Study on

a case with
Attachment issue

Module 2 Assignment - EPP

Lecturer : Anne Plantade-Gipch,
Ph.D., Assistant professor, Psychologist
Students :
1. Alice Le Nguyen Ha Anh
2. Ho Thi Viet Nga
Date of submission: 10/08/2023
CONTENTS
Page 01. Page 02.
Client's introduction Maternal family
Why now? Married life
Appearance and attitude
Symptoms

Page 03. Page 04.

Attachment style Professional supports
Intervention approach Current case progress
Working conditions

Page 05.
Current case progress
Long story short and thanks
Client’s introduction:
T., female, 28 years old, currently works as a media specialist and event management
coach. She used to study abroad, has a bachelor’s degree and is on a master’s course.
Getting married from the beginning of 2022, having a 6th month old son and temporarily
separating with her husband. She does not follow any religious belief. She was born and
raised in Ho Chi Minh city.

Why now?
T. met the psychotherapist (the psych) when they both joined a class for career
orientation. T. had been in a marriage crisis with her husband for several months and felt
very confused, depressed and powerless. She found it hard to decide to leave her
husband or not, at the same time was under her mother’s pressure to make the decision
as soon as possible. Too much stress made her feel overwhelmed and had a serious
impact on both her daily emotions and her jobs. Therefore, she decided to find a
professional psychotherapist to help her overcome this complex situation. When she knew
that was the job of the psych, she offered to receive psychological intervention. She chose
to work online through Google Meeting platform with the psych.

T’s appearance and attitude at the first session:

In this session, T. appeared in time. She looked neat and tidy in office clothes. She wore
makeup, had a chin-length bob hairstyle, and a good-looking face. She had a smooth and
calm voice.
Her attitude was polite, she called the psych by “sister N.”, which is a normal way to call
strangers on the first meeting in Vietnamese culture. She was quite intelligent with logical
and coherent thinking and a diverse way of language use.

T’s symptoms:
The psych and T. went through the PHQ-9 test for depression with the validated
Vietnamese version (Trung Nghia Nguyen et al., 2020). Combining with some knowledge
from DSM-5, the results showed that T. had exhibited many symptoms of moderate
depression and anxiety for 3-4 months before the first session:
Poor sleep, often having sleep paralysis.
Her eating habits were normal, but she gained a bit of weight because of intense
stress. Alcohol and coffee was restrained for her baby’s sake.
The mood was often in a depressed state, crying a lot when being triggered.
Having given birth for a baby only several months; there were thoughts of suicide or
mild self-harm after the birth of a baby.
Self-doubt and insecurity about appearance.

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 The ability to work and self care is still normal, however, she had found many things to
work on and study so that there was no free time for intrusive anxious thoughts. These
thoughts’ content was mostly about her marriage and her mother’s forceful behaviors.
There were no problems of accidents or other physical illnesses.
From the details above, the psych suggested the hypothesis that her depression and
anxiety were more or less affected by her life events as well as pregnancy. Since she was
still able to maintain life function, the psych would temporarily not recommend psychiatric
support, but still need to follow up her diagnosis.

T’s maternal family:

There are 4 people in T.'s maternal family including her:
First, her father who was born in 1966 in Quang Nam province, moved to Ho Chi Minh City
with T’s mother and stopped studying after high school to earn a living and get married.
Several years later, he continued to take higher education and got a master’s degree. He
currently owns a logistic company.
Second, her mother who was born in 1969, originally from Binh Dinh, living in Quang Nam.
She got a bachelor’s degree in pedagogy and used to hold the position of vice principal at
a public school in Ho Chi Minh City. Now, she works as a math teacher.
Third, T. has a brother who was born in 2000.

