Feedback Session
Case Descriptions
Mr T is a 22 year-old university student from Sibu. He has only one elder brother who is two years older than him. According to Mr T, his relationships with the people around him are fine. He is now still single. Currently, he is living with a roommate near the university.
Mr T had been feeling very demotivated and lazy in studying. He mentioned that he started to dislike studying without realising since he entered Form 3 in secondary school and in fact, he felt that he got even lazier after he entered university. He could not carry out tasks that require long time to finish such as assignments, projects and revisions, where he would only do well in the first few hours and very soon, he would start to feel bored of the task. Eventually, this led him to start procrastinating. Besides, when Mr T was in primary school, he used to be very ambitious where he would think of who he will become when he grows up. However, he stopped thinking about his future without realising. He described that he is now merely living through day by day. “When today is over then it is over. Tomorrow is a new day. Every day I will just think how to pass the day.”
As he procrastinated, he tended to do work at the last minute before the due dates. When asked how did this problem affect him emotionally, he insisted that this did not cause him any emotional distress and instead, he mentioned that it actually made him feel freedom. He had no intention in making any changes. When questioned on whether he is satisfied with his current state, he bluntly answered “How do you want someone who do not care about anything to feel satisfied?” When asked about what are the things, excluding studying, that he would feel motivated in, he immediately answered that “My life only involves study, playing with phones, eat and sleep. What kind of motivation would you expect me to have?”. He said he does not know what kind of things can keep him motivated as it is not even the future yet and things can change in the future. He even mentioned that he is fine with the way he is living now. In addition, he also mentioned that he had been waking up at 3am in the morning very frequently these two weeks without knowing the reason.
When he was asked to think of what he wants in his life, it took him a while before he mentioned that he hopes that he can make his family live happily. He thought that they are the ones who raised him up and therefore, it is his responsibility to do so. It is not his life goal. When asked what he wants for himself as his own life goal, he said he does not know as he had never thought that. “I think that things will just go with the flow. What I want is to achieve my life goal, but I don’t have one in my life.” In addition, he also could not answer what kind of job he wants in the future. He would just do any jobs that is available to him later. He could not make up his mind for what he wants in life.
He mentioned that, when he first entered university, he really did not want to stay any longer. He was really tired of having to study to the extent that he started to have suicidal thoughts. He described that studying was too tiring and that he did not want to continue anymore. When asked how did he feel emotionally when he was thinking of committing suicide, he said he did not know and he described that he did not feel any emotions, no sadness, no disappointment. He mentioned that the only reason that had led him to having the suicidal thought was that he was tired of having to study. However, these suicidal thoughts disappeared after listening to the advice given by his friends and when he thought of his family. In addition, he did not remember a single word of the advice from his friends that had managed to change his way of viewing his matter and dispel his suicidal thoughts. In fact, he even mentioned that he forgot about those words in a day. Gladfully is that he was no longer having any suicidal thoughts occurring since the incident.
When asked how was his emotions recently, he again said that he did not know how he was feeling. He disclosed that he neither feel happy nor angry and neither laughed hard nor cried since he entered university. Even if he smiled on the outside, he did not feel joy deep in his heart. “I do not feel anything most of the time. I only laugh sometimes, very rare. Maybe watching jokes had somehow made me feel happy, but I confirm there was no crying or being sad. I also seldom get angry where I remember the last time I got angry was when I was in primary school.” He even denied that there is hardly anything that can make him down as he thought that there is nothing else he can do when things happen.
Mr T said that he can forget negative events very quickly. When asked about how did he usually deal with difficult or sad moments, he mentioned that he will not share to anyone and keep it inside himself, then he would make himself to not think about it and eventually forget about it. He described that he did not have to try hard to forget, where the shortest time he would take to forget about an event is within 3 minutes and the longest time is about 1 day.
After the assessment information was done, it was found that there were contradictions found within Mr T’s statements. Also, when asked about his emotions, he was not aware of it most of the time. Therefore, he was required to complete the Beck Depression Inventory (BDI) and Beck Anxiety Report (BAI). He showed normal test taking behavior, where there was nothing obvious behaviorally during the test.
Interpretation
The client had put 0 score for all the items except for one item, where he endorsed “I am less interested in other people than I used to be. This may indicate that he belongs to the normal range of 0-10 score, where getting 0 score may means none depression. However, clinician should carefully investigate the contradictions in the client’s responses to the chosen statement items in the test, before this profile can be interpreted with confidence. Below are the endorsed items where contradictions were found:
I am not particularly discouraged about the future. (The client stated that he is now merely living through day by day.)
