cognitive behavioural therapy case study

Student Number - 12240294

Coursework Submission Cover Sheet

Student Number: 12240294

Words: 3832

Due Date: 10/02/2014

Programme: MSc Cognitive Behavioural Therapy

Module Title: Continuing With Clinical Supervision

Module Code: 0909

Assignment Title: Case Study 7HSK0024

Lecturer: Elizabeth Simon

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Table of Contents

1. Introduction.......................................................................................................................................... 3

2. Presenting the case.............................................................................................................................. 3

3. Rationale for the use of Cognitive Behavioural Therapy...........................................................5

4. Learning Theories............................................................................................................................... 6

5. Assessment and Measurement Tools...............................................................................................7

6. Formulation........................................................................................................................................ 12

7. Problems and Goals.......................................................................................................................... 18

8. Interventions and Summary of Treatment Offered..................................................................20

9. Literature Review............................................................................................................................. 25

10. Reflections.......................................................................................................................................... 28

11. Conclusion.......................................................................................................................................... 30

12. References........................................................................................................................................... 32

13. Transcripts......................................................................................................................................... 44

14. Appendix (On Separate Pages)

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1. Introduction

This case study aims to highlight the course of treatment offered to client AR. He is a

Caucasian male referred for Cognitive Behavioural Therapy (CBT) after receiving a

diagnosis of depression, and personality disorder traits specifically morbid anger and

jealousy. To date the client has had a total of ten weekly sessions. The sessions took place in

a private practice where the author works as a Trainee Cognitive Behavioural Therapist under

the supervision of a Counselling Psychologist.

Throughout this case study, the foundations for using CBT and learning theories were

highlighted. Additionally, the assessments, measurement tools and formulations that was able

to represent a treatment plan for challenging behaviours are explained. The selected model of

treatment deemed appropriate for this client incorporated cognitive, emotional and behavioral

features. This linked well with the client, as due to the co-morbidity of the presenting

problems the individual required varied treatment interventions. Discussions regarding the

use of negative automatic thoughts and faulty thinking were supplemented with the

implementation of cognitive restructuring. Additionally, assertive skills and anger

management techniques were taught. Throughout the case study these models are presented

which are then supported by a review of the literature. Additionally, a reflective account of

the author’s experiences is presented.

2. Presenting the case

AR is a 38-year-old male who was referred for CBT by his Psychiatrist after being described

as suffering with Depression and Personality Disorder traits of morbid jealousy and anger

(APA, 2006) (See Table 1.1). Due to his aggressive behaviours he was prescribed 20mg of a

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mood stabilising drug to be taken daily. He lives with his wife and son in the family home.

The client reported feelings of intense jealousy and anger over both trivial and seemingly

important situations, which have resulted in him being very aggressive towards his wife and

physically violent on two occasions. He claims that due to his inability to control his anger it

makes him feel very depressed. Subsequently, he is reported to have experienced anxiety

when he does have social plans. Additionally, he has stated that he becomes worried about

situations that have not yet occurred which consume his mind and lead him to lash out. This

either leads him to isolate himself and ruminate his thought, which later leads to outbursts of

anger. Furthermore, he often contacts his wife and accuses her of situations he has no

evidence for. This has resulted in problems at work with colleagues, his wife and his son.

Table 1.1 – Demographic details

Table 1.1 - Demographic Details

Name ARGender MaleAge 38Ethnicity White BritishMarital Status MarriedDiagnosis Depression, Morbid Jealousy / AngerMedication Mood StabilisersOccupation Scaffolder

There are several aspects that appear to be contributing to the client’s problems that were

highlighted through two generic formulations (Padeskey & Greenberger, 1995), an anger

specific formulation (Novaco, 1975) and a summary conceptualisation model with a

maintenance cycle (Kuyken, Padesky & Dudley, 2011). By using these formulations it was

easier to make a link between the clients problems. While he presented with classic

symptoms of depression his anger and jealousy complicate the overview of his treatment.

AR’s main cognitions included feeling like he is inferior to others, feeling uncomfortable in

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his own skin, feeling stupid and like other people cant be trusted. He has noticed

modifications in his body such as becoming restless, feeling hot and having racing thoughts.

Generally, AR believes that people cannot be trusted and the world is “full of wrongens”. As

a result, this leads him to isolate himself, ruminate his thoughts and have angry outbursts. The

onset of the existing problems of mistrust/anger/jealousy appeared to have stemmed from his

childhood where he had a very critical father who physically abused him. Additionally, he

was able to recall situations from his childhood that cause him distress. For example at the

age of 13, his girlfriend who ended their relationship over a microphone at a party had

publicly humiliated him. He claimed that due to these experiences he has developed a strong

mistrust for people leading to his jealous thoughts. The client has also reported that he feels

that his depressive symptoms are due to him feeling bad about how he behaves towards

others and his inability to control it.

3. Rationale for the use of Cognitive Behavioural Therapy

Due to the features of the client’s presenting problems it was proposed that CBT would be a

useful intervention as recommended by the National Institute for Clinical Excellence (NICE,

2011 – Guideline CG77). Within research CBT has been demonstrated as an effective

therapeutic intervention for both angels of the clients problems. There is extensive

substantiation that proposes that CBT is effective for the treatment of Depression (Beck,

Rush, Shaw and Emery, 1979). Previous literature by Dobson (1989) identified that CBT for

depression was as effective as medication. This was also supported by De Rubeis et al.,

(2005) & Stunk et al., (2007) who stated that CBT is "as effective as medication to alleviate

depressive symptoms". Past research has also been able to demonstrate the benefits of using CBT for

anger. Research by Novaco (1976) has shown the effectiveness of the CBT approach to anger

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management. It has been proposed that this course of treatment can reduce anger whilst

improving motivation, self-esteem and interpersonal difficulties. This approach to an anger

management programme is able to fit well with the clients presenting problems. Generally,

research also demonstrates low drop out rates for CBT which makes it an appealing choice

for therapy (Covin, Ouimet, Seeds, et al., 2008; Hunot, Churchill, Silva de Lima, et al., 2007;

Haby, Donnelly, Corry, et al., 2006; Mitte, 2005).

4. Learning Theories

Cognitive Behavioural Learning Theories are able to provide a better understanding of the

underpinnings of AR’s behaviour and how it has established throughout his life. Operant

Conditioning exemplifies that the process of behaviour occurs through learning by rewards

and punishment. This theory sustains that there is a crucial link between a person’s behaviour

and the consequence that result from this behaviour (Skinner, 1953). The client appears to be

negatively reinforced to avoid social interaction after he has had an angry outburst. By

engaging in social interactions he feels he may be placed in a position where he was more

likely to express jealous thoughts, which could result in an angry outburst. This limited

interaction results in AR withdrawing and isolating himself from others which causes low

mood. As this avoidance removed the unpleasant angry outbursts it was reinforcing

avoidance behaviour. Although it increased feelings of low mood it became his preferred

method of coping when placed in this situation. Due to these experiences, the avoidance of

placing himself in social situations resulted in him withdrawing from seeing friends,

communicating effectively with his wife and working within a team at work making him feel

even more lonely, angry and depressed.

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However, during the period of attending CBT sessions he demonstrated a shift in the operant

conditioning. He showed that by changing the negative thoughts of “others cannot be trusted”

to, “it’s important to keep an open mind about others” he was positively reinforced to discuss

situations calmly when he felt there was a problem. As he continued to put himself into social

situations where his problems may arise, he found the experience easier.

5. Assessment and Measurement Tools

The initial assessment was conducted over four sessions (See Table 1.2). This process

followed the strategies identified by Sanders & Wills (2005) and was complemented by two

disorder specific approaches, the Model for Depression (Becks, 1987) and the Model for

Anger (Novaco, 1975). In line with Sanders & Wills (2005), the initial assessment interview

included gathering information regarding the client’s previous experiences of therapy and his

goals. By using an integrative methodology throughout, the significance of regulating

angry/jealous emotions, adapting thought processes and approaches for coping with

challenging situations was highlighted.

Table 1.2 – Assessment Process

ASSESSMENT PROCESS

Session 1

Assessing diagnostic criteria for depression to see if client’s features meet the diagnosis.

Assess problems with anger and jealousy to see if client’s features meet the diagnosis for personality disorder or personality disorder traits.

Client completed psychometric assessment tools and take SUDS. Gathering general information about client. Explanation from client of what is causing his difficulties. Expectations of the sessions and previous experiences of therapy were discussed. Explanation of Cognitive Behavioural Therapy. Discussed scepticism towards Cognitive Behavioural Therapy.

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Instilling hope. Provided information to read for homework on what Cognitive Behavioural Therapy

is in general.

Session 2

SUDS to be taken from client. Gathering background information. Completed a lifeline of significant life events. Identified problems and goals. Provide information sheet for homework regarding depression and anger and how

they can be linked.

Session 3

SUDS to be taken from client Introduction to the five systems model Completed a topographical analysis What is depression is like for you and how does it feel in your body? Explain functional analysis ABC and client this for homework

Session 4

SUDS and psychometric assessments to be taken from client. Discuss need to complete homework. Continue with five systems model. Completed a topographical analysis. What is anger / jealousy is like for you and how does it feel in your body? Socratic questioning to identify core beliefs, rules and assumptions. Set homework of identifying how core beliefs have impacted behaviour.

