Theories of Counseling
Theories of Counseling EPSY 6325
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This 17 page Class Notes was uploaded by Judah Quigley on Saturday September 19, 2015. The Class Notes belongs to EPSY 6325 at University of Houston taught by Consuelo Arbona in Fall. Since its upload, it has received 64 views. For similar materials see /class/208365/epsy-6325-university-of-houston in Psychlogy at University of Houston.
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Date Created: 09/19/15
Outline for Case Conceptualization EPSY 6325 Theories of Counseling Consuelo Arbona PhD Revised Summer 2007 Case conceptualization refers to the process in which we make sense of a client s presenting concerns in the context of a theoretical framework In other words it refers to how we explain or understand the client s symptoms personality characteristics cognitions feelings and behaviors in the light of a particular theory or integration of theories Such understanding should lead to the formulation of counseling goals and intervention strategies At this stage we will conceptualize the client s case from one theoretical orientation at a time The content of the conceptualization of the same case will differ according to the various theories depending on the aspect of human experiencing that each theory emphasizes In general however the case conceptualization process as with the counseling process itself starts with an understanding of the clients39 presenting concerns from the perspective of the client In other words Step 1 addresses the question 0 What does the client say her or his problems are In Step 2 we provide a framework from which to explain the origins of the stated problems addressing the questions 0 How is it that this person came to have these particular problems 0 Where are these problems stemming from Intrapsychic issues environment early relationships 0 What are this person s strengths And in Step 3 0 Goals for counseling are identified and 0 Specific interventions are used to address the problems identified by the counselor and the client The various theories will differ in the answers they provide to the questions posed in Step 2 and may lead to different types of interventions in Step 3 For example regarding Step 2 the psychodynamic approaches Freud Object Relations Theory and Adler will not take the presenting concerns at face value but will assume that these concerns are symptoms of deeper seated problems that somehow relate to experiences that happened earlier on in the life of the person from childhood on when hisher sense of self was formed In part the feelings and thoughts associated with these problems and early experiences are likely to be in the unconscious Therefore from the perspective of the psychodynamic theories before moving on to help clients solve their presenting concerns the counselor needs to obtain developmental information to form hypothesis regarding the origins of the presenting concerns since there may lie the real problem that needs to be addressed This developmental information will also help the counselor form hypothesis regarding the sense of self the person may have formed in the context of these early experiences In addition to capturing or describing the client s sense of self from the psychodynamic perspective the counselor will identify the mechanisms of defense the person developed early on to deal with anxiety in the context of early experiences and examine to what extent the person still uses the same defenses in interpersonal relations and in times of stress Most likely the counselor will discover patterns of behavior in relation to others and to the world that help explain how the client s particular sense of self and early experiences lead to their current con icts The counselor may also identify specific stages of development a la Erikson that were not resolved appropriately Object relations theory will pay special attention to issues of attachment and autonomy in clients development of a sense of self and consequent problems In carrying out Step 2 from the Adlerian perspective the counselor will explore the contributions of early experiences to current problems by exploring the clients life style family constellation and early recollections and identifying the content of the private or faulty logic they developed in their attempts to strive for signi cance in the context of their family constellation The counselor also will pay attention to the clients level of social interest since this is a sign of healthy mental functioning The Adlerian counselor will identify current problems in terms of clients neurotic symptoms and difficulties in meeting specific life tasks In this process the counselor will help the client move out of their discouragement and become encouraged to meet the life tasks Humanistic approaches From a Rogerian perspective in exploring the client s presenting concerns the counselor will assume that internalized conditions of worth have lead clients to disconnect from parts of themselves This disconnects in turn has resulted feelings of incongruency and anxiety has impaired their internal locus of control as well as thwarted their self actualizing tendency The Rogerian counselor may also examine the discrepancy between the client s self concept and ideal self concept Since the theory proposes that given the adequate facilitative conditions empathy positive regard and congruence in the counseling relation clients will be able to reconnect with themselves and nd their own way the theory does not offer much in terms of a framework to explain the particular issues of each client This is more a theory of the change process itself than a theory of personality development From the Existential approach one would explore to what extent the clients39 difficulties are related to the clients39 efforts to avoid facing the normal anxiety generated by speci c givens of existence Death meaning Freedom Isolation For example to what extent the