Individualized and Phase-Based Cognitive Behavioral Therapy for the Treatment of Early Onset Pure Dysthymic Syndrome in an Outpatient with Mixed Personality Features

Effects of Personality and Harm Avoidance

Many have noted significant overlap in the symptoms of PDD or dysthymia and personality dysfunction (Erkoreka & Navarro, 2017; Martins et al., 2018). Pathological personality traits, found in many individuals with dysthymia, may explain why traditional psychotherapies are relatively less effective in treating chronic forms of depression as well as why many individuals with dysthymia struggle interpersonally (Erkoreka & Navarro, 2017; Jobst et al., 2016). Supporting this hypothesis, researchers conducted a study of personality features in 80 adults with dysthymia and found that features of narcissism, specifically vulnerable narcissism accounted for 23% of the variance in depressive symptoms (Erkoreka & Navarro, 2017). As opposed to grandiose or overt narcissism characterized by arrogance, extraversion, and exploitation of others for personal gain, germane to narcissistic personality disorder, vulnerable narcissism is characterized by a subtle grandiosity with a hypersensitivity to perceived negative evaluations from others that results in inhibition, fragility, and the avoidance of anxiety in interpersonal situations due to thoughts of self-inadequacy and the possibility of being rejected or criticized (Erkoreka & Navarro, 2017; Levy, 2012). Those high in vulnerable narcissism may overidentify with suffering and emotional distress, leading to self-pity and catastrophic thought patterns inherent to chronic depression (Levy, 2012).

The shared vulnerabilities and pathways of narcissistic personality features and depression can develop from early adverse life experiences and an invalidating environment that generate low self-esteem, emotional distress, feelings of inferiority, and fear or harm avoidance of many interpersonal situations (Erkoreka & Navarro, 2017). The inability to tolerate these vulnerabilities in combination with a failure to achieve high expectations of themselves and others can lead to perpetual shame and disappointment (Erkoreka & Navarro, 2017; Kernberg, 2009). For the chronically depressed individual, this may result in both harm avoidance and reward dependence in which the individual is passively avoidant, leading to a passive dependency on others for validation, passive aggressiveness to gain validation from others, loneliness, and frequent fears and ambivalence toward potentially vulnerable situations (Cloninger, 1987). Following early adversity, this can result in distorted views of the self and a state of arrested cognitive and emotional development (McCullough & Clark, 2017). Internal and interpersonal conflict can increase with age as individuals struggle to attain their lifelong goals.

Psychotherapy for Dysthymia

Despite advances in the treatment of MDD and the diagnostic classification of chronic forms of depression, meta-analyses have been inconclusive as to whether psychotherapy is as effective as pharmacotherapy when treating dysthymia (Cuijpers et al., 2010; Imel et al., 2008; Kriston et al., 2014). However, there is a general consensus in the literature that individualized psychotherapies based on the individual’s specific problems and preferences that target interpersonal issues and have a longer duration of treatment are recommended as they show the most promise (Cuijpers et al., 2010; Jobst et al., 2016).

Once such therapy is cognitive-behavioral analysis system of psychotherapy (CBASP), which was specifically designed for treating chronic depression (McCullough & Clark, 2017). Although it has yet to be evaluated for this purpose, CBASP may be particularly effective for individuals with dysthymia and comorbid personality features, specifically vulnerable narcissistic features as it targets early adverse life events, situation-specific problem solving (i.e., “situational analysis”), behavioral skills, and their relationship with previous and ongoing interpersonal situations (Erkoreka & Navarro, 2017; McCullough & Clark, 2017). Although CBASP has many similarities with cognitive behavioral therapy (CBT), such as situational analysis, which is similar to behavioral experiments and include examinations of automatic thoughts and core beliefs in CBT, CBASP tends to highlight the impact of early adverse life events and interpersonal functioning, while also discussing the relationship between client and therapist, as well as any countertransference reactions (i.e., “disciplined personal involvement”) more than traditional CBT for depression (McCullough & Clark, 2017). In focusing on interpersonal situations, one of the aims of CBASP is to generate empathic thoughts and behavior as well as interpersonal flexibility that can lead to improved relationships.

