Becky resisted the idea of coming to counseling for a variety of reasons. First, she never felt like things were “that bad.” Sure, they “weren’t good,” but wherever that mythical line of “needing counseling” was, she didn’t think she had crossed it. Second, because she struggled with a persistent experience of depression, she didn’t have the motivation to do a lot of things; counseling was just one of them. Third, she had an aunt (her mom’s sister) who was hospitalized for hallucinations and threatening suicide several years ago. She heard the way the rest of the family talked about her aunt. She got reports about what it was like for her aunt in the hospital. Becky wanted no part of that.

Finally, Becky knew that she was coping with her depression in unhealthy ways. Waking hours were a meaningless game of avoidance, numbing, and looking forward to when she was tired enough to sleep again. Becky didn’t exercise, had an unhealthy diet, didn’t socialize with co-workers, and used alcohol to fill the time between work and sleep. She knew the list of changes the counselor would suggest, she knew the changes were needed, but she didn’t feel like making any of them.

When she reached out to you, it was half-hearted. There was no crisis. She got tired of hearing herself complain, so she thought it couldn’t hurt. She almost wanted to prove to herself that counseling didn’t work so she could quit considering it and tell a couple of family members she tried, so they would get off her back. The result of Becky arriving in counseling this way is that she had very little motivation to change.

During the first session you get some history about Becky.

  • As a child and teenager, she never felt like she had any standout qualities.
  • Her family of origin was “healthy enough” but a little distant.
  • She dated a little bit in high school and college, but nothing ever got serious. She preferred it that way for a long time, but now wonders if life would have been better had she tried harder at one of these relationships. Even though Becky is only 35 she talks like the opportunity to date and marry has passed her by.
  • Becky started drinking in high school. Nothing crazy, it was the only way she could tolerate the social environment of going to a party. In college, she experimented with other drugs, but didn’t like anything that got her “high.” She liked the mellow feeling stuff.
  • After college Becky got an accounting job. She likes that if she gets her work done, her boss leaves her alone, and that there aren’t many group projects at work.
  • Her family went to church some as a kid, but Becky says she never really “got it.” She went a couple of times after college, but the “happy clappy” music was off putting.
  • Now her life is very routine and boring. She eats the same breakfast, goes to work, skips lunch, comes home, heats up dinner out of box, watches television, and sips wine until she goes to sleep. Becky gets together with her parents and brother about once a month but doesn’t like the expectation that she has to have something to update them on.

When Becky gets uncomfortable and self-conscious telling you her story, she asks, “Pretty messed up, huh? Do you think I need to be on medication? Do you think I have one of those chemical imbalance things?” Her statement is abrupt, but not defensive. It catches you off guard because it’s not in flow with the rest of the conversation.

[Pause – how do you respond to Becky’s question?]

Becky was pleased with your answer. You explore the number of things in her life that could be contributing to her sense of depression. Because you can tell her sense of motivation is low, you ask her which of those things she would be most willing to change. After thinking for a moment, she says, “I think I would like to eat better.” You suggest she add at least one fresh fruit or vegetable to every meal and try a new dish at least once per week.

Becky comes back to the second meeting and says she can tell a difference physically from eating better, but still doesn’t enjoy life. You explore several possibilities with her:

  • Stacking together several changes like improving her diet (i.e., a light exercise routine, starting a hobby, playing ios games for money, getting a pet, and exploring social opportunities) to see what the compound benefits would be.
  • Attending a church with solemn, rather than celebratory worship style to find a sense of meaning, connection with God, and the opportunity for new friends.
  • Cutting back on her alcohol consumption, because alcohol is a depressant and is, thereby, likely reinforcing her persistent down mood.
  • Going to the doctor for a medical check up to see if there are any physical factors contributing to her down mood, lack of energy, and diminished motivation.

When you mention the doctor, Becky gets defensive, “See, you do think I’m crazy like my aunt don’t you? You were just too nice to say it when I was here the first time.”

[Pause – how do you respond to Becky’s question?]

Becky is satisfied enough – not completely – with your answer and she likes having someone to talk to, so she continues to meet with you. She agrees to try to “stack changes” but doesn’t want to cut back on alcohol or go to the doctor. She agrees to go for a walk after work each day and “try one of those solemn churches you mentioned” to try to make a few friends.

Over the next several meetings, Becky’s consistent refrain is, “I feel better. I don’t feel good.” She is increasingly willing to make better choices. She gets connected with the church you recommended and voluntarily tells you about the sermons in a way that indicates she is beginning to grow spiritually.

Finally, Becky says, “If my body is a car and my life is a road, the engine is working better but I’m still driving in an emotional fog that won’t lift.” You’re surprised that Becky mentions forgoing alcohol to see how much that helps. After a couple of months, she still says, “I feel better. I don’t feel good.”

Eventually, she broaches her defensive subject again, but this time less defensively. “You’ve heard me talk about my aunt. I don’t think I’m where she was, but I do wonder if something is broken in me like was broken in her. I’ve never wanted to admit that, but I’m tired of pretending. How would you encourage me to think about that and, if the answer is yes, what can I do to try to make some progress with that?”

[Pause – how do you respond to Becky’s question?]

Case Study Discussion

This case study was written to set up the presentation for the free webinar A Case Study on Thinking Well about Mental Health The webinar will be Thursday December 16th at 1pm EST. My goal in this twice-monthly series of free webinars is to teach one primary counseling concept or skill each month and then provide a case study that allows participants to become more proficient at utilizing that skill or concept.

These are great events for:

  • Pastors, chaplains, and ministry leaders looking to enhance their pastoral care skills
  • Counselors wanting CEU credits to help them learn more about the intersection of their faith and practice
  • Leaders in church-based counseling ministries looking to grow in their case wisdom
  • Undergraduate students looking to discern a calling to vocational ministry or a career as a professional counselor
  • Friends and small group leaders committed to walking faithfully alongside their peers in tough times