problems are related to the client s refusal to accept responsibility for self or to face aloneness These efforts to avoid normal anxiety labeled mechanisms of defense lead to neurotic anxiety and or neurotic guilt as well as other problems in living From the Behavioral and Cognitive Behavioral perspective one will be more likely to take the client s presenting concerns at face value that is as the problems that need to be solved These problems will be primarily understood as the product of specific faulty learning which has led to irrational thoughts or faulty cognitions eg Beck39s maladaptive patterns of thinking arbitrary inference selective abstraction overgeneralization etc The exploration process entails identifying the antecedent behaviors and cognitions that trigger the maladaptive thoughts and behaviors Once a theoretical framework has been applied to explain the particulars of a client39s case interventions are implemented to help the client solve the presenting concerns In the case of the dynamic approaches this will entail exploring gaining insight analysis of the transference and resolving eg catharsis changing faulty logic the early con icts that trigger the current problems and identifying the defenses the person developed to cope with these early con icts and still uses today In the more behavioral approaches interventions help clients unleam past negative behaviors and cognitions e g desensitization training self control and learn new more adaptive ones e g skills training Existential approaches emphasize awareness of life s realities and finding productive ways to cope with the normal anxiety related to living Outline for Case Conceptualization Process 1 Client39s Presenting Concerns This is outlined in the description of Mary so you do not need to repeat it on y our paper II Gathering information to generate hypothesis regarding the origins of the clients39 current problems Object Relations Theory 1 Explore current and early relationships as they relate to issues of attachment and autonomy This includes gaining an understanding of how the client understands the world and hisher relationships with others that is the clients mental representations based on internalized objects Understanding the clients internal frame of reference will help the counselor understand the clients behaviors 2 Describe the ideas and feelings about self that the client might have developed in the context of these early relations internalized objects 3 Establish a relationship between the clients39 sense of self and current problems identify con ictive patterns that the client may be repeating in current life explore to what extent current experiences trigger in the clients emotional reactions elicited by past experiences relieving the trauma 4 Uncover defense mechanisms embedded in clients presenting concerns and other symptoms and explain how they relate to the clients current difficulties and past experiences 5 Help the client become aware of issues described above and help client and processes and resolve early con icts Adlerian 1 Identify how presenting concerns relate to client s ability to successfully meet specific life tasks 2 Explore family constellation to discover experiences that might have led client to develop hisher specific faulty logic Describe the content of this faulty logic and the sense of self the client developed in the context of these experiences 3 Establish a connection between the content of the client s faulty logic and l experiences in the family of origin 2 problems in current life and 3the senseofself in relation to the world that the client developed 4 Identify the underlining purpose of the client s problematic behavior and describe how they prevent the client from successfully meeting the life tasks Existential 1 Identify how presenting concerns problem behaviorscognitions relate to specific givens of existence 2 Elucidate how these difficulties represent as mechanisms of defense or are the consequences of clients39 efforts to avoid facing the normal anxiety generated by specific givens of existence 3 Describe how these defensive behaviors have lead the client to experience of neurotic anxiety and or neurotic guilt and further problems BehavioralCognitive Behavioral l Relate the presenting concerns to faulty learning irrational thoughts and0r faulty cognitions 2 Identify the client s irrational thoughts Ellis andor speci c faulty cognitions 0r maladaptive thought patterns Beck and illustrate how these lead to the problematic behaviors 3 Describe the antecedent behaviors and cognitions that trigger the client s maladaptive behaviors and thoughts this is called behavioral assessment III Goal Setting and Interventions The information provided in the conceptualization process leads to specific counseling goals In the dynamic approaches these will likely include o Resolving earlier con icts Modify negative aspects of the self Facilitate the development of positive aspects of the self in the context of the therapeutic relation Reconciling splitolT aspects of the self Changing aspects ofthe persons sense of self eg feeling unlovable Identifying and modifying faulty logic Gaining encouragement to face lifetasks and or develop social interest Identify the underlining purposes of symptomatic behaviors Work through con icts in attachment and autonomy Interventions may include Free association Dream analysis Confrontation Interpretation Gaining insight Analysis of the transference Lifestyle assessment Paradoxical Intention Spitting in the Soup Catching oneself Acting as if Task setting In the Rogerian approach the goal is to create a safe trusting relationship that will allow clients explore the parts of themselves that they have denied or distorted This will entail recognizing and giving up the internalized conditions of worth Clients will likely then develop and internal locus of evaluation become more open to experience and achieve self trust The Intervention is for the most pa1t the relationship