Application of Different Therapy Types

3866 words (15 pages) Essay in Psychology

18/05/20 Psychology Reference this

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Case Study – Teddy

Theory

The theory that will be used for the case study of Teddy will be Bowen family systems. Bowen suggested that individuals in a family system are instinctively in constant interaction between being together but also trying to maintain individuality and a significant source of anxiety in families is the imbalance of either too much closeness or too great a distance in a relationship (Brown, 2014; Papero, Frost, Havstad, & Noone, 2018). This imbalance often occurs when a significant stressor enters the family dynamic, and the individual’s responses can cause conflict; in this case study, the death of Teddy’s mother is the major stressor.

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In this theory, Bowen uses concepts based on how a family’s multigenerational emotional processes are used to resolve anxiety and stress as a family unit. The basis for this approach is that the emotional reactivity of individuals, to the anxiety, overpowers their capacity to think and reflect; Bowen refers to the ability not to respond automatically to emotional pressures and anxiety as having differentiation of self (Nichols & Davis, 2017). In the case of Teddy, neither he nor his father have a high differentiation of self and have too great a distance in their relationship resulting in being emotionally cut-off from each other. Because Teddy is the only one from the family system participating in therapy, it is hoped that he will be the process of change for his family.

Specific and Crucial Elements

The lost relationship between Teddy and his father after his mom died is crucial to this case. Teddy said he and his father were close and he spoke highly of how he was when his mother was sick, but after she died, they lost touch. Teddy’s father distances himself by working long hours, and Teddy resents that his father makes no effort to have a relationship with him. When he turns eighteen, Teddy will cut-off any ties with his family.

Clinical Hypothesis

My clinical hypothesis for Teddy is that the generational pattern of emotional reactiveness, especially with how grief has been dealt with, is a contributing factor to Teddy and his father being emotionally cut-off from their relationship.  The goal will be to help Teddy see his role in the family dynamic, reduce his emotional anxiety and reactivity, which will increase his level of differentiation of self.

Interventions

The interventions that will be used for Teddy’s case will include a genogram of three generations, process questions, relationship experiment, coaching, and using the “I” position. Another of Bowen’s techniques is neutralizing triangulations. In this case, the only emotional triangulation that may be present would be between myself and Teddy when discussing his role in the family dynamic.

In the initial assessment portion, the genogram will give insight into Teddy’s familial history of emotional reactivity and adaptiveness to stressors including how grief has been dealt with in previous generations, how difficult family situations were processed and if any themes are present. Once the genogram has been evaluated, I will proceed to ask Teddy some process questions. These questions are designed to allow for Teddy to not only see how his father’s behaviour affects him but also how his reactions and behaviours are correspondingly part of the presenting problem of being emotionally cut-off.

Relationship experiments are designed to help Teddy improve his ability to resist being driven by his emotions and try something different when situations arise. Teddy’s family will react, but his new stance is maintained even though there is pressure to revert back to the original position. The hope is that the modified behaviour will start a change in the whole extended family

Since Teddy is the only member of his family trying to develop a greater sense of differentiation of self, coaching is done by me giving input and support. The final intervention for Sean will be the “I” position. This allows him to make personal statements about his thoughts and feelings to facilitate a greater sense of responsibility in a relationship (Brown, 2014)

Personal and Professional Experience

When using Bowen therapy, it is necessary for myself, as the therapist, to have done my own family of origin work to increase my personal differentiation of self and minimize emotional reactivity. This will enable me to provide a calm, therapeutic environment where emotional reactivity is low.

It is also essential for me to remain cognisant to the process of therapy and not the content to avoid being pulled into an emotional triangle with Teddy and his family unit. I will need to stay objective and avoid taking sides and becoming an ally to either individual or influencing individuals to accept more responsibility for making things better (Corey, 2017).

