Integrative Counselling and Psychotherapy: The of Rebecca - Case Study Example

INTEGRATIVE COUNSELLING AND PSYCHOTHERAPY: The Case of Rebecca INTRODUCTION Integrative Counselling and Psychotherapy is a strategy which the BritishAssociation of Counselling and Psychotherapy (BACP) employs in order to equip its graduate Counsellors or Psychotherapists with knowledge and skills they will use to address the problems of people with all varieties of mental health issues. Integrative Counselling and Psychotherapy means counsellors will use multi-modality approaches (MMA) which are generated from theories such as the Person Centred Approach (PCA), Cognitive Behavioral Therapy (CBT) and the Attachment Theory (AT). Since these theories are different in their approaches, they are viewed through a theoretical lens of the Trans-theoretical Model (TTM). However, to arrive at the set goal, the multi-modal approach will not be self-sufficient if it only sticks to the three approaches stated above. Otherwise, several approaches will have to be integrated in the process if the client is to become self actualized. For example, the Maslow’s Hierarchy of needs (McLeod, 2007) and Multimodal Behaviour Therapy (Lazarus, 1989) techniques will be seriously engaged in this case. Notice that as a requirement of the ethical issues of counselling and psychotherapy which the British Association for Counsellors and Psychotherapists (BACP) upholds, the writer of this case (therapist) will use a fictitious name (Rebecca) to mean the client. Rebecca has been in therapy with the therapist for four weeks in 50 minutes sessions. Rebecca was suggested by the Social Worker because she demonstrated signs of emotional stability, self growth and development. Therapy took place in a one to one environment, in a room where the client would feel relaxed. Besides, the therapist made the environment much friendlier to make the client feel at home. As such, the client was able to confide in the therapist all her experiences. In this environment, throughout the four sessions, Rebecca reveals that she was depressed because she was being problematic the past few years. So far, therapy is going on with the case. There will be further recordings to try to get more into the intervention. This case has been split into several subheadings to try to simplify understanding. HISTORICAL BACKGROUND According to the audio recordings, Rebecca is 36 years old. She had caring and loving parents and was well brought up. At the age of nine, she was sexually abused by an adult male who was their trusted neighbour and she told no one. Instead, she became withdrawn and isolated. That was the beginning of the change of her life. At eleven, she sustained a bump on her head when she got involved in a car accident as she was riding her bicycle. Rebecca became more confused and troublesome; and tried to kill herself by setting fire to her bedroom. The audio recordings further reveal that her troublesome life forced her parents to take her to a Care Home at thirteen. They could not cope with the burdens she was pressing on them. She remained in the Care Home, a gang that was equally mentally unhealthy, until she was eighteen. When she came out, she met her mother and told her what happened to her when she was nine. At the age of 19, Rebecca fell pregnant. The guy (a young man who was also mentally unhealthy and was undergoing therapy) who she met in the Care Home was responsible for the pregnancy. After delivering her first son, the guy became extremely violent and abusive. She experienced domestic violence for years; and this affected her son negatively. He experienced emotional neglect; hence the social workers took him away. A few years later, she had another child that she lost at birth with a new partner who was also physically violent and abusive towards her. In 2012, she met another man who she felt was cool and treated her well. They had a child together. A day after the child (James) was born, the Social Workers took him away from Rebecca for safe upbringing. James is now living with his father and Rebecca is allowed, under the supervision of the Social Workers, to see her son for four hours four times a week. Unfortunately, this restriction has made Rebecca experience emotional turmoil and depression as she wishes to be with her son. RISK ASSESSMENT According to Health and Safety Executive (2011) and Moss (2010), Risk assessment is defined as the identification, evaluation and estimation of the levels of risks involved in a situation, their comparison against benchmarks or standards and determination of an acceptable level of risk. You consider how dangerous something is and how best that danger can be resolved by using the following steps: identifying hazards; deciding who might be harmed and how; evaluating the risks and decide on precautions; recording findings and implementations; and reviewing your assessment and update if necessary (see appendix 1). The purpose here is to look at accidents, lifestyles and illhealth that ruin and affect people’s lives if not attended to. The therapist together with her supervisor looked at Rebecca and discovered that she was at