Essay Title – Using the case study provided at the end of the module identify and explain the client’s issues and devise a course of treatment for him, taking in to account any ethical issues.
Word count – 2422
Introduction
This assignment is based on a case-study of Mr X who attended an initial consultation presenting with several concerns and issues. Most of the client’s self-referred problems appear based on his perception of the world, people around him and his relationship with these, probably related to low self-esteem. I shall explore the issues presented by the client and base them on a theoretical framework. The client reveals many strengths in his life and character, which I shall highlight, and will serve as basis for a positive formulation into his needs. I will also explore appropriate therapeutic approaches for this client and suggest a course of action based in theory and clinical applications.
Client initial presentation
During the initial consultation it was evident that Mr X was looking for some change into his life. He disclosed a deep wish to move on but he also felt that he was being held back by his insecurities and fears. The main issues highlighted by Mr X were :-
Wanting to apply for the job promotion, feeling he is able to do the job but insecure of applying for it;
Feeling that his work colleagues find him boring, because he does not go out with them for a drink;
Desire to improve his ‘relationship’ with his work colleagues, by proposing another day out. However he fears that they will say no;
Unsure if he wants to marry his ‘sort-of’ girlfriend because he has not much to offer to her at present;
Pressure to get the job to impress his mother and offer more to his girlfriend;
Interestingly, many of the issues presented by MrX appear linked to each other. Some of these are functional difficulties, since they derive from the way he interacts with others. The issues presented by Mr X transpire from his personal dimension to reflect on his professional needs and goals. He is being reserved in his approach to his colleagues. He is underselling his skills and even doubting his professional ability to perform a managerial job. The client is presenting with apparent low self-esteem, social phobia and anxiety, faulty beliefs about how he is perceived by others, and attributing respect from others to professional success
Interpretation of Mr X’s issues
Mr X’s apparent different issues appear to be related to the way he currently perceives the world around him and his position in it. According to Psychodynamic Theory the client’s subconscious presents a great part in the way he is interpreting his difficulties. His behaviour is regulated in accordance with certain basic principles, for example: survival, competition, protection, need for love, or need for success; however at time these come into conflict with a person’s own motives, fears, with each other, and with the external reality. In this example, the client has a need for success and he knows that he can be successful in a managerial role, and he would receive a great deal of respect from his mother and work colleagues. However, there is a conflict with his need to be loved by the same colleagues he will be asked to lead. Also, if he takes this new job he will have new responsibilities which will clash with his current way of living, such as emotionally over-dependent on his mother, and having more responsibility at work and to his work colleagues. It could also be that his relationship with his mother has been based on misconceptions of success and achievements, and he only wants to be ‘a great’ man to prove his capacities to his mother. This man has construed a stable identity for so many years, and all can change if he accepts the job as a manager. However, accepting the job is itself a trigger to lower his self-esteem, since he may feel or believe that increase responsibility may expose him as inadequate, or even fear he has double-crossed his colleagues.
The example displayed by Mr X illustrates the ‘pleasure-pain principle’, which states that behaviour is designed to pursue pleasure and to avoid pain. Each individual has their own personal hierarchy of pleasure and pain. This client sees pain in responsibility and commitment; and he also sees pleasure in his safe zone and comfortable way of living. In essence, this client appears to be avoiding responsibility and commitment, and presenting fear about being less respected by his mother if he does not get the job. He uses the visits to his mother as an excuse not to go out with his friends. He demonstrates that his pleasure is in visiting his mother, and shows pain in going out with friends; however, he acknowledges that he would also want to go out sometimes with his friends and often his visits to his mother are painful and detrimental to his self-esteem. He then chooses “the lesser of two evils” but appears to suffer from either.
Mr X’s implicit and identified strengths
Initially, it was apparent that Mr X was avoiding social contact with his work colleagues outside his work environment, maybe even generalised social anxiety. However, Mr X has been working as an estates agent for 18 years, this showing a professional and personal resilience to a job that requires a lot of social contact, communication skills and client persuasion. It is more likely that this man is not used to going out and may feel sensitive about that, but this cannot be categorised as social phobia. Mr X is not a shy person; otherwise he would not have been successful at his employment for so many years. He also has worked as an acting-manager when cover was needed, this showing leadership skills and capacity to progress to his goals. Mr X appears to be well liked at work. He mentioned that his colleagues may think he is boring, but this quality is far from being negative in many senses. He has managed his colleagues in previous occasions; they may be used to his ways of working and could indeed be happy with him as a manager. Mr X is also in a relationship and would like to get married. Although he sees his girlfriend as a ‘sort of’ girlfriend he shows deep feelings for her and wants to provide the best he can for the relationship. He is a likeable person, gentle and sensitive. All these qualities can be drawn into the treatment.

Hidden agenda and Secondary gains
Many people presenting with issues and problems, are often underlined by hidden agendas and secondary gains. These are features in one’s character that will prevent the client to move forwards, since they may disguise the real issues and jeopardise progress. The hidden agenda is the client’s subconscious processes behind his behaviour, such as fear of success or failure. The secondary gains, on the other hand, is the excuse or ‘the less obvious benefit to a behaviour”. It is always worth identifying these prior to treatment so that progress can be achieved. This client’s “secondary gains” are probably being reinforced by other people or situations.
