Integrative Counseling and Psychotherapy: The of Janet - Case Study Example

CASE STUDY OF JANET By Case Study of Janet Case Introduction Integrative Counseling and Psychotherapy is one of the major strategies used by the British Association of Counseling and Psychotherapy (BACP) so that it can equip its psychotherapists with the right knowledge and skills to use in addressing problems with all varieties of mental health issues. Integrative psychotherapy is a counseling practice that embraces a particular attitude towards the practice of psychotherapy and affirms the inherent value for each individual. As such, a unifying psychotherapy responds effectively and appropriately to the person at the affective, behavioral, cognitive, as well as, physiological levels of functioning. this approach requires counselors to use multi-modality approaches generated from a number of theories, key among them the Person Centered Approach, the Attachment Theory, as well as, the Cognitive Behavioral Theory. The difference in the approaches within these theories demands their approach to take place through a theoretical lens of the Trans-Theoretical Model (TTM). This case is however not self sufficient, and as such, will require incorporation of other approaches in order to make the client congruent and self actualized, engaging theories such as the Multimodal Behavior Therapy techniques, as well as, Abraham Maslow’s Hierarchy of Needs Theory. Furthermore, for the therapy to be successful, the therapist handling the psychotherapy issues in a counseling session should have a great personality. This practice also requires adherence to ethical issues in counseling and psychotherapy as upheld by the BACP. The therapist writing this case uses a fictitious name for her client, Janet, who attends weekly sessions for fifty minutes per session. This recording of the therapy took place on the eighth session of the therapy. The therapist will use the three theories stated above in redefining the case of Janet and relating her case to each of the theories and intervention practices reliable in the Trans-Theoretical Model. This case of Janet was a self-referral case by the client in trying to demonstrate signs of self-awareness and identity of the client. The occurrence of the therapy sessions took place in a one on one environment whereby the client and the therapist were in the same room in order to introduce calm and relaxation to the client. Furthermore, the therapists tried to make the environment friendlier in order to make the client feel at home. This would open up the deepest thoughts of the client, thereby enabling the client to confide all her experiences to the therapist. In this environment, throughout the eight sessions conducted so far, Janet revealed that she was suffering from low esteem, and felt insecure of herself and lacked an identity of self. This was the case all through the years, and now worsened with the passing of her mother. Presenting Issues Janet is a female aged thirty-six. Janet is a same-sex partner and as such, lives in the same apartment with her partner of the same sex. This marriage took place two years ago. The couples are now foster parents to a child of their own after they adopted one. However, Janet gave birth to her first child called Freya last year, and the child is now eighteen months old. A fortnight before Janet put to bed; she lost her mother to cancer. The family background of Janet is that of a normal upbringing. She had both parents and two older brothers. However, she experienced a considerable level of exclusion, as well as, isolation at school, particularly so at the secondary school. She also suffered the same level of exclusion when she went to work after school. Mother Passing Janet referred herself to counseling because of the growing burden on her shoulders over the passing of her mother. While presenting her issues to the therapist, she focused on her body image and other self-esteem issues majorly for those caused by the passing of her mother. Janet grew up in a stable upbringing with loving and nurturing parents. However, she failed to find a sense in herself, as well as, her identity within the family environment because she felt due to her position in the family as the youngest member, she did not get the recognition that she deserved. Self Esteem As such, the sense of self and identity forms a running theme within the therapy room. Janet’s struggles to find her a place within the family and while at school led her to forming a deeper connection, as well as, an anxious attachment to her mother. This mother-daughter connection was potential and formidable because of their same sex, as well as, the security base that the daughter found with her mother. Consequently, the death of her mother dealt a hefty blow on her, and she falls back to the identity crisis she was once in, with the lack of caring and zero connection with her mother. This formed the strongest part of her identity. The loss of her mother has in turn affected her relationship, thereby making her vulnerable to identity search (Norcross & Prochaska 2013, p.68). Body Issues This situation continuously suppresses and pushes down Janet’s identity and sense of self. In addition, since putting to bed, she has had a feeling of unhappiness with her body, and as such does not feel like being intimate with her partner. She also has low confidence, and her partner is not helping to remedy the situation due to her low affection. For instance, whenever Janet attempts to make a move for affection with her partner, her partner tends to turn down or reject such opportunities for affection. As a result, Janet feels even the more worthless in her current relationship. However, a few changes bring about a difference in her life, one of them being the fact that they will be moving house. Janet anticipates happily this change