I get as much satisfaction out of things as I used to. (When questioned on whether he is satisfied with his current state, he bluntly answered “How do you want someone who do not care about anything to feel satisfied?”)
I can work about as well as before. (The client had been very demotivated in anything. He also mentioned that he could not carry out tasks that require long time to finish such as assignments, projects and revisions, where he would only do well in the first few hours and very soon, he would start to feel bored of the task. Eventually, this led him to start procrastinating.
I can sleep as well as usual. (The client mentioned that he had been waking up at 3am in the morning very frequently these two weeks without knowing the reason.)
In addition, the clinician should be alert to the client’s emotional part as the client may be having alexithymia, where he showed symptoms of (1) difficulties in identifying feelings and emotions; (2) limited ability to communicate feelings to others; (3) a lack of fantasies and imagination; (4) behaving less altruistically than others and (5) poor life satisfaction. The clinician may wish to consider asking the client to complete the Twenty-Item Toronto Alexithymia Scale (TAS-20), the Bermond-Vorst Alexithymia Questonnaire (BVAQ) and the Observer Alexithymia Scale (OAS) to check for signs of alexithymia (Legg, 2019). If the client were to have alexithymia, he may be co-occurring mental health condition such as depression or no diagnosable mental health conditions (Legg, 2019). The client who is close to meeting the symptoms of alexithymia need further appropriate investigation for the possible co-occurring mental health condition.
The client had also obtained rather low score of 3 for BAI, which implies that he falls under low anxiety. However, if the contradictions found between the client’s responses and the endorsed items in BDI are true, there may be great possibilities that the BAI scores are subject to change.
Endorsed Items
BDI
Mr. T endorses the following BDI statements:
· I do not feel sad.
· I am not particularly discouraged about the future.
· I do not feel like a failure.
· I get as much satisfaction out of things as I used to.
· I don't feel particularly guilty.
· I don't feel I am being punished.
· I don't feel disappointed in myself.
· I don't feel I am any worse than anybody else.
· I don't have any thoughts of killing myself.
· I don't cry any more than usual.
· I am no more irritated by things than I ever was.
· I am less interested in other people than I used to be.
· I make decisions about as well as I ever could.
· I don't feel that I look any worse than I used to.
· I can work about as well as before.
· I can sleep as well as usual.
· I don't get more tired than usual.
· My appetite is no worse than usual.
· I haven't lost much weight, if any, lately.
· I am no more worried about my health than usual.
· I have not noticed any recent change in my interest in sex.
BAI
Mr. T endorses the following BAI statements:
· Unable to relax. (Mild)
· Heart pounding / racing (Mild)
· Nervous (Mild)
Discussion on Feedback Session
During the feedback session, Mr. T had mentioned that some of the options of the statements in BDI do not fit him and that he needs some scores in between the options given to accurately describe him. This is true for the Statement 3, Statement 6, Statement 8, Statement 14 and Statement 16.
For Statement 3, he thinks that he failed a little more than average person when he does his work at the last minute and ends up not being able to submit his assignments in time. He also feels that his quality of his work often does not meet what it should be as he is always in a rush of completing his work. For Statement 6, he thinks that he should get 0.7 because he always avoids from checking messages regarding assignments in the chat groups and this sometimes makes him to feel disappointed of himself. He feels that he may be punished whereby he is afraid that he may be excluded from the group and eventually not able to obtain any marks for the assignments.
For Statement 8, he thinks that he scores above the item “I don’t feel I am any worse than anybody else” because sometimes he realises his mistakes of doing things at the last minute as well his forgetfulness. He will tell himself that he should prevent these mistakes from happening the next time. On the other hand, he thinks that his score should be below the item “I am critical of myself for my weaknesses or mistakes.” when his forgetfulness occurs during the times when he is doing something beneficial instead of doing something unnecessary.
For Statement 14, he is above 0 score because he sometimes forgets the basic routine of taking care of own appearance such as shaving and combing his hair. However, he is not too worry about looking old or unattractive because he thinks that he does not have to care for others’ opinions about him. Whereas for Statement 16, the item of 0 score only fits his previous condition where he could sleep well without any disturbances. However, he tends to fall asleep early without him realising and caused him to wake up around 3am in the morning very frequently. He then takes around 1 hour in order for him to fall back sleep. This makes him more tired in the day. Yet, he thinks that he is below item of 1 mark because he thinks that he had deep sleep.
