Developing Emotion Regulation With Integrated Psychotherapy Approach: A Case Study
Assist. Prof. F. Zehra ERCAN [1] MD. PhD. Tahir ÖZAKKAŞ[2]
The ways in which psychotherapy approaches deal with people have evolved toward a more unified approach over time. This unified trend has three phases. The first is theoretical integration, which means unifying theories. The second is the practicing of technics which is accepting the effect of different psychotherapy techniques, and using them in case of a need. The third is to evaluate the client, who is the subject of research and intervention, in a unified way with the dimensions of behaviour, cognition, emotion and relationship. Advances in neurobiology have also affected psychotherapy theories. The recording of emotions in the body since infancy and the key role of experiential memory in the formation of the self, show that emotions are effective factors in self disorders. In this context, the importance of the quality of emotions, the effect of emotions on the self and emotion regulation in psychotherapy have increased.
In this study, the development in emotion regulation of a client, whose therapy process is carried out with an integrative psychotherapy approach, which is based on the integration of different theoretical approaches and techniques, will be analysed. The ways in which the clients express their emotions in the sessions, emotion labelling, emotion themes, change and development in the emotion regulation will be examined. This study is designed in qualitative method. The research will be conducted by content analysis. The research objects are deciphering texts of the therapy process of a client, whose therapy process is conducted within the framework of integrative therapy approach, and video recordings of the sessions.
Keywords: Integrative psychotherapy, emotion themes, emotion regulation.
INTRODUCTION
This research deals with the psychotherapy process of “Onur”, one of the clients of psychotherapist Tahir Özakkaş. The therapy process took place between 2005-2009. All sessions of the therapy process were videotaped with the permission of the client in order to contribute to scientific studies. These records were deciphered and transcribed later. These transcripts were read, and the process was analysed by watching the videos of the client’s first and last sessions. This study is a descriptive qualitative study. The aim of the study evaluation the development in emotion regulation of a client whose therapy process is carried out with an integrative psychotherapy approach, which is based on the integration of different theoretical approaches and techniques, will be analysed. The ways in which the clients express their emotions in the sessions, emotion labelling, emotion themes, change and development in the emotion regulation will be examined.
This presentation consists of three parts;
1. History of the case
2. Treatment plan
3.Evaluation of the therapy process and outcome
4. Discussion
A CASE HISTORY
Background information: The name of the case is “Onur”, a 30-year-old male, civil engineer, and owns a company with his partner Caner, who is also a civil engineer. He is single, and does not intend to marry anytime soon. He is the youngest of three siblings and only boy in the family. His family lives in a different city. Onur has lived with his family until university, then went to a different city for university education. Onur lives in Istanbul for work and lives alone. Apart from his job, he does not have much social life. He has no alcohol or smoking habits. He has difficulty in establishing and maintaining social relationships. He has performance anxiety in environments where he can be commentated, and he is quite bored in this kind of atmosphere. He is bored of being a part of long chats while communicating with his friends. He avoids making independent initiatives. He is unable to act independently from her mother in making decisions about important events in her life. For example, he had not married with his girlfriend, who has been in a relationship with him for 2.5 years, because his mother did not give consent to it. Onur is a hardworking person who does and manages his job meticulously, and he is eager for therapy.
Family Features
His father is a stove craftsman. He grew up as an apprentice in his father’s workshop. When his business deteriorated, he entered the municipality and retired from labor. His father is shy, his social relations are weak, and he is a profile that is very afraid of getting hurt. Their children are afraid of hurting their fathers. He speaks of his father with love and mercy. He portrayed his father as an insecure, uncourageous person. His father passed away when Onur graduated from high school and won the university.
“I wish he had been knowledgeable and educated us for a better life. If only he had raised us more confident. For example, we take after from father, we take father as a model by observing the him. “
His mother is a housewife. The mother had a heart disease for a long time, and her children and her husband had to take care of her constantly. She has a profile that indicates some conversion disorders with (tachycardia, psychological) fainting. She has controlled the family with her disease. The mother is very sociable, easily establishing and managing relationships with people. She has a nature that controls the family and suppresses her children.
