Fictional Male Case Study

(Adapted for professional illustration)

A Therapeutic Relationship Leaves A Presence In A Talk Therapy Room

Why This Matters

This case illustrates how substance use, anger, and identity can function as responses to unresolved psychological pain. It evidences an integrative therapeutic approach combining relational psychotherapy, CBT-informed interventions, and psychodynamic exploration.

Client Context

The client, a male in his forties, was referred to counselling following concern from his partner regarding his health and alcohol use. He described a longstanding commitment to being a “good man,” shaped by a desire to be different from an aggressive and abusive father.

Professionally, the client held a senior management role within a public service organisation and presented as competent and well-functioning. However, he reported increasingly secretive alcohol use, including hiding empty and unopened bottles at home and at work.

The client attended therapy initially as a “visitor,” having been encouraged by others to seek support. His stated therapeutic goal was to address anger management.

Clinical Formulation

Early formulation suggested that anger functioned as a surface expression of deeper shame, guilt, and fear of failure. Alcohol use appeared to serve a regulatory function, numbing emotional distress and internalised self-criticism.

Given the client’s history of parental abuse, internalised moral pressure, and difficulty accessing vulnerability, an integrative relational approach was clinically indicated. This allowed for attention to cognitive patterns, unconscious processes, and the therapeutic relationship itself.

Therapeutic Approach and Work in the Room

Initial sessions (1–3) focused on establishing safety and trust. Substance use was not immediately labelled as addiction, as premature naming risked reinforcing shame and defensiveness. The client frequently described alcohol as a reliable, non-judgemental companion.

A rupture occurred when the client experienced a perceived judgement regarding alcohol dependency. This moment became clinically significant. Rather than withdrawing, the work focused on repairing the therapeutic relationship and exploring the client’s emotional response.

CBT-informed techniques were introduced to examine anger-related automatic thoughts and behavioural patterns. Concurrently, psychodynamic concepts - including unconscious drivers, guilt, and the role of the superego (internalised critical voice) - were used to explore the historical origins of these responses.

As sessions progressed, the client identified a recurring fear of failure linked to paternal expectations and unresolved grief. Alcohol use was increasingly understood as a means of soothing shame and maintaining emotional control.

Risk Awareness and Ethics

Throughout the work, alcohol use, emotional regulation, and relational functioning were regularly reviewed. The pace of intervention was adjusted to maintain emotional safety, and boundaries around scope of practice were maintained.

Therapeutic Shift

Change initially emerged non-verbally, through reduced agitation and increased emotional tolerance. A significant shift occurred when the client recognised deep dissatisfaction in his career, connected to an ongoing attempt to gain approval from a deceased parent. This insight marked a transition from skills-based counselling into deeper psychotherapeutic work focused on identity, loss, and self-worth through transference.

Reflexive Learning

This case highlighted the importance of monitoring confirmatory bias, particularly in relation to gendered narratives around anger and substance use. Somatic awareness (tightness of breath, shifts in posture) informed my understanding of countertransference and supported attuned relational work. It reinforced the necessity of pacing, non-judgement, and relational repair when working with shame-based presentations drawing on humanistic aspects.

Wider Clinical Reflection

This work reflects a common experience among men who internalise expectations of being “good” or “functional” while remaining disconnected from emotional needs. Substance use may develop quietly within otherwise high-functioning lives until distress becomes unmanageable.

Engaging in therapy as a “visitor” requires significant courage. For this client, relinquishing reliance on alcohol represented not simply abstinence, but the beginning of an authentic relationship with himself.