psy476 counseling final project running head: claire · client’s presenting problem, attributes,...

PSY476 Counseling

Final Project

July 15, 2016

Running Head: CLAIRE – A CASE STUDY AND RECOMMENDATIONS 1

Client’s Presenting Problem, Attributes, and Circumstances

The client, Claire was experiencing chest pains and shortness of breath. Claire visited the

emergency room, and was given a clean bill of physical health after an EKG and other tests

proved Claire had no medical anomalies. After talking with Claire for about 15 minutes, the ER

doctor believed Claire should follow up with a professional counselor to investigate whether her

shortness of breath and chest pains could be rooted in something psychological which might be

exacerbating her anxiety and possibly related to her seemingly excessive binge drinking.

Presenting Problem

Claire decided to visit a counselor, not because she believed she could possibly have

psychological issues or that she drank too much, but to prove that the ER doctor was an idiot, he

didn’t know what he was talking about, and possibly should have flunked out of medical school.

Once Claire showed the counselor that she was fine, she would go back to the ER doctor and

prove her point.

Attributes

The following information was taken from the initial intake form and interview with

Claire from her initial assessment. The counselor had asked Claire several open ended questions

to allow Claire to reveal important information about herself which would allow the counselor to

determine which counseling approach or model might be the most beneficial for Claire to attain

and experience her ideal life.

Demographics. Claire is a 42 year old Caucasian female. She is married to a Caucasian

real estate agent who provides a comfortable home for Claire and their 3 children, two daughters

21 and 19, and a son 17. They have been married just a little longer than 21 years. Until about 2

PSY476 Counseling

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CLAIRE – A CASE STUDY AND RECOMMENDATIONS 2

years ago, Claire stayed home to raise the kids. Once their middle child graduated high school

Claire began working at her father’s business and eventually replaced her father as the CEO

when he decided to retire.

Presenting Problem. Claire seems to be high strung and displays a need to feel superior

to others. Claire is quick to judge and point out other people’s shortcomings or what she

perceives as mental deficiencies, or to point out even minor honest mistakes. She will cover her

right hand with her left hand and pull it up to her right cheek while pointing out something with

her right finger and making an exaggerated facial gesture with eye movements to show that she

is trying not to hurt someone’s feelings. According to Claire’s family, it is common for Claire to

“polish off” a full bottle of wine in one evening and say she shared it with her husband, but he

doesn’t drink wine; however, when asked how much wine she drinks, Claire’s answer is, “you

know, the occasional glass of wine.” She is in denial of the possibility of a problem with her

drinking habits.

Claire is obsessive about not only being right all the time, but also convincing others to

admit that she is right no matter how petty or insignificant the situation. She will go to great

lengths to prove she is right about anything no matter how trivial or petty it is. This is evidenced

by the way Claire’s decision was made to go to counseling in the first place. Claire’s plan was to

endure a few counseling sessions, and then go back to the doctor and make him “eat his words”

once she showed him she still had chest pains and shortness of breath. After all, Claire didn’t

have a psychological problem, rather the ER doctor who must have earned his medical degree by

mail order was the problem.

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Appearance Behavior and Mental Status. All outward appearances display that Claire

is very well put together and in control. She is always nicely dressed in slacks or high-end jeans.

She wears age appropriate blouses, and she is always clean. Her hair is primped with a blonde

weave and nicely styled. She pays attention to detail. Her hands are nicely manicured. Claire

wants to be respected and acts superior to achieve the respect of others. Claire does not go to

church or participate in any organized religion.

History. She attended college, which is where she met her husband. She worked for a

hospitality management company while attending college, and was on track to be very

successful; however, she quit her job and married her husband after discovering she was

pregnant with their first child. Prior to that, she was a wild child. As an adult, she has divorced

herself from her past to hide things so that her three children never know she was not always

straight-laced and perfect, and so that they don’t make the same mistakes she did.

When problem started and how often it happens. Within the last two years, and about

the time that Claire began working for her father’s company, Claire was finding herself more

tightly wired than usual. Coincidentally, this was about the same time that her beautiful

Columbian step-mother was pregnant with her father’s newest son, Claire’s newest step-brother.

Claire developed a slight twitch when things would bother her. She became easily

annoyed with things and always had to “do something” about the annoyances rather than

accepting that sometimes everything is not going to be perfect. An example of this was her

reaction to the drivers who would drive too fast through her neighborhood, which was the

catalyst behind her decision to run for council so she could get a stop sign put up even though

she had never been into politics.

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Family history. Claire grew up in a predominantly white neighborhood. Her father was

the sole provider for the family. She has a gay brother who is 2 years younger. He recently

married his partner. They had adopted a Korean baby girl a few years earlier. Claire has a

strained relationship with her mother because her mother was a “complete control freak” and

“extremely narcissistic”; however, she is willing to try to please her mother because Claire’s

mother seems to like Claire’s brother more than Claire. This bothers Claire to the point of

competing with her brother to get her mother’s attention. When Claire and her younger adult

brother are around their mother, they both regress to act like young children.

According to Claire, her mother is narcissistic, controlling and continually insults Claire

about all her choices, from clothing to her husband. Her mother recently invited Claire’s ex-

boyfriend to have dinner at Claire’s home. During the dinner, her mother made comments about

how the boyfriend would have been a great catch. Claire pointed out to her mother that her

husband was a great catch as he was sitting at the same table with the ex-boyfriend. Claire’s

mother ignored Claire and moved on without acknowledging, which is one of the many ways her

mother is able to push Claire’s buttons.

Claire is close to her father, and they have a very strong relationship, but at times Claire

loses sight of their bond and tends to feel that she needs to compete with her brother to get her

father’s love and attention. Claire is jealous of her father’s young beautiful wife. She feels

threatened because her step-mother is able to turn heads and get all the attention.

