3.1. Sessions 3.1.1. Before the Sessions

Before starting the psychotherapy sessions, the measurement tools mentioned above were applied to the client. Brief information was given about the psychotherapy process, and the first date of the clinical interview was clarified.

3.1.2. First Two Sessions (Anamnesis)

T: How would you describe the future that awaits you?

C: I never thought of the future!

T: Haven’t you thought about it lately?

C: I cannot think of it! I don’t have a future goal right now.

In the first session, it was observed that the client was very timid, and his anxiety levels were high. He was not fully seated in his chair, his hands were constantly between his knees, and he was in a forward-bent body posture. This was also a position he often entered while describing his relationships with his father. His father has a total of 20 children from both wives. Losing his sister was the most painful event in his life. The client who has an anxious attachment style stated that he had a good relationship with his mother and that sometimes his mother spent time with him lying on his bed when he woke up in the mornings. One of the factors triggering his anxiety was seeing his mother die in his dreams. He thinks that he has not been receiving the attention he expected from his family, and he has been blamed too much by the family members, especially by his father.

To sum up, the anamnesis sessions were conducted in two sessions. In this process, a comprehensive story was taken from the pre-natal period of the client to now. More than a hundred questions which are about questioning family dynamics, self-design, sexual life, and the dreams he wished to realise were asked. The questions asked to the client made him feel that he was worthy of attention, and a therapeutic alliance was established. This step is significant because the first session’s essential role is for the therapist to check the client’s capacity to establish a healthy relationship [26]. 3.1.3. Third Session

‘I heard the news of her death. I don’t want to believe it! As if there was no such thing… I slept and woke up… I don’t know… I am not even aware that I was sleeping. Such a thing cannot happen! She lives, among us! My eyes are always looking for her, but I cannot find it…’

The anamnesis process was summarised to the client, and it was stated that the next sessions are psychotherapy sessions, therefore he will not be asked many questions unless necessary. The orienting started with the metaphor of “a blind man and a suburban train”. At this point, this story explained what the roles of the client and the therapist should be, and his insight was tested by receiving feedback from him. This metaphor is about the journey of a blind old man and a young woman on a suburban train. The story is summarised as follows [37,39]: The blind man offers to make their trip more enjoyable for the young woman. The rule of the game is simple. Each time the train stops to pick up passengers, the young woman will describe everything around the train to him, and he will tell her where she is. The game starts. The young woman starts to explain everything she sees, and the old blind man guesses correctly. Then, when they reach a long dark tunnel, the young woman stops to describe it. After passing it, she begins to describe everything again, but this time the old man does not know, and the young woman cries “No! You could not know this time!” “But how come?” asks the old man and adds “Did we go through a long dark tunnel?” The young woman says “Yes…!” amazedly. Then, “You would tell me everything you saw. We had agreed like this. If you do not tell me what you saw, of course, I would not know!” says the old blind man, and the story ends like that.

After the story, it is asked to the client:

T: So, who is the young passenger in this story?

C: Umm, I guess I am (laughs).

T: Old man?

C: That is you too.

T: Because?

C: Because… I am going to tell you what I see, and you will make me realise the events that I cannot see or understand.

T: Great! Let’s start. The train is moving… Choo, Choo, Choo…

After this introduction, it was observed that the client expressed his feelings more sincerely and without manipulating himself. In this session, the death of his sister was discussed. He stated that his sister had joined a terrorist organisation and was later killed. He was allowed to talk about his memories with his sister and go through the mourning process. Then, the reasons underlying the sentence he completed as “Men are more fortunate than women!” was worked on with him. This sentence was extracted from BSCT which is one of the incomplete sentences and starts with “Men……”. It was observed that he felt intense anger towards his father and blamed his father for the death of his sister. However, the session ended by expressing that he respected his father because his superego was dominant. The statements of the client regarding the death of his sister were as follows:

“If she was a boy, she could go to school. My father did not allow her to get an education just because she was a girl. However, if she had studied, she would have been a very successful and educated person and would not have had to go to the mountains. It would not end like this either.”

3.1.4. Fourth Session

“I used to be comfortable in front of everyone. Now, why did I become like this? I don’t understand. I don’t want to stay behind in my education life. I want to be a good role model for my siblings.”

In this session, the client talked about the impact of his brother’s death on him. He described how his brother died traumatically while he was working in the field, by being crushed under a rock rolling from a mountain. In this emotion-focused session, traumatic events thought to cause anxiety were discussed, and catharsis was ensured. Moreover, in this session, it was observed that the client experienced the feeling of “industry versus inferiority” and made these emotions more manageable by using a “projection” defence mechanism. For example, he claimed that the reason for failing to pass the university entrance exam in the first years was “the evil eye of the peasants” and continued: “I could not pass, because before I took the exam, the peasants said that I would definitely pass the exam and place to the law department at the first entry. That’s why I failed. Due to their evil eye…”

3.1.5. Fifth Session

“That day… I wish I didn’t go to that lecture!”