In the past, her family lived in difficult financial conditions, so her parents almost decided to
abort T., but finally decided to keep the baby. During her toddler years, she had the
impression that she was forced to go to kindergarten school to be taken care of by
outsiders, since her parents could not do so. She felt attached to the school even more
than her own family. T. felt that she “lacked of care and love from family, no emotional
connection with parents.” Although her relationship with her dad and brother was not bad,
her harsh relationship with mom and her mom’s power in the family still had the biggest
impact on her childhood. She thought she “was an unwanted child, did not feel any gentle
and loving gestures or behaviors from her mother”. She described the mother as being
overly controlling of her children’s life and put a lot of high expectations about academic
achievements, morality and even marriage on her daughter. Nevertheless, the mother did
not respect her reputation in front of neighbors and strangers, usually invalidating her
abilities. Therefore, T. had plentiful trust issues with her mother.

T’s married life:

Her husband is an only child, was abandoned by an American father and has lived with his
mother. He currently works as a photographer. He always wants a wife who can obey and
take care of her mother. That was how T. became his wife: by approaching his mom and
showing T’s ability to care for her. T. said that she is not her husband’s woman type, but
she wanted to marry him because he was really attractive. T’s mother was against this
marriage, somehow, this attitude became a motivation for T’s to marry him.

02
However, during the marriage, the control of the mother-in-laws and the neglect of the
husband became extreme stress factors for T. When T. was pregnant, the husband told
her to abort the child but she still gave birth to the baby. After the child labor, T. received
no sign of care from her husband, she felt so frustrated that she temporarily broke up with
him, lives with her son in another house now.

A hypothesis on T.’s attachment style:

The psych suggests a hypothesis that T. may have the anxious and avoidant attachment
style, based on the works of John Bowlby và Mary Ainsworth.
The fact that T. cannot feel her mother’s love, the neglect and control of her mom on her
lead her to develop a fear of being rejected when she becomes adult. Hence, she tried to
find the closeness and comfort from someone that has the same characteristics with the
mother, who is her husband. She feels anxious and insecure with the absence of the
husband and often checked on his whereabouts. T. usually doubts her husband’s loyalty
since he used to have a playboy life: “I am afraid that he cannot keep himself together”,
“He does not seem to love me at all”.
The psych feels that this marriage was T’s way to rebel against her mother, and her son is
the string she created to maintain the relationship with her husband. There is a repeating
pattern that T. was almost never born, and her son has the same fate.
The psych also thinks that T. has an avoidance tendency whenever stressful incidents
come. In order to deal with the hard feelings they bring, she separates herself from closed
ones, overworking to distract her from reality and her own mental state.

Intervention approach:
The therapeutic process involves the application of Cognitive Behavioral Therapy (CBT) as
the primary intervention technique, supplemented by Acceptance and Commitment
Therapy (ACT). These methods are employed during sessions to assist the client in
comprehending and accepting both positive and negative aspects of her life. Through
activities like recording daily activities, identifying emotions, thoughts, and behaviors, T.
engages in self-awareness and self-reflection. The psych employs empathetical listening
skills, content and emotion feedback, summarization, and interpretation to help T.
recognize psychological stressors, enabling emotional regulation.
After addressing the client's immediate priorities, the psych integrates the Attachment
Theory to address attachment-related issues, if the client expresses the need.
Expected number of sessions: 12 sessions, each lasting 60 minutes. After every four
sessions, psych and client engage in an evaluation of progress and make necessary
adjustments.

Working conditions:
The psych conducts online sessions from home, while the client attends sessions from her
workplace after regular working hours, typically after 18:00.

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This prompts questions about T's perceived discomfort within her home environment,
reflecting potential feelings of insecurity.
The online format optimizes time and travel expenses for the client, allowing for flexible
location and scheduling. However, challenges exist in observing T's nonverbal cues due to
unstable internet connections and the limit of the screen, which affects session quality in
some extent.

Possible professional support sources:

Supervision: Timely supervision from the therapist's supervisor is challenging to secure,
leading to some hesitancy in addressing therapy process concerns.
Peer consultation: Colleagues acknowledge the complexity of the case and experience
difficulties during case analysis. She support employing CBT & ACT to intervene on
priority complaints of the client (like how to decrease stress level, how to make decision
on marriage) at first, and perhaps heading towards intervening at a deeper level
challenging, starting from Session 5 onwards, if necessary.