Social relationship history. Clair tends to be closer to her family than to non-family

members. She is so competitive that she has acquaintances rather than good friends. She is the

self-appointed event planner of the family, which is natural for her since she worked for a

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hospitality company and would have had a very different lifestyle had she stayed with the

company.

Claire’s former co-worker, who took over her position when she left the firm 21 years

ago is now running their Paris office. Claire feels sorry for her co-worker since her co-worker

does not have a family like Claire. Claire bends over backwards to prove to her former co-

worker that having a family was a way better option than a successful career and being able to

travel around the world; however, just 5 minutes before her co-worker’s visit during which

Claire was planning to show off how much she had, her kids had been cleaning the kitchen and

spilled several bottles of wine all over themselves, made a huge mess of the house in a panic, and

her husband got locked in a porta-potty that was outside the house while they were having some

remodeling done. It was not the ideal clean family image Claire was trying to show her former

co-worker. Incidentally, that visit from her co-worker did precede Claire choosing to go to work

for her father.

Medical history. Claire is generally healthy and takes good care of herself and no

medical issues until her recent scare when she admitted herself to the emergency room

complaining that she was experiencing shortness of breath and chest pains. There were no

medical indications to explain Claire’s symptoms. The ER doctor released Claire with

instructions to see a counselor for her anxiety and excessive drinking.

Counseling history. The client, Claire has never been to a counselor before, but in order

to prove that the ER doctor is an idiot, she agreed to see a counselor. This is her first time seeing

a counselor.

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Circumstances

Claire’s husband has always made the money to support the family, but Claire has always

been in charge of running the household. Everyone in the family was aware they depended on

Claire for all their needs. She made sure all the people in the family were cognizant that she was

indispensable and they were incapable of running the house without her. Once she went to work

for her father’s closet company, she began to see that her husband and kids were able to survive

without her. This realization made her become even more critical of the way things were

handled differently than the way she would have handled them. For example, she got upset with

her husband because he allowed their son to complete his project in his room instead of hovering

over him at the kitchen table. She proved her point when they went upstairs to check on him and

he had a toy out and appeared to be playing. As it turned out, he was using parts from the toy to

finish his project.

Inwardly it bothered her that her husband was doing a fine job taking care of things while

she was at work. At the same time, Claire struggled with her peers at work because she felt they

didn’t think she was good enough for the job and only worked there because she was the boss’

daughter. These realizations made Claire begin to have feelings of inadequacy as a mother, wife,

co-worker, and daughter. Although she kept up her appearance of having it all together, deep

down inside she was feeling insecure. She began drinking as a way of relaxing after work to

curb her anxiety.

Multicultural Considerations

The client, Claire had little exposure to cultural diversity as a child. Claire revealed in

her initial assessment that growing up in a predominantly white neighborhood, she was not

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exposed to the idea of different cultures or the idea of same sex relationships. She lived a typical

suburban lifestyle, went to a white school, her father worked, and her mother stayed home with

the kids.

Once she reached adulthood, everything changed. Her parents divorced, her father

married a Columbian woman, her brother “came out” and announced he was gay, and then he

adopted a Korean child with his domestic partner. Her brother married his partner when gar

marriage became legal. So her entire childhood cultural experience was challenged, but Claire

seemed to take the changes in stride.

Claire accepted her brother’s boyfriend and accepted his being gay; however, she didn’t

embrace it hitting closer to home when her middle daughter was dating a boy with flamboyant

mannerisms and everyone but her daughter could tell he was gay. Claire even asked her brother

and his boyfriend tell Claire’s daughter that her daughter’s new boyfriend was gay. Claire was

quick to point out that it had nothing to do with being homophobic, she just didn’t want her

daughter to fall in love with a boy that wouldn’t be able to fulfill her expectations.

Another cultural dilemma Claire struggled with, was the one-sided competition she

maintained with her step-mother who was only a few years older than Claire. Claire’s jealousy

was based on her beauty and the attention she received, not her Latin heritage. Claire also

exhibited a sibling rivalry with her step-brother that she was not proud of. Claire does not go to

church, but she does have a healthy fear of God.

Claire’s counselor is a half Dominican / half Caucasian woman in her 50’s who also grew

up in a white neighborhood. The counselor’s mother was Irish and her father, a native of

Dominican Republic moved to America as a child. Her counselor attended catholic school, and

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she is a spiritual person but does not believe in organized religion because of her experiences in

Catholic school. She does respect and encourages others’ rights to practice any religion they

believe in as long as it does not cause harm to others. The counselor has many gay relatives and

grew up with a strong Hispanic influence which includes a family who is very open and loving

and non-judgmental of others. Claire’s counselor is able to connect with Claire on a

multicultural level given her own life experiences.

Initial Assessment

The client, Claire presents with anxiety. According to Freud, “anxiety is a feeling of

dread that results from repressed feelings, memories, desires, and experience that emerge to the

surface of awareness.” (Corey, 2009. p. 63)

Hypothesis of Client’s Primary Presenting Problem

Based on Claire’s initial assessment, her anxiety is caused by a desire to prove that she is

perfect, which is an unattainable goal. Her inability to be perfect makes her feel compelled to act

in ways to prove her superiority to others. Claire cannot wrap her mind around people that are

not bothered by the little things in life, like her husband who allowed their son to play with toys

in order to put his project together. Rather, she wants people to be as bothered as she is no

matter how small the issue is, so she tries to make people see things or handle projects the way

she does or would. She also tends to be highly critical of others, and feels compelled to point out

when other people make mistakes as if to show that she would never do something so ludicrous,

like the time she sent her husband to the store to pick up a turkey, and he couldn’t even do that

right. She completely ignored the fact that he did pick up the turkey, but he was robbed at gun

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point while trying to purchase a very rare baseball card as a gift for her father, and the thief took

the cash, the baseball card, and the turkey.