in itself which must include three conditions 0 Congruence or genuineness 0 Positive regard o Accurate empathic understanding Specific counselor s behaviors to facilitate the relationship and foster client change include 0 Re ection of feeling Paraphrasing rephrasing Questions for clari cation In the existential approach goals may involve to Help clients gain awareness of the choices they are making in their lives Encourage clients to face the givens of existence that they may be avoiding and helping them become aware of the defenses they are using to avoid the normal anxiety generated by the givens of existence Help clients become aware of the negative effects these defensive behaviorscognitions have in their lives and to recognize how these defensive behaviors are related to their presenting concems Encourage client to take responsibility for their lives and make active choices regarding the life situations they are facing Interventions may include Confrontation Process interpersonal dynamics of the counseling relationship attending to the emotions generated by the counseling process in the context of the here and now relationship with the counselor Paradoxical intention Situational reconstruction Compensatory self improvement In the behavioralcognitive behavioral approaches counseling goals are likely to emphasize resolving the presenting concerns by learning new behaviors changing environmental conditions and replacing irrational thinking with more rational thoughts Interventions may include Modeling Behavioral rehearsal Skills development training eg assertiveness social behavior Self control or selfmonitoring Stimulus control Contingency contracting Systematic desensitization Recognizing and changing irrational thoughts 0 Cognitive restructuring to change maladaptive thought processes 0 Learning a new internal dialogue 0 Relaxation training Client Theory I Presenting Concerns Refer to the case s description 111 Case Conceptualization 11 Goals and Interventions I I I Conclusion Client Richard I Presenting Concerns Richard presents himself as depressed following his recent divorce He feels lonely and unworthy He also reports feeling great anger towards his former wife and unable to move on with his life after the divorce He considers that the divorce was caused mostly by lack of communication between he and his wife Richard recognizes that he has had great difficulty in communicating with others throughout his life and that only recently he has become aware of this He reports that previous to this marriage at the age of 44 relationships with women had been short and noncommittal Throughout the interview Richard revealed that both parents were alcoholic and that he was very isolated and angry as a child He grew up moving frequently from the homes of relatives including on of his grandmothers 11 Case Conceptualization PsychodynamicObject Relations Theory Hypothesis based on theory s concepts It seems that as he was growing up Richard did not have the opportunity to form adequate attachment bonds with his mother or father he reports both parents as alcoholic It appears that he also lacked other adult figures in his environment relatives siblings with whom to form significant relations he reports being very lonely and isolated as a child Because of this deprivation of a significant nurturing relationship as a child Richard must have felt great pain together with the pain he likely experienced great anger both towards himself and towards others He might have concluded that he was not loved because he is defective and therefore not lovable developing a negative sense of self In order to avoid this pain it is possible that early on Richard disconnected himself to a certain extent from his emotional self This disconnect from his own emotions has made it difficult for Richard to connect with others feel empathy and develop intimate relationships These early experiences may have led Richard to believe that as an adult he is not lovable he doesn t have much to offer emotionally to others and that he cannot trust others to meet his needs he appears to uctuates between believing that he doesn t deserve other s attention and care and believing that others are mean and will not give of themselves He seems to feel that he needs to always be on the defensive because this is a dog eats dog world This pattern of relating to others most likely emerged in the context of his early relationship with parents where his basic emotional needs of nurturing and affection were not met The anger he experiences now may have originated earlier in his life as a way of coping defense with the intense pain 10 generated by this early emotional deprivation Deprivation that he carries with him today and perpetuates by his inability to bond with others he seems to be repeating in his adult life the patterns of early relations with his parents His failures in current relationships make him feel angry all over again This negative view of self and his detachment from his own emotions in order to avoid the pain defensive behaviors makes it difficult for Richard to develop emotionally satisfying intimate relationships He is probably scared and overwhelmed by the idea of getting too close to another person Because of his inability and fear to get close to others Richard has chosen to establish superficial short relationships with women he does not allow the other person to really come close to him nor does he truly give of himself At some level it is almost as he feels that he does not have anything to give except his pain which he cannot really face and his anger which may feel overwhelming With his behaviors Richard ends up pushing other people away which serves to confirm what he already knew 7 that people are not good to him and makes him feel angry all over again In this way Richard may be responding to others not only according to who and what they are but also according to his internalized negative objects that is unresponsive and uncaring significant