Ethical and Legal Issues

Because Teddy is a minor, signed informed consent must be given by his father before any therapy can proceed. Through the process of informed consent taken from Pope and Vasquez (2016), Teddy will understand that I will be providing the counselling and what my qualifications are. He will understand what approach will be taken and what is expected of him in the process. An understanding of the client-therapist confidentiality relationship will be made, he will also be informed of the fees and procedures regarding missed or cancelled appointments. An understanding of the exceptions to confidentiality, privilege or privacy regarding any disclosure of harm to self or others will be presented.  This will be an ongoing process throughout the therapeutic relationship. Continuously I will revisit the informed consent process and clarify any conflicts that may have surfaced during therapy.

Principles of Diversity and Inclusiveness

It is my duty as a professional to always be conscious and purposeful in the awareness of cultural and inclusive sensitivities into all aspects of the counselling process (Arthur and Collins, 2010). As a counsellor, it is my professional responsibility to assist individuals in finding answers that are congruent with their own values, not mine. I also have an ethical obligation to be inclusive, recognize diversity issues, appreciate the influence of culture and be able to understand, respect and work within the client’s worldview. When doing Teddy’s genogram, more information about his culture and background will be revealed. Should any information arise, that causes any biases toward therapy and treatment, I will address them with my supervisor, and the proper protocol will be followed.

Case Study – Morgan

Theory

 The conceptual framework that will be used for the case of Morgan will be Cognitive Behavioural Therapy (CBT). This approach will help demonstrate how emotional reactions and behaviour are influenced by thoughts, beliefs, and perceptions. As a result of doing an assessment of Morgan’s presenting problems and a formulation of the causes and motivation of the problem behaviour, I will be able to determine what steps to take in the treatment.

 CBT can only be successful if we have a collaborative therapeutic relationship. I will support this relationship by having a non-judgmental environment where Morgan feels listened to, valued, understood, and cared for. This is the primary change agent in CBT and both myself, and Morgan must work together to establish common goals and treatment (Pinninti & Gogineni, 2016). This non-judgemental support and acceptance allow for normalization, which is key in reducing shame and stigma that can come with mental health issues (Brabben, Byrne, Longden & Morrison, 2016). I will also explain to Morgan how this type of therapy engages the client as well as the therapist and that a commitment is needed for the treatment goals to be successful. 

 The main focus of therapy will be on what is happening now, and our main concerns will be the processes currently maintaining the problem. During the initial assessment, Morgan will list what he is currently struggling with, and goals for treatment will be established. The formulation step in this approach will help Morgan understand the connection between the perceived meaning of an experience and how behaviour maintains the problematic emotion. Through the use of Socratic questioning, Morgan’s thoughts and behaviours will be questioned for accuracy of perception and the helpfulness of the current behaviour.

 

Specific and Crucial Elements

The prevalent information that I have for Morgan regarding the disruptive behaviour is that this is the second time this week that there has been an episode of Morgan having thoughts that the cafeteria food is poisoned and that there is a plot to “give me poison that will bend my mind and give me failure.” Morgan has not been violent in any way and, at present, does not show signs of harming self or others. Another essential element, in this case, is that when Morgan becomes incoherent, there is enough reasoning and communication with the guards that Morgan agrees in meeting with me.

School records show that Morgan has had a multitude of stressors within a short period which include: moving away from a small town to go to school only four months ago, a demanding course load with barely passing grades, and exams are coming up. There have also been some personal stressors that Morgan spoke of, where there was a disappointment after being turned down when asking someone out on a date and a voicemail from Morgan’s parents stating that they are getting a divorce. It appears that just after the disclosure about the divorce Morgan is triggered back to the behavioural symptoms.

Clinical Hypothesis

My clinical hypothesis for Morgan is that when the nature of the symptoms are understood, and the maintaining influences are determined, cognitive and behavioural skills can be used to self-monitor and manage the symptoms. CBT will allow Morgan to realize that it is possible to change the relationship between thoughts and behaviour and that you don’t have to change the thoughts only the behaviour that is associated with them. If Morgan can change the interpretation of the thoughts then behaviours can be managed.