Claire has a difficult time accepting when someone may be right about something, which

in her mind means that she is wrong. She will obsess about proving herself right to the point of

trying to get complete strangers involved with a situation until she alienates them.

Claire’s anxiety has led to occasional binge drinking. She drinks a full bottle by herself

at least 1 to 2 times per week. She is in denial of her binge drinking as evidenced in the way she

claims that she “shared” a bottle or two with her husband - who does not drink.

Goal for Counseling

The first goal for Claire in counseling is to help Claire develop understanding and

acceptance to recognize that nobody, including herself can be perfect, and that means she may

not always be right, and that is okay. By accepting this, Claire can develop skills to help her to

learn to be more self-aware and ultimately relax and enjoy her family without unrealistic

expectations that cannot and will not be achieved. The second goal is to help Claire to cut down

on her binge drinking before it becomes a risk to her health.

Summary of Current Counseling Methods

The basic models or methods currently used in counseling can be categorized into four

approaches; Psychodynamic; Relationship-oriented or Experiential approaches; Action therapies;

and Systems perspective approaches. Each has several disciplines and those each have strengths

as well as limitations.

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Psychodynamic Approaches

The psychodynamic approaches include Psychoanalytic therapy and Adlerian therapy.

Both are based upon early childhood experiences. However there are some key differences.

Psychoanalytic therapy. Sigmund Freud, considered the father of psychoanalysis, grew

up with a very authoritarian father and loving and protective mother in a small apartment with 7

brothers and sisters. With limited income his parents still recognized Freud’s high intellectual

abilities and he was able to go into medicine. He became devoted to formulating and extending

his theory of psychoanalysis. When he was in his 40’s Freud experienced many psychosomatic

disorders, strong fears of dying and other phobias. As a result of his own disorders, he became

involved in the task of self-analysis. He explored the meaning of his dreams and gained insights

into the dynamics of personality development. Examining his childhood memories, he realized

the intense hostility he felt for his father, and childhood sexual feelings for his mother. He

clinically formulated his theory as he observed his own patients work through their problems in

analysis.

The belief of psychoanalysis is that people are determined by their psychic energy

combined with their early experiences. The unconscious plays a heavy role in present behavior.

Irrational forces are strong and people are driven by sexual and aggressive impulses. Revisiting

early childhood experiences are key in discovering later personality problems because these

experiences are so strong they shape future meaning and understanding, and will affect the way

the child handles conflicts as an adult. Freud believed that all habits were cemented into a

person by the time they were 6 years old. He believed that all actions could be explained by a

sexual aggression developed in early childhood.

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Strengths and limitations of psychoanalysis. According to James Hanson in his article

in the Journal of Counseling and Development, when talking about psychoanalysis, the primary

mechanism of healing is interpretation. Interpretation is the verbal intervention designed to

reveal unconscious processes. For example, allowing a client to free associate about anger, the

counselor may offer an interpretation that the anger is defending against a deeper sadness that the

client is trying to avoid. (Hanson, 2009) pp. 186-193. The strength of the analysis is in the

interpretation. If the counselor correctly interprets the stressor, then the client can benefit from

learning ways of coping or dealing with the deep rooted issues. Given this strength, the

limitation is also tied to the interpretation – if the counselor is not equipped to understand the

true underlying issue, and gives an incorrect interpretation, the client could be given the wrong

intervention and therefore no beneficial change would occur.

Adlerian therapy. Once a colleague of Freud, Alfred Adler began to believe that

although Freud’s theories were powerful, he recognized they were circumscribed and he chose to

expand on the theories developed by Freud. Adler believed it was true that humans were shaped

by early childhood experiences; however, he also believed that people were free to make choices

that would change their experience. He did not agree with the theory that everything was hinged

upon early sexual fantasies as Freud concluded. Adler believed there was more to it than that.

As a child, Adler struggled with illness and almost died from pneumonia. He overheard

the doctor tell his parents he was lost. That is when he decided he would become a physician.

Being ill most of his childhood, his mother pampered him, but when his younger brother came

along, she seemed to love his brother more, and he developed feelings of inferiority, not only for

his brother, but also for his peers. He was determined to compensate for his physical limitations

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and over time he was able to overcome them. One of his teachers told Adler’s father that he

would not amount to being more than a shoemaker. Being strong-willed, he did go on to study

medicine. Adler’s theory was shaped by his childhood experiences, and believed rather than

fate, a person could shape their own life.

Adler’s principles were applied in a practical way to help people meet the challenges of

daily life. Adler believed behavior is purposeful and goal-oriented, and consciousness rather

than unconsciousness is the focus of therapy according Schultz & Schultz, in the text by Gerald

Corey Theory and Practice of Counseling and Therapy 8th Edition (Corey, 2009. P 98).

Strengths and limitations of Adlerian Therapy. Adlerian therapy attempts to view the

world from the client’s subjective frame of mind, understanding that not all people experience

the same situation in the same way. This subjective reality, described as “phenomenological”

pays attention to the way people perceive their world as far as their thoughts, feelings, values,

beliefs, convictions, and conclusions. Adlerian perspective gives less importance to objective

reality and more to how we interpret reality and the meaning we attach to what we experience.

This approach has been adopted by many other approaches to therapy and goes to support the

timeless strengths of Adler and his theories (Corey, 2009. P 99). Limitations would be realized

based on the competency of the counselor’s interpretations and application of proper guidance,

or lack thereof, based on the client’s perceptions and not the counselor’s. For example if a

counselor were to use their own phenomenological experiences when deciding on the path used

to treat the client, then the direction of therapy might not be ideal for the client’s needs.

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Relationship-oriented or Experiential Approaches

These approaches are more humanistic than the psychodynamic approaches. Rather than

concentrating on early development, they concentrate on the entire life of the client.

