Student number
1007545
Case Study
CBT Application in the Treatment of GAD
Introduction
Cognitive Behavioural Therapy (CBT) is a widely recognised and accepted approach of
treatment for a host of different psychological difficulties (Westbrook et,al.,2007), and
there are a large number of well constructed experiments that have show it to be highly
useful in treating depression and anxiety disorders, including GAD (Carr 2009). The aim of
this case study is to examine the application of CBT e.g., contents, structure, processes,
theory, research knowledge and practice skills, in relation to working with a client
experiencing GAD. The first process in this case study will
contain the back ground
information about the client and the necessary consent forms. Following on, a brief
discretion of the theoretical framework of CBT will describe the theoretical framework of
CBT therapy used in this case study. The next process will disciple how information about
the clients past and present problems, are gathered to form an assessment and to structure
the clients therapy. During the assessment process an agenda is also implemented in order
to structure sessions, review, and give feedback during each session. Following this, and
form the information gathered during the assessment the next process will describe
contextual information about the client, and how it guilds and structures the course of
treatment, and provides goal towards resolving the clients problems through the use of
interventions specifically used in the treatment of anxiety This case study will also
demonstrate the importance of developing a collaborative therapeutic relationship
throughout therapy sessions, and thoughtful practitioner skills, pulse any key therapeutic
issues arising in the course of therapy. Finally a follow-up and conclusion of this case study
will reflect critically on the observation of the client/therapist during therapy. For example,
what went well/ what could have been done differently, how successful the therapy was in
the achieving the clients goals, and what the client felt was most helpful about CBT, along
with any professional development issues that need to be address. 352
Back Ground Information.
For reasons of confidentiality, the client will be referred to by a pseudonym “John”
John was a registered carer for his father and was referred by Arbroath Angus Cares (AAC).
John informed me that over a period of several months he had been feeling; anxious, found
it hard to concentrate and had problems sleeping. The rational for John having treatment
was based on his presenting systematic/physical/psychological (GAD)problems and towards
the resolution of
his
difficulties. All necessary professional ethical guidelines/forms
required e.g., client informed consent, confidentiality, audio recording consent, full Scottish
disclosures forms and practice insurance were approved and signed before therapy began.
The nature and role of supervision, was used to give support /guidance for dealing with any
difficulties/obstacles experience by the client and therapist during therapy sessions. The
supervision was provided in one to one monthly sessions by AAC and three two hour group
sessions over a period of nine months at Abertay University. Psychometrics test employed
during the case study included: Beck’s Depression Inventory (BDI), Hamilton Anxiety Scale,
and Hospital Anxiety and Depression Scale. Furthermore, thought diaries and activity rating
scales, (WAS) were used to assesses, document and monitor John’s levels of anxiety. In
addition, text taken form an audio recording during a therapy session (see Appendix)
demonstrating the practice of CBT was supplied as another relevant source of evidence. No
other information from other professional was required.
The Client.
John is a single male, 34 years of age, unemployed factory worker, with no children. He was
educated at a local school and left with three GSE. Although he liked school he was not
academic. Having left school he started work at a factory. His mother looked after both his
father and John until she became ill and died over two years ago. However, over the past
several months he has struggled to feel confident after the death of his mother. In addition
his sleeping had become disturbed. Over a year ago his father had a heart attack, and now
John is responsible for looking after his father, and he worries about losing him too. In
addition, he was made redundant then subsequently got another job but found it too
difficult to go to work on the first day due to anxiety so resigned. He recognises his difficulty
is anxiety and wishes to be more social, but finds himself worrying whenever he is away
from his father than something bad may happen to him. He finds he can manage to spend
time away from home with friends when he is distracted but feels he is still grieving for his
mother 195
CBT Theory of Anxiety.
The CBT theoretical frame work in this case study is based on Beck’s (1976) `cognitive triad’
that is ... through experiences, and events in childhood (and later) `schemas’ are developed
which refer to the basic beliefs and assumptions an individual may have about self, world
and future and interpersonal relationship, which allow us to make sense of ourselves, the
world and the future. However, if an event or series of events violates an individual’s beliefs
and assumptions, then dysfunctional assumptions, negative biases and automatic thoughts
become more active, and distressed states such as depression/anxiety can result. Common
negative biases in depression and anxiety include: over generalising (one person rejected
me so the whole world will too), mind reading and predicting the future (things aren’t going
to change so wants the point). The crucial component of CBT therapy is to challenge/change
negative thoughts, assumptions, and core beliefs, (unhelpful patterns) with more
functional/thought-feeling-behaviour (helpful patterns). The CBT interventions specifically
used in the treatment of anxiety (during this case study) included: Becks depression/anxiety
Inventory (BDI) Hamilton Anxiety Score (HAS) Hospital Anxiety Score (HAS), home work,
record/thought dairies, activity/sleep records, behaviour experiments, relaxation,
techniques and Socratic questioning in order to gain a deeper understanding of the clients
difficulties, maintaining difficulties and developing strategies towards resolving difficulties.