others In this way Richard seems to be wrapped up in himself 7 which is labeled by the psychodynamic approach as a narcissistic personality trait The lack of adequate emotional support and care as a child did not allow Richard to fully grow out of the normal narcissistic stage experienced by infants as described by object relations theory In terms of defense mechanisms Richard seems to be experiencing some splitting between his cognitive and emotional self which leads to intellectualization and expression of contradicting rigid ideas For example he says that he desperately needs a woman in his life but describes women as bitches he professes to love his exwife Connie and feels sorry for her because she must be suffering but is extremely angry with her and would like to have the opportunity to yell his anger at her In some ways Richard s negative perceptions of others are a projection defense mechanism of his anger and negative view of himself which in turn stem for the internalization of the negative relationships he had early on internalization of bad objects To compensate defensive behavior for his negative perception of himself Richard is in search of the perfect other that will lead to the perfect relationship At some level probably unconscious Richard may believe that being with a perfect woman will compensate for his profound sense of inadequacy because being with someone perfect will make him acceptable and good However perfect women do not exist Therefore the goal of finding perfect women is also a defensive behavior that protects Richard from allowing any body coming close to him true intimacy is hard for him which perpetuates the cycle of loneliness pain and anger The unavailability of a good enough woman gives him an excuse that masks his true feelings and fears ll In addition Richard s difficulties with intimacy may stem from his great emotional neediness He may fear that if he allows someone to come close to him he will feel overwhelmed and lose all control According to Objects Relation theory lack of proper attachment has likely impaired his ability to form an autonomous self which may be where the fear of intimacy is stemming from If he allows someone to come close to him he might feel overly dependent emotionally on the other person and not know how to keep a healthy boundary This con ict may be inferred from the fact that even though he reports that he and his wife had very poor communication and a relatively hostile relationship Richard still feels that by leaving she has taken everything away from him mostly I believe himself Goals for Counseling From a psychodynamic and object relations perspective the goal of therapy is to help Richard connect with his emotional self feel the pain and rage associated with his early negative experiences to achieve emotional catharsis and gain insight regarding how these early experiences are related to the relationship problems he has experienced in his life In the process it is also expected that by forming a close bond with the therapist Richard may learn how to experience closeness in relationship at the same time maintaining appropriate boundaries Interventions Establishing the relationship Given Richard s lack of significant nurturing relationships in his life issues of trust were particularly difficult with him This was addressed in an empathic way early on in the relationship 7 I told him that I recognized and understood that it would likely be difficult for him to trust me the therapist but that as he felt comfortable it was important for him to gain some trust so that the therapy may work I also encouraged him to communicate to me how he felt regarding being or not being able to trust me even if it felt uncomfortable for him to talk about trust issues Initially Richard was very guarded tended to make jokes or become hostile with me when the counseling came close to painful issues for him In some of these instances I pointed out his behavior and asked him what he might have been feeling about himself and about me immediacy of the relationship just before he said the remark Sometimes instead of asking I re ected to him feelings of discomfort or anger that I picked up in relation to the issues we were discussing Sometimes I shared with him immediacy of the relationship how his jokes andor angry remarks made me feel in the relationship with him eg when you respond in that way 7 make a joke about something serious we are talking about or respond angrily at me 7 makes me feel like you are pushing me away And using parallel process other times I wondered out loud to what extent others in his life may feel like me when he behaves that way Analysis of transference I helped Richard recognize and process when he was pushing me away In these instances I asked him to stay with and explore the feelings that he was experiencing which often included fear anxiety pain disbelief that the therapist cares As he 12 was able to recognize and label these feelings I encouraged him to make connections with other times in his life when he had felt in similar ways As I described above these intervention entailed confronting Richard with what was happening in the here and now of the counseling relationship With some time Richard experienced the connection between his early experiences of abandonment and his current difficulties He allowed himself to experience and accept the pain of his lost childhood and the anger he felt toward his parents for the constant fighting in the house and for not loving and caring for him During these times I assured Richard that regardless of the parents problems their behavior had been wrong and that as a child he deserved better This served as a corrective emotional experience he was able to feel that his anger was justified and that another person the therapist was able to accept him with his anger whereas in the past he interpreted his feelings of anger as further proof of his badness and feared that if the parents knew of this anger they would