Existential therapy. Viktor Frankl had founded Youth Advisement centers in Vienna

from 1928 to 1938. During this time, he had begun developing an experiential approach to

clinical practice, and he believed the truths expressed by existential philosophers and writers,

including the view that love is the highest goal to which humans can aspire and that our salvation

is through love. Frankl was captured and held as a prisoner from 1942 to 1945 in the Nazi

concentration camps at Auschwitz and Dachau where his family died. That experience deepened

his belief that we have choices in every situation, and even in the most terrible situations we

could preserve a vestige of spiritual freedom and independence of mind. He learned

experientially that everything could be taken from a person except one thing: “the last of human

freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way”

(Frankl, 1963. p.104).

In existential therapy, the central focus is on the human condition and its capacity for

self-awareness. Freedom of choice to decide one’s fate, responsibility, anxiety and a search for

meaning are all part of existential therapy. Being alone as well as being in relation to others,

striving for authenticity, as well as acceptance of living and of dying are all key.

Rollo May was the American proponent of existentialism. He initially studied with Adler

in Greece. He then ended up in a sanitarium for 2 years when he came down with tuberculosis.

During his recovery, he experienced a great deal of anxiety, and spent time studying

Kierkegaard, which brought him to recognizing the existential dimensions of anxiety. His

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existential perspective reflects a concern with the nature of human experience, recognizing and

dealing with power, accepting freedom and responsibility, and discovering one’s identity. He

believed he could help people by helping them discover the meaning of their lives, and helping

them understand they should be concerned with problems of being rather than problem solving,

including issues of sex and intimacy, growing old and facing death.

A major strength of the existential approach is the dramatic way in which Frankl’s

theories were tested through his own tragedies. His life was an illustration of his theory and his

very survival can be attributed to his own approach. Existential therapy is more a way of

thinking than any style of therapy and is best described as a philosophical approach influencing

the counselor’s therapeutic practice. Once clients begin to recognize why they have simply

accepted circumstances and surrendered, they can start on a path of consciously shaping their

own lives. The first step of existential therapy is to get the client to recognize their role in

creating their own life predicament, then they have the power to change that situation.

Person-centered approach. Another humanistic therapy is the person-centered

approach which was originally developed as person-centered therapy and later evolved to include

more than just people, but education, family life, industry, health care, interracial activity, and

international relationships. The focus here is on a view of humans as positive. Carl Rogers is

recognized around the world for originating and developing the humanistic movement in

psychotherapy, pioneering psychotherapy research, writing books on the theory and practice of

psychotherapy and influencing all fields related to the helping professions (Corey. 2009, p. 165).

All humans have an inclination toward becoming fully functioning. The therapeutic goal is to

have the client experience feelings that were previously denied or held in to awareness. The

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client moves toward increased awareness and becomes better equipped to trust in their inner

voice. The ability to trust in self and become spontaneous is the desired outcome for person-

centered therapy. The person-centered approach shares concepts and values with the existential

approach. Roger’s basic assumptions are that people are essentially trustworthy with a potential

to understand themselves and resolve their own problems without direct intervention by the

therapist. Rogers challenged the commonly accepted therapeutic procedures of advice,

suggestion, direction, persuasion, teaching, diagnosis, and interpretation. He based this on his

belief that diagnostic concepts and procedures were often misused – inadequate or prejudicial.

Rogers omitted those procedures from his approach and began a nondirective approach.

Nondirective counselors avoided sharing about themselves, and instead focused on reflecting the

clients’ verbal and nonverbal communications in an effort to help clients become aware of and

gain insight into their feelings. Rogers gave the name client-centered therapy to his approach in

order to emphasize the client rather than the nondirective methods.

The person-centered approach is associated with an understanding, self-exploration, and

improved self-concepts. There is a value to the therapeutic relationship and the client’s

resources as a crux for successful therapy. Person-centered therapy cannot be successful without

the existence of the core conditions required. The attitude of the therapist, including an empathic

understanding of the client’s world, and the ability to communicate a nonjudgmental stance to

the client are basic to successful therapy outcome.

Gestalt therapy. According to Corey, Frederick S (“Fritz”) Perls, joined the German

Army and served as a medic in World War I. His experiences with soldiers who were gassed on

the front lines led to his interest in mental functioning. That led him to develop Gestalt

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psychology (Corey. 2009, p. 198). In Gestalt therapy, the client strives for wholeness through

the integration of thinking, feeling, and behaving. Key concepts in Gestalt therapy include

contact with others and contact boundaries, as well as an awareness. The client is felt to have the

capacity to recognize how earlier influences are related to present difficulties. Gestalt therapy

gives attention to existence as individuals experience it and affirms the human capacity for

growth and healing. This is achieved through interpersonal contact and insight (Yontef, 1995).

Gestalt therapy focuses on: the here and now; the what and how; and the I/Thou of

relating. (Brown, 2007; Yontef & Jacobs, 2008). Today, most therapists who practice Gestalt

therapy use a style that is supportive, accepting, empathic, dialogical, and challenging. The

emphasis is on the quality of the therapist-client relationship and empathic attunement while

utilizing the client’s wisdom and resources (Cain, 2002).

Fritz Perls was influenced by psychoanalytic concepts; however, he disagreed with

Freud’s views on many grounds. Rather than focusing on repressed intrapsychic conflicts from

early childhood, Perls relied on examining the present situation. The Gestalt approach focuses

on the process rather than on content. Gestalt therapists developed experiments to increase

clients’ awareness of what they are doing and how they are doing it. The belief is that

understanding how people behave is more crucial to self-understanding than why they behave as

they do. Gestalt therapy includes exercises to help the client experience rather than talk about

situations. Role playing between the Gestalt practitioner and the client results in client growth.

For example the practitioner will play the role of the client’s parent. The client is instructed to

tell their “parent” the things they have been afraid to say. With practice, the client becomes less

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anxious about having the conversation with their own true parent. Thus helping the client to

grow and to stand on their own feet and to deal with their own problems.

