Marcia, 29 years of age, came to you six weeks ago with issues of poor self-esteem and lack of self worth. She has been married for 8 years to Michael, however in session she speaks little about him and when the conversation turn towards him she quickly tries to change the subject or issue. Although you have noted this shift you have not challenged her regarding this relationship as you work on different areas and issues leading up to the relationship.

At the appointed time today Marcia shows up with an unannounced Michael for her session. He said he was there because Marcia was changing and he wanted to play a role in the process, while getting a notion about what was in Marcia’s mind at the moment.

Throughout the session you watch Michael dominate and bully Marcia into answers that she, you feel, would not normally give. At one point Michael tries to stand over you when you challenge this behaviour. Throughout the session you feel uncomfortable and have feelings of melancholy for your client.

At the end of a very strained session Michael declares that he thinks it would be better if he came to all Marcia’s sessions so he can see what going on and what you’re filling her head with. After they had gone and you have reflected on the session you discover how his behaviours and her passivity have triggered feelings of unresolved helplessness in you – similar to those that you felt when your parents displayed these behaviours.

As her counsellor, how would you react to this situation?

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Category: Group Counselling
Author: Kathleen Casagrande

A Support Group had been advertised on the display board of the local Drug and Alcohol Treatment Centre in the City where the Counsellor had been seeing each of the members for private counselling prior to the start of the programme.

Ten clients enrolled in the group but by 7:15pm only 5 of the ten group members allocated for the 7pm time-slot, had arrived. Cancellations and rescheduling unfortunately are an issue with people who are challenged with substance misuse. The 5 members present, included:

1. Gemma, whose partner died from drowning in a pool next to her at a party where there were many drugs being used of all types; mainly ecstasy, fantasy and speed.
2. Wesley, who has been out of prison for six months now. He has been addicted to morphine and heroin and has since taken up alcohol (because it’s legal).
3. Cobi, previously a paramedic who was diagnosed with A.D.H.D. and used amphetamine/methamphetamine (speed) because it used to get him through the horrors of his nights.
4. Effie (Frangelica), who has deep-seated self-esteem issues. She used to smoke cannabis, just to take her away from reality and ultimately aiming to de-stress her.
5. Jasmine, who became an alcoholic when her husband died in her arms from an operation that went terribly wrong.

The goal of the group was to share ideas and strategies associated with the maintenance and well-being of each group member. Each week a member would be expected to deliver a positive idea or event that happened to them during the previous week. 

Introduction

Group Facilitator will be abbreviated to GF.

GF: Good evening. I am the facilitator of this group where we will be predominantly working with the effects of addictions. We have all decided to create a support group for sharing our experiences, our strengths and our weaknesses so that we begin to understand that we are not alone in our situations. Because some of us have journeyed along a path that has been amazingly eventful, we all want to know that our stories are all confidential and must not be shared with others outside of this room.

If you choose to elaborate on a story that belongs to somebody else, please be aware that it is expected you do not use that person’s name. 

Please remember that my duty of care, as it exists for us in counselling, also applies here. So if I consider that you, or another person, are at risk of harm, I am obliged to uphold your safety and the safety of others. This may mean that I will need to disclose information to people outside of this group. Of course, where possible I will seek your support on this before acting. Is that understood?

GF: (Addressing the group as a whole) I would like to find out what everyone in the group thinks about the issues of addictions in their own lives. Let’s move around the circle now starting with you, Wesley.

Wesley: While I was in jail I was medicated most of the time because of my aggressiveness, I just wanted to fight everybody because I hated myself. I’ve been hated all my life from when I was a little kid, my mother would tell me all the time how much she hated me ’cause I looked like my Dad. 

So after five years of being given morphine for pain from many beatings and then heroin when I got out I didn’t want to start stealing again to keep feeding my habit so I slowly went off heroin with anti-depressants I got from the doctor, then I became addicted to Valium and used that too much with rum to wash them down. I know I was just swapping the witch for the bitch to cover my own self-loathing.  I realise this but I have all this anger inside me.