risk. The evaluation conducted as seen from appendix 1 made Rebecca qualify for therapy. In trying to identify the hazards in different people, the therapist worked with Home Care Workers, Social Workers and her professors who helped her come up with a number of possible clients who show hazards related to the theories the therapist is studying. To decide who might be harmed and how, the therapist picked out two ladies’; and then from the two, she picked out Rebecca on whom this report is based. Rebecca was in a high risk situation of depression because of the life she has gone through (see appendix 1). Her past life has greatly affected how she is living presently and the consequences that may affect her forever. The therapist used different assessment tools such as therapy sessions, counselling skills, observation and timelines. The therapist also documented and recorded the sessions and observations made in order to find the best strategy of helping the client. The therapist used a set of four fifty minutes sessions during which she interacted at length with the client. She tried to motivate and encourage the client at every point as noticed in the audio recordings. The therapist also engaged the client in filling the responses she gave during the session in the timeline to express, her thinking and feelings. CASE FORMULATION CBT for Therapists (2009) and Padesky (2011) define Case formulation as a blue print which helps the therapist and client figure out what is going on. It involves a number of overlapping elements such as getting a list of problem, issues and goals; diagnosis; core beliefs; key dysfunctional assumptions; vicious circles and maintaining factors; triggers; modifiers; vulnerability factors; critical incidents; time plan; alternative core beliefs, assumptions and policies; and typical cycle of event, thought, mood, physiology and behaviour. In trying to come up with her case, the therapist looked at Rebecca’s problem critically by analyzing her historical background, where she sees Rebecca as a happy and well brought up child, who is later affected by sexual harassment and accident, lack of parental affection and matrimonial violence. Rebecca is later affected by all the bad things that have happened to her. She feels ashamed, worthless, neglected and insecure. She also looks at people as being cruel and heartless. She therefore is afraid both internally and externally. She develops ways of protecting herself such isolation, withdraw and seeking lovers. Unfortunately, all these means make her even more depressed (see appendix 2 for details). SUMMARY OF INTERVENTIONS In the fourth session, the therapist reached a stage of intervention in which she used the timeline as a tool. According to Good Therapy (2013), time line therapy (developed by Dr. Tad James in 1986) is an unconscious treatment which allows a client to surrender negative emotions linked to past experiences and transform their internal programming in a short time. It represents the person’s mental photo album and their own ability to distinguish between images of the past and perceptions of the future. It aims at changing the client’s behaviour patterns so that they can react to present experiences based on present conditions and not react to situations that present themselves today based on emotions linked to previous life events. It deals with emotions such as depression, fear, apathy, sadness and anxiety. It helps people liberate themselves from their past beliefs and create new ones which are more positive and can help them move to new life. Using Maslow’s hierarchy of needs (McLeod, 2007) as heard from the audio recording, the therapist and client engaged in filling in the timeline the client’s past memories which finally revealed the root cause of the client’s present disorder; and her fight towards self-actualization. The client uses a variety of questions following the BASIC I.D. approach (Lazarus, 1989) to find out more from Rebecca as explained below. According to the audio recording, Rebecca had all the necessary basic needs as a child. For example, she had shelter, warmth, food, air, drink, sleep, protection, security, stability, friends, family affection, and positive self-esteem. There were no problems until things turned out bad when she was sexually abused at nine. The audio states further that from the age of nine to date, she feels insecure and unstable until she is finally taken to a Care Home. There is no more affection and relationships she used to enjoy just like Maslow (1951) states. Rebecca further explains that she is able to give out affection but not receive it. She feels she had positive esteem when she was young. She wanted to achieve education, training and employment; but today she lacks that. Finally she feels sorry for the child, James, who she thinks is lacking her care. She thinks the four times she sees him are not enough. She feels the child is lacking Maslow’s needs and attachment to her is at stake. She fears the child will be affected in one way or another just like the theories of behavior change explain. SUMMARY OF THE THEORIES The key theories that have been used in this case are the person centred approach, the cognitive behavior therapy, the attachment theory, the transtheoretical approach and the multimodal approach. All these theories have given the therapist much energy to tackle issues of counselling to Rebecca as highlighted below. McLeod (2008) quotes Rogers (1951) that the Person Centred Theory states that an individual has within himself or herself vast resources for self-understanding, for altering his or her self-concept, attitudes and self-directed behavior - and that these resources can be tapped if only a definable climate of facilitative psychological attitudes can be provided. Mearns (1988) adds that the client consciously and rationally decides for themselves what is wrong and what should be done about it.  