For instance, if he gets a job promotion people around him will also have to change their lives.
His colleagues may be benefiting from not having him as their manager; they may prefer him as their ‘mate’ and, if he gets the job, the boring colleague will then be the bossy manager.
His mother, who receives frequent visits from his son, would be faced with fewer visits due to his increased amount of responsibility at work. He would have to work late most days, travel around the country looking for new estate deals, and even expanding the business. His mother is clearly elderly and at this stage she may prefer to have a less successful son but who visits often, than a successful son who never visits.
His girlfriend may feel free as single woman, and if he got the job she would feel pressured to marry him. It is possible that she fears that his increased job responsibilities would take him from home for most time of the day and she would feel lonely. She may see her relationship more rewarding as it is – after all, money is not everything.
His current manager may like his skills, he may like him as a replacement for a few days, he may recognize his strengths and capacities to do the job, but he may have someone else in mind for the job, and may unconsciously be discouraging this man to apply for the job.
Potential treatment
After having identified Mr X’s main issues, clarifying Mr X’s priorities, hidden agenda and secondary gains, and having interpreted all these in a meaningful way, I would propose to the client a course of therapy for improving self-esteem. Although self-esteem is just one of the dimensions where Mr X has difficulties, it is nonetheless, vital for improvement since it affects other areas, such as motivation, anxiety, and depression. Self-esteem is one of the fundamental influences on nearly all human activity. When our self-esteem is low, almost all areas of one’s life – job, relationships, family life – become more complicated. We do not know much about Mr X’s past at this point, but we can assume that his low self-esteem may have started when he was a child after many years of “negative programming” from judgemental parents, in this case his mother. It can be that he always felt underachieved and lacks the necessary esteem to accept that he is as capable, or more, to do this job like anyone else. At this point I would also check if the client is on any medication or has any specific contra-indication that would prevent him to attend hypnotherapy.
Mr X appears to be within the visual modality I would assume, due to his profession he could sustain a more authoritarian style of induction, but this would also be assessed during the initial consultation. Afterwards, Mr X and I would agree with an appropriate induction and programme to improve self-esteem. This programme aims to improve self-esteem permanently and to reprogram the subconscious to: eliminate past negative programming; improve self-projection; increase confidence and self-acceptance, and change the person’s relationship to the given problem. This reprogramming is presented within the agreed induction screed, which would be read to the client during sessions. The screed would contain an appropriate relaxation module, a safe place, a deepener, the suggestion, the trigger method, and the awakening. These have been adapted to Mr X’s likes and dislikes. These would be revised after each subsequent session following Mr X’s feedback and impressions. After all, for a therapy to be efficient a client has to feel that he is empowered and a co-therapist.
During the initial consultation we would discuss goals, to help the client identify a goal that is clear and realistically achievable. Since this client has many different goals, which may clash with each other, it is more realistic to work on the common ground for each of these goals – his self-esteem. When setting these goals, one has to remember that the subconscious mind does not readily recognize negatives and when a client thinks "I don't want to have low self-esteem" their subconscious will translate to "I want to have low self-esteem". Obtaining realistic goals is crucial for effective inductions. Such goal setting also involves a plan of action to suggest the amount of sessions required, what therapeutic approach to take, and any home-based work the client needs to achieve in-between sessions. I believe that I have to be very clear and ethical at this point and not propose more sessions than the client needs. I can nevertheless suggest that the client as a course of sessions for self-esteem, and if he is happy to do so we can work on other issues, such as levels of motivation. At this point a contract of therapy is essential and fees need to be discussed. I believe that an ethical therapist needs to have constant awareness of their own skills and be prepared to refer the client to more experienced professionals if the client is not responding to the proposed therapy. Having said that, if the therapy is appearing not to work, the therapist needs to revise their approach and adapt it, without detriment to the client.
Concluding the therapy
As with most therapies, eventually a client improves – the aim of the client and therapist – and the therapist needs to ensure that the therapy has produced a ‘real’ positive outcome. In my practice, if I was seeing the client in this study I would produce a final/follow-up interview to assess how the client is doing in the same social situations he complained initially. Obviously, as the sessions progressed I would find out if the client applied for the job, improved relationship with colleagues and so on, and this would be enough evidence of progress. However, for a more clinical outcome, I would also introduce the measures described above to assess improvement in self-esteem and anxiety levels. I could use these scales as more reliable measures to show progress to the client. I would predict that with the induction presented here, and with good rapport and follow-ups, the client would improve dramatically in his areas of concern.
Conclusion
The case-study presented here was a simplistic example of someone presenting with a range of personal and social difficulties mainly caused by low self-esteem and confidence. The client had identified these in the context of his work and family relations, and how these often clashed with his own internal processes and goals. The client presented with potential hidden agendas and secondary gains, but also with strengths that could be used within the proposed action plan. I believe that by involving the client at all stages of therapy can be predictive of a positive outcome; however, without assessing the client myself I found that my answers are rather theoretical and based in assumptions and presumptions