Alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is Shedding a Heavy Load Leigh Bettles Abstract: This paper is a case study, presenting the work with a client who was referred to me for six counselling sessions. This case illustrates the effectiveness of using a relational therapy in short term therapy so that the client was able to move from a place of feeling stuck in her life. Key Words: case study; relational psychotherapy; short term therapy; integrative psychotherapy _______________________ Azra was invited into the office where I would be assessing her needs and if counselling would be appropriate for her. I was aware that she was laden with bags, which as she walked in hid her very thin childlike frame. She put her bags to the side of the chair. Azra, a young woman in her early twenties was living at home with her mother, younger sister and younger brother. She had been brought up as a Muslim by her parents who were originally from Pakistan. She was working as an Environmental Project Officer. She had been signed off by her doctor for 6 weeks due to depression. Even though she had put her bags to the side of the chair, the way that she slouched forward in the chair made me wonder how someone so small, was able to carry bags that seemed so heavy. She looked as though she was carrying a heavy burden. I could see that her problems were embodied in her physiology and that she was being weighed down. She told me how she was feeling low, had lost her appetite and was feeling tired all of the time. She had no interest in doing anything and was also over analyzing everything, which meant she was going through different situations in her mind but ending up stuck and unable to sort out how to go forward and then felt that she was going around in circles. She told me that she was not currently on any medication. She had attempted to take an overdose in October of last year, when the relationship with her boyfriend had broken down. She was no longer having thoughts of suicide and said that it was a reaction to her situation at the time. She was then referred to a Psychiatrist who had assessed that she did not need long term psychiatric help; he recommended that she be referred for counselling. International Journal of Integrative Psychotherapy, Vol. 1, No. 2, 2010 48 She had still been seeing her boyfriend (Joe) and was having a sexual relationship with him which she had instigated. She commented that she had felt that she needed some control in the relationship and this is how she felt she had it. I made a mental note that she had mentioned that she needed to feel in control. She told me that she knew this relationship was not good for her but she could not find the strength to leave him and didn’t understand why. I used historical and phenomenological inquiry to find out about her life history and what her experience had been, of growing up within her family. I was also looking out for any evidence of any script beliefs that she may have made at an earlier developmental age, which may be influencing her life now. She told me that she had felt lonely as a child. She spent a lot of time on her own in her room. Her father was never around and when he was, she saw him being violent towards her mother. She remembered her parents as distant and that when they were together there was a lot of fighting and screaming. Her mother was the kind of mother who was not outwardly affectionate. If Azra fell over or was upset her mother would not respond. There was a lack of attunement from her mother. She would not give her daughter an encouraging smile or give her the eye contact, to let her know that she had someone there, caring for her and giving her the security that she needed. If Azra came home from school with an A for an essay, her mother’s response would be to ask her why she had not got an A star. Azra had not been able to make an impact on her mother and receive the praise she wanted for working hard and getting an A. Because of her parent’s culture and religion they were unable to satisfy Azra’s need to be valued and accepted for who she is. When Azra did not conform to the beliefs that her parents had, she lost their love and respect. As a consequence of the lack of care and her parents inability to satisfy her developmental and relational needs she grew up thinking that her parents did not love her. She told me that she loved to go to school and if she worked hard the teachers would give her praise and encouragement, so by doing this the teachers compensated for the encouragement that she did not receive from her parents. I considered the fact that the care she had received as a child was inconsistent. She met Joe when she was 19 years old. She fell in love with him but he was from a different culture and religion. She kept their relationship a secret because she knew that her family would not approve of her being with him. She then decided to tell her mother that she was seeing him. I inquired how she had come to the decision to tell her Mother at that time. She told me that she had been thinking about it for weeks before. She said that she could have never made the decision on her own and that she talked to friends who told her that they thought her mother would understand and support her if she told her. She fantasised about telling her mother and that in her fantasy her mother reacted as her friends had told her they thought she would. She had gone through the fantasy so often that she thought that it could be a reality. It was a spur of the moment decision when she actually told her mother. The reality was that she told her and it led to a massive argument. Azra