Case prognosis
Alec improved during the treatment. Symptomatically he no longer met criteria for any mood or anxiety disorders, and he was able to manage occasional bouts of anxiety effectively. His early difficulty in regulating self-esteem had improved, though occasionally he was vulnerable to the familiar tendency to think in black and white terms, judge intentions based on the outcome, and expect that he needs to be perfect to be accepted. He worked and managed work stress, was financially self-sufficient, and had a fulfilling relationship with Kate. He was developing a sense of identity and building his own family. What allowed these changes to happen? These changes occurred against the backdrop of the maturation and development of Alec in terms of identity, career, and intimacy, which were both challenges and opportunities for his growth (Levenson, 1978). Initially, these areas of his life had posed challenges and evoked fear of disappointments and failures. Due to his difficulty regulating his self-esteem and the desire to preserve an ideal sense of himself, he had retreated into the comfort of his parents’ home. Through processing the difficult experiences of growing up, gaining greater clarity regarding the self-defeating ways in which he was protecting himself from disappointments and failures, and developing a deeper attachment in therapy, he rejoined the developmental trajectory. The reality of his life became the source of change. His life had posed an ultimatum: he felt pressed to choose between working for the family company versus overcoming his fears, developing his own career, separating from his family, and declaring his own identity. Moving forward with his own wishes challenged his role identification with his family members that resulted in paralysis (like his brother), avoidance (like his mother), and an expectation that life is a joyless process of sacrificing one’s needs (like his father). As he rejoined the developmental trajectory, he navigated the complexities of work, his romantic relationship, and his own independent life. Initially, these evoked fears that were understandable given his difficulties regulating self-esteem and reintegration into life after a long break. Alec showed the ability to learn from his experiences, regulate his emotions in service of pragmatic outcomes, and resolve ambivalent and mixed feelings in the face of new experiences. He continued to use therapy in a productive way and developed a new recognition that it is possible to rely on others. The new experiences of love, commitment, and evolving intimacy in his relationship with Kate allowed him to see himself and her as lovable despite imperfections. He also discovered his professional capabilities as well as his ability to manage conflicts and stress at work. He was learning from life experiences. Similar to earlier stages in treatment, the therapy process and life experiences worked synergistically to promote growth and new learning, and challenge maladaptive ways of functioning.