The therapist is more of a friend who listens, accepts, understands, shares and encourages on an equal level. In this case, as Rogers (1986) says, if the clients condition is to improve, therapists should be warm, genuine and understanding. The theory also says the client should focus on the present and future than on the past. In this way, the client will achieve personal growth and eventually self-actualize. Using the principles of this theory, the therapist guides Rebecca to discover the problem that led to her suffering by looking at the past. The councellor further uses the past to solve Rebecca’s present, the Person Centred Theory states. Both the therapist and client listen, accept, understand and share views from either sides. Both build a therapeutic alliance when the client is able to explain freely what made her enter into her present state. She is also free to explain her current problems and fears and what she thinks should be done for her to reach self conceptualization. For example, Rebecca fears for her son’s upbringing in the audio (from the fourth session). He is lacking the mother’s attachment which is very crucial in child development. She also says that meanwhile, one thing which remains for her to get out of depression is her being away from her child. She is also giving out affection to her family but is not able to receive it. Rebecca is being guided to arrive at that; and this is what the theory of Person centred approach states. Client-centered therapy operates according to three basic principles that reflect the attitude of the therapist to the client: the therapist is congruent (genuine or authentic) with the client; the therapist provides the client with unconditional positive regard; and the therapist shows empathetic understanding to the client (Rogers, 1951). All through the audio recording, the therapist shows congruence, unconditional positive regard and empathy as she interacts with the client. The environment is typically friendly and relaxed – a situation which makes Rebecca feel free to express herself positively. On the other hand, Cognitive behavior therapy (CBT) is a psychotherapeutic treatment that helps patients understand the thoughts and feelings that influence behaviors (Cherry, 2005). It helps clients deal with their problems. Clients learn how to identify and change destructive or disturbing thought patterns that have a negative influence on behavior. Using the case of Rebecca (as the audio shows), the Therapist has put strategies that are helping the client to identify the problems that led her into her present condition. For example, the therapist has used a timeline on which Rebecca explores her past and discovers her turning point. From this timeline, Rebecca is able to see how best she should behave in order to reshape her life. Cherry (2005) emphasizes that the key issue of CBT is that our thoughts and feelings play a fundamental role in our behavior. For example, the audio recording reveals that Rebecca is depressed because she is suffering from mild depression from her past experiences, especially the taking away of her baby (James). The goal of cognitive behavior therapy is to teach patients that while they cannot control every aspect of the world around them, they can take control of how they interpret and deal with things in their environment by using different approaches to combat destructive thoughts and behaviors. In this case, the audio recording shows that Rebecca is going through typical therapy that will help her discover how her earlier thoughts destroyed and made her depressed. Rebecca says in the recorded audio that her core belief is that she is bad and not loved. On the other hand, McLeod (2009), quoting Ainsworth, 1973 and Bowbly, 1969) defines attachment is a deep and enduring emotional bond that connects one person to another across time and space. It is characterized by specific behaviors such as seeking proximity with the attachment figure when upset or threatened. Attachment in adults towards the child includes responding sensitively and appropriately to the child’s needs. Listening from the audio recording, it is evident that Rebecca was strongly attached to the parents and they responded to her needs. For example, they took her to different places; they gave her lots of needs such as a bicycle, beautiful clothes with her sister; freedom to play with her friends; she was