felt and believed that she had the right to be with whom she wanted to be with and International Journal of Integrative Psychotherapy, Vol. 1, No. 2, 2010 49 wanted her mother to be able to accept her choice in partner but because of her religious beliefs her mother couldn’t accept that. Her father, who at the time was living in the house next door, over heard the arguing and came to find out what was going on. Azra was sitting on a bed in the bedroom, opposite her mother, sister, and brother when her father came in. When he found out what was going on, he hit Azra. I inquired about Azra’s response to her father hitting her. She told me that she had not responded when her father hit her. This was because it was normal for her to be hit by her father, when she did something wrong. It was evident that at some point she had made an implicit experiential conclusion that that was the way it was when she did something wrong, she thought that she deserved to be hit and so did not retaliate. Her family also did not respond to her father’s behaviour which reinforced the conclusion that she had made. It seemed that this conclusion was made from the cumulative trauma, of her father hitting her as she grew up. When her father picked up a television and went to hit her with it, her brother stepped in and stopped him. As Azra was telling me what had happened I felt shocked and angry that her family could not accept Azra and let her live the life that she wanted. I inquired what Azra was feeling, as there was no evidence of any emotion in her voice. She was not aware of feeling anything. It seemed that I was experiencing the feelings that she had needed to disavowal because they were so painful and hard to tolerate. She talked of how she ran to the bathroom where her father knocked the door down. The police were called and her father was charged with assault. He received a fine and a criminal record. Azra told me that she hated him and she now denied the fact that he was her father. Because he had threatened to kill her on more than one occasion the police classed it as an honour based crime and she was sent to a hostel in another city, for her safety. She hated it there and felt very alone. We had 5 more sessions and she told me that she would like to talk about the relationships with her family and Joe and try to get a better understanding of them, so that she could deal with situations better in the future. I asked her if she had any questions and if she felt comfortable coming to talk to me again. I wanted to give her the opportunity to say if she was not happy about anything that we had talked about. We agreed to meet again at the same time the following week. In our next session I let Azra take the lead. I wanted her to have a sense that she was in control of the sessions. She had already talked about a lack of control in her life and that she had needed to feel that she was in control in her relationship with her boyfriend. From when I first met Azra, my intention was to build a safe working environment, where I could focus on her relational needs. Her immediate needs seemed to be for security and self definition. From what she had told me it also seemed that relationships in her life had been inconsistent and she was aware of being judged by people, according to her beliefs and her behaviour. She talked about how she was angry at her mother not being able to cope on her own. Her mother had not learned English; instead she had relied on her father for International Journal of Integrative Psychotherapy, Vol. 1, No. 2, 2010 50 all of her needs and had not thought that he would maybe not be around one day. I considered the fact that Azra was now living in a different generation to her mother. She had received an English education where she was more likely to have been encouraged to ask questions when she did not agree with something. She had witnessed how things could be different and as a consequence was more likely to question rather than accept and conform, as her mother and other women had done in previous generations. She felt that if her mother had a terminal illness then she would be able to see the situation differently; she had seen that in situations where her mother was on her own, she was able to cope by getting other people to help her or by managing to deal with the situation herself. Azra commented that she did not want to upset her mother. She was the only person that on her return from the hostel had stood by her, even though it was against her religion. Tears welled up in her eyes as she told me that she thought that she had lost her mother for good and when her mother let her return, it was the first time that she had realised that her mother did love her. This went against the belief that she had grown up with and it was still hard for her to believe. She was constantly aware of looking for evidence in her mother’s behaviour to support the belief that she did now care. The fact that her mother now turned a blind eye to her relationship with Joe was evidence that she cared. She felt that it was not her responsibility to look after her mother. As a result of this she felt angry at her mother. Because she was suppressing her anger for fear of upsetting her mother, her anger was coming out in more aggressive ways, by her being snappy and irritable with everyone around her. This led her to feel guilty about her behaviour and although she did not want to look after her mother, she had the belief that she should be doing so. We looked at how she could express her anger in more healthy ways. We explored what she would like to be able to say to her mother and ways in