The theoretical frame work of CBT also contains an assessment of the clients contextual
information e.g., relationships, personal, work and medical and an agenda. The agenda is
set at the beginning of every session, and contains what the client/practitioner would be
covering during sessions (what problem the client is having the most difficulty with) timing,
and number of session, goals of therapy and interventions e.g., homework tasks. Following
this, information from the assessment is used to form a formulation plan of the clients
problems in order to further explore the clients problems, and for setting goals towards
changing the clients unhelpful patterns, through the employment of intervention. For
example, from the information gathered during John’s assessment, and formation plan and
with John and I collaborating, it was agreed that John would benefit from a one hour
therapy session, delivered once a week over a period of 10 weeks. During the early
stagers’ of John’s therapy intervention e.g., psycoeducation and thought dairies were used,
to help John become familiar with the CBT model of anxiety and his unhelpful thinking
patterns Following on, during the middle session’s relaxation exercises and sleep records
were implemented as coping strategies and for reducing his anxiety levels. Towards the end
of Johns therapy behavioural experiments were employed to further test out Johns
unhelpful patterns and towards his goals e.g., finding work, and for resolving his
problems.
Figure 1: demonstrating John’s physical and cognitive cycle of anxiety and worry.
Thougths
Dads going to have another
heart attack
"I carnt cope" worry
Behavior
stay in don't go out any
where worry
emotions
my heart is pounding I m
shaking feel sweating feel
anxious worry
Assessment and Formulation.
The early task for any CBT counsellor is to assess the problems that the client is seeking to
change (Mcleod 2009, pp 124) This process usually elicits contextual information about the
clients: relationships, work, social and medical history (described in the background
information). In addition, during the first assessment session it is important to gather as
much information as possible regarding the clients expectations of therapy and what is
expected from the client during therapy e.g., collaboration and compliance (Westbrook
et.al., 2007). What follows is a description of John’s assessment and formulation plan and
the processes involved throughout his therapy. For example, on first meeting John I
observed he was of a nervous disposition e.g., avoiding eye contact, and displayed a slight
twitch in his right eye. Having introducing myself, (and thanking him for agreeing to take
part in my study, and having signed in all the necessary procedural forms) I asked John if he
had any objection to filling in some addition forms e.g., Beck’s DBI, HAD and HID, to assess
his level of anxiety. John reassured me he had not objections and sensing he was a little
nervous I left the room, to give him time to do so. On my return having enquired if he had
any difficulties’ filling the forms, he told me he hadn’t, and I proceeded by explaining the
therapy of CBT using Pedesky’s (2009) generic CBT model and collaborating we drew a
diagram of the model together to further demonstrate the rational for John to gain a
deeper understanding of CBT. After which I asked John why he had come today? John told
the following story: for sometime he has been experiencing anxiety, and he was having
problems sleeping. Having listened empathically and showing genuine concern, I asked John
to describe what he meant by being anxious and how long he has had problems sleeping.
John replied when he gets anxious and he can’t think straight his head is fuzzy, and he gets
confused and he finds it difficult to talk, his words get muddled. Following on, and to enable
me to gain a deeper understanding and insight of John’ s problems, I asked John if he
would describe to me (in as much detail) a resent example of his anxiety to me? John told
me, that recently he had to go to the job centre and explain to them (employment official)
why he hadn’t been looking for a job. All that week he was worried thinking about what
they might do e.g., what if the they took his money away from him, how would he cope, he
won’t be able to take his dad out anywhere, that means he will have to stay in the house ,as
he doesn’t like leaving his dad alone. As consequence of all these worries John had not slept
well, and all this worry was driving him insane and he was finding it hard to concentrate on
anything else. As I listened to John I observed he was becoming more and more agitated ,
and noticed physical changes in his appearance e.g., his face was becoming flushed, and his
right leg had started to shake and his speech had become louder. Not wishing to distress
John any further, I thanked him for putting his trust in me, and allowing me to experience
his distress, and asked John if we could further explore the problems he was experiencing
(in relation to CBT) and exploring ways (goals) towards resolving them. John agreed that
would be very helpful and using (Williams and Garland, 2002, Five Area Assessment model
Model) we drew up a diagram of John’s unhelpful thinking/behavioural patterns, physical
symptoms.