of environment and looks forward to it eager so she can make the place her own. History The audio recording provides a clear history of Janet and the onset of her problems. Janet is a 36 years old woman who is in a same sex marriage with her partner of the same sex. She also has a daughter whom she gave birth to two weeks after the death of her mother. The couples are foster parents to a child they adopted to bring up. Janet comes from a stable family, with loving and caring parents, and she was the younger of two boys in the family. However, Janet suffers a sense of lack of identity, and sense of self, which made her to cling overly to her mother as her beacon of hope in identifying herself. As such, she developed a stronger attachment to people of the same sex, as dictated with her undue relationship with her mother, and the same sex relationship she got into as an adult later leading to a marriage, which by now is two years old. The audio recording provides that Janet’s problems, that led her to seeking help from a psychotherapist, began at the passing of her mother. This fateful event transformed her life for the worst because she always looked up to her mother for her identity, since being the youngest in the family, she did not have an opportunity to air or speak out her mind. This went on even at school and later at her work place, whereby she felt the opinions and suggestions of others always took precedence before her own needs and wants. As such, she developed a close attachment to her mother, which according to John Bowlby of the Attachment Theory; children usually develop a stronger relationship to one parent of the similar sex in order to find recognition. Hence, the death of her mother destroyed her sense of identity, and lack of self. This event makes her feel even more insecure of herself, even within her relationship. Assessment Every organization uses assessment as a critical tool in establishing the viability or causation of a risk. As such, according to moss (2010) he puts forward the definition of assessment as the identification, evaluation, as well as, the estimation of the levels of risks involves in a given situation, and the comparison against standards of benchmarks in accordance with determination of an acceptable level of risk. This requires consideration of hoe dangerous a situation can be, as well as, come up with the right strategies of resolving the impending danger. This holds true through the purposeful look at accidents, lifestyles, ill health, and strong emotions that can ruin of negatively affect the lives of people if not resolved within the right time. Moss (2010) further puts it that the process of conducting a risk assessment requires due diligence in following a systematic outline of steps. The steps identified in this process include identification of hazards, deciding on who has the highest risk of suffering an injury and how, evaluation of risks and deciding on the right precautions, making a record of the findings and implementations, as well as, reviewing the assessment to update it where necessary (appendix 1). The therapist use Janet’s case in this report, whereby the evaluation of her situation provides that she is a sad and confused woman, with a lack of identity and sense of self, which puts her through depression as she tries to cling to anyone or to something in order to define her identity. The death of her mother greatly affected her life and the present condition she is living in has a detrimental consequence on her future and relationships. The therapist used cautiously the tools of interview in order to evaluate the risks and decide the precautions to take, such as timelines, questionnaires, observation, counseling skills, as well as, interviews. The therapist further recorded and documented the interviews and observations in order to find the best strategy of assisting the client. The therapist conducted an assessment session on the 6th session in which she reviewed and assessed as used at the first session. This is clearly in the appendix of the paper, and this assessment undergoes another review in the 6th session. The therapist used various models of assessment for reviewing the client’s case, such as BASIC ID and Case Formulation. The therapist needs to utilize a broad range of formal tools or instruments of assessment and informal gathering techniques, in accordance with the counseling circumstances in order to guarantee acquisition of the appropriate information necessary for the case conceptualization, tracking progress, ongoing therapy, as well as, treatment planning. Case Formulation – (Padesky Case formulation) According to Padesky (2011) in CBT for therapists, she defines case formulation as a blue print used by therapists and clients to figure out the problem that the client has, and as such involves a number of overlapping elements. The therapist uses these elements in determining the case of her client, as evident in the audio recording, whereby in the tenth minute she employs the interview tool, taken from Gestalt theory. These elements include getting a list of problems, goals and issues, diagnosis, core beliefs, key dysfunctional assumptions, vicious circles, and maintaining factors. The therapist used this model in analyzing Janet’s case through a critical digging of her family background, and relating the background to the current problems faced by the client. This is clearly exhibited in appendix 2, espcially on how to conduct the assessment. The therapist involved the processes suggested in case formulation by Padesky, such as listing the problems of the client – mother passing, identity issues, and body issues, and through this managed to develop the goals, issues and diagnosis pertaining to her case. The process of the case formulation (Appendix 2), and BASIC ID as identified by Arnold Lazarus Structure and