“Prescribing a drug also gives doctors the illusion that they have solved the problem while, in fact, all they have done is to postpone it, and they may have created a new problem in the process.” (Parkes, et al., 1996)

GF (after some further sharing from group members, initiate a break): What we’ll do at this point is take a short break with some deep-breathing exercises to relax those who have shared so far and for those who have not yet had the opportunity and may be getting a bit apprehensive about sharing.  So to begin let’s just close our eyes for a while and focus on a very safe place we have visited or would like to visit, it can be anywhere you want as long as you are feeling peaceful and relaxed.

(The GF gently touches the CD player and calming music filters out, soft orchestral slow tones mixed with bushland sounds of birds chirping and the sound of water trickling along a stony path).  “Many groups, particularly those with members suffering from high levels of mental and/or physical stress, find it useful to include periods of time devoted to relaxation.” (Brown, 1994)

Break for Supper

Two members head outside to the street to have a cigarette and when they rejoin the group they have brought in the two other members who were late because they got “side-tracked”. Curtis and Stolli have stated that they would like to join in because they’ve heard this is a group to help them get off drugs. Stolli states he wants to bring his girlfriend Chloe in who is waiting outside.

The facilitator settles the group when the members become quite agitated at this turn of events. The two new people have the procedures and rules of the support group explained to them. They must make an appointment by phoning the office the next day during business hours and they will be quite welcome to join in with the next lot of participants in four weeks time.

The first Monday of every month is designed for new members joining. This way the previous participants can continue with the support group however they must make allowances for the new participants as they arrive.  Under no circumstances are there to be anyone joining the group who is presently using any type of illicit drug.

Curtis and Stolli appeared to be using some stimulant and this created chaos with the members in attendance. This only enhanced their craving which endangered their safety and sobriety. They had come this far and having people join in who could possibly sabotage their safety was beyond their expectations.

Curtis and Stolli are not permitted to join in halfway through the group. This is a serious exercise for the participants who have made quite an enormous decision to participate in a group that has the potential to change the shape and destiny of their lives as they know it. 

Effie has been quiet up to this point and just as the time came for her to disclose her story, Jasmine who was sitting beside her and beside the counsellor/facilitator, jumped up and screamed pointing to Effie’s shirt. With this loud interruption from Jasmine who had sat silently the entire time, created havoc in the group. The participants all jumped around not knowing why they were jumping around, some almost in a state of panic. 

It took some time to settle the group and it was revealed that Effie had brought her pet rat along inside her shirt for comfort. She was so attached to this pet that she did not want to leave it at home for fear of its safety. Jasmine hated crawly things she stated and said it was ridiculous that this girl should have this rat in the group. Trying to calm the group once again, the GF asked what the rat’s name was.

There was quite a bit of discussion around Effie’s pet rat with a suggestion being offered that members bring along photos of their pets for the following week. Unfortunately Effie’s pet rat would have to stay at home through the following support group evenings and enjoy his time out. 

Time for Jasmine (the group’s quietest member). She disclosed that ever since her husband had died five years previously she had used alcohol as a sedative to help her sleep. The alcohol had allowed her to block memories of him dying in her arms and all other previous memories that led up to that time and since that time, so that each day merged into the other.

Last month she made a promise to one of her sons that she would stop drinking before his wife had their first child. She stated she did not wish to elaborate at this time, for fear of losing control of herself and ending up a blubbering mess.

According to Parkes, et al. (1996), “Some group leaders adopt a structured approach, moving from the discussion of facts, to thoughts and then feelings about what happened.  We prefer a more spontaneous approach, allowing group members to decide upon the group’s priorities and intervening only if the group becomes bogged down or dominated by one particular individual or faction. It is important that everybody has the opportunity to be heard, even though some may prefer to remain silent.”

Conclusion

GF: Thank you all for sharing; this has been a tremendous first night. We will meet again next week as planned, please be on time because the two hours fly by so fast.

And now to end this session of group work let’s conclude with the Serenity Prayer.

