Abstract
A theoretical framework helps therapists gain an understanding and interpretation of what may be happening for the client. This paper demonstrates my understanding and application of two theories to conceptualize a case study. Lastly, I summarize how these theories could benefit the client.
Case Formulation “Theories provide therapists with concepts that allow them to think systematically about human development” (Jones-Nelson, 2011, p. 8). Theories are particularly important for therapists as they provide a framework for helping the client. It helps to support therapists on how to think about a client’s behavior, how to treat them and how to respond to them during the sessions (Jones-Nelson, 2011). Summary of Case I selected the case formulation of Kasey, the 25 year old woman who has concerns about her Generalized Anxiety Disorder. I selected this case because it provides me with insight on how family dynamics and psychological vulnerabilities influence the development of anxiety disorders. Secondly, as a marriage, couple and family therapist in training, it is helpful to have knowledge of family systems and how these systems may affect the individual. Cognitive Theory The first theory that I will be applying in the case formulation of Kasey is cognitive therapy, developed by Aaron Beck. The cognitive therapy is structured, short-term, present-centered, problem-orientated, collaborative, directed at solving current problems and most importantly modifying dysfunctional thinking and behavior (Beck, 2011 & Corey, 2009). Cognitive therapy identifies psychological problems originating from natural courses such as faulty thinking, and failing to differentiate between reality and fantasy (Corey, 2009). It is an insight-orientated therapy, focusing on recognizing and changing self-defeating thoughts and maladaptive beliefs (Beck, 2011). Automatic thoughts is the key concept in Beck’s cognitive psychotherapy and plays a significant part in our thinking processes, and reflects underlying beliefs that we have about ourselves and the world. (Beck, 2011). Beck emphasized the importance of teaching clients to identify these dysfunctional thoughts and beliefs through a process of evaluation. After gaining an insight into their negative thoughts through a process of guided discovery (socratic questioning), it helps leads to clients feeling better emotionally, and to behave more functionally (Beck, 2011 & Corey, 2009). The treatment of clients emphasizes present problems, however discussing developmental history and childhood beliefs are just as relevant in order to identify schemas that cause distress and difficulties in the individual’s lives. There are two cognitive schemas that can influence an individual’s thoughts and behaviors: adaptive and maladaptive. (Beck, 2011). Client’s Presenting Problem The client has concerns around her diagnosis of Generalized Anxiety Disorder. It seems that her antidepressants are ineffective for treating her infrequent panic attacks and her generalized anxiety The Problem Based on Cognitive Therapy Based on the cognitive theory, it seems that the Generalized Anxiety Disorder is a result from Kasey’s childhood experiences. Kasey has internalized negative messages about herself. From a young age, she looked after her brother and questioned her competence and how she handled things. This is evident from her mother’s comments that “you should be able to handle these things”. I think Kasey, trying to fit a certain mold to serve her parents rather than her parents developing her sense of self, may have influenced her faulty thinking and self-doubt. Kasey states that she is afraid that she is not “smart enough” for graduate school. Another early childhood experience that may contribute to Kasey’s problem is the past abuse by her biological father and possibly tentative abuse by her brother. It seems that the altercation between her stepfather and brother triggered an extreme physical reaction. Therapeutic Relationship in Cognitive Therapy In cognitive therapy, establishing core conditions of listening and being empathetic is necessary for the development of the therapeutic relationship (Corey, 2009). It is essential that the relationship between the therapist and client is collaborative. They must work together to determine goals, homework assignments, developing and maintaining new strategies of success. (Sharf, 2016). The primary goal of cognitive therapy is to change the client’s old schemas and create new schemas. It is important that the therapist be sensitive and work towards building rapport and trust, as the client may have negative schematic beliefs about trust and relationships (Beck, 2011, Corey, 2009 & Sharf, 2016). Client’s Schemas Schemas are developed in childhood. These beliefs have been formed by the interaction between the family members. It is from these experiences and perceptions that mold the schemas and has an influence on the individual’s thoughts, feelings and behavior, particularly within the family (Beck, 2011 & Corey, 2009). In the case of Kasey, it seems that she may have had the feelings, experiences and perceptions of being unsupported, misunderstood, incompetent, lonely and perhaps victimized by her brother. This is evident from the experience of looking after her brother and how her parents responded when Kasey looked for support. The cognitive distortions that Kasey may experience due to her thought processes and schemas may be all or nothing thinking, where she may think “I’m not good enough”, or “I don’t have any strengths”. Labeling, another cognitive distortion is an extreme form of all-or-nothing thinking. She may have attached a negative label to herself. “I’m not smart”, or “I’m inadequate”. A cognitive distortion of personalization or blame, as Kasey may hold herself personally responsible for her brother’s behavior and perhaps her conflicted relationship with her parents (Beck, 2011). Therapeutic Techniques in Cognitive Therapy Developing new schemas is an important cognitive process for Kasey as her current schemas may include statements like “I am incompetent”, or “I can’t seem to do anything right”. I would attempt to change Kasey’s schemas by reinterpreting the