Treatment Recommendations

The presence of physiological symptoms of depression, such as sleep difficulties, eating and weight changes, and decreased sexual interest may be critical indicators of depression and help differentiate the presence of a chronic depressive disorder versus a characterological depression that stems from pathological personality traits (Erkoreka & Navarro, 2017). When pathological personality traits comprise part of the larger dysthymic syndrome, incorporating parts of the aforementioned therapies into an individualized or modified and extended treatment plan tend to result in improved clinical outcomes (Cuijpers et al., 2010; Erkoreka & Navarro, 2017; Schramm et al., 2017). Altogether, therapies that show the most promise for treatment: (1) assess for the influence of early adverse life experiences, examine how these experiences may contribute to (2) dysfunctional ways of thinking about the self and others as well as (3) the avoidance of potentially harmful interpersonal situations, while incorporating (4) interpersonal problem-solving in and outside the therapeutic relationship. As the client gains the insight and resources to address dysfunctional thoughts and behaviors, they may no longer feel stuck or hopeless and begin to behave more adaptively and flexibly in everyday situations, ultimately feeling more secure in relation to the self and others.

Developmental and Medical History

The client reported all of his developmental milestones to be within normal limits with no history of neurodevelopmental disorders. He also reported that he thought he had myocarditis and Hashimoto’s thyroiditis, which was described to him by a physician 3 years prior to his intake evaluation. However, after visiting a physician during the course of treatment, the client no longer was at risk of myocarditis, reducing the likelihood of psychological distress due to a medical condition. Lastly, the client reported that he has “never slept well.” He reported that he had problems falling asleep, waking up too early, and usually slept about 6 hours a night. As a result, the client would feel tired throughout the day and take a nap during the day, nearly every day.

Educational and Vocational History

The client received his bachelor’s degree from a 4-year university. He stated that he often lacked motivation for school and would “daydream a lot,” in which case he would “tune out others.” He went on to state that he would often become fidgety, restless, and bored during school and would often have “class clown moments” when he would make jokes and entertain other students.

At the time of the intake, the client was unemployed. Most recently, the client reported working as an improvisation teacher. He did this for roughly 2 to 3 years and stated that he really enjoyed this position. Despite enjoying teaching, he stated that he always experienced “imposter syndrome” and doubted his own abilities. Prior to this position, the client reported having many different and short-term job positions as well as acting without pay. During the course of treatment, the client gained a part-time job working as an entertainer for a tour company but lost his job as a result of travel bans and a lack of customers due to the COVID-19 pandemic. Despite his job struggles, the client always indicated that he believed he was “destined for greatness” if only he would put in the effort. He often talked about dropping by the improv theater whenever he wanted to, stating, “they look forward to when I drop by” and “people think of me as a Larry David.” When discussed, the client was able to reflect on these situations and determined that he generally stops by when he is feeling confident and sure that he will perform well, thus placing him with a probable opportunity to succeed.

Psychosocial History

The client moved to the U.S. at age 6 with his mother and grandmother. His father reportedly stayed behind to make money and support his family as they moved and did not join the rest of the family until 1 year later. He reported that in school, other children would bully him for his accent and not being able to speak English well. The client reported that eventually he would make jokes that other children would laugh at, which helped him fit in. Eventually, when the client learned English, his ability to speak Russian began to decrease. When his father eventually joined the family in the U.S., he was largely unable to communicate with him because he only spoke Russian at the time. The client stated that he now does not really “connect” with his European identity and remains somewhat disconnected from his family. Although the client reported that his relationship with his family was “decent,” he also reported that his relationship with his father was somewhat distant. As he has gotten older, he reportedly gets along better with his father, who is easier going than his mother, in whom he notices a lot of the same anxieties and negative thought patterns with which the client also struggles. He stated that he struggles to talk with his mother, father, and older sister when he is in need of support and that this has always been the case. The client reported that his family does not discuss their problems. He noted a cultural belief that health is left to chance and that bad things are bound to happen and, therefore, not worth talking about. An example he noted was that his parents have been separated since the client was 10 years old and are still living together but have never openly talked about it with the client.

The client noted a previous 8-year romantic relationship, which he described as “bad.” His partner reportedly cheated on him, which contributed to the client’s chronic “trust issues.” Following the break-up, the client sought mental health treatment and received drama therapy before terminating with the therapist due to treatment dissatisfaction. At the time of the intake, the client was in a monogamous relationship with a woman whom he had dated “on and off again” for about 1 year. He stated that he had broken up with her multiple times over the past year, largely due to trust issues and negative thoughts surrounding the relationship (e.g., “[she] really sees the negatives in me,” “does she like me for me?,” “do I excite her?”). Despite these concerns that the partner would be disinterested in him, the client would often reflect annoyance if his partners demonstrated any depressed affect or insecurities about themselves, stating that “she’s being such a downer” or “I just can’t stand to be around that.” In response to such situations, the client would either physically leave or use passive aggressive or callous remarks that inevitably ended in arguments, which he would admittedly regret later. Alternatively, soon after, the client would say that his partner was “great” and everything he wants.