You may wish to join in as you remember the words:

“God grant me the serenity to accept the things I cannot change, courage to change the things I can, and (the) wisdom to know the difference.” (Niebuhr)

Reference List

1. Brown, A. (1994). Groupwork (3rd ed.), London: Ashgate Publishing Ltd.
2. Parkes, C.M., Relf, M., & Couldrick, A. (1996). Counselling in terminal care and bereavement. UK: British Psychological Society.
3. Posthuma, B. (1996). Small groups in counselling and therapy: Process and leadership, (2nd ed.), USA: Allyn and Bacon.

Related Case Studies: Case Management of Anxiety and Stress, A Case of Social Anxiety, A Case of Low Self Esteem

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Category: Therapies and Approaches
Author: Jane Barry

Thomas is a 33 year old married man, who has recently become a father. He explains that he feels his self-esteem has been gradually deteriorating ever since he was married. He says that he can’t find reasons to enjoy life with his wife due to feelings of inadequacy as a husband.

In his new role as a father, Thomas had hoped to find the happiness that he was looking for; however this has not been the case. He mentions that his relationship with his wife’s family is strained and thinks that this is the root of his problem. In this scenario, the Professional Counsellor will be using a Rational Emotive Behavioural approach with Thomas.

For ease of writing the Professional Counsellor is abbreviated to “C”.

Background Information

Thomas was married 4 years ago to Helen. They met after leaving school and have been in a continuous relationship since that time. Thomas describes his relationship with Helen as a strong friendship, but also explains that they have experienced recurring problems in their relationship.

Thomas feels that the main problem is the interference of Helen’s family in their partnership. Helen has had a close relationship with her mother and father and had been living with them up until 5 years ago. Neither Helen’s mother or father approved of her relationship with Thomas, since their first meeting. Thomas is at a loss to explain their disapproval of him, and it appears that he has tried in many ways, to gain their respect.

Initially Helen was hesitant to continue a relationship with Thomas, due to her parent’s strong reaction to him. At times they even carried on their relationship in secret to avoid her parent’s reaction. It became more apparent to them that they would eventually have to overlook Helen’s parents’ opinions of their relationship and follow their own wishes.

Finally, Helen and Thomas moved into their own apartment and became engaged to be married. Since becoming married and having their first child, Thomas has continued to extend himself to great personal lengths to maintain any of his parents-in-law’s support. It is his belief that if he extends himself enough, that they will come to love him as much as they love their daughter.

He finds this position very demanding. Of particular difficulty is that Helen’s parents expect to be visited on a weekly basis, by their daughter and new grandchild. These weekly meetings are very draining for Thomas as his parents-in-law are still openly critical of him. At best, he says, they ignore him. In these situations, he finds that Helen is quite passive, though she tells him that she wishes her parents were less critical. Helen has said to him that it is usually best to just let them have their way, and this appears to reflect her pattern of coping with the situation.

Session Content

“C” firstly aims to assist Thomas to understand his feelings and beliefs about the current difficulties. They discuss Thomas’s beliefs and feelings about his relationship with his wife and parents-in-law. It appears that for a long time Thomas has held the belief that if he just tries hard enough, Helen’s parents will stop their criticism and come to respect him. He also thinks that without their approval, he will never completely gain the full respect of his wife.

“C” used humour to begin to challenge Thomas about his views. The use of humour in REBT is a strategy to reduce the importance and value that clients place on certain irrational beliefs. This strategy does need to be balanced with sensitivity and timing, to ensure clients do not become offended by the counsellor’s use of humour. Humour is most effective when the client is also able to enter into the joke and it shouldn’t be used to belittle the client or their feelings.

“Thomas it seems to me that you have been seeking the approval of these people, since the first day that you met them. In that time you have been ignored, belittled, backstabbed and denied respect. Even after your public declaration of love to their daughter, their behaviour towards you has not changed. Under these trying circumstances, I must congratulate you on your undying loyalty to your wife and her family!”

Thomas reacted well to the humour and responded with a joke about his wedding vows, “On my wedding day, I never realised that I also had to love, honour and cherish my wife’s mother and father!”

“I am absolutely certain that you never would have vowed that on your wedding day. After all, a marriage is the unity of only two people”, replied “C”. “This leads me to wonder about your reasons for continuing to appease Helen’s parents, in what appears to be beyond the call of duty and in the face of such adversity.”