further reject him Insight As part of the therapy process Richard came to understand how his early deprivation which was not his fault led him to not trust himself or others and feel bad about himself and how these feelings have made it very difficult for him to enter in close relationships with others In summary this process involved both emotional and intellectual insight With the support of the therapist he allowed himself to get in touch feel the pain generated by his early deprivation which lies beneath the strong anger that he feels today During this process my role as a therapist included providing emotional support helping Richard hold and contain the strong pain and anger that had been pent up in him for so long and feel accepted as he was I often assured him that his feelings were reasonable given the experiences he had had and communicated to him verbally and nonverbally that it was ok to express them and that I was not overwhelmed by his pain anger and fear In some ways he was able to relive his painful childhood experiences in the context of a relationship where he felt accepted and psychologically taken care of These experiences constituted a corrective emotional experience With this new insight and corrective emotional experiences Richard started to be less defensive and more open in relationships with women He realized that his search of perfection in others was in part an effort to cover his strong sense of inadequacy insight that also served to keep others away This realization helped him to work towards accepting himself and others shedding away the mechanism of defense as they are with good and not so good things Adler39ian Hypothesis based on theory s concepts 13 From and Adlerian perspective one would say similar things about working with Richard but using slightly different language In the context of his family constellation Richard was not able to achieve a place of signi cance because his parents seemed to be immersed on their own problems and basically neglected him His inability to nd a place of signi cance with his family led to the development of strong feelings of inadequacy In this context he developed a life style characterized by feelings of unworthiness the belief that nobody will care for him overgeneralization and that he has little to offer to others These experiences and feelings have generated signi cant levels of anger He often finds a place for himself in the world by asserting his anger e g situations at work with female coworker He has also come to believe that in order to be signi cant to be ok and accepted self ideal he must achieve a perfect relationship with a perfect woman which constitutes a misperception of life demands These faulty beliefs have led him to have difficulties in meeting the life tasks Because of his lack of nurturing relationships in his family constellation he has developed a very poor sense of himself he does not accept himself and has difficulty accepting others for what they are He is having and has had throughout his life major difficulties with the life task of forming intimate relationships Because of his inability to trust others and his belief that he does not deserve others to be there for him faulty logic he does not seem to allow the women he dates or the woman he married to come emotionally close to him At the same time he is not able to give of himself in these relationships His problems in relating and the anger he feels have also affected his worker role He has had various interpersonal problems at work that have led to him being fired He also is having difficulty in finding meaning in his life At times he feels suicidal because all his pain and suffering seem worthless He also lacks social interest Until very recently he felt that this is a dog eat dog world and that he needed to be ready to strike first He feels very discouraged to face a new relationship and life in general His recent divorced have heightened these feelings to the point of making them unbearable Goals for Counseling Goals for counseling include helping Richard a identify and change the faulty beliefs about himself others in general and woman in particular that he developed in his family of origina identify and stop his selfdefeating behaviors regarding his difficulties in relating to others his anger and c developing social interest Interventions From an Adlerian approach I helped Richard to identify and change his faulty beliefs that nobody will care about him that he has nothing to offer to others and there is something totally wrong with him As part of this process I gently confronted him with the underlining purpose of his anger Mostly it protects him from facing the pain and feelings of inadequacy generated by the deprivation and neglect he experienced in his family of origin Using immediacy I 14 encouraged him to explore what he was feeling and what he wanted to accomplish when he got angry at me in the session 7 eg push me away change the topic I helped him see that this anger prevents others from coming close to him something that he desperately wants but is very afraid of I brought to his attention the importance of developing social interest I encouraged him to think about a project he could initiate that involved helping others As therapy progressed Richard volunteered with a mentoring program in his company where he served as a mentor to a child who experienced difficulties at home This helped him feel better about himself and allowed him to start discovering good things about himself that he can give others I also encouraged Richard to revise his beliefs about women which seemed to include very negative thoughts and expectations He understood how he was projecting on all women the anger and distrust he felt towards his mother in Adlerian language he was operating from the faulty logic that all women are selfish angry and rej ectful and that women are ultimately at fault for the pain he feels These beliefs and expectations regarding women led him to