Two different measures were used to assess the level of the client’s problems and progress

during therapy, the Beck’s Depression Inventory Second Edition (Beck, Steer, & Brown,

1992) and Novaco Anger Scale and Provocation Inventory (NAS-PI) (Novaco, 2003). The

BDI is a 21-item scale that measures the severity of self reported depression in adults. AR’s

scores on the BDI fluctuated over the ten-week period (See Table 1.3, 1.4 and Graph 1.1). On

average he demonstrated a moderate level of depression. The scores that AR demonstrated

are congruent to his presentation in the sessions and appear to reflect well on his current

situation. When analysing the items in more detail it can be observed that the areas in which

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AR is experiencing the most difficulties includes agitation, concentration, self dislike, and

worthlessness and self criticalness.

Table 1.3 - Becks Depression Inventory Classifications

Score Classification

0-7 Minimal

8-15 Mild

16-25 Moderate

Table 1.4 – Becks Depression Inventory Results

BDI Score Classification

Week 1 22 Moderate

Week 4 21 Moderate

Week 7 18 Moderate

Week 10 14 Mild

Graph 1.1 – Becks Depression Inventory Results

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Becks Depression Inventory (BDI)

0

5

10

15

20

25

Week 1 Week 4 Week 7 Week 10

Session Number

Sco

res

The NAS-PI tool was also selected; this is a self-report questionnaire that assesses an

individual’s experience and expression of anger. An individual’s score reflects their overall

level of anger, with high scores indicating relatively higher anger levels (See table 1.5, 1.6).

Table 1.5 – Novaco Anger Scale and Provocation Inventory Classifications

Definitions of NAS-PI T-score Ranges

<29T Very Low

30T-39T Low

40T-44T Low Average

45T-55T Average

56T-59T High Average

60T-69T High

>70T Very High

Table 1.6 - NAS-PI Results

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Week 1 Week 4 Week 7 Week 10

NAS Total Very High Very High High High Average

Cognitive Domain

High Average High High Average Average

Arousal Domain

High Average High High Average Average

Behaviour Domain

High High Average Average

Provocation Inventory

High High Average Average

Anger Regulation

Very High High High Average Average

AR’s scores fluctuated over the ten-week period. However, it was evident that in all areas his

anger levels had decreased over the course of therapy. Like with the BDI initially the scores

went up and then went back down. Overall, the NAS-PI suggests that the results obtained by

AR appear consistent in the way that he represents his anger. After taking all of these scores

together and analysing AR’s current behaviour it could be suggest that AR generally does

experience deficits in his ability to regulate his anger.

In addition to these measurement tools, the Subjective Units of Distress Scale (SUDS) were

taken from the client to assess his level of anger over the previous week. The graph 1.2

demonstrates the results from the SUDS. Overall, his mood fluctuated over the ten-week

period.

Graph 1.2 – SUDS Results

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Thoughts"I want to go home"

"I cant get motivated""Why do i feel like

this""What is going on with

me""Everything bad

always happens to me"

EmotionsJealous

DepressedEmpy - like something

is missing

BehavioursWorrying about it

Moaning Withdraw

Dont SpeakSulking

Short temperedRing Wife

Physical Sensations

Hot Racing Thoughts

TenseHeart rate increases


Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

0

1

2

3

4

5

6

7

8

9

10

SUDS Results

Session Number

Scor

e

6. Formulation

The initial part of the formulation consisted of two Topographical Analyses, Cognitive ABC

(Pedesky & Greenberger, 1995) (See Fig 1.1, 1.2). From this aspect of the formulation the

therapist and client were able to begin to identify the thoughts, feelings, behaviours and

physical sensations when the client was placed in situations such as things going wrong at

work or being told that his wife has slept with someone else. These situations caused the

client to have angry outbursts. He also stated that he felt sad much of the time because of

situations like these.

Fig 1.1 Topographical analysis - Depression

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Situation

When a project at work is not going to plan

Thoughts"I dont know if i should

believe her or not"It isnt ture"

"The answers that i am getting from her arent

good enough""I dont believe her"

"Everything bad always happens to me"

EmotionsFrustrated

AngryMixed up - dont know

what to thinkSad

BehavioursAsk wife about it

Ruminate about what she tells me

Withdraw from everyone

Distant from wife

Physical Sensations

Heart RacingFeeling uptight


Fig 1.2 Topographical analysis – Anger/Jealousy

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Situation

When someone told me that someone else had slept with

my wife.


Following on from this generic formulation an anger case formulation (Novaco, 1975) was

completed (See Fig 1.3). Through this model the therapist was able to elicit the clients

cognitions, behavioural reactions, physiological arousals and what environmental

circumstances are likely to trigger this. For AR, often when he is at work and something went

wrong he called his wife to discuss it. If she is unable to answer the phone his cognitions

cause him to think negative thoughts such as “what is she doing”, “who is she with”. These

thoughts make him feel out of control and leave him feeling hot, sweaty, shaky etc. As a

result he often responds to such situations by accusing his wife of doing things that he has no

evidence for and shouting at her or at his colleagues. His wife then refuses to talk to him

when he is in this highly emotionally angry state and subsequently, AR begins to feel bad and

isolates himself.

Fig 1.3 Anger Case Formulation

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ANGEREnvironmental Circumstances

At work something doesn’t go my way call wife and she doesn’t answer the phone.

Behavioural Reactions

Shout at wife / colleagues Avoid seeing / speaking to wifeWife is angry with me

Cognition: Structure & Processes

“What is she doing”“Who has she been with”“Why would she love me when she can be with someone else”“Everything I do makes her upset”“I wont stand for her lying to me”“No-one cares about me“I’ve got no control over what I might do”I”I cant control my anger”


Additionally, a collaborative case conceptualization model with a maintenance cycle

(Kuyken, Padesky & Dudley, 2011) was used to bring the two problems together. By

adopting the method of using an idiosyncratic longitudinal formulation process the

individual’s life, presenting problems and CBT can be linked together. Its also able to

incorporate the early years of the individual and how these experiences developed into core

beliefs (See Fig 1.4). Some of the clients developmental experiences such as having a very

critical father who physically abused him led him to develop core beliefs such as “I am

inferior”, “I feel uncomfortable in my own skin”, and “I am stupid”. This led to AR

developing underlying assumptions such as “If I take control then I can prevent bad things

from happening”, “If I want to be seen as competent then I must do everything well”, “If I

want people to love me I have to be able to do things well” and “If I prepare for the worst I

am never going to fail”. The strategies that he uses to achieve this is to shout at his wife when

she doesn’t allow him to be in control, work to a high standard, constantly worry about

making mistakes and avoid responsibilities when things go wrong or don’t go his way. The

onset of the current emotional problems that he experiences are thought to be due to

challenges at work such as things going wrong or people talking about his wife. This causes

him to feel angry and low in mood. As a result he has thoughts of “I feel out of control”, “I

hate it when people do things like this to me”, “Why does no one respect me”, “I am useless

and stupid”. These thoughts originally cause him to confront his wife and individuals at work.

He then ruminates over what he has said to them and begins to avoid social situations. This

avoidance then maintains the negative thought processes leading to the cycle continuing to

occur.

Fig 1.4 Colaborative Case Conceptualization Formulation

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Core Beliefs

PredisposingFactors

Developmental Experiences

Critical FatherPhysical Abuse

Difficulty making friendsHumiliated at school by his girlfriend who ended the relationship over a microphone at a party


7. Problems and Goals

The client’s problems and goals and appropriate interventions could be highlighted through a

9-box model (Thompson, 2012) (See Fig 1.5). When completing this, the client and therapist

ensured that they were in line with the SMART goals model (See Fig 1.6). These made it

easier to identify both long and short-term goals for therapy. Some of the main therapeutic

goals include improving reduction of avoidance and more effective processing and regulation

of emotions.

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Core Beliefs


Fig 1:5 – 9 Box Model Problems and Goals

COGNITIVE PROBLEM

“What is she doing”, “Who has she been with”, “Why would she love me when she can be with someone else”, “Everything I do makes her upset”, “I wont stand for her lying to me”, “No-one cares about me”, “I’ve got no control over what I might do” “I cant control my anger”.

COGNITIVE GOAL

To be able to manage feel comfortable around people

and manage my racing thought.

COGNITIVE INTERVENTION

Cognitive Restructuring, Analysing common faulty thinking, Problem Solving - define problems more clearly and specifically with set goals and develop understanding as to why this is important, Cognitive Avoidance, Safety Behaviours

FEELING PROBLEM

Sad, Upset, Angry, Hot, Sweating and Racing

Thoughts

FEELING GOAL

To be able to manage the feelings and symptoms of

anger, to feel more in control and able to cope

FEELING INTERVENTION

Psycho Education anger responses and the role of avoidance in maintaining anger, Relaxation techniques – progressive relaxation

BEHAVIOURAL PROBLEM

Shout at wife / colleagues, Avoid seeing / speaking to wife, Worrying about it, Moaning, Withdraw, Don’t speak, Sulking, Short tempered, Ring wife.

BEHAVIOURAL GOAL

Be able to attend the engage with people at ease without being worried about how I may react or if I will have a

violent outburst.

BEHAVIOURAL INTERVENTION

Thought Record, Anger log, Avoidance Behaviours and Rumination, Anger hierarchy, Stress inoculation plans, Assertive skills, Distress Tolerance Skills and Coping Strategies, Role playsSMART Goals

Fig 1:6 – SMART Goals

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MEASURABLE – my progress throughout the sessions will be measured using the psychometric assessments (BDI, CFSEQ, NAS-PI). I will also keep thought records in order to identify changes in my thought patterns over the course of therapy.

