Case Study CBT Laura S

Student Number 130039386Theoretical Models in Counselling Psychology PS3504

Case report of an individual therapy case using CBT

Student Number : 130039386

Word Count : 2,729

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CONTENTS

Section 1: Theoretical framework and Rationale

Pages 3-4

Section 2: Psychological Assessment and Case formulation

Pages 5-7

Section 3: Content of therapy and techniques employed

Pages 8-10

Section 4 : Evaluation, learning and reflection

Page 11

Linking this case study to the Ethos of Counselling Psychology

Page 12

References

Pages 13-15

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Section 1: Theoretical framework

Cognitive behavioural therapy (CBT) is an integration of Ellis’ (1996) rational emotive

behaviour therapy (REBT) and Becks’ (1976) cognitive therapy.

Central to REBT theory and practice is the ABC framework which offers a simple

explanation of understanding the client’s feelings, thoughts and behaviours (Wolfe, 2007).

‘A’ is the activating event. ‘C’ is the emotional or behavioural consequence that follows from

‘A’. ‘B’ is the person’s belief (most likely unhealthy beliefs for a client seeking CBT) about

the event (A) and it is the belief that creates the emotional or behavioural consequence (C).

Ellis (1996) postulates that we all have the ability to change our cognitions, emotions and

behaviour by choosing to examine and challenge the irrational beliefs (B) we hold about an

event (A). One way in which the client’s irrational beliefs can be challenged is to get them to

conduct behavioural experiments either collaboratively with the therapist or individually by

setting ‘homework’. The aim of this is to test the accuracy of the client’s beliefs (Hollon &

DiGiuseppe, 2011).

Beck (1976) proposed that emotional disorders are manifested at the ‘surface level’ by

negative automatic thoughts (NAT’s). An example of an NAT could be “I will not pass this

interview”. An underlying assumption is then created (Bartlett, 1932), “If I do not pass this

interview, then I am stupid”. Negative Core beliefs arise from these thoughts and are

accepted as internal truths about the self which in turn may alter the way they construe the

world and what the future holds for them. Enabling clients to ‘Capture’ NAT’s before they

turn into core beliefs is fundamental to CBT and essential for cognitive change (Trower et al,

2011).

Although CBT has been proven to be effective with the treatment of mental illness,

the generic nature of CBT does not allow the counsellor to target specific difficulties of the

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patient (Gaag, 2014).Therefore I must be careful when discussing the formulation with Jenny

as there may not be time to work on some specific difficulties that she may bring to the table.

Rationale

I chose to employ a CBT framework for intervention because it is a short-term, focused

therapy (Fennell, 1989), has collaborative nature, and it is highly structured and directive

(Beck, 1964). I believe this would apply well to Jenny as her life appears to be lacking

structure and guidance. Cognitive-behavioural techniques have helped alleviate ‘worry’ in a

relatively short amount of time (Wells, 1995) by teaching the necessary adaptive and

functional skills to guide one through everyday life.

I also chose to use CBT as Jenny was adopting social and job related cognitive

distortions that caused her to worry about the future. CBT will aim to modify Jenny’s

thinking and belief system (Beck, 1995) through making her aware of how her avoidance of

work manifested itself cognitively, behaviourally and physiologically. A change in cognition

may positively alter the way Jenny thinks about herself and the world around her which will

in turn change her behaviour, the way she feels and her thought patterns (Greenberger and

Padesky, 1995).

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Section 2: Psychological assessment

Referral

Jenny was referred to a counselling psychology service by her GP, which offers Solution

Focused Brief Therapy in an NHS primary care setting. The referral stated that Jenny has

been on sick leave from work for 6 weeks and was experiencing bouts of low mood and

disinterest in normal activities like socialising. The client requested the counselling herself as

she felt she was not “coping well with her life”. The service offers a maximum of twelve,

fifty minute sessions and I have supervision once a fortnight for two and a half hours.

Bibliographical information and family history

Jenny is a 23 year-old, single, White-British female and lives at home with her parents and

younger sister. Last year, Jenny graduated from University and went travelling for 3 months

before commencing her job as a civil servant. Jenny was brought up in a “traditional family

who had very clear set values and expectations”. She described an isolated childhood and still

continues to feel “ignored” at home. Despite not being close to her parents, Jenny relies

heavily on them to complete tasks for her such as cooking at mealtimes as she gets little sleep

and therefore has no energy. She explained that she has always wanted to be an artist but her

parents ignored this wish of hers.

Therapist’s initial impressions

Jenny’s manner was polite, however I sensed that she felt anxious as she spoke in an

undertone. I began the session by introducing myself and explaining issues of

confidentiality. The latter was important to Jenny as she expressed concern about her parents

finding out. She was reassured when I explained that a breach of confidentiality would be

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discussed with her first. As she noticeably became more comfortable with the environment

we began to establish a rapport and I was pleased she was able to discuss her difficulties

openly. Jenny was tearful for part of the sessions as she believes that therapy is her “last

resort” in terms of her going back to work.