Form the information gathered during John’s assessment it was important to further
explore, and ascertain, why and when he was experiencing his anxiety. There are many
interventions used within the “tool box” of CBT model Westbrook et, al., (2007) therefore, it
is important to investigate what would help John and what wouldn’t, through guided
discovery and collaboration and investigated all the possible solutions into challenging and
changing Johns negative biases, core believes and physical difficulties for more helpful
ones (Holland 2001). Having informed John how factors of GAD can escalate and maintain
the condition, i.e. behavioural responses, thought control attempts and emotional
symptoms, thereby maintaining his vicious cycle. I asked John if it would be helpful to draw
a diagram of the problems he was experiencing (together) in order for us to focus on his
goals towards resolving his difficites, and to provide evidence of any changes during his
therapy. John agreed, and from the information gathered during his formulation and
collaborating John was able to recognise his anxiety may have been triggered by the sudden
loss of his mother, his father’s heart attack, and the sudden changes in this life, and feelings
of overwhelming responsibilities. In addition, I asked John if he had experienced anxiety
before, and drew his attention to the thought that some individuals use worry to block more
distressing thoughts; a type of cognitive-emotional avoidance. John went quite for a
moment where upon (hesitantly) he told me, that when he was about twelve he was taken
out of school as his father was ill. John went on to tell me, he wasn’t quite sure what it was
his dad was ill with, but he thinks it may have been a nervous break-down, as he didn’t work
after the incident and his mood changed towards him. Sensing John was finding recalling
his past emotionally difficult to talk about I reassured him that he was in a safe place and he
had nothing to fear and empathically asked him if he wanted to proceed. John said yes he
hadn’t spoken about the incident ever and it was possible his anxiety may have started
when his father’s mood had changed towards him. With genuine concern, I asked John
what he meant by change. John replied that, his dad would get upset and shout at him if he
wasn’t on time and he had became very anxious about late, and although in time his dad
went back to “normal” he still gets anxious if thinks he may be late. Form what John had
told me about his past and present difficulties together we were able to draw up a list of
goals and coping strategies for helping John resolve his unhelpful pattern and physical
symptoms. For example, Johns short term goal were for reducing his physical symptoms
and improving his sleeping patterns, by introduce relaxation exercises. Midterm goals
involved raising Johns self –esteem and confidence levels, in order for John to gain control
of his thoughts and emotions. With long term goals for the future set at gaining more
independence e.g., finding a job
Figure 2: Illustrating John’s formulation plan: containing vulnerability factors, core beliefs, critical incident,
maintaining problems, and goals for change (based on Westbrook et.al, (2007) Basic Formulation Plan).
Vulnerability factors
anxiety
due to
fathers mental break
down at the age of 12
Critical incidents.
Core beliefs I’m stupid, unlovable.
Sudden loss of mother two
years ago
It’s all my fault.
The problem. can't stop worrying, thoughts going
over in my head, feelings of fear and worry .
Behaviour:
I don’t sleep well, find
overwhelming .
things
.Emotions:. Feeling low –sad worrying about dad
being left on his own, something bad may happen.
Physical. Body feels hot, feel sick in the stomach,
and agitated.
Current triggers
Fathers illness , loss of job, hand
injury
Maintaining processes
Do less activity, on the computer,
more, watchers T.V. till late.
Maintaining: Sleeping patterns
disturbed.
Maintaining:
Avoids
social
interaction/passive activity
Goals/targets:
to reduce symptoms of anxiety and improve
sleeping patterns .
Raise self- esteem.
more social activity
more pleasurable activity e.g., engage in
Raise confidence levels, find a work/ paid/volunteer.
CBT interventions and key therapeutic issues arising in the course of therapy.
Introduction
The general focus of the CBT interventions employed during this case study were on
changing John’s negative unhelpful patterns for more helpful positive thinking and
behaviour patterns, and teaching
John new coping strategies towards reducing his
symptoms of anxiety and for raising his confidence levels towards achieving her goals. On
refection, the key therapeutic issues that arose during the course of John’s therapy were
concerning his homework resistance. What follow is a description of the interventions
employed during this case study, and why they were selected to facilitate John moving
towards his goals and the key therapeutic issues that arose during this case study, and how
the issues were addressed?
Following on, and from the information gathered during John’s assessment and formulation
plan (shown in Figure 2) John’s unhelpful thinking and behavior patterns and symptoms of
anxiety may have resulted from John’s early experiences of levels of low self-esteem and
confidence levels. Therefore, and in order to facilitate John moving towards achieving his
goals, it was important to employ interventions (during the early stages) specifically to
reduce his symptoms of anxiety levels, and for raising his self-esteem and confidence levels.