Thomas responded to “C’s” confrontation. “I’ve always felt this need for their approval. To me, it is all wrapped up in my role as a husband. It is my duty to be a good son-in-law and I’ve just hoped that they’ll come to accept me in time.”

“C” asked Thomas about how he would prefer to be treated by his parents-in-law. Thomas replied that he wanted a friendship with his new family and to be respected by them. He wanted them to be less pushy and more cooperative with himself and Helen.

“C” spent some time then explaining the nature of irrational beliefs with Thomas. “Due to certain learning experiences in our lives, we come to accept certain beliefs about ourselves and others. These beliefs may be inappropriate for us if they don’t allow us to realise happiness or acceptance of the disappointments in life. Our beliefs are reinforced by particular thoughts that we should behave in certain ways.

If our thoughts and behaviours are more concerned with the welfare of others, rather than ourselves, this can lead to lowered self-esteem and further self-condemnation. The task that all of us face at sometime, is to realise that some of our thoughts and behaviours are not healthy and to replace these with more self-appreciating thoughts and behaviours.”

From this discussion, Thomas came to understand that he had control over his own beliefs and therefore, control over his behaviour and a chance to improve his self-esteem. The first step, “C” explained, was to identify the irrational beliefs that were controlling his life. The irrational beliefs that “C” and Thomas identified are listed below:

1. “I must have the respect of my parents-in-law”.
2. “It is my duty as a good son-in-law and husband to meet the approval of my wife’s parents”.
3. “My wife will never completely respect me if her parents do not respect me”.
4. “If I keep trying, they’ll eventually accept me”.
5. “My need for happiness is secondary to the needs of my in-laws”.

“C” said, “Thomas, you said before that you want Helen’s parents to be less pushy and more respectful of you. I would challenge you that these are preferences that you have, which you have little personal control over. You cannot expect to change another’s behaviour. Instead I would like you to think about your own behaviours and how you might have more control of them, by changing your irrational beliefs. We can do this through a process of debate, where we weigh up the pros and cons of your beliefs”

“C” began the debate by challenging Thomas about his beliefs through a series of questions. “Why do you need your parent’s-in-law approval to be a good son in law? What constitutes good parents-in-laws? If you had a son-in-law, how would you treat him? At what point do parents need to reduce their control of their children? Do you expect to be meeting your parents-in-laws demands for the rest of your married life? Where did you learn that you have a duty to obey Helen’s parent’s wishes?”

Through open debate and discussion of these questions, Thomas was able to view his irrational beliefs from different angles. He was able to see how his belief impacted on his own well being, and that his future happiness was dependent on his ability to change his belief and subsequent behaviours.

The next step involved identifying and constructing new, more appropriate beliefs with Thomas. “C” encouraged Thomas to rethink alternatives to the irrational thoughts that he identified earlier. Instead of the belief, “I must have the respect of my in-laws,” Thomas was encouraged to rephrase this as a preference. “I would like to have the respect of my in-laws.” To this belief he also added some other preferences such as “I would like to be able to respect my in-laws in return.” Other modified beliefs for Thomas included:

1. “It is not my duty as a son-in-law to accept personal criticism or being ignored”.
2. “It is my duty to be respectful of my wife’s family, though not to the point of sacrificing my happiness”.
3. “My wife respects me as her husband and partner”.
4. “My wife’s love is not determined by the influence of her parents”.
5. “My wife and I have the right to determine how we will be involved in the life of our families”.
6. “My priorities for happiness begin with myself, my wife and my son”.
7. “I accept that my in-laws may never accept me for who I am”.

“C” and Thomas also listed behaviours that could increase his personal happiness and reflect his new beliefs about himself:

1. Personally invite his parents-in-law around for visits, instead of visiting them.
2. Address any demands from parents as requests and notify them that the matter will be discussed by Helen and himself in private. With Helen, redefine boundaries between couple issues and family issues. For example, discuss the amount of time that should be spent with various family members.
3. Expect parents to be more respectful of him and do not tolerate criticism. Determine the consequences if this behaviour is not forthcoming, ie: politely leaving, hanging up the phone or ending conversations if no respect is shown to him. Encourage ways in which Helen could also expect more respect from her parents.
4. Discuss his personal changes with Helen and talk about the implication of these for both of them.