Limitations of the person-centered and experiential approaches. There is a similar

limitation shared by both the person-centered and existential approaches as far as the

accountability as there is little empirical evidence within these fields proving their success.

Neither modality emphasizes a role of techniques aimed at bringing a change in the client’s

behavior.

A major limitation of the person-centered approach is that some practitioners tend to be

too supportive and don’t challenge their clients. They misunderstand the basic concepts and

have limited their range of responses and counseling styles to reflections of understanding and

empathic listening. It is important in the person-centered approach to listen and understand, but

it is equally important to develop the skills for therapeutic interventions as well. Person-centered

counselors can sometimes find it difficult allowing their client to decide his or her own goals in

therapy. It is hard to encourage a client to make their own choices when the choices they make

are not necessarily the choices the therapist was hoping they would make.

A limitation with the experiential approach is a reflection of the therapist’s personal

limitations. According to Bohart’s perspective the therapeutic relationship is so important to the

outcome, the therapist can be responsible for “failing to be warm, empathic, and genuine;

imposing an agenda on the client; or failing to be in touch with the moment-by-moment

process”. (Bohart, 2003. p 126).

The limitation with existential therapy is the circumspection that can be imposed on the

self by the client or the client’s inability to let go to the pain. It is difficult because according to

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May, it takes courage to “be,” and our choices determine the kind of person we become. There

is a constant struggle within us. Although we want to grow toward maturity and independence,

we realize that is often a painful process. Therefore, the struggle is between the security of

dependence that delights and the pains of growth. (May, Angel, & Ellenberger, 1958.)

Existentialists are often criticized for being too individualistic and ignoring social factors that

cause human problems. Frustration and feelings of powerlessness may occur as the client

determines they can only change themselves, and not the world around them.

Like other existential and humanistic approaches, Gestalt therapy has its own limitations.

The main criticism found with Gestalt therapy is the approach does not place enough emphasis

on the role of the therapist as a teacher. Rather the emphasis is on facilitating the clients’ own

process of self-discovery. For this therapy to be effective, the therapist should have a high level

of personal development, making sure the needs of the therapist are not interfering with the

client’s process. During role play exercises, the therapist needs to be in the moment, non-

defensive and self-revealing. If inadequately trained, a Gestalt therapist may become more

concerned with impressing the client than helping them with the process. To be competent in

Gestalt therapy, the practitioner must have engaged in their own personal therapy and have

advanced clinical training and supervised experience. (Corey, 2009).

Action therapies

The action therapy models require homework on the part of the client. They are geared

toward helping the client to develop the tools needed to deal with daily routines and their

interpersonal relationships. These tools will help the client to lead a productive life and

subsequently create healthy relationships.

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Behavior therapy. B.F. Skinner is considered the father of the behavioral approach to

psychology. Skinner didn’t believe humans had free choice, he was a determinist. He

acknowledged that feelings and thoughts existed, but didn’t believe they caused our actions.

Rather, he stressed cause-and-effect links between objective, observable environmental

conditions and behavior. He believed too much emphasis was put on the internal states of mind

and motives like things that could not be seen or changed directly, and too little emphasis was

placed on the environmental factors that could be observed and changed. Skinner believed

science and technology held the promise for a better future. He applied that to his own life

through reinforcement. For example, after working many hours, he would go into a cocoon (like

a self-constructed tent) and listen to classical music through headphones. (Corey, 2009, p.233).

Behavior therapy focused on behavioral conditioning techniques as a viable alternative to

psychoanalytic therapy. Classical conditioning refers to what happens before learning that

creates a pairing effect. The well-known Pavlovian response is a perfect example of classical

conditioning. A bell sound by itself would typically have no effect on Pavlov’s dogs, however

Pavlov gave the dogs food, they salivated, and then he rang a bell. Each time he put food in the

dogs’ mouths, he rang the bell. Eventually the sound of the bell without the presence of food

created the same effect as providing the food. The dogs salivated. Pavlov conditioned the dogs

to have a physical reaction to the sound of the bell.

Cognitive behavior therapy CBT / Rational emotive behavior therapy REBT. In

spite of being the subject of harsh criticism and resistance from psychoanalytic psychotherapists

when it was introduced in the 1950s, the field of behavioral therapy has continued to grow and

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branch out to include such therapies as Cognitive Behavior Therapy (CBT) and Rational

Emotive Behavior Therapy (REBT).

CBT, considered the second wave of behavioral therapies, combined behavioral and

cognitive therapies. Albert Bandera developed social learning theory by combining classical and

operant conditioning with observational learning. Operant conditioning is a type of learning that

induces behaviors based on the consequences that follow the behavior. If the consequences are

gratifying, then the behavior will likely be repeated. If however, the consequences are

unpleasant, then the behavior will be less likely reproduced. Bandera made cognition a

legitimate focus for behavior therapy.

Eventually, the third wave of behavior therapies was developed. REBT broadened the

scope of CBT to include dialectical behavior therapy, mindfulness-based stress reduction,

mindfulness-based cognitive therapy, and acceptance and commitment therapy. Operant

conditioning and observational learning were combined to develop social learning theory.

Faulty thinking tends to be incorporated into the decisions which lead to emotional or

behavioral disturbances. In the action therapies, the therapists conduct a behavioral analysis to

determine what types of situations precede certain actions or behaviors. For example a client

having difficulty sleeping may do well with relaxation tapes. By identifying consequences that

will either increase or decrease a behavior through this assessment, a therapist is able to help the

client gain insights and attain the goals of therapy through recognizing what behaviors can be

altered and in what ways. Behaviorally oriented practitioners are great problem solvers and act

as consultants.

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Reality therapy. Based on choice theory, this approach assumes we need quality

relationships to thrive. Reality therapy is a short term approach focusing on the client learning to

accept responsibility for the outcomes they create by their actions.