taken to different places of fun; and had nice food. Unfortunately, when she was sent to the Care home, she lost it and it continuously caused depression in her. Bowlby (1958) adds that attachment provides safety and security for the children when under stress or threatened. Similarly, in the audio recording, Rebecca concedes that she had security and safety before she became stressed and threatened after the sexual harassment, accident and her being sent to a Care Home instead of being close to her parents. In addition to that, the attachment theory of Bowlby (1969) further advocates that attachment falls into different types. The types demonstrated in this study are avoidant and anxious attachment. According to the audio recording, Rebecca displays the avoidant attachment to the therapist. She does not want to tell her past memories until she is urges to do so. Because of her emotions, she also failed to care for her children; and this is why they were taken away from her. However, towards the end of the recording, Rebecca is displaying an anxious attachment in the sense that she wishes to be with her child (James). She also wants to be loved by her family just like she does to them. Furthermore, Pro-Change Behavior Systems (2010), quoting Prochaska (2005), states that the Trans-theoretical Model (TTM) of Behavior Change is a model which emphasizes that change is a process which follows distinct stages of readiness, and provides approaches to help move people forward through the stages of Pre-contemplation, Contemplation, Preparation, Taking action and Maintenance stage. The audio recording so far indicates that Rebecca is in the contemplation stage. She has gone through the pre-contemplation stage. She is currently unaware of how to change; but knows there is a problem. She has so far explained so many past issues but does not know how to change them. This therapy therefore is trying to raise her consciousness to the changes and steps she should take into the preparation stage. This means the therapist should develop strategies that will encourage Rebecca to get out of isolation and withdraw so that she has many chances of interaction with other people where she can find more clues of change. Finally, according to Lazarus (1989), the multimodal assessment and treatment (MMT) style uses multiple modalities to interactive physiotherapy because people behave differently. It has capacity to separate sensations from emotions, distinguishing between images and cognitions, emphasizing both intra-individual and interpersonal behaviors, and underscoring the biological substrate. Lazarus (1989) adds that the MMT uses seven modalities of Behavior (B), Affect (A), Sensation (S), Imagery (I), Cognition (C), Interpersonal (I), and Drugs/Biology (D), hence it is called “BASIC I.D." Using the BASIC I.D., the therapist is able to get much detail from Rebecca as follows: When the therapist asks about her life, she says she was problematic the past few years hence answering the “Behaviour” (B). When the therapist asks her about how she felt when she was sexually harassed, made an accident, harassed by her boyfriends, she says it was bad, hence fulfilling the “Affect” (A). She also says she likes a purple colour, the sights at the wedding, the clothes her mother gave her, etc, thereby fulfilling the “Sensation” (S). Rebecca also has vivid pictures of the weddings, visits, the clothes, past painful experiences. These fulfill the “Imagery” (I) section of the BASIC I.D. When Rebecca is asked about how she feels about her past experiences, she says it was very good until later when she started experiencing sad situation; and started seeing herself as a worthless person. As she fills the timeline, she is able to express her beliefs, attitudes and emotions, hence fulfilling the “Cognitive” (C). She also explains that she loves others but they do not love her in return. She also worries about her son. That is the “Interpersonal” (I) part. Finally, on the “Drug and Biology” (D) part, she does not take any drugs or substance and is generally in good health. COMPLICATING FACTORS Rebecca is older to the therapist by 8 years; and she is from a different working class and educational background. The therapist has been aware of these differences within the sessions and has felt there may be some holding back from Rebecca’s perspective as she may see a younger middle class female sitting in front of her, perhaps she feels judgment from the therapist’s perspective and so judges herself and status as an individual. This worries the counsellor and makes her wonder how to address this within the room; and how to congruent her feelings on their cultural differences. THE ROLE OF CLINICAL SUPERVISION The therapist made visits to see Jazz Kang, her supervisor since December. The supervisor provided her with grounding and a secure base which has encouraged her confidence to grow as a therapist. Jazz has supported her decisions on where to move forward with clients and has provided advice and publications for progress with clients. The supervision has been invaluable to her practice and development as a therapist and for her personally on her