In summary of the session, “C” expressed enthusiasm at Thomas’s willingness to explore his irrational thoughts and self-condemning behaviours. “C” recommended a further discussion of Thomas’s self-statements and establishment of a program of behaviour change, structured on his new beliefs.

For homework, Thomas was required to identify other problems and self-defeating beliefs that were affecting his life. For each of these, he needed to challenge their rationality and record these thoughts in a personal log book. The log book would act as an inventory of all of Thomas’s irrational thoughts and beliefs. He could refer to this book as a reminder to himself of the beliefs that he was challenging.

“C” also suggested that he could begin to identify more appropriate thoughts to supplement his irrational thoughts and record these in his log book. “C” highlighted to Thomas that disputing irrational beliefs was something that required practice and to not expect this to happen automatically.

Thomas also suggested inviting Helen to take part in counselling with him, so that she would be more aware of his new beliefs and for them to discuss mutual strategies for managing their family problems.

At the end of the session, “C” reminded Thomas of the presence of irrational and self-defeating beliefs that he holds and how these impact on his opportunity for personal happiness and self-confidence. The challenge for Thomas was to continue to become more aware of the presence of self-defeating beliefs in his life and to energetically replace these with more personally satisfying thoughts.

End of Session

Some points to consider with Rational Emotive Behaviour Therapy are as follows:

People have the capacity for rational and irrational thoughts and beliefs. Irrational beliefs can also be described as absolutistic cognition’s. Absolutistic cognitions by nature demand that certain situations or behaviours should, or must occur in order to meet certain standards that the client believes to be necessary.

REBT proposes that humans are fallible and imperfect and endeavours to help clients realise and accept their fallibility and construct more satisfying thoughts and beliefs. We often seek counselling due to the consequences that we are experiencing because of our irrational thoughts and beliefs.

The focus of REBT is to help the client to understand the connection between their irrational beliefs and their present problem. The counsellor aims to expose the irrational and self-destructive beliefs and to challenge their value to the client. For example, if a client thinks that they need the approval of everyone around them, then the REBT therapist will identify this belief and dispute the client’s reasons for holding this belief.

Once exposed, the therapist and client can then work towards identifying more appropriate and rational beliefs. From these beliefs it is hoped that new feelings and thoughts will arise for the client. This process is known as the ABC theory of personality where:

(a) The activating event or stimulus, paired with the

(b) belief about the activating event, causes a

(c) consequence (the emotional and behavioural response)

(d) is the disputing intervention that is introduced to change the (b) belief. After which a new

(e) effect (more appropriate belief) becomes associated with the original (a) activating event. Lastly new

(f) feelings arise which are associated with the new beliefs about ourselves.

The methods involved in REBT include:

1. Disputing irrational beliefs in a systematic and logical way.
2. Changing one’s language from shoulds, oughts and musts to preferences.
3. Using humour to reduce the exaggerated effects of irrational thoughts and beliefs.
4. Doing cognitive homework to identify absolutistic beliefs behind their problem. This can include assignments to observe their self-fulfilling prophesies, reading self-help books and listening to tapes of earlier counselling sessions to critique their original self-defeating beliefs.
5. Using modelling and role play in the session to encourage the client’s use of more rational thoughts and beliefs.

Related Case Studies: A Case Using Logical Consequences, A Case of an Integrative Approach to Relationship Counselling, A Case of Stressful Life Change

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You have been retained by a company to counsel a member of staff who is currently on stress leave from her job.

During the first session with this person you discover that her immediate supervisor is a private client who has been coming to you for counselling for some time.

The staff member tells you that this supervisor is the main cause of the problems which have led to her being on stress leave.

What would you do to resolve this ethical dilemma?

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Related Dilemmas: An Issue of Client Referral, A Sensitive Client Request, Helping a Highly Stressed Client

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Category: Stress Issues, Case Management
Author: Leanne Chapman

Leah is a 24 year old woman who was recently discharged from the Army on medical grounds. During her four years in the Army, Leah experienced high levels of stress and anxiety which she coped with by drinking heavily. When she presented for counselling, Leah had been sober for 55 days and was seeking strategies to cope with her anxiety that didn’t involve drinking.