meaning of previous experiences. Part of this process involves Kasey recognizing the automatic thoughts that have been derived from her core beliefs. It is important for Kasey to realize that these thoughts are distorted (Beck, 2011). These can be replaced with new functional beliefs such as ‘I can do this”, and “I am good enough”. By introducing new schemas, Kasey will be able to insert her new belief in place of the dysfunctional one. Learning and implementing these new schemas and illuminating negative thoughts are important when Kasey applies them within her family environment (Beck, 2011). From formulating Kasey’s case, it sounds like she has difficulty making decisions. It may be helpful to ask Kasey to list the advantages and disadvantages of each option and help her to draw a conclusion about which choice seems best. This technique will help increase her confidence in making decisions and help her move away from an all-or-none situation (Beck, 2011). Another cognitive technique that may be beneficial for Kasey is cognitive rehearsal. I would work collaboratively to find ways in which a certain problem can be handled. By “rehearsing” ways of dealing with a particular situation, Kasey will be better equipped for when such situations should arise (Sharf, 2016). Advantages and Disadvantages Technique Dialogue COUNSELOR: Kasey you mentioned last week that you wanted to get help in deciding whether to get a teaching certificate or study history at graduate school. KASEY: Yes COUNSELOR: How about we write a list weighing the advantages and disadvantages. Have you ever done that before? KASEY: No, I have kind of thought about it though. COUNSELOR: Great! I think that once you start writing them down your choice of either graduate school or teaching will be made clearer. Which one shall we start with graduate school or teaching certificate? KASEY: I think teaching certificate. COUNSELOR: Good. Let’s write “advantages of teaching certificate” on the left and “disadvantages of teaching certificate” on the right. On another piece of paper write “advantages of studying history at graduate school” and “disadvantages of studying history at graduate school”. Once we have completed our list we can look at scaling the most important choice from 1-10. One being the most important. KASEY: Okay COUNSELOR: You mentioned that you have already had some thoughts about obtaining a teaching certificate. What have you been thinking? KASEY: Well, if I start the teaching certificate I will be able to move out on my own and start earning some proper money. COUNSELOR: Great, so you can write that in the advantages list. Is teaching history to children something that you might enjoy? KASEY: Yeah, I think so. COUNSELOR: Good! Write that one down in the advantages list. Can you think of another advantage for obtaining a teaching certificate? Formulation Two Reality Therapy The second theory that I will be using to help formulate the case of Kasey is reality therapy, developed by the work of William Glasser. It focuses on human conditions rather than a mental illness, and encourages individuals to control their behavior, to help them make more effective choices in their lives (Bradley, 2014 & Lujan, 2015). Reality therapy focuses on the individual’s current issues and the future rather than what the individual has experienced in the past. It is based on the idea that people experience mental distress when their basic psychological needs have not been met. There are five basic psychological needs: survival, love, and belonging, power, freedom and fun (Bradley, 2014, & Lujan, 2015). Glasser claims that the need for love and belonging is the most important need as humans are social creatures both needing to receive and provide love (Bradley, 2014 & Lujan, 2015). It is the therapist’s responsibility to help the individual prioritize needs, this is based on choice theory. Individuals develop a mental “quality world”. This quality world contains specific images of people, objects, ideas and beliefs that help fulfill their needs. It is a unique picture of perfection (Lujan, 2015). When understanding total behavior in the perspective of reality therapy, four components work together towards understanding an individual’s experience of happiness: thinking, feeling, acting and physiology. The important concept of changing behaviors encourages the individuals to focus on changing their thinking and acting in order to change feelings and physiological reactions (Lujan, 2015). The main focus of reality therapy is on addressing the issues of unsatisfying relationships, which is often the source of the client’s problems and behaviors. Instead of blaming and finding fault, the individual has to consider their own choices and behavior. Client’s Problem Based on Reality Therapy From the reality therapy and choice theory perspective, Kasey is choosing her behavior of anxiety and panic attacks. Glasser believed that psychological problems are the results of a person’s inability to fulfill one’s basic needs of love and belonging, power, freedom, survival and fun (Lujan, 2015). Kasey seeks love and belonging from her family. She wants her mother to love her unconditionally and to accept her regardless of what religion she adheres to. She may also seek freedom, desiring independence. Kasey describes about not wanting to attend church and her parents threatening her. She would possibly like to fulfill the need of power, so that she is able to survive her brother’s “bad temper” without having a migraine or a near panic attack. “When the individual perceive themselves as stronger in interacting with others, they feel safe and happy” (Lujan, 2015, p.18). Reality Therapy Therapeutic Relationship The main focus of reality therapy is to address the problems concerning unsatisfactory relationships. The therapist must be able to make a connection with the client. This is important for the learning process on how to establish and maintain better relationships. The therapist helps the client to create goals in order to make behavioral changes (Bradley, 2014). To make a connection with the client, the therapist must have certain qualities, such as empathy, positive regard, able to use humor and