Cognitive Behavioural Therapy and How it can Help Jane

At present I am working with a client whom for the purpose of this case study I will refer to as ‘Jane’ in order to adhere to the ethical principle of fidelity. Furthermore I will also change the names of anyone else mentioned throughout in order to protect their identity. I have had six sessions with this client each lasting one hour. She is thirty-five years of age and comes from a working class back round. At present Jane is unemployed and is not actively seeking work as she suffers from a bad back and as a result of this is a recipient of sickness benefit. She is co-habiting with her fiancé of three months whom she plans to wed later in the year, although no date has yet been finalised. This client self referred to ‘Care In Crisis’ as she had heard about the organisation through a friend and felt she ‘needed to talk.’

During the initial assessment she disclosed that her mother had passed away as a result of cancer in March of this year, hence her reason in coming for counselling is to help deal with the bereavement issues surrounding this. Since loosing her mother she has felt very low and misses her terribly as they were very close. Furthermore, Jane also feels that it is starting to take its toll on other relationships in her life as she finds herself snapping at people. She also stated that she has low self esteem and has barely any confidence in herself. Her goals in coming for counselling are to be able to accept her mother’s death as well as building her self esteem and confidence. Firstly I feel that some Cognitive Behavioural Therapy approaches may work well in overcoming Jane’s needs. “Psychoeducation and normalising interventions are frequently used in ACT and CBT.”

Bach & Hayes (2002) I can see that they are relational interventions because they involve teaching people new relations. I believe it would be beneficial to psycho educate her on the ‘seven stages of grief.’ My aim in doing so would be to help Jane make sense of the emotions she is going through and to help her understand that they are perfectly normal, in other words ‘normalising.’ As well as using some CBT approaches I would choose to remain faithful to the integrative model which at the heart lies the person centred approach. One of the key concepts within this approach is self actualisation. This is the belief that as humans we will pursue what is best for us as introduced by Maslow in 1943 and his famous ‘hierarchy of needs.’ He himself refers to self actualisation as; “The desire for self fulfilment, namely the tendency for him [the individual] to become actualized in what he is potentially. This tendency might be phrased as the desire to become more and more what one is, to become everything that one is capable of becoming.” Maslow (1943)

Research does support the notion of self actualising tendency (Sheldon & Elliot 1999) and I can also recognise it in myself. In actual fact, recognition of my self actualising tendency has helped me understand some of my self destructive behaviours, which were introduced in my younger self. I’m hoping that this will also be the case with Jane. I consider this client to be very self aware which will aid her in self actualising and she had clear cut goals. In order to encourage her to reach self actualisation, myself as the therapist needs to ensure that I am offering Rogers’ core conditions of; empathy, congruence and unconditional positive regard, in doing so I will be assisting her on her journey. I will aim to be real and genuine and by doing so I hope my client will experience something of my ‘real self.’

Furthermore I will try my upmost best to see things from their frame of reference without being influenced by my own feelings and experiences. In the first counselling session I contracted with Jane and explained the limitations with confidentiality such as disclosing anything which breaks the law or child protection issues. I also stated that I was a member of the BACP. By doing the above I feel that I was demonstrating safe work and professional practice. I used active listening skills as well as non verbal communication in the form of small nods to show that I was tentatively engaging with my client’s story. The head nod is the most common gesture in listening “Small ones to show continued attention, larger and repeated ones to indicate agreement.” Argyle (1992)

I felt it important to show to my client that I was engaged with her telling her story as she mentioned in the initial session that she has never been able to open up to anyone before since her mum has passed. The majority of the first session was spent just staying with my client and giving her the space she needed to talk out loud about what sort of a person her mother had been and the lead up to her death. As a counsellor I used skills such as active listening, restating and paraphrasing to demonstrate this, as I felt these were the appropriate skills needed in order to meet the client’s needs. It is safe to say that in this session I was safely following Jane’s lead without prescribing any particular interventions. In session two my client reported a little change since our last session saying she had ‘felt heard’ and that it was a ‘release’ as she had been keeping everything to herself.

By following my empathic hunch it opened up a lot of unfinished business regarding my client wanting to share and tell her mother things but had not had the chance to. Therefore this prompted my decision to suggest the CBT approach of writing a letter to her deceased mother in her own time and if she wished she had the opportunity of sharing it in the session. This is something Jane was very keen on doing and would maybe even consider doing it that week if she got the chance. I can see that the letter writing process is therefore collaborative and would enable her to work at her own pace while also facilitating client empowerment. This would be important in helping to build her self-esteem and confidence which are areas she is lacking in.