During the course of therapy, the client ended this relationship and began a new romantic relationship almost immediately that lasted through the end of treatment. Throughout the course of therapy, however, the client described thoughts in which he contemplated ending this new relationship as well. He reported concerns regarding whether the relationship was “right for [him],” often contemplating, “is this a sign we need to break up?” The client often reported automatic thoughts such as “I’m being treated unfairly” or people “don’t see all of my good qualities” following disagreements with his partners. Rather than being satisfied with his current relationships, which seemed to be healthy and make him happy, the client always seemed to fantasize about the “perfect relationship” and constantly wonder if the grass was greener on the other side.

The client reported being socially active and also noted being “overly-dependent” on interpersonal support and communication to cope with his current difficulties. He described that for situational problem-solving, he often relies on friends’ advice but rarely seeks help for emotional difficulties. He also described that when he is unable to consult a friend, he often feels incapacitated when forced to plan ahead or make decisions. At the beginning of treatment, the client had lived in an apartment with two roommates for less than a year, but within weeks of the start of the pandemic, largely moved into his girlfriend’s apartment. In general, he struggled to start projects or gain behavioral activation unless another person was involved in the activity. His social support network appears to be extensive as he reported talking to others in times of need, in addition to the fact that during the course of the intake, the client traveled and stayed with friends. Although he reported having friends, he denied having a best friend. When talking about seeing old friends, the client would often make remarks indicating that he was jealous of his friend’s successes. Rather than being happy for his friend’s, he would say things like, “I guess, good for them, but I can’t help but think ‘why can’t I have those things?’.” Lastly, the client denied any history of impairments or difficulties related to substance use.

Psychiatric History

From 2018 to 2019, the client saw a drama therapist following the end of an 8-year relationship with his past girlfriend. He terminated treatment with this therapist because he thought the therapist’s approach was “too life-coachy.” Before termination, he reported receiving a diagnosis of dysthymia. In the summer of 2019, he was prescribed Lexapro to treat his depression. He noted some alleviation of symptoms but also side effects in which he felt he was in a “haze” and had low sex drive. He stopped taking this medication after a few months due to the side effects and refuses to take alternative medications. The client denied any history of trauma, including physical or sexual abuse.

Pretreatment Assessment

The client completed several pretreatment measures as part of the intake process that occurred over four sessions with the same treating therapist. On the Acceptance and Action Questionnaire (AAQ-11; Bond et al., 2011), the client’s score indicated difficulties related to psychological inflexibility (AAQ-11 = 15) and on the Difficulties with Emotion Regulation Scale (DERS; Gratz & Roemer, 2008), the client’s score indicated difficulties regulating his emotions (DERS = 79), specifically when engaging in goal-directed behavior and finding successful emotion regulation strategies. In addition, he reported moderate levels of worry on the Penn State Worry Questionnaire (PSWQ = 45; Meyer et al., 1990) and mild symptoms of anxiety on the Beck Anxiety Inventory (BAI = 3; Steer et al., 1993) with a general dissatisfaction with life (Quality of Life Inventory = −2; Frisch et al., 1992).

On measures of depression, the client’s scores varied. On the Beck Depression Inventory (BDI-II = 6; Steer et al., 1999), the client’s depressive symptom levels were minimal with an endorsement of items related to sadness, pessimism, a loss of pleasure, and being easily fatigued. Conversely, on a measure of depression from the Personality Assessment Inventory (PAI; Morey, 2014), the client scored higher than 97% of his age and gender-matched peers (T = 68), indicating difficulties largely with affective and physiological depression. On the Diagnostic Interview for Anxiety, Mood, and OCD and Related Neuropsychiatric Disorders (DIAMOND; Tolin et al., 2016), a structured clinical interview, the client reported that he has felt depressed “for as long as [he could] remember,” with difficulty falling asleep and waking up too early, feeling easily fatigued, hopeless with difficulty concentrating and making decisions, and low self-esteem. He stated that his emotional distress “comes and goes” but is present most days for most of the day with an average intensity of 40%. The client also stated that he has not gone more than 2 to 3 days at a time for as long as he can remember without feeling depressed.

