Seeking Approval, Self-Worth Through Risk: A Case Study
When a 25-year-old sought counseling for exhaustion, work issues, and risky behavior.
Rachmanas Counseling
Presenting (Psychological Counseling) Problem
She was twenty-five. She was exhausted. And she had run out of ways to explain to herself why she kept doing what she was doing.
The client worked in a mid-level IT role. She came to Rachmanas for psychological counseling carrying three overlapping concerns: emotional exhaustion, declining work performance, and a pattern of sexual behavior she described as compulsive and self-defeating. She was articulate about the pattern.
She understood it, at least intellectually, better than most clients at the point of first presentation. Understanding it had not been enough to interrupt it.
The behavior followed a recognisable structure. She sought encounters with multiple partners. These encounters were not primarily about desire.
She described them as being about a specific and temporary feeling: the feeling of being seen. Of mattering to someone in a way that felt immediate and unambiguous. The encounters often involved tolerating humiliation or dominance.
She tolerated these things not because she wanted them but because they were the price of the validation she was seeking. Afterward, without exception, came shame. Emptiness. A fatigue that was not physical.
She was also in a committed long-distance relationship. Her partner was gentle, consistent, and respectful. She described him with genuine warmth. She had also been repeatedly unfaithful to him.
The unfidelity was not about dissatisfaction with him as a person. It was about something his gentleness could not provide: the sharp, immediate reinforcement that casual encounters delivered.
His consistency felt invisible. The encounters felt real. She knew that equation was distorted. She could not, on her own, correct it.
The childhood history surfaced early in the assessment. Her parents had been chronically critical. Validation had been rare.
Conditional at best. She had grown up inside a household where the question of whether she was good enough was never settled in her favour. She connected that history to the present pattern herself, unprompted.
Episodes of parental criticism, even now, reliably preceded the urge to seek external approval. The connection was not a clinical interpretation she needed to be shown. It was something she had been carrying, unprocessed, for years.
Assessment and Formulation
The assessment at Rachmanas included a structured clinical interview and self-report measures covering mood, impulsivity, and behavioural patterns.
The results did not support a diagnosis of compulsive sexual disorder in any formal clinical sense. What they indicated instead was a well-established, approval-dependent coping pattern with roots in chronic early invalidation.
The cognitive-behavioural formulation had a clear architecture. The core belief, operating below the level of conscious articulation in most moments, was that she was fundamentally not good enough.
That belief had been installed across years of criticism and confirmed, through selective attention, by every subsequent experience of not receiving the unconditional validation it required.
Young and Klosko (1993), in their work on early maladaptive schemas, identified the defectiveness and shame schema as one of the most clinically significant patterns arising from chronic childhood invalidation.
Its central feature is a deeply held conviction that one is fundamentally flawed, unlovable, or inferior, a conviction that feels like fact rather than belief and that generates powerful compensatory strategies designed to manage the pain it produces.
The compensatory strategy in this case was approval-seeking through sexual encounters. The logic was not conscious but it was coherent: if the core belief said she was not good enough, then immediate and intense expressions of desire from another person temporarily overrode it.
The override was brief. It was also reliable enough to have become the dominant coping mechanism across several years.
The trigger was specific. Criticism, whether from her parents directly or from her own internalised critical voice, activated the core belief with particular force.
The behavioural response followed: seeking an encounter that would produce the feeling of being wanted. Temporary relief arrived. Then shame. Then the belief, reinforced rather than resolved, waiting for the next trigger.
Linehan (1993), in her foundational work on dialectical behaviour therapy, described invalidating environments as contexts in which a person’s emotional responses are consistently met with dismissal, criticism, or indifference.
The long-term consequence is not simply low self-esteem. It is the failure to develop the internal emotional regulation capacity that consistent validation in childhood builds.
The client had not been taught, because her environment had not provided the conditions for this, that her own emotional experience was a reliable and trustworthy guide. She had learned instead to look outward for confirmation that her experience was real and that she herself was acceptable.