“My mother is very meticulous, she is still very meticulous, as a mother she wants the best for me … lives according to people, cares very much about what the world has to say about us”
His older sister is married to someone, who his mother does not approve of. She is a high school graduate, and did not go to university because of low success in school. She works as a journeyman in a pharmacy. His second older sister is a teacher, she is single and lives with her mother.
Description of the problem:
The reason for the client’s arrival is social anxiety, excessive sweating in social situations, the client’s emotion, fear of sweating, fear of losing control and embarrassment. “The extreme growth of social anxiety started suddenly in high school. I had shyness in primary school and middle school, and teachers used to mention me as shy to my family at the parents’ meeting. ” He begins to sweat in situations of fear, anger, distress, and shame. He is afraid of sweating, he gets angry when he cannot control sweating, and embarrasses because of sweating. He had previously applied to psychiatry and received cognitive behavioural treatment. There are some conditions in which individuals with social anxiety have an increased anxiety level. Onur expressed all these symptoms. These are 1. Going to the party, 2. Attending meetings, 3. Speaking in front of the group, 4. Eating in public, 5. Being in public places, 6. Meeting someone else, arranging a meeting, 7. Talking with authority figures, 8. Starting a conversation. 9. To keep talking, 10. To talk to people who are not known foreigners. (Di Nardo et al. 1994).
In cases of social anxiety, individuals have difficulty in regulating emotions. Intense fear and anxiety often cause suppression of other affects. Social anxiety cases have difficulty identifying, experiencing, and communicating their positive and negative emotions to others. Suppression of negative emotions causes suppression of positive emotions. In this context, the response of individuals to positive life events is also decreasing. This situation appears as individuals being emotionally blunt and behaviorally more mechanical. Social anxiety symptoms experience increase not only being negatively evaluated condition but being appreciated condition. Traces of suppression of positive emotions, can also increase the anxiety of individuals.
The therapist diagnosis
The therapist focused on diagnoses that could be an alternative to the diagnosis of social phobia, since the client had previously received therapy and did not fully recover. He thought that the diagnosis closest to social phobia might be Kohut’s vulnerable narcissism. He thought that the abstentional traits could stem from behavioral learning, partly the vulnerable narcissist’s fear of injury, protection from feelings of worthlessness, and odipal anxieties. He considered the possibility that dependent personality traits could result from an overly controlling manipulative mother relationship. The weak, insecure and inadequate perception of the father incline to think of the possibility of the deficiency of secondary mirroring. Since he had cognitive behavioural treatment before, he concluded that it should be worked on more deeply.
It was thought to be important to focus on oedipal anxieties and vulnerable narcissistic elements. There are two types of manifestations of primary narcissism, according to Heinz Kohut, these are vulnerable narcissism and grandiose narcissism It is stated that individuals with vulnerable narcissism characteristics may have grandiose thoughts about themselves, but they may have a sense of shame due to the presence of these thoughts and exhibit avoidance behaviors due to their insecurity in social relationships. Vulnerable narcissists may be shy, anxious for fear of inadequacy and embarrassment in social situations, hopeless after breakage, feeling very lonely, insecure and avoidant in human relations. According to Kohut, primary narcissistic personality structures may have a vertical cleft and a horizontal cleft in the psyche. Vertical cleft is more associated with grandiose narcissism. Horizontal cleft is more associated with vulnerable narcissism. In the child of the horizontal cleft individual, there is a primitive narcissistic swelling desire that is suppressed upon the mother’s inability to respond positively. Narcissists with a horizontal cleft at the forefront are vulnerable narcissists with low self-esteem and prone to shame.
TREATMENT PLAN
The therapist focused on diagnoses that could be an alternative to the diagnosis of social anxiety, since the client had previously received therapy and did not fully recover. He thought that the diagnosis closest to social anxiety might be Kohut’s vulnerable narcissism. He thought that the abstentional traits could stem from behavioural learning, partly the vulnerable narcissist’s fear of injury, protection from feelings of worthlessness, or oedipal anxieties.