The discrepancy between scores on depression may reflect a tendency to underreport problems and symptoms on measures that are more face valid and obvious in what is being measured (i.e., BDI-II), with higher scores occurring on a measure that is less face valid and less obvious in what is being measured (i.e., PAI). This conclusion is consistent with the PAI, in which he scored high on a measure of inconsistent response style (T = 70, 98th percentile). In parallel with the clinical interview, this inconsistency in reports likely indicates the client’s inability to admit personal limitations, weaknesses, and problems, and a tendency to distance himself from the person he is (e.g., flawed) and the person he wants to be (e.g., idealized). It is also notable that the client was unable to report these difficulties when filling out questionnaires in private and then readily admitted these difficulties in conversation with the current therapist. This, again, may reflect a tendency to avoid personal limitations except when support from others is readily available.

On the NEO Five-Factor Inventory (NEO-FFI-3; Costa & McCrae, 2014), the client scored high on the subscale of neuroticism (T = 63, 91st percentile) and very low on the subscale of conscientiousness (T = 16, <1st percentile), indicating that he may be very sensitive to negative thought patterns and depressed mood, struggle to organize his thoughts and activities, and feel easily overwhelmed when faced with everyday tasks, errands, and obligations. On the Inventory of Altered Self-Capacities (IASC; Briere & Runtz, 2002), a measure of personality and the client’s response to interpersonal situations, the client scored highly on subscales of interpersonal conflict (T = 95, >99.9th percentile), abandonment concerns (T = 80, 99.9th percentile), and affect dysregulation (T = 77, 99.6th percentile), but scored within normal limits on subscales measuring his sense of identity. Specifically, he reported frequently experiencing thoughts of disbelieving someone when they say they care about him and becoming angry at the thought of rejection. Similarly, on the PAI, the client scored in the elevated range on the borderline subscale of negative relationships (T = 68, 97th percentile), indicating that he has a significant history of intense and unstable relationships. The client also scored in the below average range on measures of dominance (T = 44, 30th percentile) and warmth (T = 46, 34th percentile), suggesting a passive and distant approach to relationships. Individuals with these characteristics are often withdrawn, put little effort into relationships, and tend to be passive-aggressive when confronted with the needs of others. On the Personality Assessment Schedule (PAS), the client received a total score of 43 (M = 1.79), indicating the presence of a moderate personality disorder (Tyrer et al., 1984). Although his score was highest for dependent personality (Dependent = 12), the client’s scores on the PAS were not notably elevated for any particular subscale. Rather, the client struggled most with traits of anxiousness, pessimism, resourcelessness, and dependence, supporting his reports and previous findings.

Assessment During Treatment

During the course of treatment, the client’s progress was monitored using the Patient Health Questionnaire (PHQ-9; Kroenke & Spitzer, 2002) to measure depressive symptoms, and the General Self-Efficacy Scale (GSE; Schwarzer & Jerusalem, 1995) to measure the client’s sense of mastery over everyday situations. Given the importance of self-efficacy in the development and maintenance of depression, as well as the specific cultural implications of self-efficacy in depression (Wardle et al., 2004), a measure of self-efficacy was thought to be a relevant measure of progress. Figure 1 shows significant improvement in the client’s depressive symptoms and self-efficacy over the course of treatment. Following the intake process, the client’s PHQ-9 score decreased from 14 to 2 at the end of therapy, indicating minimal depression (Kroenke & Spitzer, 2002). His scores on self-efficacy increased from 13 to 21, indicating an increased sense of mastery over his environment.

OPEN IN VIEWER

Figure 1.

Depressive (PHQ-9) and self-efficacy (GSE) scores over the course of therapy.

Origins, Personality, and Interpersonal Difficulties

The client’s depressive symptoms likely originated following his family’s immigration to the U.S. from Eastern Europe, after which the client experienced a loss of identity and struggled to adapt to U.S. culture while maintaining his native cultural roots. This resulted in not only a loss of personal identity, but also a loss of cultural and familial identity, as the client felt disconnected from his family. Relatedly, the client struggles with a fear of abandonment and insecure attachment style, which he describes as “trust issues,” and is generally associated with greater internalizing problems, depression, and anxiety across the lifespan (Chauhan et al., 2014). This style of attachment may have originated when his father “abandoned” he and his family during their move to the U.S. and when trying to adapt to U.S. culture in the face of bullying classmates. In response to early adversity, the client developed humor early in life as a means to relate to others and to avoid emotional discomfort, often in interpersonal situations, which is a coping mechanism he still relies on as an adult. This insecure style of interpersonal relatedness was maintained by a cynical and emotionally avoidant familial environment and exacerbated in early adulthood when the client discovered his previous long-term partner was cheating on him.