Neff (2003), in her research on self-compassion, identified that individuals with chronic shame tend to respond to emotional pain with self-criticism rather than self-care.
That self-critical response intensifies distress rather than reducing it and drives further compensatory behaviour.
The shame following each encounter was not moving the client toward change. It was deepening the wound that the encounters were attempting to address.
The formulation at Rachmanas therefore identified three clinical priorities. The core belief required examination and gradual restructuring. The emotional regulation capacity that her developmental environment had not built required explicit development.
And the shame cycle, which was maintaining the pattern rather than interrupting it, required a specific clinical response.
Intervention
The psychological counseling process at Rachmanas was structured around these three priorities. The approach was integrative. Each modality was introduced in response to where the client was clinically at each stage.
1. Cognitive Restructuring
The early sessions were oriented toward the belief structure the formulation had identified. The clinical approach was Beck’s (2011) collaborative empiricism. Beliefs were treated as hypotheses.
The question was never whether her feelings were valid. They clearly were. The question was whether the interpretive framework producing them was an accurate account of her situation.
The core belief, “I am never good enough,” was not challenged directly in the early sessions. Direct challenge of deeply held shame-based beliefs tends to produce one of two responses: defensive dismissal or deeper shame.
Neither is therapeutically useful. The approach instead involved slowing the automatic thought process down enough to examine its components.
When did the belief first arrive? What evidence had she gathered for it? What evidence had she systematically discounted?
The discounted evidence was considerable. She was professionally capable. She maintained relationships with genuine warmth. She had sought help for a problem that many people would not have had the courage to name.
None of this had been incorporated into her self-concept. It had been filtered out by a belief system that was selectively attentive to confirming information.
The automatic thought linking self-worth to others’ approval was examined with particular care. The client could articulate, intellectually, that approval from a casual sexual encounter was not meaningful evidence of her worth.
The intellectual articulation and the felt conviction were not yet connected.
That gap is where the cognitive work lived. Beck’s model does not promise that the gap closes quickly. It provides tools for narrowing it, gradually, through repeated examination and accumulating disconfirming experience.
Butler and colleagues (2006) documented that CBT’s effectiveness in addressing patterns driven by core beliefs is most robust when the approach engages the specific belief content rather than generic negative thinking.
The restructuring work here remained tightly bound to the actual thoughts the client reported in session.
2. Mindfulness and Self-Compassion
The second strand introduced mindfulness-based practices alongside an explicit self-compassion framework. These two components addressed different aspects of the same clinical problem.
The mindfulness practices were functionally specific. The target was the interval between the trigger, typically a critical interaction or internalised self-criticism, and the behavioural response. That interval had been very short. The urge followed the trigger quickly. The behaviour followed the urge before any deliberate choice could intervene.
Kabat-Zinn’s (1994) formulation of bare attention provided the underlying principle. Brief, practiced pausing in moments of emotional activation. Noticing what was arising. Identifying the emotional trigger before it produced the automatic behavioural response.
Creating enough space for a different choice to become available. The client practiced this through short breathing exercises and a structured pause technique she could use when urges arose in daily life.
The self-compassion component drew directly on Neff’s (2003) clinical framework.
Self-compassion, as Neff defines it, involves three elements: self-kindness rather than self-judgment, recognition of common humanity rather than isolation, and mindful awareness of painful experience rather than over-identification with it.
For a client whose dominant response to her own distress was shame and self-criticism, each of these elements required explicit practice.
The clinical reasoning here is important. Shame does not motivate change. It deepens the wound and drives further compensatory behaviour. Self-compassion is not self-indulgence.
It is the psychological condition under which genuine change becomes possible, because it removes the self-critical pressure that makes the compensatory behaviour feel necessary in the first place.
Neff and Germer (2013) documented that self-compassion training produces significant reductions in shame, self-criticism, and anxiety.