to engage the client with hope and positivity. The emphasis in reality therapy is the investigation of the client’s needs, wants and perceptions. It is important that under the therapeutic direction the client stays on task, focuses on present behaviors and does not explore past events. The basis of the therapeutic relationship is to help the client gain a deep understanding of their current behavior and their relationships, to implement for future problems (Bradley, 2014). Thinking, Feeling and Physiology Glasser uses the term ‘total behavior to describe his concept of behavior. There are four components that make up ‘total behaviors’ these are: thinking, feeling, doing and physiology. All four components are occurring all the time (Lujan, 2015). Kasey’s doing component of the total behaviors is not active like running or walking. Her thinking component may be fantasizing or reasoning about her relationship with her parents. Kasey may be feeling depressive or anxious, which may cause her to experience headaches and shallow breathing. If Kasey was to change her doing behavior, to taking a brisk walk, it may likely change her thinking, which will in turn change her feelings and physiology. Three Treatment Strategies Reality therapy techniques will help focus Kasey on changing her actions and thoughts. Questioning using the wants, direction, evaluation and plan (WDEP) system will help Kasey to explore her wants, determine direction behaviors, conduct self-evaluations and plan for change. With skilful questioning, I would encourage Kasey to explore her picture quality world, and how they fulfill her needs and wants. The direction emphasizes the overall direction of Kasey’s life and where her behavior appears to be taking her. I would encourage Kasey to change what she is doing and thinking, not just how she is feeling. Having Kasey evaluate her behavior will help her focus on her desired direction. After Kasey has decided what she wants to change in her life then a plan of action is formulated to replace old behaviors and integrate new behaviors. (Bradley, 2014). The expected outcome of this strategy of questioning within the WDEP framework, will enable Kasey to evaluate her situation with a better perspective of themselves, and can make more desirable choices for her needs. Another technique that I would use as Kasey’s counselor would be to stay focused on reinforcing the positives of what she can and has achieved. By emphasizing Kasey’s positive actions, the expected outcome is she will gain strength, hope and self-esteem through the acknowledgement of positive behavior. The final technique that I would implement with Kasey would be confrontation. Although this technique involves direct confrontation, empathy and encouragement are used. Providing confidence in the client’s ability to think and act will direct them to their quality world. The expected outcome of this strategy would be that Kasey would increase her level of awareness, so that she would be motivated to change her thoughts and behaviors. Choices According to reality therapy, Kasey is making the choice to anxietize. She is keeping her anger under control. Perhaps she is angry for having to look after her brother who has a “bad temper”. Kasey is making the choice of not participating in any positive addictions, such as running or meditation. Without any positive addictions Kasey, may experience low energy and self-esteem. She is also choosing to think that she is not smart enough, helping her to avoid what she is afraid of doing, which is studying history at graduate school. Technique of Questioning Within the WDEP System The following is an example of the type of questioning used within the WDEP system COUNSELOR: Kasey, What do you want from your relationship with your mother? KASEY: Well, I want her to acknowledge that I was right about Jason. He has always had a bad temper. I constantly told my mum when Jason was young that he had a bad temper and she never believed me. COUNSELOR: I would like you to try and focus on what is happening with Jason currently and not what happened when you were younger. What have you tried so far in terms of talking to your mother? KASEY: Well I haven’t really tried because every time I try to speak to her I start feeling anxious and panicky. My breathing is shallow, and then my head hurts. COUNSELOR: It sounds like you really want to talk to your mum but you feel overwhelmed. KASEY: Yes I do. I have these thoughts that she will never want to see me or speak to me again. COUNSELOR: By thinking what you are thinking is it helping you? KASEY: No COUNSELOR: So, do you think that when you talk to your mother face-to-face your thought processes breaks down. Can you think of another way to communicate with her in the short-term? KASEY: Yes, I find talking to her really challenging. So, maybe I can email her. COUNSELOR: Great! How about you write an email with what you want to communicate and bring it with you to our next session. We can start a plan of action on how to communicate with your mother. Conclusion Kasey appears to be a client that would benefit from cognitive therapy and reality therapy. Although they are different theoretical approaches, they both need active participation including homework tasks. Kasey could expect significant improvements in her levels of anxiety, her long term well-being, education and relationships from both theories.

References
Beck, J. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York: Guildford
Bradley, E. (2014). Choice theory and reality therapy: An overview. International Journal of Choice Theory and Reality Therapy, 1, 6-13 vol. XXXIV
Corey, G. (2009). Theory and practice of counseling and psychotherapy (8th ed.). Belmont: CA, Thomson Brooks/Cole
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Jones-Nelson, R. (2011). Theory and practice of counseling and therapy (5th ed), England, London: Sage Publications Inc
Lujan, S. (2015). Quality counseling: An examination of choice theory and reality therapy. International Journal of Choice Theory and Reality Therapy, 2, 17-23 vol. XXXIV
Sharf, R. (2016). Theories of psychotherapy and counseling concepts and cases (6th ed). Boston, MA: Cengage Learning