SPECIFIC – I would like to feel more able to control my angry outbursts

A

M

S


8. Interventions and Summary of Treatment Offered

The proposed treatment plan was informed by the Anger Treatment Protocol (Novaco, 1975)

and the Cognitive Therapy of Depression Protocol (Beck, Rush, Shaw, and Emery, 1979).

This was directed by the assessment, which highlighted two main difficulties; managing

emotional regulation and problem solving (See Table 1.7). After the completion of the

formulations the information was discussed with the client. From this a collaborative decision

regarding the treatment plan was made (See Table 1.8 & 1.9).

Table 1:7 – Treatment Plans

Domain Treatment Plan

Cognitive Domain Cognitive RestructuringAnalysing common faulty thinkingProblem Solving - define problems more clearly and specifically with set goals and develop understanding as to why this is importantCognitive AvoidanceSafety Behaviours

Feeling Domain Psycho Education anger responses and the role of avoidance in maintaining angerRelaxation techniques – progressive relaxation

Behavioural Domain Thought RecordAnger logAvoidance Behaviours and RuminationAnger hierarchyStress inoculation plansAssertive skillsDistress Tolerance Skills and Coping StrategiesRole playsSMART Goals

Relapse Prevention Review all of treatment programmeBlueprint skills and session contentIdentify high risk situationsIdentify most effective coping strategies learnedEncourage practice of skills for continual development

Table 1:8 – Session Content

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A


Treatment Session

Aims of treatment – Session content

Session 1 Assessing diagnostic criteria for depression to see if client’s features meet the diagnosis.

Assess problems with anger and jealousy to see if client’s features meet the diagnosis for personality disorder or personality disorder traits.

Client completed psychometric assessment tools and take SUDS. Gathering general information about client. Explanation from client of what is causing his difficulties. Expectations of the sessions and previous experiences of therapy

were discussed. Explanation of Cognitive Behavioural Therapy. Discussed scepticism towards Cognitive Behavioural Therapy. Instilling hope. Provided information to read for homework on what Cognitive

Behavioural Therapy is in general.

Session 2 SUDS to be taken from client. Gathering background information. Completed a lifeline of significant life events. Identified problems and goals. Provide information sheet for homework regarding depression and

anger and how they can be linked.

Session 3 SUDS to be taken from client Introduction to the five systems model Completed a topographical analysis What is depression is like for you and how does it feel in your

body? Explain functional analysis ABC and client this for homework

Session 4 SUDS and psychometric assessments to be taken from client. Discuss need to complete homework. Continue with five systems model. Completed a topographical analysis. What is anger / jealousy is like for you and how does it feel in your

body? Socratic questioning to identify core beliefs, rules and assumptions. Set homework of identifying how core beliefs have impacted

behaviour.

Session 5 Take SUDS from client Review homework and previous session Feedback formulation to client

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Complete Anger Case Formulation. Set homework of keeping a diary of negative thoughts

Session 6 Take SUDS from client Review homework and previous session Feedback formulation to client Complete Collaborative Case Formulation Discussed treatment options and the rationale for each treatment

that was suggested as a result of the formulation. Decided on SMART goals. Complete pros and cons of having an angry outburst for

homework.

Session 7 Client complete assessment tools and take SUDS Review homework and previous session Discuss anger as a normal emotion, what is anger and what

purpose does it serve? Discuss relaxation strategies Discuss self-monitoring of anger. For homework ask client to describe their favourite relaxing,

calming image or picture.

Session 8 Take SUDS from client Review homework and previous session Discuss how high levels of stress affect thinking and behaviour. The purpose of relaxation Development of relaxation strategies Provide client with anger log for homework to record any

situations where they feel angry.

Session 9 Take SUDS from client Review homework and previous session Anger treatment decision matrix Cost benefit analysis Building on an anger hierarchy Review progressive relaxation and set this to practice for

homework.

Session 10 Take SUDS from client Review homework and previous session Continue to develop the anger hierarchy Introduction to stress inoculation procedure. Ask client to continue to complete the anger logs.

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Table 1.9 – Future Session Content

Treatment Session

Aims of treatment – Session content

Session 11 Client to complete assessment measures and take SUDS Review homework and previous session Explain and carry out cognitive restructuring. For homework review different situations where the client has felt

angry and make attempts to perspective take.

Session 12 Client completed assessment tools and take SUDS Review homework and previous session Discuss clients faulty thinking Discuss situations where faulty thinking occurs Challenge NAT’s to make RAT’s Identify ratings for how true the thoughts felt at the time of the

situation and at the time of cognitive restructuring Connect cognitive restructuring with the clients formulation Explain a thought record and provide for homework

Session 13 Take SUDS from client Review homework and previous session Develop cognitive restructuring to include perspective taking. Discuss scenarios with client and review how they might cope

successfully. Discuss effectiveness of various coping strategies and role-play

these. Positive self-talk – set this to practice for homework.

Session 14 Take SUDS from client Review homework and previous session Review and discuss problem solving through effective

communication. Assertive skills, difference between passive and aggressive For homework set the worksheet of effective communication in

angry situations.

Session 15 Client completed assessment tools and take SUDS Review homework – discussed why it is important Work on 6 steps to problem solving method Devise an action plan For homework ask client to work on their action plan.

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Session 16 Take SUDS from client Review homework and previous session Discuss dealing with rumination and escalation through attentional

focus. Discuss why using coping strategies is more difficult in an

escalating situation. Discuss strategic withdrawal Ask client to practice coping strategies and record all those that are

used.

Session 17 Client completed assessment tools and take SUDS Review homework and previous session Discuss dealing with repeat provocation Review appropriate responses for repeat provocation Review how to have less aggressive arguments within

relationships. Ask client to complete the dealing with anger incidents – personal

reminder sheet for homework.

Session 18 Client completed assessment tools and take SUDS Review homework and previous session Discuss and role-plays saying ‘no’ assertively. Discuss unhelpful beliefs and ways of saying ‘no’ Discuss dealing with constructive and destructive criticism. Role play giving each type of criticism For homework ask client to review helpful and unhelpful thoughts

in relation to criticism.

Session 19 Client completed assessment tools and take SUDS. Review homework and previous session Complete the relapse prevention plan Encourage practice of skills for continual development Make goals for the homework

Session 20 Take SUDS from the client Review homework and previous session. Recap on generic formulation completed Recap on some of skills learned including pros and cons, cognitive

restructuring, assertiveness Identify high risk situations

Session 21 Client completed assessment tools and take SUDS. Review homework and previous session Complete the relapse prevention plan Encourage practice of skills for continual development

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9. Literature Review

The tempestuous emotion of anger is a feature of a widespread array of diagnoses (Koop &

Lundberg‚ 1992; Novello‚ Shosky‚ & Froehlke‚ 1992). The fundamental problem that

individuals tend to have when suffering with anger issues is the inability to regulate the

emotion meaning that the initiation, countenance, and consequences transpire without apt

controls (Goldstein & Glick, 1994). Due to anger often being intertwined with other clinical

issues, getting control for behavioural change can be an intangible target (Dryden, 1968).

Overall, as anger functions as a sentinel to self-esteem, it often results in interconnecting

negative responses and can cause the individual to experience depressive symptoms

(Renwick, Black, Ramm & Novaco, 1997 and Watt & Howells, 1999). Persistent anger is

often the result of difficult past experiences and can undoubtedly lead to dysfunctional ways

of apportioning with life’s encounters (Novaco & Taylor, 2004, Hanks, Temkin, Machamer

& Dikmen, 1999). These difficulties often cause individuals to have problems with personal

relationships, employment and physical health (McKay, Rogers & McKay, 1989). This was

clearly evidenced with client AR.

Through the six main meta-analyses that have been carried out for anger treatments in CBT a

moderate effect size has emerged (Tafrate, 1995; Edmondson & Conger, 1996; Beck &

Fernandez, 1998; DiGuiseppe & Tafrate, 2003; Del Vecchio & O’Leary, 2004). This implies

that approximately 75% of people who undertake CBT treatment for anger demonstrate a

significant change compared to those in controlled conditions. However, when taking these

findings into account, further supportive research into this area would allow for a more robust

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multi-model assessment design to be identified (Watt and Howells, 1999). Despite the limited

research there are several non controlled, case series and case study reports that have been

able to demonstrate effective CBT treatment for anger for individuals with multifarious needs

(Novaco, 1997 & Stermac 1986).

Research has also shown that individuals who have difficulties in regulating their emotions

have both cognitive and behavioural difficulties (Beck & Fernandez, 1998). Furthermore,

people with anger/jealousy problems often experience depressive symptoms in response to

their behaviours (Baker & Wilson, 1985; Battle, 1994). With the current client it was evident

that he had both cognitive and behavioural difficulties. However, with regards to the

treatment plan it was apparent that due to the risks that his behaviour posed it was felt that it

would be more advantageous to work on the behavioural element first. These models were

selected for the current client, as they were able to incorporate treatment interventions that

were able to meet the client’s needs. It also allowed for elements of flexibility where parts of

the Beck’s Protocol for Depression could be introduced so that the client and therapist could

respond to all of the presenting problems. When reviewing the Becks Protocol for Depression

it was evident that aspects such as addressing faulty thinking and cognitive restructuring were

able to overlap with that of the Anger Treatment Protocols (Blashfield, 1990). The benefits of

using two different protocols with co-morbid clients allows for more problem directed

solutions (Cain‚ 1987; Paykel, et al., 1999; Scott et al., 2002).