Exposure therapy. Eye movement desensitization and reprocessing (EMDR) is a form

of exposure therapy. It involves cognitive restructuring and the use of rapid, rhythmic eye

movements or other stimulation to treat clients who have experienced traumatic stress. (Shapiro,

2001). Because this therapy can bring intense reactions from the client, it is paramount that the

therapist have proper training and experience to safely and effectively administer EMDR.

Limitations of the Action Theories. A challenge that behavioral therapists face is the

ability to develop empirically based recommendations for how behavior therapy can be

beneficial to culturally diverse clients. According to Corey in the text, Spiegler and Guevremont

point out that although behavior therapy is sensitive to differences among clients in a broad

sense, it is not so obvious with specific issues pertaining to diversity. Race, gender, ethnicity,

and sexual orientation variables do influence the process and outcome of therapy. Therapists

need to be aware of the cultural differences and how they affect the client individually. (Corey,

2009, p. 260). Additionally, when clients make significant personal changes, it can affect the

people in their environment. Therapists must discuss how these changes may affect the client

before goals for therapy are determined. The client will need assistance in assessing the potential

consequences of attaining their goals. Once therapy is underway, the client must have

opportunities to talk about any concerns or issues created as a result of the client’s

transformation. Failure of a therapist to recognize and identify problems in the client’s

environment could cause harm to the client.

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Systems perspective models

Feminist therapy. This approach was developed by the efforts of many women. The

main focus is a sincere concern for the psychological oppression of women as well as the

constraints the sociopolitical status of women has created. The therapist must intervene with

some sort of social action. Feminist therapy is not just for women, the feminist perspective uses

an approach to understanding the roles that have been delegated to women and men, and the

social acceptance thereby created, then challenges those beliefs in therapy. The feminist

therapist will address how socialization of women affects identity development, self-concept,

goals, aspirations, and emotional well-being. (Belensky, Clinchy, Goldberger, & Tarule,

1987/1997; Gilligan, 1982). According to Natalie Rogers, socialization patterns tend to result in

women not realizing that they are giving away their power in relationships. (Rogers, 1995).

Family systems therapy. In family therapy, the basic assumption is that to help the

individual, it is critical to consider her within the family system. The client’s problematic

behavior develops from the interactional unit of the family and the larger community and society

as a whole. The focus on family therapy is usually on a specific problematic symptom. It is for

that reason that family therapy is typically short-term, solution-focused, and action-oriented.

The goal of family therapy is generally to use interventions to enable individuals and the family

to change in ways that will reduce their distress.

The therapist will focus on perceptual and cognitive change; or they may deal mainly

with changing feelings; or the therapist may emphasize behavioral change. The goal being to

emphasize the change with the relationships, not just the individual for whom the therapy was

originally initiated.

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Limitations of systems perspective approaches. Feminist therapists are value oriented,

which should be a good thing; however, they do not take a neutral stance and could influence

their clients with their own agenda. It is imperative the feminist therapist allows the client to

reach their own conclusions. Similarly, in family therapy, the therapist has to be aware of his or

her own values and monitor how those values may influence the family in therapy.

Theoretical Models: Review and Orientation

Three applicable theoretical models are presented; strengths, and limitations of models

are addressed and thoroughly analyzed (14 points possible this portion)

Review of applicable theoretical models

Claire’s counselor considered three different counseling approaches and weighed out the

strengths and limitations of each theory before determining the approach with which the

counselor believed she could best help Claire attain her therapeutic goals.

Existential therapy. Existential therapy is described as a philosophical approach that

influences a counselor’s therapeutic practice. The belief is that being free to make choices and

choose our actions, we are also responsible for those choices and for our actions. As humans, we

design our own pathways we choose to follow. The aim of existential therapy is to encourage

clients to reflect on life, recognize their range of alternatives available, and to realize we are not

victims of our circumstances, rather we are authors of our lives.

In existential therapy, the task is to encourage clients to explore their options for creating

a meaningful existence. Seeking a balance between recognizing the limits and tragic dimension

of human existence on one hand and the possibilities and opportunities of human life of the other

hand is the existential tradition. (Corey, 2009). The counseling profession has placed a high

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value on the construct of self-awareness (Hansen, 2009). Self-awareness includes awareness of

alternatives, motivations, influencers, and personal goals. Sometimes a client is blissfully

ignorant until the self-awareness opens the doors onto his or her world. When that happens, a

client can experience turmoil before coming to experience a more fulfilling life. Existential guilt

can occur when a person has a sense of incompleteness. The guilt comes from evading a

commitment, or choosing not to choose. Assuming responsibility is a basic condition for

change. According to Russell (1978), we create our own destiny, our life situation, and our

problems. Clients who refuse to accept responsibility by persistently blaming others for their

problems will not benefit from existential therapy.

The two central tasks an existential therapist must perform to help a client who feels he or

she has lost control of his or her life are inviting the client to recognize they have allowed others

to decide for them, and encouraging them to take steps toward choosing for themselves. The

counselor might make a statement for the client to consider, “Although you have lived a certain

pattern, you have now discovered what it costs you. Are you willing to consider creating a

different pattern?” The therapist must respect the client and why they came to therapy.

A strength found with existential therapy is the discovery of new courses of action that a

client can choose that will lead to a change in their situation. A limitation within existential

therapy is that a client may have difficulties when adjusting to a new set of values once the client

releases their old values and way of thinking. There can be a time the client experiences more

anxiety from the uncertainties of not having a new set of values that are clear. The client is

expected to go out in the world outside of therapy and decide how they will live differently, and

if the therapist doesn’t properly prepare the client, it can be overwhelming to the client.

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Reality therapy. Many military clinics that treat alcohol abusers rely on reality therapy

as a preferred therapy. According to Corey, reality therapists believe the underlying problem of

most clients revolve around an unsatisfying relationship. The inability to connect, or get close to

others, or to have a successful relationship with at least one significant person in their lives.

