly goes out for drinks with colleagues, business partners, or potential clients. Most of his leisure time is spent with his wife or current mistress, with whom he says he often has meaningful and intimate relationships with. The client reported his affairs can last from one month to several months with the same woman.
The client is unable to remain faithful to his wife and has a history of infidelity. His attachment history was insecure as he was not provided with a safe, nurturing environment while growing up. Due to this, the client’s needs were not met, including his need for safety, warmth, and love (pp. week 3). The client presented his childhood caretakers as insensitive, emotionally unavailable, abusive and neglectful. As a result the client developed an avoidant attachment style, a realistic adaptation for him considering his circumstances (Muller, 2012). For instance, difficulty trusting others may have served a purpose for the client’s childhood experience living in a brothel. His internal working model for relationships includes rejection, abandonment, sex as a commodity, and an impersonal nature (pp).The client presented qualities of being strong, independent, and self-reliant. These developed qualities are unsurprising considering he had to care for himself while growing up. The primary caretakers afforded to him were not reliable or dependent, leading to the client’s developed view of others as unreliable and unhelpful. Thus, when the client is distressed he does not engage in support seeking as a coping strategy; instead he falls back on avoidance strategies including distancing himself from his wife, and heavy drinking and smoking to manage his stress.
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The client seems to be emotionally detached from his feelings and denies the impact of early attachment relationships on his relational development, including their effects on his feelings of disconnect towards his children and wife.
The client’s present problems include:
1. Infidelity: The client is unable to remain faithful to his wife, and his relationship attachments and connections are short term. He remained faithful to his ex-wife and current wife only at the beginnings of the relationships, but soon becomes distant and seeks out extramarital affairs. The client seems to avoid getting too close or intimate to anyone. He keeps relationships at a superficial level, the honeymoon stage, and then breaks off the relationships or distances himself.
2. Substance abuse: The client consumes alcohol regularly, including first thing in the morning and at work. He experiences blackouts, misses commitments with his children, and has become unreliable and unpredictable at work.
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Treatment goals include:
1. Exploring the client’s attachment issues and their impact on his relationship outcomes and dynamics, as well as connecting the client’s symptoms to attachment related issues. For example, the client must make the connection between his drinking and his spousal relationship. Working on relational issues will potentially make therapy more meaningful and its results longstanding; working with only the symptoms will not get to the root of the client’s problem.
2. Processing past unresolved emotions related to the client’s trauma and loss. Suppression of trauma related material requires considerable psychological and physiological work; however, not addressing these unresolved emotions can lead to increased health problems over time.
3. Re-establishing relationship with his wife. The client proclaims to love his wife and does not wish for another divorce.
4. Finding others ways to cope with distress other than with alcohol and sex. The client’s avoidant defenses are no longer working effectively, as he is no longer able to ‘hold it together’ and is ‘falling apart’.
Strategies used for working with the client include:
1. Building a therapeutic alliance. This will be achieved by using Carl Rogers’ three conditions for therapeutic change: empathy (accurately sensing the client’s feelings and personal meaning, and communicating this understanding to the client); genuineness (not putting on a professional façade, and making herself transparent to the client so that the client can clearly see the role of the therapist in the relationship); and unconditional positive regard (accepting the client in his totality, without any conditions, and accepting the client in any stage of life, and in whatever immediate feelings the client is experiencing: confusion, rage, fear, jealousy, love or pride are all accepted without any prejudgements) (Rogers, 1980). Providing a safe and trusting base for the client to explore his emotions and thoughts is of central importance. Clients who have experienced considerable rejection and hurt in their families of origin, rejection that has gone acknowledged and unresolved, need a safe context within which they may be given the opportunity to experience relationships in new ways (Muller, 2012).2. Working in the here and now. The rationale for using here and now rests on two basic assumptions: 1. The importance of interpersonal relationships; and 2. The idea of therapy as a social microcosm (Yalom, 2002). The interpersonal problems of the client will manifest themselves in the here-and-now of the therapy relationship. The client is likely to use many of his avoidant relational characteristics in therapy including deactivation of emotions, or memories that arouse the attachment system, and minimization or denial of trauma related issues. The therapist then can work collaboratively with the client on attachment issues that are occurring in the session and provide meaning and understanding to them.
I imagine working with this clinical population (avoidant attachment individuals) would be challenging. The client presents himself as someone who is strong, resilient and does not need to depend on anyone. I imagine feelings of hurt, a sense of incompetence, self-doubt, and anxiety would arise as a result of me being the therapist. As therapists, we are drawn toward the helping role, as we value being needed, being relied on, and making a difference in the life of another. As such, I would have to continuously check in with myself to make sure that I am not acting out on my emotions, and to express the feelings of disconnectedness and rejection that I would likely experience from the client. Additionally, I imagine myself working too hard to build the therapeutic alliance to compensate for the client being distant and avoidant.
Another countertransference I would have to be aware of includes my own personal feelings towards infidelity. As a female, I imagine experiencing a more judgmental and less understanding stance, perhaps even experiencing feelings of annoyance, or even anger.
The last countertransference I would have to be aware of is my own romantic or fantasy feelings towards the client. The client is good looking, intelligent, successful, and very charming. I would also see that underneath that hard shell is an insecure, vulnerable, and hurt individual. Further, the client presents himself as very mysterious and challenging, which is another appealing quality. Thus, I would have to be aware of any romantic feelings I could be developing or experiencing towards the client, and would have to remind myself that the client is asking for help, and that my primary duty is to provide said help.