Counselling Case Study: An Overwhelmed Client
Chris came to counselling because he was experiencing increasing feelings of being stressed, overwhelmed and weighed down by his commitments in life. He has been particularly concerned about his negative thoughts and attitude at work and at home and would like to change this. Chris has been seeing a Professional Counsellor for three sessions and together they have been using an eclectic approach using Cognitive Behavioural Therapy, some Solution Focused Therapy and Gestalt techniques. For ease of writing the Professional Counsellor is abbreviated to “C”.
Chris is a husband of three years to Michelle and father to 18-month-old James. He is 45 years of age and a nurse at a local hospital. He has also been studying part time for his Masters degree in Nursing for three years. His wife is also a nurse and together they work shift-work in order to look after James. Chris states he enjoys his job but it can be demanding and physically tiring at times. He has previously enjoyed his studies but is now finding it difficult to finish the work with the responsibilities of a small baby. For financial reasons he has not been able to complete his studies full-time.
Chris has recently found the demands of being a husband, a nurse, a father and a student to be taxing on his physical and emotional health and he has found himself to be snappy, irritable, exhausted and unmotivated at home and at work. He has noticed that his relationship with his wife Michelle has become strained and he has begun to resent her for asking him to complete even minor chores around the home. He is feeling unloved and taken for granted by his wife. He has started questioning whether he wants to finish his studies and whether he wants to stay in the marriage.
Chris was prompted to come to counselling at the suggestion of his doctor. Chris presented to his doctor’s surgery complaining of an itchy rash covering his arms and torso, and of throbbing headaches at night and in the morning. Chris stated that medical tests revealed no physical reason for these complaints and his doctor suggested that working through some of the demands and pressures Chris had in his life may relieve the symptoms, as they may be directly related to stress and tension. Chris was happy to do this as he stated he was unhappy with his reactions and attitude at this time, as he had always been a happy, positive sort of guy.
In the first three sessions, C worked through identifying the above issues and asked Chris what he felt was the most important issue requiring attention. Chris identified this as his negative thought patterns and pessimistic way of looking at each day in the morning.
C worked to immediately change this by using Ellis’ Rational Emotive Behaviour Therapy ABC model. Using this framework to identify the behavioural and emotional consequences of his thought patterns, Chris chose to work on his attitude to going to work everyday. Before using the ABC model, Chris’ thoughts and behaviours looked like this:
A – Alarm rings every morning at 7am
B – Chris says to self “Oh, no. I hate my job. This is going to be another horrible day”
C – The behavioural consequence here is that Chris is often late for work because he procrastinates about going and then is often reprimanded by his supervisor.
D – The emotional consequences are that Chris has a sense of despair about his ability as a nurse
After applying the ABC model to change his irrational beliefs (in B), Chris has found the following pattern when his alarm rings in the morning:
A – Alarm rings every morning at 7am
B – Chris says to self “I can do this. Every day is a new day. I will work well today”
C – The behavioural consequence has meant that Chris has not been late for work and therefore not in trouble from his supervisor – in fact he has been praised for his promptness in front of other staff (thus reinforcing his behaviour to be on time!)
D – The emotional consequences for Chris have included a greater sense of satisfaction with his work, a feeling of being appreciated at work, and more importantly, the knowledge and evidence that he is in control of his own thoughts.
Current Session Content
After Chris had noticed some considerable improvements in his thought processes and felt more in charge of his meditating thoughts about work, he and C moved onto discussing the feelings he was having about his studies and his marriage.
Chris had noticed that his more positive attitude at work had certainly influenced his mood at home, but something was still not right. He also noted that his rash and headaches in the morning had somewhat subsided, although he was still suffering throbbing pain in his temples at night after work. C began asking questions:
Extract, Counsellor and Client
Counsellor: “Chris, you talked in our first session about wanting to leave your marriage and maybe not finish your Masters, how do you feel about this now we have worked on your positive thinking?”
Client: “You know, as much as the positive thinking has helped with getting up each day and getting through work, I don’t know if it has changed my other feelings. I dunno, I still don’t know whether I want to finish my Masters. I mean, I feel better about my marriage, but I still find myself lying awake at night wondering at the “why” of everything. Know what I mean?”
C: “Tell me more about the “why”. Just your marriage and studies?”
Client: “Well, not really just that. I mean, I’m 45 now. I have a son and a wife and a job, but something just doesn’t seem right. Like maybe something’s missing.”
C: “Chris, can I just ask a question for a moment?”
C: “If I could wave a magic wand and you could wake up tomorrow and everything was worked out, everything was the way you wanted, what would it be like?”
Client: “It would be great!”
C: “Great, how?”