Presenting problems

Jenny said that she started to experience feelings of low mood and isolation when she got

back from travelling. She feels anxious and paranoid around her boss and work colleagues,

and believes they are often critical of her. She finds herself spending a lot of time ruminating

about things that have been said to her. She says she has developed a “fear” of going back to

work. These problems could be maintained by her parents as they reaffirm her negative

beliefs about herself. As she is living “under their roof”, she feels that she has little control

over her immediate environment and therefore is reliant on them. Due to her perceptions of

what her work colleagues say to her, Jenny is finding it difficult to build relationships.

Jenny also explained how she had been experiencing somatic sensations when confronted

with people at work such as uncontrollable sweating. She found these experiences extremely

unnerving and has avoided them by not being at work.

Case formulation

I employed Clark and Wells’ cognitive model of social phobia (1995) and ‘The five aspects

formulation model’ (Greenberger & Padesky,1995) to focus on the relationship between

Jenny’s difficulties at work and her cognitions and behaviours.

It appears that Jenny’s negative thoughts about what her colleagues think of her leads

to the negative expectation she has prior to any interactions at work (Clark and Wells, 1995).

It may be this expectation that leads Jenny to have negative interpretations of her colleague’s

responses which could be why she finds herself ruminating over them. Therefore, Jenny may

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not be able to focus her attention on how her colleagues are actually behaving towards her

(Pineles & Mineka, 2005). It could well be that her colleagues are acting in a positive manner

e.g. offering her constructive feedback as opposed to criticism. This sequence of events is

potentially linked to her avoidance of work.

Clark and Wells’ model explained the ineffectiveness of exposure work alone in

treating individuals who had a fear of social situations (Butler et al, 1984). This made me

conscious of what techniques I would use in therapy with Jenny. Furthermore, their findings

were specific to ‘socially anxious individuals’, and so cannot be ascribed to a pattern of

Jenny’s low mood and disinterest in normal activities.

The five aspects formulation model can help to identify a link between her

experiences at work in terms of her thoughts, moods, behaviours and physical reactions.

Jenny’s negative thoughts about the comments her work colleagues make bring about the

uncontrollable sweating sensations which leads to her avoiding work and as a result, feeling

down about not being able to go in. This model would suggest that one can target any of

these aspects and it will have a positive direct impact on the other related issues.

Therapeutic goals

Collaboratively, we set the following goals:

Challenging her thoughts and restructuring her core beliefs and negative expectations

(cognitive intervention) so that she is able to go to work and build relationships.

To explore preventative and coping techniques using a behavioural intervention like

activity scheduling.

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Section 3: Content of therapy and techniques employed

Sessions 1-4

The first intervention session was used to share and discuss the formulation and to complete

some Psycho-education on the CBT model explaining the way in which her thoughts,

feelings, physical sensations and behaviours link up (Padesky,1990). I asked Jenny to identify

a situation she found difficult and complete a five aspects model of her own. Jenny found it

difficult to identify her thoughts on her own and so, through Socratic questioning (Padesky,

1993), we were able to uncover the thoughts that were present in that situation. It seemed that

Jenny had initially struggled to grasp the cognitive aspects of the model but by working

collaboratively, Jenny was able to experience some sense of achievement.

We began to explore the use of thought records (Greenberger & Padesky,1995). We

were able to uncover negative thoughts and fears that were present when her colleagues

criticised her work. Jenny remembers feeling ‘stupid’ and thought that her colleagues were

probably thinking the same about her. When we looked at the evidence that did not support

this thought, she came to the realisation that she isn’t stupid as she had achieved a 1st class

degree at University. She then suggested that maybe she just wasn’t strong at performing that

particular task, and thought about seeking help for it next time. It was possible that this was a

turning point for Jenny.

Sessions 5-8

Jenny started to bring in her own ideas to the sessions such as wanting to create a plan for

getting herself back to work. I believe that this seemed important because it meant that she

was starting to take control of what she wanted in the session which may have been an

important first step in her taking control outside of the session. However, I explained that

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before creating any plan I wanted to carry on focusing the therapy on her thoughts about

particular situations.

Now that we had formed a strong therapeutic alliance, it felt like the right time to

delve a bit deeper into Jenny’s belief systems using the downward arrow technique (Beck,

1979). This was used in order to identify some of Jenny’s ‘core beliefs.’ She discussed her

fear of being criticised and judged by her work colleagues. This often lead her to feeling

upset, paranoid and rejected. As a result, we identified a key core belief as “I am stupid”. The

aim of exploring Jenny’s thought processes here was to try and encourage Jenny to be able to

see herself in a more realistic light and so having both strengths and weaknesses. I explained

that if her thoughts about herself changed, she would be able to alter her thoughts in specific

situations that could be effecting her relationships (Beck,1967). She would no longer have as

many thoughts with the theme of “I am stupid”. Instead, for example, when she made

mistakes, she would think “I am not good at this”.