own journey. CONCLUSION AND LESSONS LEARNED It is evident that Rebecca, the case, has gone through such a tormenting time starting from the time she was sexually abused, made an accident, sent to the Home care, impregnated thrice and her staying away from her parents. It is also evident that Rebecca is willing to change completely for the better. Her warm interaction with the Therapist is indicative of how much she is yearning for this change. On the other hand, the use of multiple behavioral change approaches is necessary if an Integrative Therapist is to achieve positive results. As a therapist, several lessons have been drawn from this study. Amongst many, it is necessary for integrative counsellors to be exposed to several theories of behavior change if counselling is to be successful. Besides, the therapist took the right focus; and it seems she is going towards achieving the goal. She should now try to prepare sessions that will move the client to the “Preparation Stage” as explained in the CBT above. Her expressions and questioning style are all splendid; but should remove the fear she has on the age differences between herself and the client. She has a good knowledge of the theories, hence has the capacity to do even much better. REFERENCE Bowlby, J. (1958). The Nature of the Childs Tie to His Mother. International Journal of Psychoanalysis, 39: 350-371. Bowlby J. (1969). Attachment. Attachment and Loss: Vol. 1. Loss. New York: Basic Books. CBT for Therapist. (2009) CBT Formulation: Case Conceptualization. (Online) Available from http://cbtfortherapists.blogspot.com/2009/10/cbt-formulation-case-conceptualisation.html Cherry, K. (2005) What is CBT? British Association for Behavioural and Cognitive Psychotherapies (BABCP) Mapping Psychotherapy. (Online) Available from: http://www.babcp.com/silo/files/what-is-cbt.pdf (accessed on 11th April, 2014) Good Therapy. (2013). Time Line Therapy: Helping people find therapists. GoodTherapy.com. (Online) Available from. http://www.goodtherapy.org/timeline-therapy.html (accessed on 12th April 2014) Health and Safety Executive. (2011) FIVE STEPS TO RISK ASSESSMENT: Health and Safety made Simple (Online) available from: www.hse.gov.uk/simple-health-safety/index.htm (accessed on 10th April, 2014) Lazarus, A.A. (1989) The Practice of Multimodal Therapy. Baltimore: Johns Hopkins University Press. Maslow, A. H. (1943) A Theory of Human Motivation. Psychological Review, 50(4), 370-96. McLeod, S. A. (2007) Maslows Hierarchy of Needs. (Online) Available from: http://www.simplypsychology.org/maslow.html (accessed on 9th April, 2014) McLeod, S. A. (2008). Person Centered Therapy. (Online) Available from: http://www.simplypsychology.org/client-centred-therapy.html (accessed on 11 April, 2014) McLeod, S. A. (2009) Attachment Theory. (Online) Available from: http://www.simplypsychology.org/attachment.html (accessed on 11th April, 2014) Mearns, P., & Thorne, B. (1988) Person-Centred Counselling in Action (Counselling in Action series). London: SAGE Publications Ltd. Moss, M. (2010) How to write a risk plan (Online) Available from: http://www.ehow.com/how_2305645_write-risk-management-plan.html (accessed on 10th April, 2014) Padesky, C.A, et al (2011) Collaborative Case Conceptualization Rating Scale and Coding Manual Pro-Change Behavior Systems(2010) The Transtheoretical Model: Evidence Based Behavior Change. Pro-Change BehaviorSystems, Inc. (Online) Available from: http://www.prochange.com/transtheoretical-model-of-behavior-change (accessed on 11th April, 2014) Rogers, C. (1951) Client-centered Therapy: Its Current Practice, Implications and Theory. London: Constable. Rogers, C. (1986) Carl Rogers on the Development of the Person-Centered Approach. Person-Centered Review, 1(3), 257-259. Appendix 1 (a): RISK ASSESSMENT TEMPLATE Hazard Is the hazard present Y/N What is the risk? Risk rating H = High M = Medium L = Low Controls (when all controls are in place risk will be reduced). Is this control in place? Action/to do list/outstanding controls in place Person Responsible Signature and date completed Note: If there is one or more High Risk (H) actions needed, then the risk of injury could be high and immediate action should be taken. Risk Assessment Carried out by: __________________________________________ Date: _____________________ Appendix 1 (b): RISK ASSESSMENT TEMPLATE Title: ____________________________________________________________ Date Assessment Carried: _____________________ Assessment Carried out by: ________________________________________ Date of next review:__________________________ Activity or area What are the Hazards Who might be harmed and how? What are you already doing? What further action do you need to take? Who needs to carry out the action? When is the action needed by? Done / Remarks Appendix 2: Case Formulation What do I do to protect myself from others? How we worry that we live in other’s What I do to protect Minds internal key fears sometimes myself from myself. Have a “core belief” flavor to them They might be a bit less “verbal” Than traditional CBT core beliefs though. Appendix 3: Rebecca and Therapist, Session Four Recording Read More