As a result, the client struggles to trust his romantic partners and distances himself emotionally from others, often retreating from situations or relationships that may result in potentially negative evaluations. Related to theories of vulnerable narcissism and chronic depression, this guarded interpersonal style helps the client to preserve his positive view of himself and distance himself from personal weaknesses and disappointment with himself and others (Erkoreka & Navarro, 2017). A similar pattern of behavior emerges in his professional life as he engages only in opportunities in which he knows he will succeed (e.g., going to improv when he knows that he will perform well, procrastinating career tasks that are more challenging or could result in rejection). Although this style of harm avoidance may have some cultural roots and may have been an adaptive response at one point to reduce stress and boost his self-confidence, the client now utilizes this strategy indiscriminately. At odds with his own grandiose fantasies and expectations, the client often feels stuck, unmotivated, lonely, and perpetually disappointed by himself and others as a result of avoiding shame and disapproval and, ultimately, his own long-term success and achievements (Cloninger, 1987).

As a way of coping with distress as well as everyday minor problems, he is often dependent on others in the hopes that they pull him out of this cycle. He has a tendency to disclose situational information that may not necessarily reflect poorly on him, while struggling to disclose dispositional information that may expose his vulnerabilities and personal weaknesses. When positive reinforcement is not received from others, he finds these relationships taxing, difficult to tolerate, and tends to devalue others. At times, he rebounds from person to person or relationship to relationship, attempting to engage support or emotional positivity until he finds the result for which he is searching.

Despite his difficulty tolerating many interpersonal situations, the client genuinely cares about others, but lacks the persistence, motivation, thought organization, and emotional capacity to follow through on his good intentions. Instead, he may lash out impulsively when upset, not knowing entirely where his emotions are coming from and leading to increased interpersonal difficulties. In general, he is unable to tolerate unpleasant interpersonal situations because of the potentially negative connotations they may reflect about him (e.g., this means something is wrong with me, I am defective/a failure). Because unpleasant interpersonal situations are a necessary part of life, his chronic depression is maintained.

Dysregulated Thoughts, Emotions, and Behaviors

The client struggles to regulate his emotions and thoughts effectively and demonstrates an inability to maintain positive emotions, thoughts, and motivations when they seldomly arise. Despite describing himself as “silly, easy going, provocative, and sociable,” the client also reported feelings of anxiety regarding his romantic relationships and demonstrated a catastrophic style of thinking in which he worries and ruminates about “what will go wrong next?” and always expects the worst out of people and situations. Consequently, he tends to be very sensitive to everyday problems, becoming easily overwhelmed, distracted, and discouraged, often failing to see life’s rewards through its challenges. He also tends to be a pessimist, constantly dissatisfied with life, even under normal circumstances, but avoidant and unable to acknowledge or understand his problems and limitations.

Relatedly, the client demonstrates a cognitive dissonance in which there is a discrepancy between his relatively problem-free view of himself and the litany of problems he reports in his life. This leads to chronic feelings of disappointment and depression without fully knowing what these feelings are or where they come from. The client’s profession may help to reinforce this style of thinking as his cynicism and avoidance of personal weaknesses results in an unbridled comedic repertoire that may, at times, be appealing to others. However, the result of these systems are immense feelings of hopelessness, depressed mood, and worry at the cost of his self-esteem and self-efficacy, leaving him feeling little control and autonomy over everyday situations. As a result, the client often engages in cycles of self-defeating and, at times, impulsive behaviors (e.g., ending relationships, putting off work). Most predominantly, the client struggles to be active, particularly when he is emotionally distressed. This results in a cycle of increasingly depressed mood, dissatisfaction with the self and others, and increased inactivity. In general, this has caused him problems in his personal life as well as his social and romantic relationships.

Sessions i to iv: Intake

The intake included a comprehensive psychological assessment conducted over four sessions. In addition to a semi-structured clinical interview, a structured diagnostic interview (DIAMOND), and cultural interview, several pretreatment questionnaires (e.g., symptoms, substance use) and personality assessments (i.e., PAI, PAS, NEO-FFI-3, IASC) were administered. Following the intake, a collaborative feedback session was conducted reviewing the results of psychological testing, working diagnoses with the client, recommendations and plans for treatment, and the client’s goals for therapy. Although the entire assessment was part of the therapeutic process, the ultimate mode of therapy was not commenced until both the client and therapist were both in agreement.