The item “I am less interested in other people than I used to be” is the only item with a score of 1 that Mr. T had endorsed, as he had chosen items of 0 score for all the other statements. He explained that he refused to know the people around him any deeper than merely knowing them as who they are, including his friends. He avoids himself from acknowledging how they feel emotionally and anything happened that involve emotions such as sad and angry. He thinks that it is troublesome to console or help them, as he himself do not know how to do so. When asked whether he was like that before, he cannot remember.
In order to clear up the contradictions found between Mr. T’s statements in the previous session and his scores in the BDI, a few clarifications were made during the feedback session. Referring to the contradictions listed in the Beck Inventory Interpretative report, for the item “I am not particularly discouraged about the future.”, Mr. T clarified that since he will just go with the flow where he does not think much about the future, therefore he does not feel discouraged about it. For the item “I get as much satisfaction out of things as I used to.”, the reason why he chose this was because he is satisfied and grateful with the results he get even though he did not study much due to laziness.
Besides, for item “I can work about as well as before.”, he understood this item in terms of his academic performance, where he mentioned that despite the diminishing motivation in him, his academic performance seems to maintain, which is why he thinks that I can work about as well as before. However, his motivational issue is becoming worse.
For BAI, Mr. T is unable to relax mildly when he had not finished the assignments and yet the due dates are near. He also cannot relax when he is doing presentation. Besides, Mr. T had also chosen a mild level for his heart pounding, where he clarified that this normally happens when he is doing presentation as he is not prepared at all. Mr. T also feel nervous mildly. He feels this when he could not finish the assignments in time, where the more nervous he gets, the more he could not think of any ideas and this made him anxious.
Upon the first session of assessment information and second session of feedback, Mr. T had showed symptoms of alexithymia. Alexithymia is a construct that involves difficulty in experiencing, identifying and expressing emotions (Legg, 2019). Mr. T had showed symptoms of difficulties in identifying feelings and emotions, limited ability to communicate feelings to others, a lack of fantasies and imagination, behaving less altruistically than others and poor life satisfaction.
His difficulties in identifying feelings and emotions is showed when he disclosed that he neither feel happy nor angry and neither laughed hard nor cried since he entered university. Even if he smiled on the outside, he did not feel joy deep in his heart. He even denied that there is hardly anything that can make him down as he thought that there is nothing else he can do when things happen.
It was also obvious that he had limited ability to communicate feelings to others. When asked how did he feel emotionally when he was having the suicidal thoughts, he said he only feel tired of studying, he don’t feel anything like sadness, disappointment. Besides, every time when asked about his feelings, it took him quite a while to think of his own emotions and at the end of the day, he still failed to describe his own emotions most of the time, even though the explanations or response he gave during session clearly reflected certain emotions in him. For instance, when asked whether he feels worry while doing presentation, he denied. However, he then explained that he normally thinks that he may cause his group members to get low marks because of his bad performance or how to make the lecturers not deduct their marks. This clearly shows that he feels worry and yet, he denied it.
Another symptom that can be seen on Mr. T is lack of fantasies and imagination. According to Taylor and Bagby (2000), the fact that they know very little about their own emotions and are unable to relate their emotions with specific situations, fantasies or memories can be revealed through thorough questionings. Mr. T could not describe his own feelings during the times when he was having suicidal thought at all. He showed a thinking style that only focuses on the external events and a very strong avoidance of focus on the inner experiences. He mentioned that he only knew that he was tired of having to study and that was why he wanted to end his life. Besides, he also showed little imaginative capacities during both sessions. He stopped thinking about the future without realising and mentioned that he is now merely living through day by day. He even described that his life now only involves studying, playing with phones, eating and sleeping. he does not know what kind of things can keep him motivated as it is not even the future yet and things can change in the future.
There is a possibility that Mr. T is behaving less altruistically than others. This can be seen when he mentioned that he refused to know the people around him any deeper than merely knowing them as who they are, including his friends because he wanted to avoid himself from acknowledging how they feel emotionally. He did not want to be involved in the matters of others, especially the ones involve emotional distress. On the other hand, poor life satisfaction can be seen on Mr. T when he bluntly mentioned how can satisfaction exist for someone like him who does not care about anything.
References
Legg, T. J. (2019). What to know about alexithymia. Retrieved from https://www.medicalnewstoday.com/articles/326451.php
Taylor G. J., Bagby R. M. (2000). “An overview of the alexithymia construct,” in The Handbook of Emotional Intelligence eds Bar–On R., Parker J. D. A., editors. (San Francisco, CA: Jossey–Bass; ) 41–67
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