In line with this, it should also be noted that whilst the client demonstrated with a co-morbid

problem the underline issues that emerged through the longitudinal formulations suggest that

his problems were all in some way connected. As a result it was hypothesised that as one

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aspect of the problem is treated it will also help to alleviate other presenting symptoms

(Hunsley, Crabb, & Mash, 2004). This explains why it is not necessary to complete two full

treatment protocols for each presenting problem as not only would it be repetitive but may

not be any more effective (Mahoney‚ 1993; Lochman‚ 1985).

Although the development of the client over the past ten sessions of therapy was evident and

it was apparent that the correct protocols were followed, there were other noteworthy models

that were not used. For example the Unified Protocol for the Transdiagnostic Treatment of

Emotional Disorders (Barlow et al., 2004). A fundamental feature of this model involves the

use of underlying treatment ideologies of change that overlap different treatment styles and

diagnostic classifications (Boswell & Goldfried, 2010; Norcross, 2005). More specifically,

this transdiagnostic ideology is focused on emotion and can be applied to any disorder that

encompasses a protuberant emotional constituent for example mood disorders (Barrett,

Mesquita, Ochsner & Gross, 2007). The aim of this type of therapy is to focus on deficits in

emotional regulation (Mennin, Heimberg, Turk, & Fresco, 2007; Greenberg, 2008). As a

result, this type of therapy aims to increase individual’s awareness of their emotions and how

this awareness can change behaviours (Greenberg, 2002a). Although some aspects of this

model would appear to benefit the current client there were also aspects of it that did not meet

the client’s needs. Whilst more recently, the evidence base for CBT has been critisised

(Nathan & Gorman, 2007), their effectiveness in treating specific disorders is very good

(Tafrate, 1995; Edmondson & Conger, 1996; Beck & Fernandez, 1998; DiGuiseppe &

Tafrate, 2003; Del Vecchio & O’Leary, 2004).

25


With regards to particular interventions used with the current client, one of the main focuses

was on stress inoculation for anger control (Meichenbaum, 1985). The concept of this

involves teaching cognitive behavioural coping techniques (Ekman, 2003). During this

training the individual learned to identify their own triggers for anger and how to deal with

this effectively when it occurs (Shapiro, 1994; Lindsay, Overend, Allan, Williams, Black,

1998). This process is similar to that of social skills and assertion training (Liberman, DeRisi

and Mueser, 1989). By expending a methodical approach to problem solving when

experiencing anger individuals are more able to effectively manage situations (Novaco,

1978). In summary, the stress inoculation approach to treatment has been found to be

effective with a wide range of populations (Novaco 1994b, Tafrate, 1995, Edmondson and

Conger, 1996, Beck and Fernandez, 1998, Taylor, 2002; Siddle, Jones & Awenat, 2003).

10. Reflections

Over the course of therapy that has been carried out with AR so far, significant time has been

spent reflecting on the content that has been covered. One of the main points that emerged

during my own reflection was that it was very important to distinguish the link between the

two presenting problems of the client and how these can be connected over the course of his

life span. Overall, the clients’ responses to situations, which cause him to become angry, have

changed and he has been able to learn more effective skills for regulating his emotions. As a

result this has decreased his depressive symptoms.

During therapy there were some problems that were encountered. Throughout the sessions

the client appeared to be reluctant to complete homework. Some of the reasons that he

provided for not completing the homework were that he found it too difficult, he did not find

the time within his week or that his handwriting was not very good. These issues were then

26


raised during the therapy sessions. I found that by addressing this within therapy we were

able to develop an action plan to work on this. By doing this I was able to help overcome this

problem collaboratively with the client whilst still allowing him to understand the benefits of

completing homework. Initially I found that I was getting frustrated when the client was

attending sessions without having completed the homework previously set, by working

through this problem, I could deal with my own frustrations as well.

Additionally, within therapy at times I found it difficult to empathise with the client. I found

that when he was justifying some of his behaviours such as verbal aggression towards his

wife these ideas contradicted with my own personal values. I found that my personal feelings

towards him at times were very negative and this was something I was able to work on within

my supervision. By bring this to supervision I was able to develop ways of communicating

my views to him in a constructive manner. I also found that by keeping a diary about my

experiences I was able to vent my frustrations and express my thoughts about our sessions,

which helped immensely. I also was able to realise that I could complete effective CBT even

when I did not personally like the client.

With regards to my overall practice, when reflecting on my work, I was able to identify that

during the concrete experience stage of Kolbs Learning Cycle (1984), I was able to apply my

academic understanding into practice by adapting theories to ensure the therapy carried out

was individualised. Following on from this, during the reflective observation stage I was able

to identify both the positive and negative aspects of the therapy, which contributed to the

formation of the sessions. For example, after completing the formulation stage with the client

I was able to identify that anger, jealousy and depression were the problems that were causing

the client the most concern. By using this information when I reviewed the literature, I was

27


able to classify models for therapy that applied to the clients needs. During the abstract

conceptualisation stage of my learning I found that reviewing aspects of the sessions that

could have been carried out differently was very helpful. Additionally, throughout the course

of the client’s therapy I found that I was using reflection through active experimentation. I

discovered that by regularly reviewing my practice allowed me to generate ideas for how to

improve my competencies in carrying out CBT with clients.

11. Conclusion

The wide-ranging conclusion regarding the outcomes of CBT for Anger and Depression

based on models by Novaco (1975) and Beck (1979) propose promising results. More

recently, researchers have begun to divert their attention towards CBT as a treatment for

anger and have been able to support CBT as effective in this (Edmondson & Conger, 1996;

Renwick et al., 1997; Beck & Fernandez, 1998; Watt & Howells, 1999; Dyer, 2000;

Deffenbacher et al., 2000; DiGiuseppe & Tafrate, 2003; Siddle et al., 2003; Del Vecchio &

O’Leary, 2004). A review of the literature by Tafrate (1995) demonstrated that of 50 studies

of 1‚640 participants an effect size of 0.70 was establish. This suggested that overall,

moderate treatment gains were accomplished within therapy. Within these studies a very

diverse group of people were used. Subsequently, the effectiveness of CBT for anger can be

generalised across several populations (Fernandez & Boyle‚ 1996; Glass‚ McGaw‚ &

Smith‚ 1981; Rosenthal‚ 1991). These outcomes are consistent with further meta-analyses

authenticating the effectiveness of CBT (Dobson‚ 1989; Van Balkom et al.‚ 1994). In line

with these research findings, the current case study followed these CBT models of treatment

in order to overcome the client’s problems.

28


Whilst recognising the positive results demonstrated by the current case study so far, the

limitations of the treatment cannot go unnoticed. The treatment aims to last for twenty-one

weeks of one-hour sessions rather than the recommended twelve weeks of an hour and a half

for this protocol. This is due to the functioning level of the client, elements of two different

protocols being used and the complexities of the comorbid problems that the client presents

with. Moreover, as the treatment has not yet been completed no relapse prevention plan or

follow up sessions have been arranged. However, at the current stage it is apparent that the

client’s views of himself, others and the world around him are beginning to change.

For future research regarding CBT and the treatment of anger, principally by Deffenbacher et

al., (2000) & Lochman & Lenhart‚ (1993) it is likely that further developments will enhance

the effectiveness of the programmes that are made available. Specifically, when evaluating

their effectiveness it may be interesting for future studies to pay focus to particular variables

such as self-efficacy‚ ability to control urges and impulsivity. By focusing on specific

variables within treatment it would allow for more specialist programmes to become

available, which would be able, to focus more directly on individuals needs. Generally, AR’s

diagnosis deemed him suitable for CBT. The therapy appears to have had a positive impact

on the client’s thoughts, feelings and behaviour. Throughout the initial sessions, the most

important maintenance factors regarding the client’s problems were emphasised; which was

able to formulate the treatment applied. This has been able to contributed to the client

beginning to achieve his goals for therapy.

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13. Transcripts

The first five minutes of the session were spent completing the psychometric assessments

T = Therapist

C = Client

57 minutes and 44 seconds plus 5 minutes complete the psychometric assessments before the

session.

Speaker Session Verbatim CTS-R Skills Comments / Reflections

T Ok alright so should we start by maybe setting an agenda for todays session

Agenda Setting

By starting the session setting an agenda it gives structure to the session.

C Go on

T so just that we kind of know where we are going with it.

T Erm is there anything that you wanted to bring to the erm session

Collaboration By asking the client if there is anything they would like to bring I was able to ensure that it is not just me engaging in the session.

42


C No not today sorry

T Nothing in particular

C No

T Ok so maybe you could have a think about that

T ok so maybe we can have a look at the homework Homework Review the previous weeks homework.

C No I haven’t don’t it I have been naughty

T Ok so we can talk about that

C Right

T So we can talk about that, that can be the first thing we talk about

Agenda Setting

Prioritising what order things will be done in

T Erm and maybe look over what we did last week do you remember do you remember what we did last week.

C Erm yeah and no to be honest

T Ok well we can look at that

C Yeah

T And I was thinking of erm continuing on with the formulation stage where we were making a picture, making sense of what we have been doing

T So last week we spoke about the depression side of things so maybe this week we could look more on the jealousy, angry sort of side

T Do you think that would be ok? Feedback By asking the client their opinion regarding what has been said I am able to confirm that they agree

C Yeah that is fine

T Then we can talk about the homework and see where we are with that, that’s fine

Homework setting

By placing the setting of the homework on the agenda it ensures that it is completed

T Ok so first thing, what what happened with the homework what went what went wrong

Agenda setting

Highlighting to the client the first item on the agenda

C Erm I don’t know to be honest I didn’t think about doing it, I don’t know why I just, I dunno

43


T Ok, erm do you remember what it was?