Process of Therapy and Assessment of Progress Interventions in the counseling process enable the therapist to assist the client in getting over their problem. This process allows the therapist to help the client to understand the adversity of her condition, and as such, make personal efforts to overcome it, but with guided assistance from the therapist. On the other hand, intervention in a case also allows the therapists to measure the level of progress made, as well as, establish the level of success achieved since the intervention program started. This exposes the various factors affecting the success or otherwise of various intervention programs, and the theories that relate to these intervention programs. This program followed a structured process, in the sense that each session had its own clear agenda. the first session involved going through assessment and contract forms, while the second session involved going through the case formulation, while the third session was going through the BASIC ID. Summary of Interventions This summary of interventions is in relation to the 7th session of the weekly therapies held with Janet. The therapist chose to apply visualization intervention in her case. This intervention is from the theory of Gestalt, which outlines the three zones of visualization techniques. According to gestalt, the three-zone theory that underlies the visualization technique contains holistic, growth-centered and existentialist, as the underlying philosophy. As such, the therapist uses this theory in Janet’s case due to its usefulness in assisting functional people to enhance their awareness with other growth-oriented therapies such as psychosynthesis. The choice of this visualization intervention by the therapist was a calculated approach that would enable the client, Janet to focus on herself, and as such, put herself on the forefront in a room because she often spoke about others rather than her own feelings. This approach would also be instrumental in assisting Janet towards her identity, as well as, developing her sense of self. According to Mulhauser, the theory underlying this is the Person Centered Theory of self and self-concept by Carl Rogers. This links directly to Janet’s core beliefs about herself, and the automatic negative thought she develops. This holds through according to the Cognitive Behavioral Therapy as well as the Attachment Theory as in Cherry (2005) and McLeod (2009), since Janet is an anxious ambivalent style because she puts others before herself, and as such, needs to be liked and to have approval. The therapist used a number of intervention practices as was evident in the audio recording. For instance, twelve minutes into the therapy the therapist begins the visualization intervention by asking the client to picture herself at the center of the room and the only one who mattered in the whole setting. This would enable her get over her inferiority feelings and create a sense of acknowledgement. The client responds that she feels more secure after beginning these sessions. These intervention measures took place in a room together with the supervisor, and the supervisor did a run through with the therapists of the intervention. According to gestalt, the visualization technique involves the usage of mental concentration and directed imagery in order to secure particular goals, whether spiritual, emotional, educational, physical or psychological. The therapist uses this technique on Janet and tries to program her mind to discover inner power and guidance, and as such, develop from within the sense of self and identity that she lacks so much. Summary of Theories – PCA, CBT, AT According to Mulhauser, the Person Centered Approach theory by Carl Rogers developed between 1940s and 1950s majorly to provide the clients with an opportunity to develop their sense of self. The therapist applied this theory in examining the Janet’s case to enable her realize the negative effects of their current situations on their feelings, attitudes, as well as, behaviors. As for the case of Janet, this therapy enables her realize how hurting it is to let the feelings and opinions of others take center stage while hers take a second place. She feels inferior to others majorly because she lacks the confidence to stand up for herself, and as such, seeks the solace of others in order to feel important and useful in the society, such as her mother, her same sex partner, her foster child, as well as, her birth child. Consequently, the removal of these aspects from her life, such as the death of her mother, leads to a detrimental crush in her self-esteem and well-being. The therapist used the self and self-concept theory in validating the client and making her feel more important and special in her own sense. The Cognitive Behavioral Therapy is another important theory used by the therapist in this case. According to Cheery, CBT is an approach used to address the dysfunctional emotions, cognitive processes and contents, as well as, maladaptive behaviors through various goal oriented and explicit systematic behaviors. The therapist used this therapy to acknowledge that some behaviors are uncontrollable, especially through rational thoughts, such as the case of Janet. She cannot control her sense of lack of identity, and as such, clings on anything that makes her feel loved and important in order to fulfill her deep-seated desire to be important. The therapist uses CBT as a problem focused approach, hence focusing on the identity blind in Janet’s case, as well as, an action-oriented approach, whereby the therapist assists the client in selecting specific strategies to help in addressing their problems (Bowlby 2005, p.45). The Attachment Theory by John Bowlby is also very instrumental in assessing Janet’s case. According to Bowlby (1958), children have a tendency of attaching or affiliating