Interventions specifically used for reducing anxiety levels include: e.g., are psycoeducation,
thought diaries, and behavioural experiments. Evidence used to monitor and evaluate
John’s therapy, demonstrating the flexibility of CBT interventions employed during this
case study are described as follows. Through the employment of psycoeducation John was
helped to identify early signs of his anxiety symptoms and self-help options to cope with
these situations. For example, John was able to distinguish the differences between two
types of worry, type 1 and type 2. That is, type 1 constitutes the normal content of worrying
(external daily events and non-cognitive internal events such as body sensations) and type 2
focuses on worry about worry e.g. all this worrying will drive me insane, and is used as an
internal safety behaviour (Wells,2009). Having explained and informed John about the
rational of his anxiety and by helping John to become familiar with his own NATs, “I feel
like I’m going in sane”, and the role they play in the generation of his emotions and anxiety
behaviours e.g., “feeling hot and out of control” through the use of ‘guided discovery’
(Beck and Young, 1985; J. Beck, 1995; Wills and Sanders, 1997) I was able to further explore
John’s unhelpful patterns and facilitated the use of the Dysfunctional Thought Record
(DTR) (Bates, 1993; Beck et al, 1979; Blackburn & Davidson, 1990; Fennell, 1989; Burns,
1999; Gilbert, 1997) and asking him specifically, to describe his behaviour response after
countering events in his life that had triggered his anxiety. For example, when was the last
time he had experienced his anxiety? John told me the following story: Last week, his dad
had falling in the kitchen, and he was worried he was having a heart attack, so he called an
ambulance to take him to hospital. I then asked John to write down in a percentage, how
high he felt his anxiety was, John marked it at 80%, and collaborating through a process of
guided discovery John was able to identify other situations throughout his life when he had
coped e.g., when his dad had his first heart attack, and what he did to help him cope e.g.,
asked for help and knowing where to get help, enabled him to think and act differently.
After which I asked John to fill in the rest of his anxiety thought dairy, and on doing so he
rated his anxiety levels much lower e.g., 40%
On critical refection, however, I felt at times I was becoming the authoritative figure and
lecturing John. Although, John never displayed any visual signs of resistance, or confusion,
(having reassured me that he understood the rational of CBT) I however, (and due to John’s
sensitive personality) I sensed he was being polite and being overly compliant to please me.
As many cognitive-behavioral treatments are time-limited the treatment may only last a
certain number of weeks, after which the patient is expected to have gained enough skills to
continue the work on their own. This works well for people who have one specific issue they
would like to address. However, the short-term focus of some cognitive-behavioral
treatments may not meet the needs of people looking for longer-term support. Although
form the information gathered from John’s assessment and psychometric scores John was
not displaying high levels of dysfunction. I sensed John’s underlying issues were not
necessary addressed during his course of therapy, due to the time restraint and structured
processes implemented throughout CBT. As I reflected on this I was convinced that, if I had
had more time
to
further explore
John’s
reluctance to talk about his
personal
relationships (an important ingredient in the therapeutic relationship) John’s experience of
my acceptance and understanding would of been more powerful and enabled him to cross
other boundaries which had previously seemed beyond his capacity.
Ending /follow – UP
Form the results shown in Johns psychometric test results CBT has shown to be an effective
therapy in reducing the physical and psychological symptoms in a client experiencing GAD.
However, caution show be taken when reading the results as other factor could also
contribute to the success of therapy non specific e.g., therapeutic relationship between the
client and counsellor, buying in to the belief that it will help, and completing relevant
assignments, During the final session (session 10) of this case study John was asked if he
would give me feedback on how helpful he thought CBT had been towards reaching his
goals and resolving her problems? e.g., what went well, what didn’t. On refection, John
informed me, although during the early session’s of his therapy, he found it difficult to
understand the importance of the thought diaries, through practice, therapy sessions, and
as homework, he was able to overcome the difficulties he was experiencing, and it had
been well worth the struggle. Furthermore, he has been able to recognize his unhelpful
thinking patterns, and biases, were unrealistic, and changing them for more realistic
helpful patterns, has given her a more confidence and positive outlook in life.