 

Interventions

The interventions for Morgan will be determined from the formulation in understanding the changes are needed to address the symptomatic behaviour. Cognitive interventions will explore Morgan’s thoughts regarding “bend my mind and give me failure.” Probing and clarifying questions may make Morgan start questioning and having doubts about the validity of the thoughts. This, in turn, can begin the development of more accurate alternative thoughts. Behavioural interventions will look into Morgan’s existing coping skills and how they maintain the problem behaviour. New skills will be developed through the homework given where Morgan can test out the skill in his environment. Morgan will provide feedback to me on how the intervention went and if it was useful and added any value. Interventions that will explore the negative beliefs Morgan has will also be used. These will aim to develop healthier core beliefs going forward to help in preventing relapse.

Personal and Professional Experience

Because Morgan presents with a possible diagnostic mental illness, it is crucial that I have ongoing support and supervision. I need to be aware of how Morgan is responding to treatment and have a continuous dialogue with my supervisor.

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I must also be self-aware of any countertransference while counselling Morgan as I had a family member present with similar delusions and paranoia. Again, consulting continually with my supervisor, I will be cognisant if I should refer Morgan’s case to another counsellor.

Ethical and Legal Issues

A significant ethical issue that needs to be addressed before therapy can begin is the offer of informed choice to the client. I must explain to Morgan that treatment is optional, and when using this collaborative approach, it requires a commitment to do the homework and add input. This is also a legal issue in that it may be questioned if Morgan is competent to consent to treatment due to the nature of the symptoms. Truscott and Crook (2013) state that if the client understands the following three issues then they are competent to consent: the nature and purpose of the psychological service, the risk and benefits of the psychological service, and the nature, purpose, risks, and benefits of alternatives to the psychological service (p. 87).

Once it has been determined that Morgan is competent to sign the consent, the process of informed consent taken from Pope and Vasquez (2016) will be given. Morgan will understand that I will be providing the counselling and my qualifications, what approach will be taken, and what is expected in the process. An understanding of the client-therapist confidentiality relationship will be made, and information regarding fees missed or cancelled appointments. An understanding of the exceptions to confidentiality, privilege or privacy regarding any disclosure of harm to self or others will be presented.  This will be an ongoing process throughout the therapeutic relationship. Continuously I will revisit the informed consent process and clarify any conflicts that may have surfaced during therapy.

Principles of Diversity and Inclusiveness

Nowhere in the case study or the school records does it indicate what gender Morgan identifies with or any cultural background. It is my duty as a professional to always be conscious and purposeful in the awareness of cultural and inclusive sensitivities into all aspects of the counselling process (Arthur and Collins, 2010). Diversity and inclusiveness are crucial to the collaborative therapeutic alliance and in setting treatment goals. Because CBT is so collaborative in nature, these important issues will be openly discussed with Morgan and will incorporate into the treatment plan.

Case Study – Sean

Theory

For Sean’s case, the future-focussed, goal-oriented therapeutic approach of solution-focused brief therapy (SFBT) will be used. This approach will focus on Sean creating his own solutions to his problem without needing to understand how the problem came about. Change can occur when allowed to reflect on times when he was successful in finding solutions to problems (Metcalf, 2017). The emphasis will be on Sean’s strengths, adaptability and exceptions to his problem and will be the main focus for achieving the goal of a preferred future.

SFBT takes on a collaborative approach between clients and therapist with a basis that the client is the expert. At the beginning of therapy, it will be essential to let Sean express his concerns and what he wants from therapy. Throughout the process, I will listen in a genuine caring and respectful way as I encourage Sean, through questioning, to identify his preferred future, what it is that he wants to change and what will be different when the problems are solved (Corey, 2017; Metcalf, 2017). This will be accomplished by using methods that include looking for differences in behaviours, exceptions questions, scaling questions and the miracle question.

Specific and Crucial Elements

 The crucial element in Sean’s case is the statement he made regarding how he worries he might “start using again…or worse”. It will be necessary to engage with Sean what he means by that to determine if there is the concern of harming himself or someone else.

 Another important element of this case is that Sean is a gay man married to his husband Tom and they have two children. This may be of importance if this is an issue that Sean wants to address in therapy, and it is also essential for me as the therapist to be aware of for context.