which she could say what she wanted in a non-aggressive way. Even if her mother was unable to acknowledge and respond to her anger the way that she wanted, it was important for her to be able to voice how she felt. We looked at the physiological signs of anger in her body so that she could withdraw earlier if she wanted to and also looked at exercises she could do as a constructive way to channel anger energy. Azra recalled what it was like for her being all alone in the hostel. She remembered sitting on her bed feeling so alone. This is when she had tried to take an overdose of tablets. I was aware of slowing down the pace of our interactions to give her the chance to feel and express what she was feeling. She recalled feeling angry and confused. She then commented that she was angry at her mother for not being there for her. I commented that I could hear the anger in her voice as she told me her mother should have been there to look after her. She had felt that there was no one in the world that was there for her, and that she was totally on her own. As she talked of the emptiness that she had felt inside, I also had a sense of the emptiness that she was feeling. I wondered how such a young person could have survived such a traumatic series of events and International Journal of Integrative Psychotherapy, Vol. 1, No. 2, 2010 51 the intense feelings of loneliness that she had had to deal with after being cast from her family, friends and the culture that she had been bought up in. As I focused on Azra, I was aware of wanting to comfort and reassure her, as I would have done with my own daughter if she had have been in that situation. I gently asked her what she thought she needed at that time. She said that she needed her mother to be there to look after her. I told her that if she had been my daughter I would have wanted to reassure her and I would have wanted to look after her. She could see how her mother wanting her to look after her, now made her feel angry. It was a juxtaposition as instead of having a feeling of satisfaction or pleasure from helping her mother, it was painful in that she remembered that her mother was not there for her when she needed her most. While writing some notes up after the session I seemed to have difficulty recalling the way in which Azra described her feelings of loneliness. I also remembered that I had had intense feelings of loneliness as a child and my way to deal with those feelings was to dissociate from them and go into my head. I wondered if my countertransference reaction had been to withdraw into my head, during the session, as I had done as a child, which would explain my difficulty describing Azra’s feelings. I made a note of this and took it to my next therapy session where we agreed that we would focus on and work through the feelings of loneliness that I had experienced as a child. When Azra talked about Joe I sensed a feeling of stuckness and that things could not change. She knew that their relationship could not develop as she would like, because his family and in particular his mother did not approve of her and would never accept her into the family. When Azra had met his mother she had looked at Azra in a way that had made her feel that she did not like her and that she was not what she had in her mind for her son. She had also made comments to her that had supported Azra’s thoughts. Azra felt anger towards her because of the way that she had judged her and had not even given her a chance. Azra had a history of being judged by people so I was aware that there could be some transference going on in the room. I asked her if at any point she had felt judged by me. She said that she hadn’t, my thoughts were that she may have unconsciously introjected for example the way that Joes mother or other people had judged her and may now be projecting that introjection onto me and be expecting me to judge her in a similar way. Joe was unable to stand up to his family. I inquired why she thought she could not move on from him. She said that she thought it may be because she did not think that she could cope if she was on her own. She then immediately made the comment that she felt that she was on her own now anyway. It was as if she had not realised this before. She had not seen Joe for a few months and she was doing alright. This realisation was an important turning point in our work and seemed to free Azra from her place of stuckness and fear of being without Joe. She could see that Joe was allowing his mother to control his life and he could not stand up to her like she had done to her family for him. This made her International Journal of Integrative Psychotherapy, Vol. 1, No. 2, 2010 52 angry as she had given up everything for him but he would not do the same for her. He had also been someone who had encouraged her to do what she wanted and had also compensated for Azra’s lack of parental encouragement. Joe was getting on with his life and said that he would support her to do the same. By Azra’s facial expression I could see that she was confused. He was telling her that she should move on and do what she needed to do but also he still wanted her to go and see him and he was also telling her that he loved her. She was feeling confused and that he was using her. She could now see that he knew how to manipulate her into being there when he needed her. She came to the conclusion that she did not want to be in a sexual relationship with him and that she did not want to go running to him when he wanted her to. She decided that she deserved someone who would be there for her and that she could have a future with. She realised that