Critically analyse and evaluate your experience of using a cognitive/ behavioural approach in a case study with a client you

have worked with throughout the period of training.

The client I worked with during this period was a male Police Officer aged 31 years working in intelligence, who had undergone quite significant changes in the last 3 years, got married which brought about the stress of responsibility, followed very quickly by 2 babies adding to his responsibilities. The pressure and stress were impacting on his marriage and generating extreme anxiety symptoms for a person who was very much aware that he constantly worries.

The client went to see his GP in February who referred the client for counselling citing anxiety, worry, and inability to unwind as reasons for the referral. When I met the client in March he stated that his reasons for coming to counselling were that he perceived he had anxiety and wanted to address it as it was affecting his relationships. When the client had his initial assessment with my colleague it was suggested that the client would benefit from Cognitive Behavioural Therapy. Literature Review: When I met with this client it was clear he wanted to understand why he behaved as he did and wanted to be able to control his be behaviour due to the consequences/ effects it was having on his health, anxiety, chest pains concerns that he was having Panic attacks which it was why it was suggested that Cognitive Behavioural therapy Would help. Elliss (19620 cognitive approach is based on the principle that irrational beliefs are the source of disturbed emotional and behavioural consequences. These beliefs consist of unconditional should, musts and demands which lead to illogical Cognitions and emotional disturbances.
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Beck cognitive theory of emotional disorders (Beck, 1967; 1976) states that emotional disorders are maintained by a thinking disorder in which anxiety and depressions are accompanied by distortions in thinking. Dysfunctional processing can present a stream of negative automatic thoughts in the clients consciousness, negative automatic thoughts reflect clients underlying beliefs and assumptions stored in memory, these are sometimes termed as schemas, or core beliefs also known as rules for living formed during childhood/early years. Once the schemas are activated they can influence the processing and interpretation of events so affecting behaviour. While the behaviour of an anxious client may seem irrational it is derived logically from the beliefs and assumptions held by the individual. Cognitive Behavioural Therapy is structured has been traditionally used a short term treatment for a wide range of emotional disorders and problems, it maximises efficiency with time, uses manual based supported treatment strategies and defines specific, measurable, and achievable goals. A focused assessment using formulation as a tool and a relatively structured session can facilitate the implementation of treatment strategies without delay and allows the therapist to make efficient use of the session time. CBT uses strategies such as behavioural experiments to enhance generalization and prevent relapse and empowers the client by providing them with skills they can use outside of the therapy session. With CBT the underlying principles are that it teaches the client to identify, evaluate and respond to their dysfunctional thoughts/ beliefs, requires a sound therapeutic alliance between practitioner and client, the emphasis is on collaboration and active participation, reviewing formulation, goal orientated and problem focused, conducted in the present, uses a variety of techniques to change thinking, mood and behaviour
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. (J Beck 1995). This client was referred to me with anxiety which is a term used to describe a feeling of unease to varying degrees ranging from mild unease to feelings of panic. Anxiety is experienced when we are in actual or perceived threat or danger and our bodies our primitive survival system (fight or flight) kicks in to help us react to this threat or danger in order to help us survive. Sometimes this system can be switched on in error when its not really needed so we experience anxiety in the absence of actual danger. The symptoms can be very intense as with this client chest pains thought he was having a heart attack, it the side effects of our survival mechanism kicking in at the wrong time. This client recognised that he was a constant worrier which made me look more a Generalised Anxiety Disorder (GAD), where anxiety is a more long-term disorder where you feel worried most of the time about things that might go wrong. Beck et al. (1985) stated that individuals with GAD have assumptions about a general inability to cope, and appraise a variety of situations in a threatening way, a key feature of GAD is recurrent and persistent worry which is excessive and uncontrollable. Wells (1944a, 1995) proposed a more detailed specific model of GAD in which the central theme is that worry is used as a coping strategy but is also viewed negatively. Worrying becomes problematic when the individual develops negative beliefs about worrying and is viewed as dangerous and uncontrollable. He presents two types of worry in this model type 1 where worries are about external events and internal non cognitive events. Type 2 worries are worries about cognition itself, worry about worry, negative beliefs