C No I don’t to be honest I haven’t looked at it

T You don’t remember what it was

T If I said to you an ABC would you what would you

C Yeah an ABC yeah that’s something to do with it

T Ok so when I say ABC to you what does that mean

C I learned it when I was two

C (Laugh)

T Ok so you brought the sheet with you that’s a good things so you haven’t lost it

Interpersonal effectiveness

Providing the client with positive reinforcement

C I put it on the side and to be honest I just left it look at it a couple of times probably looked at the paper not opened it up and just thought I’ve got to do it but

T What do you think made it difficult to do it

C Erm I don’t know I probably didn’t know what to put down

T Not really sure what to put

C Yeah yeah

T Ok

T We can look at that

T Erm (pause) I know you said before we left last week erm you were a bit kind of anxious a bit worried about doing this

C Yeah yeah

T Was it because it was a bit too it felt a bit too much what was it that made you feel anxious about it.

C Erm don’t know I just felt anxious about it, I felt a but silly last week to be honest because you was talking and I was listening but I wasn’t and I

T That sometimes happens to us though

C Yeah yeah it happens quiet a lot

C (laugh)

44


T Which is exactly why you are here

C Yeah

T So did you find what so lets stick with that for a minute did you feel you were beating yourself up about it or what

Eliciting key cognitions

Establishing what the client was feeling when in an anxious situation

C Erm probably for a little while but

T What, what were you doing in that little while

C Just don’t know just feeling a little bit silly and a little bit uptight and then as fast as I felt a bit silly and uptight I just don’t know I just blanked it out and tried not to think about it to be honest

T Was there any part of you that was thinking I shouldn’t be feeling this way there is no reason for me to feel this way or was it more that you were just kind of trying to blank it out and avoid it.

Eliciting behaviours

Establishing what the client was doing at the time of feeling anxious

C Erm I think probably I just blanked it out and avoided it

T Ok how difficult (erm) would it be for you now to think to think “it didn’t really matter, it wasn’t a significant part of my life, it wasn’t going to make any difference” how difficult is it for you to think like that?


Asking the client about their thoughts

C Sometimes it it I can think that way and other times I cant it just plays on my mind and plays on my mind and I don’t know why

T Ok

T (erm) what do you think was triggering you having that kind of blank mind last week and not being able to focus too much.

C Probably when you are talking to me I probably had something to say but I didn’t manage to get it out and then it was just going over and over in my head

T What was it that made it difficult for you to get it out

C I don’t know probably didn’t feel as though it come up in the right conversation to be able to bring it in

T Ok

C Do you know what I mean

T Yeah that makes sense

45


C Rather than just be talking, and then ill go totally off about something else and then just felt a bit silly and then trying to get it in to

T I think it is really important for us to be able to hear everything that you have got to say as you are the expert of your problem and actually what you have got to say is really really important

Interpersonal effectiveness

Building a rapport with the patient

C Yeah

T So I think maybe we could come up with some strategies where if you think you have something that you

C Really I should write it down but I am not always in the position to be able to do that I might be up a scaffold and I am working away and sometimes my mind is doing a hundred miles an hour and im with it, I wasn’t really with it today this afternoon so I made a couple of silly mistakes, nearly fell off a couple of times

T When, what was making you aware that you wasn’t really with it today

Guided discovery

Asking the client questions to help them understand what was going on with them.

C I don’t know, it was, (erm)

T What did that feel like what was going through your mind


Helping the client to recognize their thoughts

C Just as though I wasn’t concentrating on the task that I was meant to do and normally I am pretty focused at work and I am really careful

T Why do you think it was that you couldn’t concentrate

C (erm) don’t know may probably anxious about coming here on my mind

T Ok

C Erm that I hadn’t don’t this was probably there and that and obviously like today is like that day like d day

T Yeah I mean one thing about the homework is that the reason we give homework is because practicing these things makes perfect

Homework setting

Discussing the benefits of homework setting

C Yeah yeah

T So for us it is you are able to move a lot quicker in the process if you practice them I mean you know that in

46


your job you must have had to have done a lot of practice to get to the stage that you are at now

C Yeah I only (erm) I have been collage for two weeks and then for 4 days to do what I am doing now

T So mainly all of it is practical practice

C Yeah yeah and in I cant I cant go no further than what I am, well I can just go in the office or supervising but I am as good as you know like that

T Yeah

C But

T I mean it sounds like you are very knowledgeable about your job and you know what you are doing and you are focused

C Yeah

C I am entitled to be I have been doing it for long enough

T Exactly

C I have been doing it for 27 years

T 27 years so you must know a few loop holes to do things quicker and all these different things

C Yeah

T Right so that is the same thing with the homework here I mean I don’t want you to feel pressured to do it, I think maybe as well that was a bit too much but sometimes when we when we discuss like decide on some homework it is just literally to reiterate some of the things that we have been talking about in the session so

C I think I think the reason why I am not very forward in the reading and writing is because I don’t have to do it in my job

T Yeah so it is a bit alien really

C Yeah on the odd occasion, yeah it is to me it is really alien because today I had to just write out a variation sheet of what I had done and I got someone to sign it and my handwriting is terrible, and like iits where I have just finished work and I don’t know you, your adrenaline is still going as though like I am writing and I have got really no control so its like a little kid is doing

47


it

T Yeah

C I can write alright if I am just sitting there and chilled out and writing but its just where you have been working and your adrenaline is going and you have been working its

T I was going to say the last homework you did your writing looked really really neat

C It can be but it can be really thingy it all depends

T Do you think that is you putting a negative spin it again

C Maybe (erm) I don’t know I probably put the negative spin on a lot of things I suppose like make things into bigger issues than what they really are

T What does it feel like to thing about that

C I don’t know, sometimes I get my head around it and think why was I worrying in the first place and then other times it really gets to me and really plays on my mind really and just and then everything just escalates and then something else will give me and then I when you are feeling a bit down it just gives me the hump and it just escalates and evolves from there and its turns into a big thing when really I should have just dismissed it and (pause)

T what does it feel like for you to hear me say well actually your writing is really good and it is completely illegible and

C Yeah I know I can write its just when I put my heart to it, it’s the same like at school

T Like under pressure

C Yeah yeah I could write when I wanted to but I don’t know its being lazy I suppose

T Sometimes that could be the case

C I mean everyone is lazy in there own little way

T Ok so if we look at the second thing that we put onto the agenda it was to review last week

Agenda setting

Pointing out to the client that we are moving onto the next agenda item

C Yeah

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T What do you remember about last week, what we did last week

C (erm) (pause) I cant

T Its kind of gone out of your mind

C Yeah

T That’s ok

T If I show you this this formulation

C Yeah I remember that

T So we had about certain times of the day that you are doing a job and it does go to plan, so that was kind of our focus of a situation that makes you feel depressed sometimes

Conceptual integration

Reviewing the previous formulation that has been completed.

C Yeah

T So that was an example

C Or I feel as though I have too much of a conscious at times when I should when I look at other people and they don’t seem to hold things they just like

T Explain that to me a bit more what do you mean by that Guided discovery

Asking the client questions in a Socratic way to help develop a deeper level of understanding into their problems.

C I don’t know (pause) I don’t know its just like leaving stuff and it might be for being tidy or having things done a certain way or something like that but

T So you feel you do more than others Feedback Summarizing what the client has said

C (erm) I feel as though I do but I probably don’t its probably just me thinking out I don’t know I don’t know

T That makes sense (erm)

T When you feel like you do more than others when you are in a situation and you think I am going to see this out see this through to the end

C Yeah try and do it try and do a bit extra try and do it the best I possibly can

T What does that make you think about the other people Guided Helping the client to

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discovery understand how they view the world.

C Don’t know like they have got a bit of a blaze attitude towards things

T So they are not as dedicated

C But at the end of they day they are still getting paid so what’s so I think to myself so what’s the why am I getting myself in a state when they are not worried

T So they are not worried about it so why am I Feedback Repeating to the client what they have said to ensure clarity.

C Yeah why should I be worried about it

T So when you think that thought of “there not worried about it why should I be” what behaviours do you do what does that lead you to do


Asking the client to identify what behaviours they show in certain situations.

C (erm) for a little while have a little bit of a blaze attitude

T So you are kind of like oh what the hell

C Yeah yeah

T And does that lead you to stop working or take a break or what do you do

C Yeah just like anything or just (erm) but then I think to myself why have I got to be like them and then not care and that but at the end of the day (paurse) there is not a lot of caring in the world sometimes and some of us have got to care do you know what I mean

T Is it bad to care

C Not its not bad to care its not but we can probably care too much I suppose and let it play on you

T So it is like trying to find a balance

C Yeah a happy medium with it and I obviously haven’t got it.

T Ok so that is what we are looking at

T So

T (erm)

T Go on

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C Over the last week I haven’t had a bad week to be honest its been quiet good I have had a couple of moments, a few moments but

T Do you remember what those moments were

C Just generally worrying about things (erm) just getting a bit anxious then I think why am I worrying or letting it play on my thing I am doing as much as I can so no one can ask any more of me

T Yeah that is true

C And I don’t know I didn’t feel as though it was right or it was wrong the way I was feeling, do you know what I mean

T Yeah that makes sense

T What things have you worried about can you pin point any


Aiding the client in identifying what their cognitions and thoughts are.