In session three my client reported that she had written the letter to her mother and was eager to read it out. In the letter my client acknowledged many of her repressed feelings and by writing the letter she was maybe able to process them in a way she could not have in the therapy session. Zimmerman & Shepherd have stated; “We use therapeutic letters to help the patient to identify difficult feelings, processing them in another way than in a therapy session, with the chance of the patients to be finally free from these feelings. The letter writing can allow a physical way for the problem to be externalized, named and then confronted.” Zimmerman & Shepherd (1993)

In the letter she also touched on the feelings she was experiencing now months after her mother’s passing. At this point I normalised them for her by telling her there is nothing strange or bizarre about what she is feeling and that they are all normal feelings we may experience after loosing a loved one. I felt it in Jane’s best interest, which is in keeping with the ethical principle of beneficence to psycho-educate her on the ‘Seven stages of grief’ by giving her a sheet which had been given to me by my supervisor. This would help her make sense of how she is feeling and it would also provide hope for her as one of the later stages is acceptance. In the forth session Jane talked about her goals, both short and long term.

She acknowledged that whilst it was her mother at first who pushed her towards loosing weight for various health reasons, she now wanted to pursue her own goal of trying to loose some weight for her wedding day so that she could fit into her dream dress. I got a strong sense that the ‘configurations of self’ were being peeled back and the ‘real self’ was coming through, which Rogers theorised. By doing so she was closer to self actualisation. In session five we explored Jane’s lack of confidence and self esteem. It was evident that she had a low self concept of her physical appearance and dress sense.

Although she had received a compliment earlier in the week from a friend about how well she looked she perceived that the comment was made merely out of sympathy. As the therapist I got my client to explore this and by doing so we were able to get to the core of this view. It turned out that as a child she overheard her aunt telling her uncle that she had only told Jane her dress was lovely out of pity. It is said that; “Experiences are accurately perceived as meeting the needs of the core self or being consistent with the self concept and reinforcing it.” Creagh (2010)

It is therefore fair to say that Jane could not accept the compliment from her friend as being genuine as she was being true to her self concept. I offered the concept of looking for evidence borrowed from Cognitive theory in order to challenge her self concept. It appeared that there was no other evidence to support her views that compliments were only given to her out of pity, apart from the incident with her aunt. When we looked into this further her aunt said this around the time her parents were not getting on which prompted the possibility that her aunt may have been saying it to comfort her in a difficult time.

The client came up with this conclusion herself and I remained faithful to my integrative model which at the foundation has a profound respect for the client and their ability to construct their own views. Adapted from ‘The Theory and Practice of Counselling’ the ability to function and process experiences can result in being either low functioning or high functioning. I considered Jane to meet the criteria for low functioning which means; “Low functioning people are out of touch with their valuing processes. In these areas their self concept is based on conditions of worth which cause them to ignore/deny or distort the experience.” Nelson Jones (1992)

Through challenging and looking for evidence I was aiming for Jane to become higher functioning. At the end of this session I talked to my client about the possibility of audio recording our next session if she agreed to it. I felt it was in her best interest to give some notice rather than asking her on the day of recording so that it did not come as a shock or disorientate her. Fortunately Jane agreed for our next session to be taped. It was the sixth session with this client that was recorded. I made sure to highlight to my client the reasons behind the recording that it was solely for my training purposes so that she did not think it was some sort of test on her. At this point I was demonstrating safe work as I wanted to provide a non threatening environment for her. At present I attend a supervisor who is based a few miles outside of the town I undertake my placement with.

Firstly, her geographical location is convenient because when I am at placement I can call and see my supervisor when I am finished. This is beneficial as I find things tend to be much fresher in my mind if I see her on the day I have had clients. In additional her name was on the approved list issued by the college, this meant she was BACP approved to supervise therefore I got satisfaction from this knowing she worked ethically and had experience of supervision with students. Moreover because she was approved by the college meant she was familiar with the course requirements and as a result could effectively support my learning. Prior to choosing a supervisor I had some requirements including at least ten years experience of counselling and I wanted someone who worked from an integrative perspective, my supervisor met both of these.