Although Sean’s naturopathic physician referred him to me because Sean was “feeling depressed,” this may not be what Sean wants to have as a goal for therapy. When using the SFBT approach, it is imperative to allow Sean to guide the session and determine what goals he wants to accomplish. If the feelings of depression are what Sean wants to focus on, there is no need to assess any other problems that are present in the case. Regardless of the goals that Sean wants to focus on, as Corey (2017) explains, there is no need to know the cause of problems as there is no relationship between the cause and a solution.                

Clinical Hypothesis

 My clinical hypothesis for Sean is that when he can recognize his strengths, skills, and successes, he will discover he is competent to have a future where his problems occur less often.  Through identifying what Sean is doing that is working, and encouraging him to apply these skills and strengths, he will begin to eliminate the problems.

Interventions

As Corey (2017) indicates, by Sean simply making an appointment is the initial part of therapy in SFBT as it is the start of positive change. Asking about what he has done since making the appointment that has made a difference in his problem already shifts the solution making focus on him; this encourages Sean to depend less on me and more on his own means. At this point in the session, I would ask Sean what his best hopes or outcome he would want for today.

Exception questions will get Sean thinking about times when this problem wasn’t so intense or when it didn’t exist. These would be examples of success and will build confidence in making further changes toward his preferred future. The miracle question is the central SFBT intervention, it develops the goal for therapy by opening up a variety of future possibilities. The basis for the miracle question is for Sean to imagine that he woke up, and his problem was gone. I would ask, “how would you know?” and “what would be different?”. It is here that there is a shift from past and current problems to a future life that is not controlled by a specific problem.

After the goal of therapy has been established, scaling questions will be used to help Sean realize that he is not entirely overcome by the problem and show how even a little increase in an improvement.

Personal and Professional Experience

 To practice SFBT well and be effective, it will be essential for me to be proficient in the skills of the brief interventions. This not only encompasses knowledge of the intervention questions but also I need to be aware of relying on the techniques too much. It will be essential for me to stay cognizant of any resistance from Sean as this may be my own bias of what I think the problem is over what his goals are. By merely asking Sean if this is what he wants to discuss will readjust my processing back onto the path that Sean wants to go. Maintaining constant communication with my supervisor and colleagues will improve my skill level and continually allow me to gain new tools for successful SFBT.

Ethical and Legal Issues

Through the process of informed consent taken from Pope and Vasquez (2016), Sean will understand that I will be providing the counselling and my qualifications. He will understand what approach will be taken and what is expected of them in the process. An understanding of the client-therapist confidentiality relationship will be made, and he will also be informed of the fees and procedures regarding missed or cancelled appointments. An understanding of the exceptions to confidentiality, privilege or privacy regarding any disclosure of harm to self or others will be presented.  This will be an ongoing process throughout the therapeutic relationship. Continuously I will revisit the informed consent process and clarify any conflicts that may have surfaced during therapy.

As mentioned previously, I am ethically responsible for questioning and having a duty to report if Sean were to state that he is in danger of harming himself or anyone else when asked to explain his comment “start using again…or worse”. Sean would be aware of this when he read and signed the consent form before therapy began.

Principles of Diversity and Inclusiveness

It is my duty as a professional to always be conscious and purposeful in the awareness of cultural and inclusive sensitivities into all aspects of the counselling process (Arthur and Collins, 2010). As a counsellor, it is my professional responsibility to assist individuals in finding answers that are congruent with their own values, not mine. I also have an ethical obligation to be inclusive, recognize diversity issues, appreciate the influence of culture and be able to understand, respect and work within the client’s worldview. In the case of Sean, he is a gay man married to his husband Tom, and they have two children. Should this go against my own worldviews, and if  I cannot proceed with therapy with an unbiased view, then the therapeutic relationship cannot be sustained, I will refer my client to a better-suited counsellor.

 

 

 

 

 

References

  • Arthur, N., & Collins, S. (2010). Culture-infused counselling. Calgary, AB: Counselling Concepts.
  • Brabban, A., Byrne, R., Longden, E., & Morrison, A.P. (2016). The importance of human relationships, ethics and recovery-oriented values in the delivery of CBT for people with psychosis. PsychosisPsychological, Social and Integrative Approaches, 9(2), 157-166.

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