Client: “Well, I guess I would be happy. Everyday.”
C: “So would your marriage be any different? Your studies?”
Client: “Probably not. I mean, Michelle isn’t really asking more of me than when we first got together. It just seems more. The studies stay the same no matter how I feel.”
Client: “Oh, I get it. It’s not really the stuff is it? It’s me. I’m the one who has changed.”
C: “Is that how you feel?”
C proceeded to show Chris that while some things at home and work were the same as when they first married, other factors had changed. C wanted to make sure that Chris was not going to be too hard upon himself for realising that much of his own thoughts and feelings were under his own control. C pointed out elements of stress and how it works, and again they surveyed Chris’ life to examine the external factors.
Counsellor: “Chris, I just want to go back a step to the work we did around your thoughts and taking control”
C: “Are you familiar with the word stress?”
C: “I don’t just mean the bad form of stress, where you want to rip your hair out, but other forms too”
Client: “I’m confused”
C: “So am I! What I mean is, anything in your life that causes a change, causes stress. So when you find your dream wife and get married, this is stress. When you break your leg, this is stress. There are different types of stress, but mostly it is a word that means any change in your life.”
Client: “Ok. Where are we going?”
C: “When we look at your life and you say that things are still basically the same as when you married, you might be right on the surface, but underneath lots of things have changed that may have caused forms of stress.”
C: “What if we have a look at exactly what is going on in your life right now and see if it makes more sense?”
C showed Chris a copy of the Holmes Rahe Stress Scale (available easily on the Internet for use – try www.teachhealth.com) and together they identified different things that were in his life over the past 12 months, which he may not necessarily have thought of as forms of stress.
Some examples from the Holmes Rahe Scale which Chris identified included: a mortgage, change in the health of a family member (Chris disclosed that his mother had recently been diagnosed with cancer and he hadn’t really thought of this as playing an active role in the physical symptoms he was having), changes in his responsibilities at work, chronic allergies, and a change in the number of family get togethers (these had decreased due to Chris and his wife’s work and study commitments).
C helped Chris realise that there was a great deal going on in his life and that someone else in the same position may feel just as overwhelmed. This exercise served to help Chris acknowledge the forms of stress, understand how they impacted upon him and avoid falling into the trap of believing that he was the only one who had changed and everything was his fault.
Satisfied with Chris’ grasp on these concepts, C moved back to the issue of Chris being unsatisfied in life generally and searching for answers to the “why” of it all. Together they examined more closely what Chris was feeling and he surprised himself by breaking down and crying in one of these sessions. Chris talked about his own upbringing and not feeling that he had ever been good enough for his father, who had since passed away.
He discussed that his father had been a Doctor and had wanted Chris to follow the same. Chris’ grades had prevented him from achieving this and so he had chosen nursing as the next best thing. Chris was surprised at this realisation as he and C explored this issue, and he then started to examine whether nursing was really his chosen profession. C used a visual technique to examine this and coupled it with the Gestalt technique of using an empty chair because Chris’ father had died, in order to give Chris a chance to express his thoughts and feelings.
Client: “I think what it means is that somewhere I knew I was never going to be as good as him and nursing was a bit of a cop out too. Even though I didn’t get the grades to get into medicine.”
C: “Would it be possible that you may have subconsciously manipulated the situation to avoid the scrutiny or pressure of studying medicine and being a doctor?”
Client: “Yeah, you know I think that’s it. It all adds up. I mean, I like nursing, but I think I’ve always felt there was something more that I didn’t achieve, for some reason.”
C: “We call it self-sabotaging, where subconsciously a person might do the very thing they are avoiding or vice versa.”
Client: “How bizarre.”
C: ‘Would it be ok if we explored your choice of nursing further with a visual exercise?”
Client: “Sure. Whatever works.”
C asked Chris to close his eyes and using a brief relaxation technique they had employed in the earlier sessions using CBT, C asked Chris to imagine the first day he had started work as a Nurse, after graduating. C specifically asked Chris to watch the scenario as it unfolded, from an outsider’s point of view. C did not want Chris to be drawn into the scene, but wanted him to be able to note his own feelings and behaviours from a distance.
Client: “I can remember it like it was yesterday. It was such a busy day and I had no idea what I was doing.”
C: “Chris, can you imagine yourself somewhere in the middle of the day, with things happening around you?”
Client: “Yep, there was this patient who was crying in the waiting room and I went over to help.”
C: “You seem a little sad.”
Client: “Well, she was waiting for her child who was in emergency. I think there was an accident or something. It was so hard to sit there and just watch, waiting you know.”
C: “Run the scene before you until you get to the end of that situation. Watch yourself handle it.”