C No I don’t just in general just any simple thing I don’t know just

T It doesn’t matter if you cant remember

C Yeah just because obviously I am at work a lot and it’s the only thing I can really relate to, at home it has been lovely its like my son has been really lovely and a couple of times we have had to tell him off but at the end of the day he is a teenager

T Yeah that going to happen

C Yeah he is going to push his luck but overall he is lovely he is he is a really good kid, and my wife has been fine and been really helpful and understanding and this and that and so

T What has she been understanding about

C Just the way she knows I am obviously feeling down and obviously feeling depressed and that and obviously she just keeps saying the sooner you sort yourself out everything will be lovely because like she was saying we have got a lovely relationship it just needs to for you to sort yourself out

T And how does that make you feel Eliciting key cognitions

Identifying the individuals feelings

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C It makes me feel lovely but if I could flick a switch and it would be done that would be great but its not like that

T You feel like it is quiet a long time

C But I probably I think it is going to get to stage where I am doing it without even realizing it and then I don’t know and then I think to myself how do I know I am not going to be doing this for the rest of my life I am going to have to try and find a happy medium yeah but (pause) I don’t know

T I think you are right in questioning am I going to be doing this for the rest of my life and the thing is with the skills that you are going to learn through CBT you will be doing those for the rest of your life but they will become a part of your life

C Yeah Yeah

T So changing the way that you think about things and changing the way that you behave

C Yeah your whole attitude towards things

T Yes that change will be a positive change for the rest of your life, it wont be this is a real drag like being on diet ive got to stick to this, it will be a part of your life that is making your life better

C Yeah

T So that’s probably a when you think of is this going to be me for the rest of my life you need to think of the good things about it so it is going to make you feel a lot better.

C Yeah yeah

T Ok so if we just (erm) review again, (erm) finish reviewing what we did last week, we came up with lots of different thoughts that were going through your mind so when you are in this situation where things are not going to plan at work you want to go home, you cant get motivated

Feedback Reviewing what was completed in the previous session.

C Yeah

T You are not really sure why you feel the way that you do or what is going on and these and that makes you behave in ways that where you start to worry about it, moaning, you kind of withdraw and go into yourself

52


C Yeah yeah

T Ring your wife, think the worst of everyone and get quiet short tempered.

Feedback Paraphrasing what the client has said.

C Mmm

T (erm) And then in your body it feels like your heart rate increases your get kind of racing thoughts and hot and that leads to feelings of jelousey so when you are calling your wife you are wondering what she is doing, where is she

Feedback Repeating what the client has said.

C Yeah yeah

T Kind of feel empty inside maybe like something is missing

C Mmm

T Can you relate to that? Feedback Asking the client if they agree.

C That is me down to a t

T We’ve got that, ok so that is the depression side of things

C Right

T So if we can maybe look at the anger and jealousy can you think of any situations in your mind now that where you have felt angry or jealous that you can talk about.

C (erm) (pause) to be honest I have had a couple of jealous thoughts lately but not to any extreme

T That’s fine

C Compared to what it has been

T So would you prefer to talk about an extreme time or one of the ones that you have had more recently, it is up to you, you can decide

C (erm) (pause)

T What ones have caused you the most problems

C (pause) loads

T Try and maybe pin point a specific situation

C (pause) (erm) when someone at work (erm) said their

53


friend had slept with my wife

T Ok

C That caused a big problem

T So the situation was someone at work (pause)

C Said that there friend had slept with my wife

T Ok

T (pause) in what context was this was it in a jokey context or was it that they had pulled you aside

C No no no just said

T So where were you

C I don’t know I cant remember now

T A the time what thoughts were going through your mind Eliciting key cognitions

Asking the client what thoughts were going through his mind at the time of the identified situation.

C I don’t know I didn’t know weather to believe it or not

T Right “I don’t know weather to believe this or not” what else

Feedback Repeating what the client has said for clarity.

C (pause) (erm) frustrated (erm)

T So that would probably be a feeling or emotion frustrated so I will put that in that box (erm) what else were you thinking at the time, how did you know you were frustrated, what was going through your mind?

Eliciting emotional expression

Allowing the client time to identify emotions experienced.

T So we have got I don’t know weather to believe this or not

Feedback Repeating what the client has said.

C I don’t know I was just angry I suppose

T Ok so you felt the feeling of anger

T And when you feel angry what do you think? Eliciting key cognitions

Paraphrasing what the client has said to help them to identify their thought processes.

C (pause)

T Often when we are in these situations are minds are really really busy and lots is going on you have even

54


said that you experience the racing thoughts

C Your head is doing overtime

T So you have to try and grab one of them and figure out what is it that is going on, what am I thinking, (pause) maybe even now if you think back and reflect on the situation what do you think about it?

C (pause) I don’t think nothing about it, I don’t think that it is true

T So “it might not be true”

C Mmm

C (pause)

T Or “it isn’t true”

C Mm (pause)

T What else is going through your mind Eliciting key cognitions

Repeating the questions asked to gain more detail from the client.

C I don’t know

T It is quiet tricky to capture what is going through our minds

C I asked her weather it was true and she (erm) obviously denied it and (erm) I don’t know I didn’t think that that answer was good enough

T Ok so your thought was “the answers I am getting aren’t good enough”

C Yeah

T Ok yeah that is good

C Its like disbelief

T “I don’t believe her”

C Mmm (pause)

T Ok so some of the thoughts that you have come up with are “I don’t know weather to believe her or not”, “it isn’t true”, “the answers I am getting aren’t good enough”, “I don’t believe her”. So it is kind of a mixture of all the different things that are happening in this intense situation, (erm) if you could think back to that situation and the feeling of jealousy with 0 not being

Eliciting emotional expression

By asking the client to rate their emotions it demonstrates how intense the emotion is currently and at the time of the situation.

55


jealous at all and 10 being very jealous where would you say that you are

C 10 yeah

T 10 out of 10 right

T (erm) so you heard this news, somebody at work said that there friend had slept with your wife what behaviours did you do, what did you do in that instance


Identifying what behaviours the client expressed in response to his thoughts and feelings.

T So you said that you asked your wife if it was true

C Yeah it just played on my mind I didn’t say anything to them

T So you kind of ruminated it

C Yeah and it just played on my mind and played on my mind and played on my mind and I was just going into myself and brain had a shut down

T So you kind of withdrew from everyone

T And was just thinking over and over and over

T Was you doing all this at work

C Yeah while I’m still at work I was just carrying on with normal things because it really does my head in I just, all this was going on in my head but I can still carry on do my work and carry on carry on living a normal life well it aint a normal life just going through the motions of, of leading a normal life but deep down there’s something obviously wrong

T Ok so you feel like there is something wrong

T And is that something wrong with you or something wrong with other people?

Guided discovery

Using specific questions to get a deeper understanding of the clients views.

C With me

T Ok (erm) ok so thinking back to this situation (pause) what did you do when you went home, what was your behaviour?

C (erm) a bit distant (pause) as though like I am picking for an argument or

T This is with your wife

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C Yeah yeah yeah

T How did you tell her

C I asked her weather it was true

T What out right you just said this is what you have heard

C Yeah yeah

T And is this true

C Mmm

T And then what happened

C She was obviously denying it and and er we wil go and see the person and this and that so I said why involve other people in their argument I want to sort it out between us


Attempting to identify what it is they client did when placed in situations that made him feel angry

C Mmm

C And erm she was going off her head and

T And how did that make you feel Eliciting key cognitions

By asking the client how it made him feel we were able to get to a deeper understanding of what was going through his mind.

C (erm) I don’t know really just frustrated and mixed up and (pause)

T Ok what does mixed up feel like

C Just not knowing what to think, weather it is true, weather it is false so like its

T Yeah that makes sense (pause) (erm) ok so we have got quiet a lot of behaviours, we have got that you asked your wife if it was true, you were kind of ruminating with it, it was playing on your mind, thinking about it a lot, withdrew from everyone else and quiet distant from your wife and picking arguments with her. When you had these thoughts that we have got and these behaviours what was going on in your body, what did it feel like?

Feedback Summarising what has been said.

C (pause) obviously the heart racing again

T Yeah

C And feeling uptight and (pause)

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T Anything else, anything else happening in your body

C No no

T Ok so I have been writing down a few feelings and emotions that you have been saying as we have been going along so you have got frustrated, angry, mixed up because you are not really sure, not knowing what to think really, have you got any other emotions or thoughts going on with the jealousy?

C Obviously angry but not in a violent way

T What way is it?

C I don’t know I, just storming around and just trying to show that I am angry and not happy

T Ok yeah

C But to be honest I just go in myself and don’t speak and

T Was there any sadness

C Yeah obviously a lot of sadness I feel as though I am sad a lot of the time and I don’t know why just go in myself and (pause)

T Ok

T (erm) when you came here you said one of the biggest problems that you had was jealousy when is this the first situation that you can recall being jealous

C No there is loads

T When was the first time that you can recall feeling like jealousy was a problem for you

C (erm) probably all through relationships with other people paying attention to who ever I am with and obviously them paying attention to them back and obviously if it keeps occurring the attention I just cant understand and it makes me feel jelous

C So

C It makes me, (pause) I don’t know

T Does this happen with your wife that you are with now?