In this session, the dynamics that caused the client to not want to attend lectures and leave the university were discussed. He stated that the lecturer had asked him to read a text in front of the classroom and that he was very excited and fainted during this reading. When asked “Would you go back to that moment?, What is going on?”, after waiting for a while, he summarised his situation as follows: “I say to myself I will be disgraced, and in the end, I am disgraced by falling on the ground. Since that incident, my friends make fun of me every time they see me. I cannot attend lectures anymore because almost every lecturer wants us to make presentations. I cannot speak in front of a huge class!”

Intensive cognitive therapy is initiated in the middle stages of treatment. Patients are trained to understand and track their tacit and overt cognitions [26]. Therefore, this session aims to use the findings regarding the formulation and conceptualisation established in the first two sessions in a way to increase the insight of the client. Accordingly, a link was established between his need to be appreciated within the family and the need to be appreciated in his social environment. Finally, a brief psycho-education was provided about “irrational beliefs” by drawing attention to the cognitive distortions underlying his anxiety, and the session was ended. 3.1.6. Sixth Session

“Today, I visited one of my lecturers in his office. My friends also were with me. He said it seems I have changed a lot, and my conversations had become quite confident.”

The “catching automatic thoughts” technique used in cognitive behavioural therapy was attempted to be reinforced based on the A-B-C model, and examples were taken from the client’s life. Additionally, his self-awareness and therapy process were discussed in this session. The client expressed that he was aware of the change in himself and emphasised that he could see this more clearly when one of his lecturers stated this change.

3.1.7. Seventh Session

“I feel comfortable here. Before I came here, I had lost my self-confidence, I had lost everything. But now I’m getting better. I can see that…”

The late middle stage of therapy is concentrated on developing the self-management capabilities of clients. During this process, behavioural intervention strategies such as cognitive skills training, problem-solving instruction, and systematic desensitisation are applied. These strategies are not seen as simply a means of modifying behaviour. Rather, DCBT sees them as effective methods for altering emotional and tacit cognitive schemes [26].

In this session, the client’s anxiety was studied more intensely. Various CBT techniques have been used, such as imagination, assuming the worst will happen, and examining the evidence (evidence that supports and does not support negative thoughts). When the client said that he had to make a presentation in a lecture in the coming weeks, his fears regarding this issue were discussed, and the client was given imaginary rehearsals. As the duration and repetition of the imagery increased, the intensity of his anxiety began to decrease. He was asked to do these imaginary rehearsals for a week and imagine going to an empty classroom at least twice and giving a presentation.

3.1.8. Eighth Session

T: You say that you have made a lot of progress in this process, learned the techniques here, and felt more comfortable than before.

C: Yes!

T: So how about bursting into a classroom now?

C: How so?

T: Now we will get up, go faculty and enter a class, and you will explain, for example, what the A-B-C model is to them!

C: You are joking, I guess?

Considering the progress of the client, the “Exposure” technique was used in this session. The client was asked to explain the “catching automatic thoughts” technique, which he had learned in the process in a lecture he did not know at all. In the class, the therapist initiated the lesson in partnership with the client. The purpose of the therapist to do this was to confront the client with his fear by making him feel that he was not alone.

He expressed his feelings triumphantly, after this exposure as follows:

“Actually, it was not that hard, I was very excited at first, but now I’m so comfortable that I cannot tell. I thought I was a little stuck but still fine, I guess. How crowded was the class? How did you set it up? At first, it felt like it was planned when the positive reviews came. But when I heard the next criticisms and also saw the students coming late to the class, I thought that these weren’t plans. Here I am very comfortable right now.”

3.1.9. Ninth Session (Termination)

“After the session, we reserved some seats in a cinema with friends for a comedy movie. It will start at 13.30.”

The last phase of treatment focuses on problems of closure and prevention of regression. The termination process is seen as the time of consolidation of the progress and improvements achieved in counselling. The closure process is perceived to be a period of consolidation of success and change in therapy [26]. In this last session, the client’s achievements in the therapy sessions and his feelings about ending the sessions were reviewed. It was observed that the client was comfortable and able to tolerate separation anxiety regarding the termination.

“I am very comfortable right now, I have reached a level where I can make presentations in any lecture, and I started to socialise with my friends again. You have said before that the termination of these sessions means that I am getting better, and it does not mean that we will not meet again. Also, I already know where I can find you (Laughs).”

Finally, his victory in the previous session was discussed, and the process was completed with positive emotions.