The therapy process is planned in accordance with the framework of the integrative psychotherapy approach. This unified trend has three phases. The first is theoretical integration, which means unifying theories. The second is the practicing of technics which is accepting the effects of different psychotherapy techniques, and using them in case of need. The process has carried on humanistic way which means client-centred therapy. Evaluate the client, who is the subject of research and intervention, in a unified way with the dimensions of behaviour, cognition, emotion and relationship. Then design therapy plan which reconstruct according to client’s needs during the treatment process.
THERAPY PROCESS
The techniques used in therapy, the therapy process has started with the attack therapy, which includes the general knowledge of three generations of relatives and the narration of a few memories about each relative of the client, describing the client’s personal history together with spatial features in a descriptive manner, and in this narrative process the therapist gives psycho-education. After the client’s talking about his relatives and personal history, ego-enhancement hypnosis, which is also a part of the attack therapy, were applied. It is aimed to improve the insight and awareness of the client by providing intensive psycho-training during the attack therapy process. The therapist has tried to reinforce and settle this awareness with hypnosis. Intensive psycho-training was provided on the problems shared by the client during the therapy process. A relational therapy process has been followed according to the needs of the client. Cognitive behavioural theories and techniques are used effectively in cases of social anxiety. Although the therapist structured the therapy processes within the framework of the holistic theory, he mainly used cognitive behavioural techniques during the therapy process of this client. Life events and agendas of the client during the therapy process has determined the course of the therapy. It is seen that the therapist has the roles of educator, life coach.The therapy process has continued mainly in a supportive manner. The processes that are followed by the therapist were as follows;
First of all, the process has started with the explanation of psycho-education about the cognitive behavioural approaches. The therapist continued his psycho-education while the client gave the family tree information, he talked about three generations of relatives. The client is provided the with an education on communication and effective listening. The therapist made some suggestions to the client’s sharing about work life. He had recommendations on the importance of transparency and accountability, and trustworthy relationships. He explained Freud’s topographic model and structural model, and concretized the theory by relating it to current examples and the experiences of the client. He culturally linked Freud’s theoretical argument about libidinal and aggressive energy with lust and wrath in the Islamic tradition. He tried to raise awareness in the client about his oedipal conflict. He made interpretations of auto-castration by exemplifying the inhibition of self-activation in his attempts. Then he explained the defence mechanisms. He said that defence mechanisms work automatically and unconsciously, and that defences do not come to light by thinking and planning in advance. He explained the sweating situation and social anxiety by associating it with defence mechanisms.
He explained the Masterson theory of the real self, false self, separation and individuation approach. He emphasized the real self and false self by stating that a normal individual would not be too afraid of making mistakes and would not feel too embarrassed. He explained the relationship between the problems arising in the separation and association process, and dependent personality and self-disorders. Later, he explained the self-disorders in the Masterson theory. He associated the social anxiety and abstention of the client with the closed narcissistic self-disorder with intense fear of hurt. He interpreted it as an effort to not activate the worthless core.
It was observed that the client showed resistance by speaking less, giving short answers, and making short comments about the problems at the beginning of the therapy. Emotional expressions focused on fear. The therapist made the client tell an anecdote in order to comfort him and break his resistance.
The therapist continued to provide training on many theories related to the problem brought by the client during the therapy process. He has developed a vision that allows the client to make sense of his problems. Other theories that the therapist explains are, in summary, transactional analysis, ego states, object relations, self-psychology, existentialism theories. The therapist concretized the client’s problems by interpreting them in theoretical frameworks.
During the therapy process, the client was assigned to write diaries, watch the sessions recorded on video, read the books suggested by the therapist, watch the training videos and autohypnotic studies.
It was suggested to the client to participate in group studies as well as individual therapy. Group work is recommended to improve interpersonal interaction, especially in cases of social anxiety. The client did not have the courage to participate in group therapies for a while. He participated in group therapies in the later stages of the therapy.
Close Relationships
Onur had not thought of getting married when he started the therapy, 5 months later, he had a girlfriend named Şule, who is a doctor and continuing her specialization in the field of eye. The therapist had supportive, encouraging and guiding attitudes in the process of meeting his girlfriend and running the relationship. He acted independently of his mother during the selection of his girlfriend, managing the relationship and making a marriage decision, and took a serious step towards the separation and individuation. Due to his abstention in his relationship with his girlfriend, fear of sweating and social anxiety, he had resisted Şule’s desire to meet her friends for a long time, and this demand and resistance from time to time caused a crisis in the relationship. With the support of the therapist, he was able to resolve these crises and met with Şule’s friends, and accompanied him in Şule’s professional parties. 18 month later he married with Şule. There was a decrease in the symptoms of social anxiety at a level that would allow him to participate pre-wedding and wedding rituals, which include many crowded meetings in Turkish culture.