C Yeah yeah yeah

T And did this happen before this situation

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C Yeah yeah yeah

T So even before this situation there were times were you were out and people were paying her attention

C This has happened a few times yeah

T So other people paying your wife attention

T (erm) because the only thing I am quiet mindful of is that this situation so someone at work saying that your wife has slept with someone else, it would probably depend on the context but it would probably be quiet normal for you to be jealous of that situation

C Yeah of course yeah

T It depends on the context though so if it were maybe in a jokey way not so much as someone confidentially telling you a situation

C Yeah yeah yeah

T Do you remember anything about the context that it was in?

C No I cant remember not really it happened a little while ago to be honest and I try not to think about it

T So if we stick to like maybe other people paying your wife attention rather than you does that happen now

C (erm) er (pasue) I suppose it does like when she goes out or what

T Any times that you can think of

C Yeah but sometimes it seems a little bit more, more I cant put it into words

T More prominent?

C Yeah more prominent sometimes like obviously people are going to smile at each other and just but sometimes it tends to go on a lot more

T Do you think it is going on a lot more or you are noticing it a lot more

C You are noticing it a lot more

T Ok (erm)

C But I say to my wife about it and she says there is nothing there or she is not doing it and I don’t know

59


why

T So if you think of yourself in this situation, so you have got other people paying your wife attention and she is paying it back to them what thoughts are going through your mind then


Identifying the clients thoughts

C (erm) angry, hurt

T Ok so they are the emotions, good

T The emotions are that you are angry and hurt (pause) yep, what are the thoughts what are you thinking at the times, so you have got this situation where you feel like, that your, there is somebody looking at your wife and your wife is looking back at them, what is going through your mind?

C I don’t know I cant really put my finger on it

T You cant really put your finger on it, that’s ok

T So we have got your feelings as being angry and hurt what when that happens what do you do, you said to me that you speak to your wife

C Yeah but she just denies it and then I question myself weather I am reading more into it or I don’t know

T So you question yourself you might say something to her, what sorts of things might you say to her

C (erm) challenge her on, on the attention that she is been giving someone else

T So you challenge her, can you think of what you might say?

C No no

T No

T (erm) do you think that you would do it in an aggressive way or not

C Yeah probably a little bit aggressively

T Ok and then what happens does she get defensive

C Yeah yeah

T Does that end up in an argument?

C Yeah it just escalates and then just goes all up in the air

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and..

T How does it disappear

C (erm) just (erm) we don’t talk about it and then just blank it

T So you kind of avoid it

C Yeah avoid it

T Ok so what would it mean to you if other people were looking at your wife

Guided discovery

Understanding the deeper meaning behind the client’s core beliefs.

C (erm)

T And she was looking back at them

C In a way it is just being friendly but sometimes I don’t see it as that I don’t know what I see it as

T But what would it actually mean to you?

C I don’t know really

T So imagine this situation were true, we are in a situation, we are in a bar your wife there is a guy across the room who smiled at your wife and you wife smiles back, what does that mean to you.

C (erm) nothing because obviously people are smiling but if it keeps happening and I don’t know it just

T What is it about the situation that makes you feel uneasy

C (erm) I don’t know it could be that I feel a bit inferior that I feel a bit (erm) I don’t know

T Yeah that makes sense, that makes perfect sense

T (erm) do you think it is true that you are inferior?

C No but that is probably the way that I feel a little bit I don’t know as though they have got something that I haven’t, it looks like

T Ok so they might have something that you haven’t

T Ok so there is thoughts going on that “they might have something that I haven’t” what if they have, what if they have got something better than you. What would that mean

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C (erm) (pause)

T They are quiet tricky questions

C Mmm

C Well they have obviously done (erm) well it all depends if it is material or or I don’t know or they are better looking or whatever and that I don’t know

T What would it mean to you though

C (erm)

T So we have got that it might make you feel inferior anything else

C (pause) yeah I would just feel inferior to them, that is all like just

T Ok so imagine that you are in this situation where there is a guy looking at your wife and your wife is looking back at them, you feel inferior because of that situation what does that say about you

C That I am not comfortable in my own

T So you don’t feel comfortable in yourself or

C Ye ye in myself in my own skin if you know what I mean like

C (pause)

T Ok, how are you able to recognize this this so this feel of inferior and this feeling of not being comfortable when do you think that started? Where did that come from?

C I don’t know I really don’t know, I probably felt like it for a really long time to be honest

T So as a child or more as an adult

C Probably more as an adult

T Can you recall any situations that might have led you to feel that way in the past other than the ones that you have mentioned so far

T Can you think of any

C No

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T Not really

T That’s fine

T Ok so this belief of being inferior, feeling uncomfortable in your own skin is that something that you feel all of the time is it

C No no just

T Or is it in certain situations

C Yeah probably in certain situations and I cant and that’s across the board not necessarily just with my wife its probably dealing with situations and probably not being able to answer or answering in the right way

T Tell me a bit more about that, what do you mean?

C (erm) (erm) somebody will say something and I should have an answer and about five minutes later I have thought of the answer but its probably too late

T Why

C I’m probably a bit slow

T Why should you have an answer?

C (erm)

T Is that a rule for living that you have? Guided discovery

Identifying rules and assumptions

C No its just I feel as though I need to

T So when somebody speaks to me I have to answer them? Or I have to have the right answer

C No no

T What is it

C Just I cant put my finger on it

T That’s fine

T If for example I asked you a question now and you didn’t have the right answer or you didn’t have an answer to give how does that make you feel

C Erm ok because I know you will write about it (laugh)

C (erm)

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T So what is it about this situation and other situations that is different?

C This is, I am here for you to train me to think otherwise

T Ok

C And obviously I am going to make mistakes I am going to be this I am going to be that and until I can grasp it, I am not going to feel the way that I should do

T Ok so it is ok in some situations not to have the answers

C Yeah yeah

T But the rest of the time you should do

C Mm

T Ok

C My wife is really quick like we went to lakeside last night (erm) went in a shop and I wanted to get a case for my phone because (erm) I lost my other one and there was a case there for £3.99 and I thought yeah I will get that and I took it to the man and he said £6.99 but it was priced up wrong and I challenged him and said it was £3.99 and er he said no they they are £6.99 when really I should have had that or at that price because it was priced up and I just said well if I wasn’t rude or anything I just said if it was £6.99 I wasn’t going to have it and I said erm goodbye and thingy and I said it to my wife and she said oh you should have said this and that but at the time I probably didn’t think of it I probably didn’t want to be rude to him or thingy or try not to be rude to him

T Yeah

C But thinking about it after I should have been quicker but I wasn’t

T Ok so it sounds like that you felt like you should have

C Yeah I don’t know I felt a little bit silly and she will be on the phone and will think quicker on her feet and

T Some people are a lot more assertive than other people

C Yeah

T Which is definitely something that we can look at as well

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C Yeah yeah

C (erm)

C And I think if I was a little bit better at that I could be a lot happier as well

T So maybe looking at some assertive skills Conceptual integration

Making goals and plans for following sessions.

C Yeah yeah

T That is definitely something we could do, maybe we could do some role plays on how we can get you to act more assertively in certain situations particularly ones that make you feel a bit uncomfortable

C Yeah and I, I was thinking about it and thinking about it and then I said oh I am being silly really, and this and that and I tried to dismissed it, I mean I ended up buying one at £6.99 anyway so it was just something and nothing really do you know what I mean

T Yeah

T Ok well we can definitely look at that

C Yeah

T So if ok so just thinking about that situation quickly what thinking back on it how would you behave differently what would you have done

C I would have said it is priced for that I should be able to buy that at that it is not my fault it is your problem obviously say that without being rude obviously get your point across

T So not aggressive not

C Yeah yeah

T Yeah just getting the point across, that sounds like a good idea

C I can be like that but I can probably sound aggressive

T I think getting in between the line of being passive and aggressive and then getting to the in between bit which is assertive is really difficult

C Yeah and I haven’t mastered that

T I think it is a real skill

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C And I beat myself up over that to be honest and I think about it

T So that is another thing that you might beat yourself up about

C Yeah

T What, when you think about not being able to be assertive what does that make you feel? What does it make you think of yourself

C (erm) its silly really a bit stupid

T So I am stupid

C Yeah yeah

T So its like I cant do that I must be stupid

C Yeah yeah just putting myself down

T Yeah ok so putting yourself down about it (erm) ok we have come up with quiet, with regards to like the anger and jealousy it fits really well with the depressed stuff that we were doing last week it kind of all connects together and links up because we get the feelings of sadness when you do have these situations where you feel jealous which can probably lead to acting in the depressed ways that you do

C Yeah yeah

T And in the same sense you said that when things aren’t going well at work you might call your wife and if she doesn’t pick up you get jealous which leads to the other things

C Yeah I try not to call her now unless I can be happy and chatty and that because a couple of times I have spoken to her and she has said oh (erm) saying oh you’re her being sarcastic and saying oh you have cheered me up no end with her being all nice and chirpy but sometimes we cant be chirpy all the time

T Yeah we cant be happy all the time

C And obviously it is nice to hear a friendly voice and like and a friendly and understanding voice and like I try not to give her a feeling that I’m a little bit shitty and that

T So you might try and avoid talking to her

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C Yeah and I try and avoid talking to her and just talk to her when it is nice so it is a nice memory for her

C To think about

C Yeah to think about rather than just being all doom and gloom

T Yeah no that would make a lot of sense, I think it has been really good for us to get to the core of some of the beliefs that you have so you have all these different thoughts and behaviours and feelings going on but the reason why you are having those there always has to be like a central point of where those come from and for us I think today we have kind of come up with that you feeling inferior in situations and you feeling uncomfortable in your own skin and sometimes feeling stupid in situations is probably where it routes from I mean there is probably lots more as well