On first meeting my supervisor I feel that there was a connection so I instantly felt comfortable. Before commencing supervision I had the view that they would be like a boss, however now that I have been several times this view has been diminished and I consider my supervisor as someone to consult with. I get a strong sense of being facilitated and supported by my supervisor. For example while working with this client I had limited experience of working with bereavement so my supervisor gave me a book which would support my counselling, in addition I was facilitated by being given a sheet on the ‘seven stages of grief’ which I could give to my client. At first with Jane I was working from a person centred approach because I felt unfamiliar with bereavement and felt this was a safe angle for me to work from.

With the support and guidance I received at supervision I was able to change my approach with this client by being more integrative. I was able to bring in some Cognitive interventions which I do not feel I could have done confidentially on my own without the aid of my supervision sessions. My supervisor is quite directive in the sense that if I do something effective in the sessions she will acknowledge my style of practice and vice versa if I do something that may not have worked so well she will then encourage me to challenge this and look at alternatives. As a result of this my confidence has grown and I feel a little more competent in my role as a counsellor to the point that I would trust my intuition with regards making appropriate decisions with my client work. By continuous supervision I hope to learn and grow as a counsellor as well as developing new techniques and interventions and as a result improve the value I provide to my clients.

Since working with Jane I feel that I have grown personally as I have increased awareness around death and bereavement. It is inevitable that I will loose a loved one at some point throughout my life. By hearing all about Jane’s grief of loosing her mother I feel I will be more prepared if I am faced with the death of someone close to me. My own mother has battled with health problems for the most part of her life and has been under close supervision of the medical profession especially in recent months. Having worked with this client has brought me in sync with reality and now I can see that there is a chance I may loose my own mother soon. My work with Jane has prepared me a little if this does happen and I now have a sound understanding of the stages of grief and the emotions that come with it.

Furthermore working with Jane has taught me to appreciate the people I am close to in my life and I have learnt to cherish every moment with them as they could very easily be taken away. As a mother myself to a three year old boy, I feel I have made more time for him knowing how precious he is to me. Professionally I have also developed at a result of working with Jane. In order to meet her needs I took part in a one day course held at my placement organisation which was based on bereavement. From this I learnt the various techniques and skills required when working with this client. Not only did this course help me when working with Jane but it will also help me when counselling clients with similar situation. Also a fellow peer in my placement shared a poem about loss with me. I was very appreciative of this and felt it may be of benefit to my client as she is artistic and creative.

I shared it with Jane in one of the sessions and she informed me that she got great comfort from it. The following week she told me that had put it on her fridge so that every time she opens the door she can read it. I can safely say that support from my peers has helped with my client work and as a result helped me to develop professionally. In the first counselling session with Jane we engaged in contracting. A contract can be defined as “A mutual agreement negotiated between the client and the counsellor prior to commencing counselling.” Provence (2008)

I made sure it articulated my responsibilities towards the client and also the client’s responsibilities in the counselling relationship. I made sure to inform Jane about the strict confidentiality policy that counsellors abide by and told her about the exceptions to this such as breaking child protection or the law as it would not be ethical for me to withhold this information. In addition to this if the client disclosed that she was of risk to herself I could not keep this to myself as this would not be in keeping with the BACP’s ethical principle of non-maleficence. By informing her of this I was hoping to provide a safe environment for her to share her story but at the same time letting her know the boundaries. I was also letting her know that I was obeying the ethical principle of fidelity.

The importance of the contract became apparent in session four, in which my client disclosed that her mother had been one of the only women she had ever really gotten along with and that in general she did not get on with women. This prompted my decision of using the skill of immediacy to establish what our relationship was like for the client with me being a woman. It was reassuring to learn that I was not like most other women she had encountered as I was not judgemental or bitchy. This proved to me that I was working in an ethical manner and respecting my client’s autonomy. When I first began keeping notes they were rather long and detailed, however now I have learnt to keep concise and factual notes. I recognise the importance of not noting opinions or judgements in the notes in the off chance they may be called for in a court hearing.

Each client’s notes are kept in their own personal folder which is kept in a locked filing cabinet in a locked room and each client is identified with a seven digit code. This ensures maximum confidentiality which is in keeping with the ethical framework principle of fidelity. In an emergency for example if I died and client’s notes needed to be accessed the receptionist could identify the client by searching the code on the computer system. Furthermore I am aware that a client has the right to access their notes at any stage. I respect that the client has the right to be self governing which is in keeping with the ethical principle of autonomy.