(Corey. 2009, p. 316). Very few of the clients realize their problem is the way they are choosing

to behave. Clients usually find themselves feeling pain or anguish because they have been told

to seek therapy by someone of authority. In Claire’s case, that would be the emergency room

doctor. In other cases, it could be a court official, a school administrator, or a parent.

In reality therapy, the belief is clients choose their behaviors as a way to deal with the

frustrations they experience due to unsatisfying relationships. It is essential for this reason that

the reality therapist develop a satisfying relationship with the client. Once this occurs, the

therapist then becomes a teacher. The reality therapist teaches the concept of choice therapy to

help clients identify the needs they need to try to satisfy. Choice theory posits everybody has

five needs, just in different amounts. The needs that drive us all our lives are: survival; love and

belonging; power or achievement; freedom or independence; and fun.

In the case of Claire, she had stopped having fun to get married and raise her children.

She also lacked a feeling of power or achievement when she found out her former co-worker

went on to run the Paris office after she left her successful job to get married when she

discovered she was pregnant. She had also lost her freedom and independence as she suddenly

woke up and found herself a stay at home mother of three. Glasser believed the need to love and

belong was the primary need because we all need people to satisfy our other needs. (Corey,

2009. p. 317).

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Choice theory teaches that people don’t satisfy the basic needs on their own, rather the

people in their lives do. The reality therapist is charged with being the kind of person that clients

would consider including in their quality world. The world that would have all their needs met

in the right proportions. Once the therapist is able to break through and enter the client’s quality

world, the client can begin to learn how to interact with and get close to the people they need.

Choice theory changes the focus of responsibility to choice and choosing. Therefore the

reality therapist will deal with clients as if they have choices. The therapist will also have the

client use descriptions of feelings as parts of the total behavior, for example, rather than saying

the client is depressed or is being anxious, implying a lack of personal responsibility, the

therapist says it is more accurate to use verb forms such as “depressing,” “headaching,” and

“anxietying” to describe the client’s feelings. That way the client is more able to see it is a

choice, and that the client chooses misery by developing a range of “paining” behaviors. It is

true the client doesn’t choose the behavior, instead it is the unchosen part of their total behavior.

It’s the client’s effort to satisfy needs by displaying the behavior they believe will get them what

they need.

The reality therapist will ask the client to consider how their choices are affecting their

relationships and whether the choices they make are effective. Once the client learns how to

make choices that give better consequences, the client begins to feel better about themselves

resulting in less ineffective and self-destructive behaviors.

Practicing reality therapy utilizes two major components: 1) creating the counseling

environment; and 2) implementing specific procedures that lead to changes in behavior. When

the client is motivated to change, then change will occur. Wubbolding (2007b) uses the WDEP

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system to help clients explore their: Wants or Needs; Direction or Doing; self-Evaluation; and

Planning. The WDEP system gives clients a map to follow to plan based on their self-evaluation

what they need to do or which direction to take to get what they need or want.

The strength of the reality therapy is the power the client gets from realizing they have

control of their actions. Barriers to a satisfying life disappear once the client understands they

have choices. The limitation of reality therapy is that it may not take into account the external

forces affecting the client that operate against them in their daily lives. Some forces outside the

client’s control may get in the way of what they want. It is important while the therapist is

teaching the client they have choices, that the therapist not discount those unfortunate

circumstances that can’t be changed, like racism or discrimination which do exist.

Rational Emotive Behavioral Therapy (REBT). One of the first cognitive behavioral

approaches, REBT provides clients with the tools to restructure their philosophical and

behavioral styles. (Ellis, 2001b; & Blau, 1998). According to Ellis, believed to be the parent of

today’s cognitive behavioral approaches, REBT is based on the assumption of a cause-and-effect

relationship between cognitions, emotions, and behaviors which all interact significantly.

Because all three modalities and their interactions are consistently emphasized, REBT qualifies

as an integrative approach.

Ellis was inspired by the ancient Greeks, including Epictetus, the philosopher who said

“People are disturbed not by events, but by the views which they take of them” (as cited in Ellis,

2001a, p. 16). Adlerian theory had a big influence in his developing REBT, which is evident

when recognizing the importance of goals, purposes, values and meanings in the human

experience. The belief within REBT is that our emotions stem from our beliefs, evaluations,

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interpretations, and subsequent reactions to life situations. The client in REBT therapy learns the

skills needed to identify and dispute irrational beliefs that have been acquired and self-

constructed and are maintained by self-indoctrination.

The focus is on working with thinking and acting, rather than with expressing feelings.

Therapy is educational. The therapist collaborates with the client like a teacher with a student.

The therapist assigns homework, like keeping track of absolutist thoughts, or applying the A-B-C

model to everyday situations. She or he teaches strategies for straight thinking. Straight

thinking is the same as rational thought; contrary to straight thinking is crooked thinking or

irrational thought. The idea is that humans are predisposed for self-preservation, happiness,

thinking and verbalizing, loving and communion with others, and self-actualization. According

to Corey, humans also have propensities for self-destructive behaviors, like avoidance of

thought, procrastination, perfectionism and self-blame, and intolerance. Ellis believed that to

recover from a neurosis or personality disorder, we need to stop blaming ourselves and others,

and we need to learn to accept ourselves in spite of our imperfections. REBT teaches humans it

is acceptable to be imperfect, and that we as humans will continue making mistakes, so we need

to learn to live with our true selves and be more at peace.