CBT has been criticised for denying the importance of the client’s past

(Weishaar,1993). However, if there were no time limit, I would have liked to explore the fact

that since a young age, Jenny could remember the way her parents had made her feel

“inferior”.

Sessions 9-12

In order to help Jenny to get out of the house more and to acquire some independence, we

completed an Activity Schedule (behavioural intervention suggested by Farmer and

Chapman, 2008) and then tried to schedule in some activities for Jenny to do. Jenny was

more open to taking part in activities in her home such as cooking a meal for her family

which gave her a sense of achievement.

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I then tried to expose Jenny to her fear of feeling paranoid and rejected through role-

play. The aim of this was so that we could prepare an action plan (Greenberger & Padesky,

1995) for Jenny that suggested ways in which she could respond to different types of

criticisms. One way that I taught Jenny to do this was by asking her what would be the worst

thing that might happen to her if for example, she was confronted by her colleagues. We then

made a list of all the negative things that they may think of her. Jenny’s first thought was

“I’m stupid” which I noticed she had written down on her thought records. We discussed her

thought record again, specifically concentrating on the evidence that did not support that

thought.

On leaving therapy, Jenny reported feeling in a better mood and more positive about

the future as she felt that she could finally speak to someone about her difficulties. She also

felt a little bit more in control of identifying her thoughts and cognitions. We reviewed the

tools that worked best for her in terms of overcoming worries about work in the hope that she

can continue to utilise them beyond the therapy room.

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Section 4: Evaluation, difficulties and reflection

On reflection, I wonder whether I could have used the CBT model in a more flexible manner

in a way which was tailored to all of Jenny’s needs. I felt like I took quite a directive role and

I could have used more of the time in a client-led fashion, allowing for some sessions to be

more exploratory and non-directive. My supervisor suggested that I should let Jenny lead part

of a session for herself using Socratic questions to guide her. However, Jenny expressed that

she would rather concentrate on making an action plan relating to work. Although Jenny took

initiative to help herself early on, I thought that it might have been better to revert to working

cognitively and then return to the activity schedule later on. Perhaps, using a more pluralistic

approach (Cooper & McLeod, 2007) by employing some techniques from other perspectives

could have contributed towards the strengthening of the therapeutic relationship and towards

guiding the client in making discoveries for herself.

Furthermore, one of the regular concerns I had for Jenny was that she was always

going back to a household she was not comfortable in. Perhaps it may have been helpful to

have part of the case formulation based around family dynamics and belief systems and how

this impacts on the client (Cockx, 2010). However, Jenny specifically expressed that she

wanted to focus on getting back to work. To try and overcome this issue, I was advised to

include familial activities in her activity schedule e.g. cooking a meal for her family. Jenny

was able to do this which not only gave her a sense of achievement in regards to cooking but

also that she was able to ‘socialise’ with her family.

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Linking this case study to the Ethos of Counselling Psychology

The importance of establishing a strong collaborative relationship in therapy is now firmly

established in CBT theory and practice (Wills, 2008). Beck (1995) stressed the need for

therapists to develop a strong TR where they can collaboratively develop therapy goals, ways

of working and homework tasks. In this case study, Jenny and I collaboratively agreed

together on what her goals were. The TR in CBT was important as it gave Jenny a sense of

responsibility for her own circumstances. Woolfe (1990) identified the significance of the TR

in Counselling psychology and that using therapeutic techniques are only useful if there is a

strong therapeutic alliance between client and therapist (Sanders, 2010).This is why it was

important that I used emotion-focused methods like role playing only when the TR was

established.

Counselling Psychology emphasises the importance of engaging with subjective

experience, values and beliefs in seeking to understand the ‘inner world’ of the client

(Strawbridge & Woolfe, 2010). Due to the nature of CBT, it generally does not allow

considerable amounts of ‘exploratory’ time and therefore, it may be difficult to fully engage

with the subjective experience of the client. However, I felt that this was paramount in

creating a strong TR with Jenny, which in turn would lead to the desired outcomes. I believe

that this was down to the non-judgemental atmosphere that I created and my appreciation

towards her life experiences (Woolfe et al, 2003), as I continuously immersed myself into

Jenny’s subjective experience of how she sees herself, the world and her future.

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Ellis, A. (1996). Better, Deeper, and More Enduring Brief Therapy: The Rational Emotive

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Case Study CBT Laura S

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