It also increases the willingness to acknowledge and address problematic behaviours without the defensive avoidance that shame produces.
3. Skill Building and Alternative Sources of Validation
The third strand addressed the absence of alternative sources of the felt experience the client had been seeking through sexual encounters. She wanted to feel seen. She wanted to feel capable. She wanted evidence that she was acceptable.
The encounters had been providing a distorted and ultimately self-defeating version of all three. The clinical task was not to eliminate the need but to develop healthier pathways toward meeting it.
The practical work involved identifying activities and contexts in which the client could develop genuine competence and receive genuine recognition.
Creative outlets she had abandoned in her early twenties were revisited.
Skills relevant to her professional role were identified as areas for deliberate development. Social connections outside of sexual contexts were mapped and, where possible, strengthened.
Deci and Ryan’s (1985) self-determination theory provides the relevant clinical framework here. Genuine wellbeing requires the satisfaction of three basic psychological needs: autonomy, competence, and relatedness.
The client’s approval-seeking pattern had been attempting to address the relatedness need through means that simultaneously undermined her sense of competence and autonomy.
Building genuine competence in non-sexual domains addressed the same underlying need through a pathway that reinforced rather than eroded the other two.
4. Family Intervention
With the client’s explicit consent, a structured conversation about the family dimension was included in the psychological counseling process. The Rachmanas team did not direct the client toward or away from any particular position regarding her parents.
The therapeutic task was more specific: to support her in articulating, for herself, what the chronic criticism had cost her, and to explore whether a different kind of dialogue with her parents was something she wanted to pursue.
She decided it was. The sessions provided preparation and psychoeducation for that conversation. Her parents were not participants in the counseling process.
The preparation was for the client: how to approach the conversation without accusation, what she wanted to communicate, and how to manage her own emotional response if the conversation did not go as she hoped.
The outcome of that conversation was partial. Her parents were receptive to a degree she had not expected. The criticism did not disappear. But its hold over her internal landscape began to loosen, partly because she had named it directly and survived doing so.
5. Risk Reduction and Safety Planning
The fifth strand addressed the practical safety dimension of the presenting behaviour. The client had engaged in encounters without adequate attention to her own physical safety.
Psychoeducation on sexual health and risk reduction was provided without judgment and without any implicit suggestion that the sexual behaviour itself was the primary clinical problem. It was a secondary concern. But it was a real one.
A safety plan was developed collaboratively. It identified high-risk situations, the conditions under which impulsive decisions were most likely, and specific alternative responses available at each point. The plan was not designed to restrict the client’s autonomy.
It was designed to ensure that in moments of high emotional activation, she had a structured alternative available rather than a binary choice between the familiar behaviour and nothing.
Progress and Outcome
Progress in a case of this kind does not announce itself. It accumulates in small shifts that are only visible in retrospect.
The first shift the Rachmanas team noted was in the quality of the client’s relationship to her own pattern. By the third session, she was describing her behaviour with less shame and more clinical curiosity.
That shift matters. Shame produces concealment. Curiosity produces examination. The examination is where the work happens.
By the middle of the process, the pause technique was functioning reliably in lower-intensity situations. She reported declining several encounters that would previously have felt inevitable.
The declines were not effortless. The urge was present. She had developed enough of an interval between urge and action to make a different choice. Several times she had made it.
Lapses occurred. They were expected and addressed without catastrophising. A lapse is not a failure of the therapeutic work.
It is clinical material. Each lapse was brought into the session and examined for what it revealed about remaining triggers, gaps in the coping repertoire, and the conditions under which the old pattern still had sufficient pull.
Her work performance improved as the fatigue lifted. The fatigue had been, in significant part, the cost of carrying the shame cycle across every working day.
As the cycle became less consuming, cognitive and emotional resources became available for other things.
The long-distance relationship remained unresolved at the close of the counseling process. The client did not arrive at a clear decision about it. What she did arrive at was a more honest relationship to the question.