themselves to one of the parents for protection and identity. This theory describes various dynamics underlying the long-term relationships between human beings with the most important aspect of the theory being its outline that it is necessary for an infant to develop such a relationship with at least one of the primary care givers. This is similar to the case of Janet and her mother, whereby the attachment was to enable her to acquire both social and emotional development normally. Janet attached herself to her mother because she was the younger of the two boys, and this made her seek solace in people of the same sex. In addition, she attached herself so much to her mother because it gave her a sense of identity for existence, and as such, her death traumatized her as it eliminated every identity structures that she previously developed. The therapist combines all the three theories in analyzing Janet’s case, as well as, coming up with the necessary intervention programs to succeed in assisting her. According to Cassidy & Shaver (2002), attachment in clinical applications requires the user to let go of her past feelings and embrace a new future of her own. The therapist uses a particular attachment style known as the anxious ambivalent to secure. As such, within the room with Janet, the therapist models a secure base for her client, as well as, ensuring that she too remains secure during each session. The therapist mainly has a secure base with female figures and women, as part of her attachment to her mother was secure. However, sometimes this security goes into anxiety especially in relation to life experiences encountered by the therapist when she was a teenager. This traumatic event was the divorce of her parents when she was fourteen years old. The therapist has an anxious ambivalent attachment style. Nonetheless, within the therapy sessions with Janet, the therapist manages to model a secure base in order to assist Janet to find her secure base. TTM – The Transtheoretical Model The counseling procedure also required proper incorporation of necessary modules of counseling and therapy, which enable counselors to undertake their practice. For instance, the British Association of Counseling Psychotherapy (BACP) provides that a counselor should apply the Transtheoretical model of behavior change. This model enables the therapist to assess the readiness of an individual to act upon a new healthier behavior, as well as, provide the necessary strategies or processes of change that guide an individual through the various stages of change to Maintenance and Action. As such, this model requires the therapist to apply various related theories of counseling approach that will ensure effective management of the client’s case. These theories include the Person Centered Approach (PCA), the Cognitive Behavioral Therapy (CBT), and the Attachment Theory. These three theories assist the therapist to evaluate the case of Janet in her search for identity and recognition. The TTM has five major stages of change that enable the therapists establish the progress achieved through a client after a number of sessions. The first stage is the precontemplation stage whereby the participants are not ready to commence any healthy behavior within the near future. The next stage is contemplation stage where the participant is getting ready to begin a healthy behavior. Due to Janet seeking counseling on her own, we can see that she is at the contemplative stage of the TTM Model. As such, this requires the therapist to engage in interventions that raise Janet’s self-awareness, as evident in gestalt theory, whereby an individual is only as strong as they perceive themselves to be. The third stage is preparation whereby the participant is now ready to start taking action in overcoming their problems. The fourth stage is action whereby the participant changes their health behavior and makes efforts to moving ahead. The final stage is maintenance, whereby the participant is already over their problem and living free from its clutches. According to Prochaska & Velicer (1997), the process of change is the covert and overt activities that people make using of in order to progress through stages. The process of change provides Janet with an important guide for her intervention program in a ten steps process, whereby the first five are experiential processes at the early stages of transition, while the last five are the behavioral processes at the latest stages of transition. These first five steps in the process of change are consciousness raising or increasing awareness, dramatic relief or emotional arousal, environmental re-evaluation or environmental opportunities, and self re-evaluation or self-appraisal. the last five steps in the process of change are stimulus control or re-engineering, helping relationship or supporting, counter conditioning or substituting, reinforcement management or rewarding, and self liberation of committing. According to these stages of change, Janet is at the first step in the experiential category, consciousness raising whereby she discovers the amount of suffering she is going through due to her condition. BASIC ID (Lazarus) The therapist also uses the Multimodal Approach of psychotherapy engineered by Arnold Lazarus, according to Lazarus (1989). This approach underscores that all humans are biological beings that interact, imagine, sense, feel act, and think, whereby the proposer advocates for the use of all these modalities in addressing a particular psychological treatment. This multimodal assessment and treatment program follows an approach known as BASIC ID, which incorporates seven core interactive, as well as, reciprocally influential dimensions of psychology or personalities. These modalities are Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal relationships, and Drugs or biology respectively (Lazarus 2006, p.23). B – Behavior –Janet always put down her feelings before others. A – Affect – the death of Janet’s mother affected her self-identity S – Sensation – lack of self-identity and recognition I – Imagery – inferior to others C – Cognition – feels self-insecure I - Interpersonal relationships – more affiliated to the female gender D – Drugs/Biology - Complicating Factors As Janet described her case about the passing of her mother, the therapist became more emotional as this case reminded her of the passing of her grandmother sometimes back. However, the therapist discusses this case with her supervisor and manager and felt ok to continue handling the case. According to Costigan (2004), it is imperative for the therapist to create a social awareness environment that will enable the client to open up to the counselor, as well as, empower the counselor to absorb what she hears, and give the client the necessary help and support needed. According to Holmes (2011), the memory of the passing of the grandmother of the counselor should not affect her conduct and professionalism in dealing with Janet’s case. The Role of Clinical Supervision The therapist made several visits to see her supervisor, Jazz Kang from December. These visits were an opportunity for the supervisor to provide the therapist with appropriate grounding, as well as, a secure base thereby encouraging her confidence to grow significantly as a therapist. Furthermore, Jazz Kang also supported the decisions made by the therapist on where to move forward with her clients, especially in relations to specific advice and publications necessary for progressing with clients. This supervision is very instrumental in the therapists practice, as well as, development as a professional therapist. In addition, the progression also encompasses the personal growth of the therapist, as well as her own journey for progress with clients in accordance with submissions from Lahad concerning clinical supervision and psychology. The supervisor particularly gave advice to the therapist on the 3 zones of the visualization technique, and how it would best relate to her client’s cases. These zones are holistic, growth-centered and existentialist, which enable her to view herself as important and relevant in the community. Summary Conclusions and Lessons Learned In conclusion, it is imperative to note that various psychological cases require specific intervention measures in order for the therapist to tackle them appropriately. This includes taking appropriate approaches to aspects such as theoretical models to use, the intervention models, as well as, the client’s participation in the whole process. The therapist learns that incorporating the client’s ideas and belief in the whole process is far much instrumental in supporting them to overcome their problem and be free from it. For instance, the case with Janet enabled the therapist know how to assist her future clients to overcome their problems related to identity and sense of self. The therapist can improve herself more in the next audio recording through a critical evaluation of the TTM as evidenced in Pro-Change Behavior Systems (2010) which requires a therapist to integrate various intervention measures in dealing a particular case of psychotherapy in order to get the most successful results. Reference List BACP Ethical Framework Guidelines. Retrieved from http://www.bacp.co.uk/ethical_framework/ Bowlby, J. (1958). The Nature of the Childs Tie to His Mother. International Journal of Psychoanalysis, 39: 350-371. Cassidy, J. & Shaver, P., 2002, Handbook of Attachment: Theory, Research, and Clinical Applications, Second Edition, Guilford Press, New York. Cherry, K. (2005) What is CBT? British Association for Behavioral and Cognitive Psychotherapies (BABCP) Mapping Psychotherapy. (Online) Available from: http://www.babcp.com/silo/files/what-is-cbt.pdf (accessed on 11th April, 2014) Cherry, K. Attachment Theory: The Importance of Early Emotional Bonds. Retrieved from http://psychology.about.com/od/loveandattraction/a/attachment01.htm Cherry, K. What Is Cognitive Behavior Therapy? Retrieved from http://psychology.about.com/od/psychotherapy/a/cbt.htm Costigan, L. (2004). Social Awareness in Counseling: A Critique of Mainstream Counseling from a Feminist Counseling, Cross Cultural Counseling, and Liberation Psychology Perspective, Blooming Ton, Indiana: iUniverse. Holmes, J., 2011, the Search for the Secure Base: Attachment Theory and Psychotherapy, Routledge, London. Lazarus, A., 2006, Brief but Comprehensive Psychotherapy: The Multimodal Way, Springer Publishing Company, New York. Lazarus, A.A. (1989) The Practice of Multimodal Therapy. Baltimore: Johns Hopkins University Press. McLeod, S. A. (2009) Attachment Theory. (Online) Available from: http://www.simplypsychology.org/attachment.html (accessed on 11th April, 2014) 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) Mulhauser, G. An Introduction to Person-Centered Counseling by Carl Rogers. Retrieved from http://counsellingresource.com/lib/therapy/types/person-centred/ Norcross, J. & Prochaska, J., 2013, Systems of Psychotherapy: A Transtheoretical Analysis, Cengage Learning, Stamford, Connecticut. Pro-Change Behavior Systems (2010) The Transtheoretical Model: Evidence Based Behavior Change. Pro-Change Behavior Systems, Inc. (Online) Available from: http://www.prochange.com/transtheoretical-model-of-behavior-change (accessed on 11 April 2014) Rogers, C. (1986) Carl Rogers on the Development of the Person-Centered Approach. Person-Centered Review, 1(3), 257-259. Sapp, M. (2004). Cognitive-Behavioral Theories of Counseling: Traditional and Non-Traditional Approaches, Springfield, Illinois: Charles C. Thomas-Publishers, Ltd Appendices 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: Janet and Therapist, Session seven recording Read More