John also found the relaxation exercises very helpful in providing practical strategy s for
relieving his feelings of anxiety. On refection, I was aware that some of the difficulties John
was experiencing (with his homework) may also have been due to my lack of experience,
knowledge and practice skills of CBT On reflection, I would have dealt with this dilemma
differently, and taken more time to explain the process of CBT more clearly, at a pace that
was more sensitive to his cognitive abilities. Furthermore, I would have discussed the
difficulties I was experiencing (during John’s therapy sessions) with my supervisor to
eliminating the difficulties I was experiencing. On further reflection, I pleased John had
benefited from CBT, and reminded him that he could return for therapy at any time if he
felt he needed to ( for relapse prevention), as the service was available to him through
ACC and follow up arrangements would be arranged.
In Conclusion.
The aim of this study was to examine the application of CBT in relation to working with a
client experiencing GAD. Form
the evidence provided form the results of the CBT
intervention implemented in this case study i.e., psychological tests, relaxation techniques
and behaviour/ experiments CBT has been shown to be a successful therapy in helping John
reach his goals and in resolving his difficulties. . Moreover, there is good evidence to suggest
that counselling has an important in preventative role in relation to mental illness: by
preventing less serious problems from becoming more serious, and by helping people to
maintain reasonably good levels of mental health.
Not only for identify unhelpful thinking and behaviour pattern, but for providing strategies
toward changing unhelpful patterns for more helpful positive patterns (Beck, Rush, Shaw &
Emery, 1979; Padesky, 1996). In addition, and with both the client and counsellor
maintaining an therapeutic relationship containing; empathic listening, trust, and genuine
concern, counselling has shown to be most successful in helping John finding coping
strategies for reducing his symptoms of anxiety.
From a practical point of view, although
at the beginning I found it difficult to implement the process of the agenda. On reflection,
the problem I was experiencing may have been due to my lack of experience in the
application of agenda setting. However, as the session went on I stated to gain more
confidence in the application of both agenda setting and recognising Sonia’s NATs and
core beliefs, In addition, I found the process of agenda setting helpful for focusing, and
concentrating on what was important throughout sessions (instead of diverting) and
preventing therapy session from being aimless or taking on a ruminative quality, which
could of end up reinforcing John’s unhelpful thinking and behaviour patterns. I have
learned that CBT is a most effective therapy in enabling a client to be able to identify,
reflect on, and come up with alternatives to unhelpful thinking, but as a means to an end,
not as an end in itself. From a personal perspective the main issue I experienced was
implementing thought diaries, and deciding which interventions to employ during therapy,
due to the many choices of intervention available within the “tool box” of CBT interventions,
and which interventions were relevant for identifying Sonia’s key problems? However, after
reviewing John’s learning style, i.e., a step at a time, and discussing the problem during
supervision, the therapeutic relationship was maintained, and the problem was resolved. On
reflection, these issues have highlighted weaknesses I need to address. Form a professional
standpoint, and in order to address these issues, I need to practice and gain more
experience in the application of CBT skills. In addition, I need to think more about what I was
doing, and why I was doing it, rather than just thinking about using techniques and
strategies. From a personal standpoint I need to gain more confidence within myself, and
increase my own self-awareness with regard to the type of questions used and how they
are used as at times I felt I was been dialectic. Such refection could be achieved through
discourse analysis e.g., video-recordings of therapy session, role play and support through
supervision during training. In addition having a better understanding of questioning
techniques, and their use in the therapeutic process has the potential to benefit my
training and treatment outcomes and professional/personal status as a counsellor
References
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New
York: Guilford.
Brokovec, T., D. (1993).Efficacy of applied relaxation and cognitive-behavioural therapy in
the treatment of generalized anxiety disorder, 61(4): pp 611-9.
Padesky, C.A., Greenberger, D. (1995) A Clinician’s Guide to Mind Over Mood. New
York: Guilford Press.
Persons, J.B. (1989) Cognitive Therapy in Practice: A Case Formulation Approach.
New York: W.W. Norton.
Williams, J.M.G. (1997). Depression. Science and Practice of Cognitive Behaviour Therapy.
Oxford: Oxford University Press. pp. 259283.
Wells, A. (1999). “A Cognitive Model of Generalized Anxiety Disorder.” Behaviour Modification 23(4): pp, 526–556
Carol Vivyan (2009) www.getselfhelp.co.uk/unhelpful.htm. permission to use for therapy purposes.
Huppert, J., D. (2009). The Building Blocks of Treatment in Cognitive-Behavioural Therapy
Department of Psychology, 46 ( 4 ) pp: 245–250.
The overall aim of the programme is to offer a sufficiently safe, supportive yet challenging
learning environment that will enable participants to develop and demonstrate those personal
qualities and professional skills deemed necessary for competent and reflective practitioners.
Self awareness, counselling theory, practice and research will be integrated to a level that will
enable course members to engage with therapeutic process in a range of counselling
relationships.