keep women at an emotional distance and often times reject them before the women had a chance to reject him This of course prevented him from forming a stable open relationship with any woman As we discussed these issues Richard realized that one way he distanced Connie from him was by being sarcastic when he felt put down or threatened by her instead of openly expressing his feelings to her In this way he came to understand and accept responsibility for his role in creating some of the problems in his relationship with Connie To help him control his anger and discover the connections between his anger and his negative feelings about self I encouraged him to catch himself when he started feeling angry toward another person and stop to explore other feelings he may be experiencing underneath the anger This was hard for him to do at first but slowly he started to recognize how feeling rejected or put down by others triggered his anger Using immediacy I challenged him to explore his anger towards me when it happened in counseling For example in one occasion when I was confronting him with his role in distancing women from him he became very sarcastic I confronted his sarcasm by telling him that I felt he was angry at me and using spitting in the soup suggested that he was being sarcastic instead of expressing the anger that his was feeling directly and letting me know how my remarks were making him feel rejected inadequate When he was able to recognize and accept his anger and feelings of rejection I asked him to act as if he could share with me other feelings he was having eg fear and sadness Cognitive Behavioral Hypothesis based on theory s concepts Richard s feelings of depression and anger are primarily cause by how interprets the events in his life He has irrational thoughts such as A second goal was ti help Richard identify and rehearse new behaviors that would lead him to deal with this loneliness 15 Goals for Counseling Have Richard identify his irrational thoughts and mistaken assumptions and identify and rehearse new behaviors that will allow him to related better to others and overcome his depression Counseling Interventions Use Socratic dialogue and guided discovery Beck to Richard identify his irrational thoughts and mistaken assumptions such as others are responsible for me I can only form relationships with women who are prefect without a woman in my life I am unhappy and miserable the failure of the marriage means that I will never be able to forma a satisfying relationship with a women Once identified I disputed Ellis these ideas to help him develop the ability to disprove these irrational thoughts for himself and replace them with rational thoughts e g it is sad and inconvenient that the marriage ended but it is not a catastrophe Give Richard homework such as what to do when he feels lonely and sorry for himself on Saturday afternoons I used modeling to show Richard how he could communicate to others feelings of discontent anger fear or pain as well as positive feelings Later on I encouraged him to rehearse those behaviors by openly expressing his feelings to me We also role played responses to situations he was facing with coworkers and acquaintances in which he would practice communicating his feelings without becoming angry and sarcastic In a slowly and painstaking process Richard became more aware of feelings underlining his anger and became more adept at sharing them with me and with others Existential Hypothesis based on theory s concepts From the Existential perspective Richard seems to have most difficulty with dealing with the givens of existence in the areas of isolation freedom responsibility and meaning Primarily he is struggling with interpersonal and intrapersonal isolation Richard is estranged form parts of himself his emotional self to protect himself form his profound pain and consequently has difficulty entering into real and meaningful relations with others He seems to be using women to cope with his fear and anger Because he is not really in touch with himself and as a way to avoid the pain of looking inwards Richard tends to blame others for his problems and therefore avoids responsibility for himself and his actions freedom His inability to form deep real relations with others makes him feel empty and his life lacks meaning The failure of his marriage has been a boundary situation that has led Richard to look at himself and seek counseling Goals for Counseling l6 Richard needs to become aware of how he contributes to his own problems freedom and responsibility issues and he needs to become more in touch with his emotional self and also recognize the limits of interpersonal relationships isolation issues Interventions As therapist I provided a real relationship to Richard to facilitate his exploration of the difficulties he has experienced in relationships and his pain and anger I would use the intervention of compensatory self improvement to help him cope with the pain of the loss of his marriage and motivate him to use this crisis to improve parts of himself he has control of e g careerwise personally The issues described in the psychoanalytic approach related to helping him become aware of how he behaves toward others in general and women in particular would also be consistent with the Existential goal of helping clients become aware of the choices they are making in life III Conclusions With time Richard became better at recognizing his anger and confronting the feelings associated with it His sense of self improved as well as his social interest He also recognized his role in keeping people away and slowly started to trust him and others more Richard still had to watch his tendency to have negative feelings toward women and to expect that all women will end up hurting him He continued to catch himself when these thoughts and feelings emerged and led him to close up and act in ways that distanced others away from himself 17
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