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and worry about worry is associated with monitoring for unwanted thoughts, thought control attempts and avoidance of triggers for worry, these responses exacerbate intrusions and prevent disconfirmation of dysfunctional beliefs. Assessment This client came to his initial assessment which was conducted by our administrator in February and I met with him 3 weeks later. The GP had highlighted that the client needed to find ways to relax and come to terms with his anxiety. At the initial assessment the client identified that he wanted to work on his anxiety, problems at work, financial problems and anger issues. When I then met the client he was quite withdrawn, he explained how he had a lot of fear of the unknown, for instance over money not being able to pay the bills, loosing his home, not being able to provide for his family. Constantly worrying about other peoples reactions i.e. driving the car, concerns about what the driver behind maybe thinking, irrational worries at work that he may not be able to meet a deadline with a report, concerns over what people think over him. These worries had got to such an extent that it was affecting his health, chest pains, feeling constantly stressed, arguing with his wife and lacking in motivation, constantly feeling tense, exhausted, eyes felt heavy. This affected his behaviour in the fact that he was quieter and withdrawn at home, bottled up how he felt, avoided in voicing his opinion in the work place and a general lack of confidence in his own ability. The way the client presented very much fitted with Wells theory on Generalised anxiety disorder, at this point it was far too early to determine what clearly was the maintenance factor, formulation suggested money, and as I was still only assessing I
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wasnt in a position to look at meta worries. What was clear was the client was presenting an anxiety disorder, his cognitive and behavioural responses to threat were being displayed with his safety behaviours, avoidance, suppression of thoughts, withdrawal from social interaction, not allowing others to get involved with tasks for fear of failure and not meeting clients standards, control issues. This client had gained a sports degree at University so was fully aware of the fight or flight theory which really helped when it came to introducing formulation and understanding the effect of his cognitions on his physiology and also on his behaviours. At this point we struggled to go into emotions as we were still working on our therapeutic alliance but the client could already see that it was himself that was putting the pressure on himself and not others. This was down to his core beliefs if I do a task myself that I know I have done it properly and I wont make mistakes, this leads to anxiety with the pressure of time, worrying that he will not deliver on time but still the need to control. The behaviours then cause pressure with stress, chest pains and result in irritability, worrying about losing his job if not meeting deadlines and again affecting him physically and emotionally. Interventions Following on from formulation I wanted to look more at the effects worry was having on the client so I asked the client to do an analysis of the advantages and disadvantages of worry. He client clearly perceived that the advantages outweighed the disadvantages, worry helped as a motivational tool, kept him focused on his goal to achieve it, I then questioned whether worry was safety behaviour as he was using it in a positive sense a copying mechanism. I then tried to identify control behaviours using Socratic dialogue as it became
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apparent during the session that the client constantly worries about money and that was having an impact on his anxiety, the control behaviour was encouraging the client to question his irrational beliefs such as not having enough money to pay the mortgage, trying to normalise his thoughts/ beliefs / worries and identify that he wasnt struggling with meta- worries being uncontrollable which could lead to a loss of mental functioning. I did consider issuing a meta worry questionnaire as detailed by Wells but was satisfied at this stage that because the client wanted to control his irrational beliefs it would be far more beneficial to look at educating the client, helping him to identify his negative automatic thoughts and I provided him with material from Trevor Powell handbook to help him firstly to understand with coeducation what is happening to his body when he has a panic attack, so helping him to normalise his physical reactions following on from our discussions about anxiety and fight or flight theory. We also agreed on a behavioural experiment as the client as a safety behaviour would not voice his opinion for fear of upsetting others and yet by not voicing how he felt this again was leading to resentment, irritability and a drop in his confidence. We agreed for the following week he would carry out a situational experiment verbalising his thoughts in the office leading to speaking up at a planned meeting the following week, and writing down how he felt on a daily basis of how it had gone. The aim of this experiment was to help the clients communication skills, self esteem and confidence. When we reviewed this at our next session the client confirmed that the gradual exposure had helped, he had purposely picked his meeting but in the general office had used humour as safety behaviour to mask how he was feeling. We again revisited the maintenance of anxiety and the benefits of graded exposure. We carried out another formulation and again it was identified that money seemed to
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be the maintenance factor of the clients worries. We used a downward arrow approach to look at the clients negative thoughts/ catastrophising and identified that it was the clients lack of communication/ self-belief which feeds the cycle of negative thoughts. The client identified that he wanted to become more assertive, so that he could express his opinions, his confidence will then grow and his negative automatic thoughts will change and he will then control his worries, I drew the chart to illustrate the effects of graded exposure on anxiety and because the client was committed to the process I could clearly see the benefits of psycho education. The next few weeks the client spent trying to change his thought processes challenging his automatic thoughts, we did discuss keeping a thought diary but agreed that it wasnt necessary the client was working hard outside the session now understanding the impact of his behaviours by using an ABC diagram he was constantly able to challenge his irrational thoughts and the client was aware this was going to take time and practice but he was committed to change, money still remained as a maintenance factor and the need to control.