Phase 1: Sessions 1 to 6

Sessions 1 through 6 included rapport building, psychoeducation regarding dysthymia and the dysregulation of thoughts, emotions, and behaviors, consistent with CBT, and an introduction to cognitive restructuring. However, it was made apparent early on that the client was not ready for cognitive restructuring. It is possible that the cognitive dissonance between his view of himself and his problems was still too great at the time, making it too difficult to introspectively examine oneself without first establishing a greater therapeutic rapport and increasing hope and motivation through behavioral interventions first.

However, during this early time period, one intervention that stood out as particularly effective was direct communication with the client regarding transference in the therapeutic relationship, consistent with disciplined personal involvement in CBASP (McCullough & Clark, 2017). Specifically, the client’s fear of abandonment was directly discussed after the client expressed a concern that the therapist would leave the client for another clinical placement during the course of therapy (e.g., “I feel that you’re having difficulty trusting me right now”). The client found the comparison between this interaction and others in his romantic life particularly illuminating and helpful. Also helpful were examinations of the impact of early adverse events (e.g., immigration, distant father) and how these events may influence the way he thinks, feels, and approaches other people. In general, discussing the therapeutic relationship and the impact of early adverse events early on helped to engage the client and provide real world and real time examples of how his dysregulated thoughts and emotions may affect interpersonal relationships and work to maintain negative expectations, insecure attachments, and depressive symptoms.

Phase 2: Sessions 7 to 22

Following psychoeducation and an introduction to CBT, therapy transitioned to a modified CBT for insomnia (CBT-I) followed by behavioral activation (BA) three sessions later, which comprised 16 sessions. Therapy emphasized these behavioral approaches early on as an individualized form of treatment due to the client’s difficulties feeling “stuck,” unmotivated, and inactive, as well as his difficulties sleeping that largely inhibited any activity, sometimes including active participation in therapy (e.g., homework), and resulted in intense fatigue. Components of BA specifically focused on appraisals of social situations and behavioral inhibitions that occurred in the context of interpersonal situations, similar to situational analysis (SA) in CBASP (McCullough & Clark, 2017).

This period of therapy was particularly important as the most significant reductions in depressive symptoms were made. Similar to research on MDD, BA was an effective early treatment for dysthymia in this case as it was consistent with the client’s goals, time-efficient, and largely did not require the complex skills and introspection needed for other CBT modalities. BA may have acted as an “introduction to CBT” and helped the client gain the motivation and personal resources necessary to identify, evaluate, and reconstruct more intimate and challenging personal and interpersonal issues. Although the principles of CBT-I and BA were maintained throughout the course of therapy, sessions eventually transitioned back to CBT with a focus on interpersonal situations when the client was ultimately able to maintain and schedule activities as a part of his daily routine. At this point in therapy, he had gained the necessary motivation, energy, and hope to participate more fully in therapy and create more cognitive and emotional growth.

Phase 3: Sessions 23 to 32

The last 10 therapy sessions incorporated principles of cognitive restructuring, particularly around interpersonal situations and his romantic relationship, as well as problem-solving. This portion of therapy was consistent with situational analysis and examinations of interpersonal experiences in CBASP, in which clients are helped to evaluate and reconstruct inaccurate interpersonal expectations and interpretations, that may be dependent on early adverse life experiences, to more accurately reflect current interpersonal experiences (McCullough & Clark, 2017). During this time, core beliefs of being defective or a failure reemerged, particularly in the context of interpersonal situations. In depth examinations of interpersonal experiences worked to increase the client’s understanding and empathy toward others and increase his ability to tolerate negative affect when it inevitably arises, which helped to address the client’s insecure style of attachment. With depressive symptoms at a minimal level, this stage of therapy helped the client maintain his progress and apply cognitive restructuring skills to current interpersonal situations. Ultimately, being active, sleeping regularly, modifying his cognitive and emotional reactions when necessary, and being able to tolerate negative affect in interpersonal situations as essential parts of relationships rather than indications of personal faults, proved most helpful to the client. In addition to reductions in symptoms, the client was better able to tolerate negative affect and uncertainties in relationships, demonstrated more compassion to his loved ones, and was even able to reconnect with his mother and father, spending the weekend with them on occasion.