Current Progress: Four sessions have been conducted so far.

Session 1: The psych established a therapeutic alliance with T., assessed her mood
and collected relevant data for case formulation. The client T's psychological support
needs, issues of concern, stressors, symptoms, and therapeutic expectations were
explored.

Session 2: The psych helped the client identify pivotal factors causing distress, wherein
T.'s core self had been eroded and dominated by imposed thoughts from her own
mother, her mother-in-laws, and her husband. The client was detached from herself.
Patterns were recognized through exercises to define thoughts, emotions, and
behaviors. Through these tools, the client realized her fear of making decisions and
assuming responsibilities, consistently leaving others to make decisions on her behalf.
T. gave a feedback during Session 2, expressing a moment of self-reflection: “This
session today with you (2nd session) can be likened to a reflective mirror, facilitating a
profound introspection into the precise points where I find myself entangled. It's as if a
sudden realization has unfolded within me. Over an extended period, I remained
oblivious (tears well up), my emotional experiences had been subject to external
influences. I get stuck and don’t know to face with it”.
🡪 At that very moment, the client could label her emotions as "getting stuck" and
"disappointment." The psych acknowledged her effort and progress in practicing exercises
that had helped her experience newfound self-awareness, acknowledge her suppressed
emotions, and the the psych responded empathetically to the emotions she had
continuously experienced.

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 Session 3: The psych addressed an activating event where the client avoided meeting
her husband but consistently tried to chat or send him message every morning. If he
did not respond, she would feel sad and distressed. T. started to realize her pattern of
wanting to end the marriage yet persisting in texting her husband. Through Socratic
questioning, the client recognized her behavior as “repetitive and addictive", likening it
to dependency”.
The client viewed her marital relationship then as "toxic" and "draining."
By the end of the session, she expressed relief and emotional release.

Session 4: The psych tackled a new activating event involving her mother's comments
about her children. The mother suggested that one of her "arms" (referring to the client)
were handicapped, implying that her children’s “disability” was unacceptable. The
mother pushed T. for a swift divorce and start new life. The mother tended to
manipulate her daughter's psyche, using statements like "I'll die if you continue with
this marriage". The client identified them as gaslighting behaviors, realizing her
mother's tendency to undermine her self-esteem. The client began asserting her
thoughts regarding her mother's attitude, although not directly responded to her
mother. She acknowledged the improved emotional regulation and expressed her
willingness to engage more fully in exercises.

Long story short:

This is the first time our team takes responsibility for a marriage crisis case relating to
attachment problems.
Initially, we found the client's story complicated and did not know what to do. We can feel
the useless feeling from both us and the client. Fortunately, after the course with EPP,
several sessions of peer discussions and the amazing efforts of the main therapist (Ms Viet
Nga) with the client, we began to figure thing out, found ways to formulate the case and
reached some good outcome.
Last but not least, we send Dr. Anne Plantade-Gipch our gratitude for your wonderful and
dedicated support in our career.

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REFERENCES
1. American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders (5th ed.).
https://doi.org/10.1176/appi.books.9780890425596
2. Bowlby, J. (1969). Attachment and Loss, Vol. 1: Attachment. New York:
Basic Books.
3. Collins, S. (2022). Gaslighting in Families: Signs of Gaslighting Parents,
derived from https://www.psycom.net/gaslighting-parents-families,
accessed on November 27, 2022.
4. J. Beck (2020), Cognitive Behavior Therapy: Basic and Beyond – 3rd
edition.
5. Nguyen Trung Nghia, Pham Le An, Nguyen Dong Phuong Tien (2020).
Reliability and Validity of Vietnamese Version of Patient Health
Questionnaire 9 Items (PHQ-9) Among UMP Medical Freshmen.
6. Stephanie A. Sakish (2023), Psychology Today, Why Anxious and
Avoidant Attachment Attract Each Other, derived from:
https://www.psychologytoday.com/us/blog/here-there-and-
everywhere/202306/why-anxious-and-avoidant-attachment-attract-
each-other