C Yeah

T But that is some of them, would you agree that is some of them

C Yeah yeah erm my left eye is been a problem from when I was younger and I have got lazy eye and that really plays on my mind like confidence

T So because of your lazy eye what do you think

C Erm I don’t know I don’t know as though people take the micky out of me and like just I don’t know I (pause)

T Have they taken the mickey out of you for it

C And then other times, yeah yeah and then other times I can just dismiss it and just get on with it and not but this is just I cant think

T When people have taken the mickey out of you what have they said

C (erm) (erm) (pause) I don’t know

T Not really sure

C Yeah I don’t know or maybe it is just me being paranoid or I don’t know

T So you cant really think of anything it might be you just being paranoid

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T I will be honest I did not notice at all and I still cant notice now

C Yeah

T So it might be you being paranoid or

C Yeah might be yeah

T You cant remember anything someone’s said

C I spoke to my wife about it and she said don’t worry it is this and that I have even er gone to er gone to go private to have it done but they said it is not bad enough for some reason

T Yeah

C But obviously when I am tired or I have had a drink it comes out more

T Yeah ok but you haven’t had a drink still

C No on Sunday no on Saturday we went out Saturday I went out and had a couple of pints of shandy but I wasn’t drunk

T What was it like to drink

C (erm) it was alright we had a bit of a late night, I woke up with a bit of a headache and that and to be honest it wasn’t very nice and I was thinking you know what I am not really missing a lot so

C (laugh) ok I think although you have struggled with the homework. (erm) sorry is there anything you wanted to add to this what we have been through so the angry slash jealous situation we said that we had kind of got to some of the core beliefs (erm)

C (erm) just (erm) my wife had a lie detector test and passed it but erm I still didn’t believe that

T Ok so you was it you who told her to have the lie detector test?

C Yeah yeah yeah (pause) it cost a lot of money as well

T So she had a lie detector test, passed it and you still don’t believe that?

C Well I didn’t but I do and I don’t know

T You still feel a bit confused about it

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C Yeah yeah yeah

T So sometimes you feel like you do and sometimes you feel like you don’t

C Yeah and the fella that she even phoned the fella up that done it but said the fella who done it is not going to say its not because he has had our money and

T So you are kind of doubting the situation kind of trying to put a negative spin on that

C Yeah yeah

C I don’t know

T Thinking the man wouldn’t tell you if it wasn’t real

C No course he aint because he has had your money and

T So can people not be trusted

C Yeah yeah

C (erm)

C Yeah I am not a very trusting person to be honest

T So you kind of see others as people who cannot be trusted

C Yeah yeah

T How do you view the world

C (erm) I don’t know there is a lot of wrongens out there in my eyes but in other I see a lot of nasty things during the day and a lot of things that people are doing and that you have got to open your eyes but to be honest nothing really shocks me because (pause) it don’t surprise me I just think that’s just people that’s just the society that we live in

T That is quiet negative but that’s fine we can look at that, ok so I do want to ask if I will I have got an idea of how we can set some homework that might be kind of related to what we have done in the session today

Homework Discussing the homework ideas with the client and how they relate to the session.

T Right so

T I was thinking maybe you could write about how your core beliefs affect the way that you behave, just a little paragraph so some of the core beliefs that you came up with were that you feel uncomfortable in your own skin

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so if I put them on her

C Yeah then I can relate back to them

T Even if you can just bullet point it (pause) don’t feel pressured

C Right

C (laughs)

T Don’t feel pressured to write so much because I know that writing is obviously not something that you like doing

C Yeah sometimes I can write a lot and then other times it is just the bare minimum and that’s it

C (pause)

T And I feel stupid so what I have done I have written down some of your core beliefs there and what what I thought would be a good idea is for you to look at the ways that these core beliefs have affected the way that you behave do you do you understand what I mean by that

C Yeah yeah

T Have you got anything that you think might stop you from being able to do the homework

Homework Discussing any problems that the client might have with completing the homework.

C Yeah that I cant be bothered

T So motivation might stop you from doing it

C Yeah

T So what can we do to make sure that you feel more motivated can we set maybe a specific time

C Beat me with a stick (laugh)

T I wouldn’t be able to do that I am afraid (laugh)

T So do you think we could set maybe aside a bit of time for you to be able to find a bit of time for you to be able to do it

T Maybe if you could think of a day you might have less on that you might be able to spend even five minutes just thinking about it

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C Yeah I can take time out to do it if I aint doing anything I am just sitting watching telly

T Ok so even if you think just five minutes of an evening just have a reflect on what we have spoken about and how that these beliefs that you have have affected the way that you behave and just get those down because it can really help us in erm the next bit that we do when we are trying to look at your goals for therapy and what it is you want to achieve

C Yeah

T And I think next week it would be a really good idea if we can kind of put these two big pictures that we have got together and bridge the gap and see how the different problems relate to each other

C Yeah does it all evolve from one thing or is it separate things

T Its likely to come from, I mean even now the core beliefs that we have got we have three different ones here so it is likely that a bit of this and a bit of that have all resulted in the way that you are feeling now

C Yeah

T But I am more than sure that if we work together we can get through some of these thoughts and feelings and behaviours that you are having and the impact that they are having on your life, we can

C I can get frustrated indoors as I can get home and I have got a lot to say and but I don’t get a chance because I cant I and then (pause)

T so that sounds like some real assertive skills are really going to be helpful for you

C Yeah and when I do get a chance to speak I feel as though I cant just bring that conversation in because it doesn’t

T Flow

C Yeah

T Does it have to flow

C Well no but it just seems a bit random to me because it has just been going around and around

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T Kind of a bit like what you were saying at the beginning of the session that it doesn’t fit well I want you to know that in here you are open bring up anything we can just pop it onto our agenda

C Yeah yeah

T And speak about and find a place in our session to speak about it because here we need to speak about all of the things that you are thinking about

C Yeah I have got loads of things going on in my head and because I don’t want to I don’t know it seems though it is weird like you talk about something and then you go on about something else

T Yeah

T Or just coming in saying like a random thing I have got a dog and like if it was it feels like that situation

T Yeah but you know what that is ok right and we will write that down right

C Yeah

T So you have got a dog and we will get to that

C Yeah but I haven’t got a dog

T Yeah I know that was just an example

C Yeah its just obviously

T How that impacts on why has that come up for you and why is that a significant thing and we are able to look at those things and we can teach you ways to be able to open yourself out and be able to speak about that when you are with your wife

C Yeah

T (erm) yeah so there is the dreaded homework

C (laugh)

T Is there anything that you want to ask about it, is there anything that you think might make it difficult for you to do other than your motivation levels that would make it difficult for you to be able to do it

C (pause)

C No it is ok

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T No

C No it is fine

T Ok so todays session obviously we looked at some of the reasons why you were not able to do the homework which is fine that I know you said writing is sometimes quiet difficult

Feedback Summarising on the session

C Mmm

T (erm) we looked at the previous session so all about the depression situations where you felt depressed and how that had impacted on your thoughts, your feelings and your behaviours and then today we kind of looked at the anger and jealousy side of things and different situations with that and with that we were able to come up with some of your core beliefs

C Also I am doubting myself about being feeling mad because the way I feel and like doing this but (pause) I don’t know like what is made I don’t know

T What do you mean by that

C I don’t know I don’t know it is hard to explain

T Yeah it sounds it

C Yeah

T What you mean you are doubting coming here or

C No I am not doubting coming here but I have just I feel as though I am mad like I don’t know

T That you shouldn’t be feeling this way

C Yeah yeah

C I don’t know but I cant really put my finger on it

T Ok so you shouldn’t really be feeling this way

C No yeah

T Ok

T So that is probably a common feeling in this sort of situation where you have got lots and lots going on

T Yeah and there has been a lot of things (erm) going on at the moment about mental health issues and I’ve obviously listened to them and this and that and I don’t

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know I just

I think the reason that you are hearing so much about it is because it is so common

C Yeah yeah yeah even just watching the something obviously 999 emergency the other night it was erm they was dealing with mental health patients and they are just sitting here taking loads of tablets in front of them and they are hearing voices and I don’t hear that but I feel as though like because the way I am I feel as though I am classed as the same as that person

T Ok so there is a lot of stigma around it

C Yeah yeah like that

T I mean like it is the same as like when like if you look at it in terms of criminals there is a massive long spectrum, you see it as they are all criminals but then you could see it as this person has done this to get out of what they have done or they have finished their treatment so does that still make them a criminal it is just the way that you are looking at things

C Yeah it is just the way that I interpret it

T Yeah interpret the situation

C Yeah interpret

T (erm) there isn’t there we cant get away from the fact that there is a stigma around mental health

C Yeah yeah

T But

C The nurses are definitely the ambulance staff are definitely not trained for it and they shouldn’t be put in that situation to be honest its terrible

T Yeah I mean we have come a long way but there is obviously more that needs to be done as well

C Yeah yeah yeah

T (erm) ok so is there anything that you feel we haven’t touched on today that you wanted to speak about anything that we have missed out from the session, we have kind of run through what we have done today and we have really been able to formulate like get a real picture of where we are so next week when we can feed

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all that back we can start with some of the interventions

C No after I have done my homework

T Yeah after you have done your homework

T Yeah ok so that’s good.

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cognitive behavioural therapy case study

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