She began asking what she actually wanted from a relationship rather than what a relationship could provide for her deficiency belief. That shift in the question is, clinically, more significant than whatever answer eventually follows it.
Lambert (2013), reviewing decades of psychotherapy outcome research, identified that durable improvements in entrenched approval-seeking patterns require both cognitive insight and sustained behavioural change. The trajectory of this case was consistent with that finding.
Ethical and Professional Considerations
All identifying information in this case has been modified to protect the client’s privacy. Informed consent was obtained before any anonymised discussion for educational purposes.
The psychological counseling process at Rachmanas was conducted in accordance with the ethical guidelines of the American Psychological Association (2017). Several ethical dimensions specific to this presentation require explicit discussion.
The client’s sexual behaviour was not treated as the clinical problem requiring correction. It was treated as a symptom of an underlying psychological pattern. This distinction is not semantic.
Framing sexual behaviour as the problem, rather than as an expression of unmet emotional needs and inadequate coping resources, would have reproduced the judgmental environment the client’s developmental history had already provided in excess.
The Rachmanas team maintained a consistent position of clinical neutrality toward the behaviour itself while engaging seriously with its psychological function and its consequences.
The question of the long-distance relationship raised its own ethical complexity. The client’s partner was not a participant in the counseling. His interests were not the counselor’s clinical responsibility.
The client’s autonomy over her own decisions was. The Rachmanas team did not advise disclosure or non-disclosure.
It provided a space in which the client could examine her own values regarding honesty and decide for herself what course of action was consistent with them.
Closing Reflection
Behaviour that looks like compulsion is often, on examination, something more specific. It is a coping strategy. It is a strategy that once made sense, in the context in which it developed, as a response to a genuine and unmet need.
It has persisted because nothing has replaced it. And it continues to produce its original function, temporarily and at increasing cost, while the need it was designed to address remains unresolved.
That is the pattern at the centre of this case. Not addiction. Not moral failure. A twenty-five-year-old woman who grew up in a household where she was never quite good enough, who learned to seek in brief encounters with strangers what she had never reliably received at home, and who arrived at Rachmanas exhausted by the cost of a strategy that was working just well enough to prevent her from abandoning it.
Psychological counseling offered her something specific. Not judgment. Not a protocol for eliminating unwanted behaviour.
A clinical relationship in which the behaviour could be examined without shame, the belief producing it could be tested against evidence, and the emotional regulation capacity her developmental environment had not built could be gradually developed in its place.
The progress was real. It was also incomplete, as progress at this stage of the work always is. The core belief does not dissolve in several months of psychological counseling. Its grip loosens.
The automatic sequences it drives become more visible and more interruptible. The shame that has been feeding the cycle begins to lift. And in the space that the lifting creates, something more durable than external approval begins to take root.
That is the work. It is slow. It is worth doing.
References
- American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. Washington, DC: Author.
- Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press.
- Butler, A. C., Chapman, J. E., Forman, E. M., and Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17-31.
- Deci, E. L., and Ryan, R. M. (1985). Intrinsic motivation and self-determination in human behavior. Plenum Press.
- Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. Hyperion.
- Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., Chapleau, M. A., Paquin, K., and Hofmann, S. G. (2013). Mindfulness-based therapy: A comprehensive meta-analysis. Clinical Psychology Review, 33(6), 763-771.
- Lambert, M. J. (2013). Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed.). Wiley.
- Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
- Neff, K. D. (2003). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and Identity, 2(2), 85-101.
- Neff, K. D., and Germer, C. K. (2013). A pilot study and randomized controlled trial of the mindful self-compassion program. Journal of Clinical Psychology, 69(1), 28-44.
- Wampold, B. E., and Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). Routledge.
- Young, J. E., and Klosko, J. S. (1993). Reinventing your life: The breakthrough program to end negative behavior and feel great again. Plume.