While working with Leah, the Professional Counsellor adopts a case management model in order to assist her to build a network of supports within the community, enabling her to maintain her sobriety and prevent recurrence of the factors which contributed to her high levels of stress. For ease of writing, the Professional Counsellor is abbreviated to “C”.

Background

Leah was an only child whose parents separated during her teen years. She felt isolated and was often bored at school. Her love of art was the only thing that gave her any enjoyment and she expressed this by covering the school buildings with graffiti after dark. Already in conflict with her mother due to her poor school performance, the involvement of the police after she was reported for vandalising public property further worsened their relationship. Her father had moved away and was no longer involved in Leah’s life.

Leah left school intending to train as an ambulance medic. On being told she lacked the life experience required for this work, Leah joined the Army on a four year contract hoping to address this requirement. However the Army turned out to be a repeat of the constrictive structure within which she had struggled both at school and at home.

Being obligated to complete the full four years, she began to feel increasingly trapped and was often anxious and depressed. She was introduced to alcohol by her fellow recruits and began using this as a means of deadening her overwhelmingly negative feelings about the course her life was taking. After three years in the Army, Leah was discharged on medical grounds, having become dependent on alcohol and unable to control her intake.

Issues identified

A case manager’s initial function is to develop an understanding of the client and help build a resource network that the client can later access on her own. In this role, C performed an examination of Leah’s environment, behaviour and immediate needs which identified the following issues:

1. Career indecision - although still wanting to be an ambulance medic, Leah had lost confidence in her ability to achieve this or any other career goal.
2. Unsuitable accommodation - Leah was sharing a flat with a young man who yelled at her if she smoked and often made unwelcome passes at her.
3. High levels of stress and anxiety - Leah continually craved alcohol during her period of sobriety and began using valium to replace the role alcohol had played in deadening her feelings
4. Large amounts of unstructured time - Leah had no other strategies in place to cope with her negative thoughts and feelings and, now she was no longer working, found herself with large amounts of time during which she had nothing else to do but think.
5. Lack of a personal support network - Leah was estranged from both her parents, had no siblings, and felt unable to contact any of her former Army colleagues because she felt inadequate due to the manner in which she had been discharged.

Plan

Following an identification of issues needing attention, the case manager then coordinates a plan to enable the client to access needed assistance within her community. In this role, C worked with Leah to outline a plan which involved the following strategies:

1. Schedule pleasurable activities
2. Obtain suitable accommodation
3. Increase support networks
4. Contact a supported job training network
5. Access Centrelink benefits
6. Undertake a drug and alcohol rehabilitation program
7. Cognitive restructuring
8. Medication monitoring
9. Ongoing support

This plan was designed to utilise Leah’s strengths and was later outlined in clear measurable terms that allowed for periodic evaluation of her progress. This is particularly important when the client is becoming disillusioned as it illustrates to her that while she may not yet have reached her goals, she has made significant progress towards them. Leah’s goals were developed with her input to encourage her to feel ownership of them, increasing her motivation.

Barriers

The following barriers to the above plan were identified:

1. Craving for alcohol - Leah had used alcohol as a way of coping with overwhelming feelings, consequently she had strong cravings whenever she was feeling particularly stressed and anxious
2. “Doctor shopping” - Leah had discovered that Valium served a similar purpose to alcohol and when her GP refused to give her any further prescriptions, she simply went to another doctor.
3. Misinterpreting anxiety and stress symptoms - Leah had become hypervigilant towards her physical symptoms of anxiety (breathlessness, increased heart rate, hot flushes, dizziness), interpreting them as medical problems resulting from her drinking, which further increased her stress and anxiety levels
4. Pessimism - Leah exhibited this internal barrier through her belief that she was solely responsible for the things that had gone wrong in her life and that because of this, there was no way for things to change and nobody would be able to help her. This left Leah feeling helpless, overwhelmed and at times suicidal.