REBT therapy would help clients like Claire who are obsessed with being perfect or

appearing to be perfect at all times. REBT helps clients find ways of overcoming unhealthy

feelings of depression, anxiety, hurt, and loss of self-worth, by learning that healthy feelings of

sadness over being unaccepted are normal and should be embraced. REBT teaches clients to

avoid irrational beliefs, like “I must do well or I am no good.” or “Other people must treat me the

way I want them to treat me, or they are no good.” or “I must get what I want; and I must not get

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what I don’t want. If I don’t get what I want, it’s terrible, and I can’t stand it.” Statements like

these are forms of internalizing that will lead to self-defeat. By learning to avoid, “Must, or bad”

thinking, the client can achieve and maintain good psychological health.

The REBT theory model has a tool for understanding the client’s feelings, thoughts,

events, and behavior. The tool is the A-B-C framework. According to Wolfe, “A” represents the

existing of a fact or activating event, or the behavior or attitude of the individual. “C” is the

emotional or behavioral consequence. Finally, “B” is the person’s belief about “A,” which

causes “C,” the emotional reaction. (Wolfe, 2007). The REBT uses D-E-F to change the

framework. “D” is the disputing intervention, or the challenge to dispute or debate the

dysfunctional beliefs. In order to do this, the client has to learn to recognize the absolutist

“must” “should” and their “self-downing” behavior, and then debate it with logical and empirical

questions to argue themselves out of the absolutist thoughts. “E" is the effect, eventually after

the client learns to critically think about things, the client will arrive at effective philosophy – a

new and effective belief system which will bring on “F,” a new feeling. The client will begin to

feel healthier emotionally.

In REBT the client learns critical thinking. Through critical thinking, the client becomes

better equipped to question the irrational thoughts and feelings with rational thoughts and

feelings. Clients learn that even though life is not always pleasant or exactly as they wanted it to

be, it can still be bearable. Because REBT is a cognitive and directive behavioral process, the

client and therapist don’t typically have an intense relationship as with some of the other

therapies. Like the person-centered therapy of Carl Rogers, the REBT therapists accept all

clients and don’t judge, and teach them to also accept others and themselves unconditionally.

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REBT therapists are usually open and direct with their clients in order to refrain from

allowing the client to become too dependent on the therapist. According to Corey, Wolfe

maintained the importance of an egalitarian relationship between therapist and client rather than

the therapist coming out as a non-disclosing authority figure. (Corey, 2009, p. 281).

The strength of REBT and other Cognitive therapies is the integration with

psychotherapy as well as its credibility proven though empirical testing. The limitation of the

REBT therapy lies within the abilities of the practitioner, and the level of training, knowledge,

skill and perceptiveness they display. The practitioner must be active, structured and have the

ability to teach life skills. The REBT practitioner who is not effective can harm the client.

Counselor’s theoretical orientation

Many of Claire’s problems were identified though the functional assessment.

Behaviorally, Claire has a drinking problem, which is occasional binge drinking. Emotionally,

Claire experiences anxiety. She feels alienated at her job. Cognitively, she worries that she

won’t be good enough, evidenced by the way she feels like her peers at work talk about her

behind her back, and she uses self-defeating thoughts, and uses broad generalizations, such as

“shoulds,” “oughts,” and “musts.”

The counselor is goal oriented and problem focused, and she subscribes to a multimodal

therapy approach. Multimodal therapy is a clinical behavior therapy that is grounded in social

learning and cognitive theory. It is an open system employing an eclectic approach with

techniques from various principles of behavior therapy, cognitive behavior therapy (CBT), and

REBT. To be successful, the counselor must be versatile and flexible and able to adjust her

procedures when needed in order to meet Claire’s goals through therapy.

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The counselor believes that with proper therapeutic interventions and training, Claire can

modify her absolutist thoughts “musts,” “shoulds,” and “oughts,” as well as learn ways to

recognize and recalibrate her self-defeating self-talks, thus training herself to identify signals that

she may be slipping back to such injurious behavior once she is no longer in therapy.

Because this was Claire’s first experience with counseling, the counselor was mindful

about explaining the therapy process to Claire. She also explained about informed consent laws

and how Claire has the right to be informed about her therapy and make autonomous decisions

about it.

She told Claire about potential factors that could create an unhealthy dependency on the

therapist and how they will be able to work together to attain the counseling goals without that

kind of dependency. The counselor explained to Claire that they are partners in the relationship,

and that Claire is in charge of designing her goals, but that the counselor will help her evaluate

and fully understand what those goals mean to her and how they may affect her when she is

successful.

The counselor conducted a thorough behavioral analysis after the assessment interview,

to identify the conditions causing Claire’s problems by gathering information about the

situational antecedents, meaning those events that preceded Claire’s most anxious moments; the

dimensions of the problem behaviors; as well as the consequences of the problem, from the A-B-

C model previously discussed. The counselor then focused on helping Claire define those areas

she would like to make changes, while helping Claire understand how her attitudes affect her

behaviors. Claire admitted to the counselor that she didn’t want to have self-defeating behaviors

or anxiety, and she didn’t like the way her family made her feel bad when she drank alone.

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The therapist then introduced behavioral skills training to help Claire in dealing with her

peers at work. She models what Claire should try, they then role play, and then they rehearse

multiple times. The counselor has built a rapport and trust with Claire. The counselor tells

Claire she wants her to try the therapy “en vivo,” which means in life – or outside of the

therapist’s office. Claire trusts her counselor when she said she is ready, and begins to feel as

though she is ready. She practices the skills she learned in various situations at the office, with

family, and at the store.

Claire has learned skills to help her cope better, and eliminated self-defeating self-talk,

she reduced her anxiety after just a few months of therapy. With less anxiety Claire no longer

drinks bottles of wine by herself. She only drinks in moderation, and never more than one glass

in an evening. She no longer felt a need to go back to the emergency room and tell the ER

doctor he was wrong, instead, she went back to thank him for opening her eyes.

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Belenky, M., Clinchy, B., Goldberger, N., & Tarule, J. (1997). Women’s ways of knowing: The

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Ellis, A. (2001a). Feeling better, getting better, and staying better. Atascadero, CA: Impact.

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