As a result of the insight and knowledge gained by the client in the 8th month, he began to define his own problems and establish causal relationships between the unworthiness, abstention and oedipal elements in his behaviours. Although the conceptualization of the client’s symptoms gave him some relief, it showed the danger of a different resistance and turning into defence.
After 10 months, the patient’s abstention, social anxiety, and symptoms significantly regressed. However, it was observed that his narcissistic aspects started to become more visible, especially in his relationship with his girlfriend. The therapist confronted and interpreted these narcissistic aspects of the client. In his relationship with his girlfriend, the therapist tried to raise awareness of the separation and individuation processes. The suffocation of the client in a close relationship indicates the separation-individuation problem. With the regression of the apparent symptoms of social anxiety, a more archaic vulnerable narcissistic structure has been revealed in the Onur.
Although many symptoms of the client regressed, the sweating problem has continued. The therapist reinterpreted the sweating problem with narcissistic aspects. It was thought that the client had interpreted sweating as incompetence, diminishing charisma and feeling worthless. He interpreted it by associating it with the scheme of worthlessness. He pointed out that cognitive distorted thinking affects sensation and sensation constitutes the physiological response. Target behaviour is not determined as sweating, but it is determined as Onur, who is sweating.
Business Life
Onur shows partially obsessive behaviours in his professional life. He takes too much responsibility in monitoring and managing the business. The limits of his responsibility are not clear. After starting therapy, the client’s business has developed rapidly and his company has grown. Along with the new businesses, he established an additional company with a partner named Ersan. His courage in business life has increased in matters such as negotiation, offering proposals, and attending important meetings. He was able to carry out these processes by overcoming the fear of sweating. In the second year of the therapy, he was able to leave his first business partner, Caner, who had incompatible behaviours. He was able to take the initiative alone on his job. He tried to create a more corporate structure by sharing the works with other employees in the company. But Ersan, his low-profile partner in training and skills, has given the entire management responsibility of the company to Onur. It seems that he had a full and unconditional trust relationship with his partner. Towards the end of the therapy, a large company that Onur worked with went bankrupt, and Onur went bankrupt by not being able to manage his business afterwards. The heaviest thing in this process was to see how he blamed him the most while he has been thinking they have the unconditional trust relationship. He was the one who provided unconditional support while earning money, and become the most blaming person when he went bankrupt.
The therapist coached the client with the guidance of his own experiences in business life and the experiences of his father. He advised him on transparency in business records, accountability, encouragement of new initiatives to the extent of their power, sharing the workload, giving importance to teamwork, and institutionalizing. He has been supportive in mending his frustration caused by the bankruptcy process. He helped him to overcome his disappointment about his partner. The therapist coached the client to recover his debts in the market and make agreements with banks. Most importantly, the therapist has been supportive of the client’s recovery after this important crisis and continuing his business life by opening his own office once again.
DISCUSSION
In this study, traces of the alternative diagnosis of the client who came with the complaint of social anxiety were followed with the integrative evaluation. It is thought that the social phobia appearance may sometimes be associated with oedupal conflicts or vulnerable narcissism. Because the diagnostic criteria for vulnerable narcissism and social phobia are similar.
It is thought that both of them may arise from the parents’ parenting styles and negative beliefs related to themselves in their developmental processes. While emphasizing the importance of the mother’s role in establishing the individual’s self-designs and basic beliefs about himself. While in social relationships the father’s role is thought to be primarily important. It is effective in the development of both social phobia and vulnerable narcissism of the father, who is perceived as shy, emotionally blunt, helpless and inadequate. Although alternative diagnoses of this case have been emphasized, the social phobia-based therapy process has been structured.