she had control in what she did and could put herself first (I was jumping for joy inside, because she was now taking control and putting herself first). She also admitted that she had a fantasy that he would one day drop everything and want to be with her. This fantasy was also keeping her from leaving him. Azra had told me that when she was young she would fantasise a lot. Her face seemed to lighten and she talked happily of how she would fantasise that she was adopted or that her mum remarried and she had a different father. She imagined a father that would take them out on trips and would be there doing things with the family and that there would be lots of happy times. I found that I was enjoying listening to the fun that she had with her imaginary family. This was a self regulating fantasy that took away the loneliness that she was feeling at the time. She invented a family that would accept her for who she was, take care of her and help her through the lonely times. She told me that she thought that she was about 5 years old when she had these fantasies. They could have been her pre-conceptual way to make sense of not having parents that were able to attune and respond to her relational needs. As a consequence of the fantasies she had built up a myth of what a mother and father should have been like. She told me that she had been brought up as a Muslim, but did not have the beliefs that her family had, which had caused so much conflict between them. She talked about how she wanted her sister to accept her for who she was. Her sister had not talked to her for the past 1 ½ years, because she did not agree with the way she had gone against their religion. I inquired about her relationship with her sister previously. It turned out that they had never agreed on anything and that if Azra liked or believed in one thing her sister usually thought the opposite. It seemed unrealistic to expect her to change. Azra concluded that rather than expecting her sister to change, she had to accept her for the way that she was. In the past her brother had stood up for her but she could see in him traits of her father that he had introjected and this made it hard for her to feel that she wanted to spend time with him. Over the 6 sessions we were able to explore some of the relationships that she had with family members and by doing this and using the script system, International Journal of Integrative Psychotherapy, Vol. 1, No. 2, 2010 53 International Journal of Integrative Psychotherapy, Vol. 1, No. 2, 2010 54 we were able to explore the script belief that she could not cope on her own, implicit experiencal conclusions, and self regulating fantasies that were stopping her from moving on. Over our time together I realised that Azra’s physiology changed. She seemed stronger and more upright and her bags seemed lighter and did not seem to weight her down like they had on our first meeting. I had commented then on the heavy weight that she brought in with her. Now she was carrying the bags with ease. It seemed that she had shed a heavy load. I contemplated on the fact that it felt that we had come a long way in the six sessions. I was reminded of the card that Azra had given to me at the end of the last session. In the card she wrote: “Thank you so much for your help and support over the last six weeks. I have come so far in such a short amount of time and I really don’t think I would have done it without your encouragement and support. I know it’s your job but still thank you”. The reason that we had been able to come so far was that we had been able to develop a good therapeutic relationship. By my being consistent, reliable and non judgmental we had built a basic trust and a mutual respect for each other. She had felt able to explore her difficulties and by doing so had felt supported and encouraged. I (like her teachers and Joe) had also compensated for the support and encouragement that she had not received from her parents. Also, I think Azra was in a place where she was ready to and wanting to explore the things that we had talked about and wanted to be able to make changes in her life. It felt good that Azra was able to express her gratitude for the work that we had done together. I expressed my appreciation for the card that she had given me and let her know that I would miss seeing her when we had finished. Azra realised that she could be in control of her life, and put her needs first. She said that she had decided that she was fed up of feeling sorry for herself. Azra started looking for a job in the city where she moved to, near her friends. She joined a Muslim dating site, where she could meet someone that she would like and who her family would approve of. She admitted that the fantasy of Joe giving up everything and being with her was still there but she was not letting it stop her moving forward. It felt that over the sessions she had grown stronger and she was more confident. My countertransference feelings were that I had been like a mother guiding her and helping her to see how she could move forward and now I was watching her leave home to make a life for herself and I felt sad to see her go. Leigh Bettles is a BACP accredited counsellor in Peterborough, UK. She works in Primary Healthcare providing counselling for the NHS and also provides counselling for staff and students in a college setting. She has a long association with the Cambridgeshire Consultancy in Counselling. She has a background in Psychodynamic and Cognitive therapy and is currently completing a two year Integrative Psychotherapy Training programme with Richard Erskine. Date of publication: 31.1.2011