Goals

Leah’s goals were written in specific behavioural terms as follows:

1. Schedule enjoyable activities - C asked Leah to make a list of five activities that had either given her pleasure in the past or were things she would like to try in the future. She listed jogging, calligraphy, painting, reading and walking on the beach. C asked Leah to carry out at least one of these activities every day.
2. Obtain suitable accommodation - C asked Leah to contact a former Army colleague who had always been very caring towards Leah and who had previously invited her to share her home. Leah did this and, upon moving in, she and her new flatmate bought a new puppy, providing Leah with further enjoyable activity on a daily basis.
3. Supported employment / job training - C accompanied Leah to an appointment with a supported employment service run by the state government. This service aimed to support Leah in regaining her confidence in returning to the workforce, providing her with vocational counselling to guide her career choices and ongoing support when searching for and commencing employment. They were also able to provide funding for retraining.
4. Centrelink benefits - C helped Leah obtain and lodge necessary forms to help her transition to Newstart Allowance once her Army benefits had run out.
5. Rehabilitation - C connected Leah with appropriate contacts to commence drug and alcohol counselling and to undergo residential rehabilitation if needed.
6. Cognitive restructuring - C provided short-term intervention aimed at identifying Leah’s irrational thought processes and replacing these with a more functional belief system. Here C took on the counselling function of the case management role and centred the work around Leah’s belief that she was a failure and would never get her life together. This process utilised Rational Emotive techniques such as Examine the Evidence and Thinking in Shades of Grey (Ellis as cited in Dryden & Golden, 1986).
7. The Gestalt technique ‘empty chair’ (Perls as cited in Patterson, 1986) and aspects of Dialetical Behaviour Therapy (Linehan, 1993) were also used to address Leah’s unresolved feelings towards her parents and to teach her to tolerate distress without having to escape through the use of drugs or alcohol.
8. Medication monitoring - C arranged for Leah to be seen regularly by a psychiatrist in addition to her local GP to ensure she was receiving the correct medication and to facilitate hospital admission should the need arise. She was also educated about the fight or flight response that was leading to her physical symptoms.
9. Ongoing support - C provided Leah with contact names and numbers for local chapters of Alcoholics Anonymous and, following successful completion of her immediate goals, C referred Leah to her local community health clinic for ongoing monitoring and medical follow-up.

Session Summary

C has provided a combination of case management and counselling functions while working with Leah. As counsellor, C has used Cognitive Behaviour Therapy, Dialectic Behaviour Therapy and Gestalt Therapy techniques to facilitate achievement of the client’s goals.

In reducing her high levels of anxiety and stress, Leah was able to address her more practical needs, for example challenging her beliefs about what her former colleagues thought of her enabled her to contact one of them to follow up on the offer of accommodation. While C provided education and support in this regard, Leah carried out most of the practical tasks herself, thereby building on her strengths and further increasing her confidence levels and reducing her pessimism.

This process occurred over a three month period, during which two progress reviews took place between C, Leah and her psychiatrist. At this time, Leah was able to see the progress she was making and was also able to draw attention to any areas with which she was experiencing difficulty or concern.

Upon completion of the above plan for meeting Leah’s immediate needs, C has referred her to services able to provide her with ongoing but less intensive support. With Leah’s written permission, C provided the community health centre with a referral form outlining Leah’s history, medication regime, and a summary of the work undertaken with C, which C had documented following each session with Leah.

C maintained contact with Leah on a weekly basis during the transition to the new service and while she became comfortable in her local AA support group. In taking this step, C has ensured Leah has acquired the necessary skills for maintaining progress on her own, with assistance available to her as needed.

References

1. Dryden, W. and Golden, W.L. (Eds). (1986). Cognitive-behavioural approaches to psychotherapy. London: Harper and Row Publishers.
2. Linehan, M.M. (1993). Cognitive-behavioural treatment of borderline personality disorder. USA: The Guilford Press.
3. Patterson, C.H. (1986). Theories of counselling and psychotherapy. New York: Harper and Row Publishers.

Related Case Studies: A Case of Stress, A Case of Social Anxiety, A Case of Low Self Esteem

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