The termination of the therapy has happened because of the moving of the client to a different city. The client’s experience of important life events during the therapy process has caused the process to be supportive rather than psychoanalytic. The therapist managed the process according to the needs of the client, and continued the sessions in different techniques and roles. Although the therapist stands out as an educator, it has been observed that he functions as a self-object by performing life coaching or secondary mirroring according to the client’s needs. During the therapy process, the client made a girlfriend, got married, grew his company and went bankrupt. At all these stages, the therapist intervened in relation to symptoms. In the therapy process, the practice can be described as a symptom-oriented study, not a character study. At the end of the therapy process, it was observed that the client, who experienced severe bankruptcy in his business life, did not experience a severe fracture, he was strong in accepting the situation and restarting again. It has been observed that his ego gets stronger and his resilience capacity increased. It is seen that he maintains a stable and harmonious relationship in his marriage, and keeps his relations with his root family in balance. He stated that the fear of sweating, which is the reason for the client coming to therapy, and his fear of getting hurt in the society is decreased, and now he rarely has these experiences. He stated that when he feels fear and shame, he relaxes himself with behavioural cognitive techniques.
Emotion regulation difficulty in social anxiety disorder continues in cognitive restructuring. Cognitive restructuring is changing the response to emotional and physiological stimuli by interpreting them in a different way. It is assumed that cognitive reinterpretation changes emotions. People with social anxiety continue to have difficulties in reinterpreting the stimuli and conditions that they perceive threateningly. Here it is an effort to consciously control automatic unconscious responses. This process can be difficult and slow.
“Things are working, my troubles are already over compared to the past.”
“I am uncomfortable during my work interviews; I still have trouble. There is no comfort. Sometimes I am relieved. Sometimes I suddenly feel annoyed, anxiety, sweating. When there is sweating, it is still a discomfort, I am sweating etc. I still cannot do it. Sometimes I have inner distress.”
It has been observed that the client has made significant progress in emotion regulation. It has been observed that he has developed in terms of expressing and accepting the feelings of fear, anxiety and shame, which cannot be expressed by the client and only interpreted by the therapist at the beginning of the therapy process. In the later stages of the therapy, it is observed that the client talks more, expresses himself and uses more emotional expressions. It has been observed that acceptance instead of fear and shame, sadness instead of disappointment, and also the joy, enthusiasm and gratitude expressions of the client has increased. Despite all these observable developments, the client’s attitude towards life is not spontaneous and emotional enough.
Mechanic of the life of the client has been continuing. It has been observed that he is far from the experience of entertainment, enthusiasm and pleasure. He still has his limitations in experiencing his emotions openly and directly. Three possibilities can be considered related to this: The first possibility is being related to the male design of Turkish society. Being the one who cares about his home and his family, is hardworking and perceives business as priority. It could be a tendency suitable to cultural elements that do not tolerate pleasure and entertainment much or even find them dangerous. In addition, individuals who do not show their emotions much may be associated with being seen more steadfast, dignified, and respectful. The second possibility is The second possibility is the bankruptcy of the client in his / her business life. The third is the pattern of worthlessness that the client has not yet completely changed, and subsequently the existence of a vulnerable narcissistic archaic structure that requires in-depth study.
The client has gained insight and awareness of his narcissistic nature. He acknowledged the performance anxiety associated with worthlessness. However, since the therapy process had to be ended, in-depth character analyses could not be done.
“The structure, which is basically worthlessness, these patterns are changing in the process, and a nucleus of worthiness is formed, right?”
The therapist said, “If someone is magnifying himself and think that one day, you will see your older brother, it means that he is still doing something by taking others as reference.”
“Yeah, my defective construction continues there, too.”
In this study, it had thought that the client needed supportive therapy. Awareness and insight has been gained through intensive theoretical training. It is considered that knowledge, awareness and insight cannot provide a full recovery. The therapist’s sincerity, mirroring and relational approach were quite effective in the client’s development. It is thought that emotion-focused therapy should be added to the process with this client, and an in-depth character study should be done in the journey of finding the real self.
[1] f.zehraercan@gmail.com, Turkey, Psikoterapi Enstitüsü/Selcuk University
[2] ozakkas@psikoterapi.com, Turkey, Psikoterapi Enstitüsü