Client: “I know I look helpless but in the end, she came and thanked me for just being there. Her daughter was alright.”
C: “That’s a smile.”
Client: “Well, it was such a good feeling on that day because in the middle of all the chaos, I sat with her and just kinda talked about stuff, to take her mind off it, and she thanked me in the end. I really felt like I did nothing.”
C: “But as you watch now…”
Client: “I think it felt good. When I see myself now, I know I handled it ok, for the first day and all, and I guess I felt I could make it.”
Chris noted that in that moment of starting work after his studies, he felt okay as a nurse. This helped him clarify that while he was not a doctor, his work was appreciated and valued as a nurse. Together he and C explored the notion of still becoming a doctor, but Chris said he felt secure in his current role. He noticed over the next few sessions since this realisation, that his feelings at work continued to improve, and that he felt happier and more valued as a staff member; and that his patients benefited from this. Despite the progress Chris had made with these feelings, it still left the issue of his unresolved feelings towards his father.
Through more discussion, Chris came to realise that the unresolved childhood event of not feeling as though he had lived up to his Father’s expectations, was still having an impact on his feelings of emptiness and unfulfilment. C explained the concept of the Empty Chair technique to Chris and he agreed to give it a try, although he was finding it difficult to put his feelings towards his father into words. As a brief explanation, here the client is asked to put feelings or thoughts into action.
For example, C encouraged Chris to use a kind of role playing (in this case, speaking to an empty chair because Chris’ father was not present). He was encouraged to tell his father how he felt about the expectations he felt as a child. Enactment here is intended as a way of increasing awareness, not as a form of catharsis and in the case of Chris he had difficulty expressing his feelings into words in front of C. Instead of badgering Chris to continue, C took a step back and changed the angle slightly and tried some integrating and body techniques.
Integrating techniques bring together processes the patient doesn’t bring together or actively keeps apart (splitting). The client might be asked to put words to a negative process, such as tensing, crying or twitching. Or when the client verbally reports a feeling, that is, an emotion, they might be asked to locate it in their body.
Another example is asking a client to express positive and negative feelings about the same person. The body techniques include any technique that brings clients’ awareness to their body functioning or helps them to be aware of how they can use their bodies to support excitement, awareness and contact. In this case C observed Chris sitting tightly and rigidly in the chair after trying to express his feelings to his father in the Empty Chair technique.
C: “Would you be willing to try another experiment?”
C: “Take some deep, deep breaths and each time you exhale, let your jaw loosely move down.”
Client: Breathes deeply, lets jaw drop on the exhale
C: “Stay with it”
Client: Starts melting, crying, then sobbing
At this point Chris was more able to speak about his feelings and loudly started to express how he hated his father, and how angry he was. C let Chris vent his feelings, which had been suppressed for many years. This was a huge breakthrough for Chris, even more so because this issue had not been foremost in his mind when he entered counselling.
This powerful technique involving role-playing may sound artificial and might make some people feel self-conscious as it did for Chris in the beginning, but it can be a powerful way to approach buried feelings and gain new insight into them. While Chris still had some way to go in working through these feelings, this session was useful for him to open to the idea of working on self-awareness.
In summary, Chris’ counselling focused on a number of issues:
- His initial complaint of negative thought patterns and pessimistic attitude to work and life
- The number of stressors in Chris’ life
- His feeling of being empty and unfulfilled in life which expanded into the issues of not living up to his father’s expectations and sacrificing a medical career
The techniques of CBT helped Chris rapidly get a hold on his negative thought patterns and he was able to implement these in his life quite quickly. Visualisation techniques helped Chris explore his notion that perhaps he still wanted to be a doctor instead of a nurse. Finally, Gestalt techniques helped Chris begin to understand his unresolved feelings towards his father.
After the session involving the Gestalt technique of the empty chair, Chris opted to change his weekly sessions to fortnightly for 2 sessions, and then visited monthly for two more sessions. He stated at this time that life had settled back down to “normal”, meaning that he was coping well at work, had mapped out a timetable to finish his nursing studies and that his marriage was happy. He discussed that Michelle constantly pointed out the positive changes in him and this made him feel even more in control of his feelings, thoughts and behaviours.
Chris stated that the feelings of anger and resentment towards his father had subsided although he found himself pondering his childhood a little more now than he used too. He said that the counselling had worked to a degree with this issue, but because he had not realised it when he came into counselling, he was still coming to terms with his feelings.
He and C discussed this being a normal phenomenon, and the notion that if in the future the issue proved too difficult to handle, or started to again interfere in Chris’ life, then future sessions might be necessary. Chris described that he was particularly positive about his future, about spending more time with his son and wife, and felt more in control than he had ever been before.
Author: Peta Hartmann