Week 1 - Session 1 (180 minutes)

 Orientation (15 minutes)

 Class on Counselling Psychology (165 minutes)

Case studies in counselling psychology: For explaining.

1. COUNSELLING CASE STUDY: LEARNING TO LET GO

Elizabeth came to counselling because she was experiencing intense anger, and was not coping with her
life. She complained of failed relationships with her ex-husband, and with another man whom she left her
husband to be with. Elizabeth cannot move on from the anger she feels about her failed relationships and
she is feeling isolated from her family and friends. This had an effect on her ability to cope with her work.
As a consequence, Elizabeth has sold her successful business.

The Professional Counsellor saw Elizabeth for 5 months and used an eclectic approach with her, including
techniques from Cognitive-Behaviour therapy and Solution Focused therapy. For ease of writing the
Professional Counsellor is abbreviated to “C”.

Background Information

Elizabeth is a mother of two; she has a son aged 18 and a daughter aged 15. She shares custody of the
children with her ex-husband, Jodi, whom the children spend a lot of time with. Jodi lives with another
woman and they are engaged to be married. The children have a close relationship with their father and
get along well with his new partner.

Despite the separation, Elizabeth’s ex-husband is still very much a part of her life through his relationship
with the children. He has retained good relationships with her family and their mutual friends, who are
very sympathetic towards him, due to the fact that Elizabeth ended the relationship to be with another
man. Elizabeth was resentful of this sympathy and of the strong relationship that the children had with
their father.

Elizabeth described her ex-husband as manipulative and verbally abusive. She felt that he was not
supportive of the needs or her career. She finally ended this difficult relationship by leaving Jodi to be with
someone who was more supportive of her at the time.

For the first two sessions, C worked with Elizabeth to reveal more of her feelings and story. At times, it was
difficult for C to clarify the many emotions and complexities that Elizabeth revealed and C became aware
that Elizabeth was veiling some information. Elizabeth spent a lot of time trying to convince C that she was
a nice person. It was important for C to understand this message and to accept Elizabeth unconditionally.

C understood that her client had many self-esteem issues in relation to her career, family, friends and
relationships. She had experienced significant verbal abuse from her ex-husband and which also
contributed to her low sense of self-worth. C was able to convey empathy and concern to Elizabeth and
her total acceptance of Elizabeth the person. C developed Elizabeth’s trust in the counselling relationship
by explaining that counselling is not about moralising or laying blame, but rather it is about empowering
clients to cope with, move on, and grow through their situations.
C was able to develop a significant amount of rapport and trust in the relationship, which allowed Elizabeth
the safety of disclosing her painful experiences.

Areas of Concern

There were five main areas of concern for Elizabeth. These were a lack of support from her family and
friends; her inability to accept her experience of unpleasant (‘not nice’) emotions; her anger concerning
her children and their relationship with her ex-husband; her loss of life-style, business and respectability;
and her inability to let go of her past relationship.

For the purposes of this case study, a description of C’s work with two of these issues will be presented.
These issues are firstly her inability to accept her experience of unpleasant emotions and her belief that
“nice people do not have hate or jealousy”, and secondly, her inability to let go of her past relationship.

Once good rapport was established and Elizabeth’s self-esteem lifted C turned to address her client’s issues
relating to negative emotions and letting go. These two issues had continually interfered with Elizabeth’s
progress and were brought up at every session. Elizabeth could see no solution or resolution of these
issues.

At this stage, C had worked with Elizabeth for three weeks for two sessions a week. She had been closely
observing Elizabeth’s continual return to these topics.

Elizabeth could not admit that she hated her husband or that she was jealous of him with the kids. She did
not accept that she was resentful of him finding another woman, and becoming engaged. The fact that the
children were comfortable with her ex-husband’s new partner and enjoyed being in their home made her
very angry. She continued to beat herself up over leaving her husband for another man – she believed
what her family and friends also thought, that she had behaved immorally.

C realised that until Elizabeth admitted how she felt, and looked honestly at her own thoughts and actions,
that she would not be able to let go. Elizabeth wanted very much to be a nice person, but a nice person
does not leave their husband for another man, they do not hate, they do not fight with their kids and they
never have jealous thoughts. She needed to reconcile the difference between her ideal and real self.

Visual Technique

To help Elizabeth begin to express her emotions, C used a visual technique. C asked Elizabeth to draw a
picture of herself in her home with her ex-husband and family.

She drew a picture of a kitchen. It had a breakfast bar that was very ornate. The picture showed her behind
the breakfast bar with a big smile on her face, her hand was holding up a glass of champagne. Behind her
was a well-defined fridge. The rest of the kitchen was quite loose comprising mostly of box shaped kitchen
appliances. In the front of the picture are her family and some friends.

C began asking questions about what this situation represented.

Extract, Counsellor and Client

Counsellor: “I noticed that the breakfast bar is very ornate.”

Elizabeth: “Yes, I designed that.”
 Counsellor: “You are proud of that…yes?”
Elizabeth: “It was something that I could claim that he could not take from me, everyone knew I
designed it. It belonged to me.”
Counsellor: “It is a very big smile”
Elizabeth: “It is not a real smile; it is my company smile”
Counsellor: “Why pretend?”
Elizabeth: “It was expected, I had to perform like a monkey for my ex-husband, he needed the social
contact but did not have the skills. I took up the slack but he never gave me the credit.”
Counsellor: “That made you angry.”
Elizabeth: “Yes”
Counsellor: “How did you feel about him at these times?”
Elizabeth: “I was angry”
Counsellor: “Just angry?”
Elizabeth: “No, I was more than angry, I do not know what I was.”
Counsellor: “Was this the behaviour in the home that encouraged you to seek understanding outside
the home?”
Elizabeth: “Yes, I could never talk to Jodi, he was always so self-centred, he never once took an interest
in my business, and I won awards and everything.”
Counsellor: “You sound exasperated. Was living with him that bad?”
Elizabeth: “Living with Jodi was hell, I hated going home, I hated pretending, I hated sleeping with him.”
Counsellor: “What about Jodi, how did you feel about him?”
Elizabeth: “I know you want me to say I hate him but that would mean I am not a nice person, it is bad
enough that I left him for another man, nobody is on my side, they do not know what I lived, yes …yes
…I know I never told them…they would not believe me…it would be a betrayal… {crying}…okay!! Yes!! I
hated him, I hate him, and I cannot believe that he has moved on, found another woman, my children
go there with no thought to me or how I feel, he still has the power…I feel he is still there, I can’t
escape him. I HATE HIM! YES! I am jealous, how dare he move on. She will find out and be sorry.”

C let Elizabeth vent all her anger, expressing the emotion that had been bottled up for a very long time.
This was a breakthrough for her, and with the release of those feelings, Elizabeth began to work them out
of her system.

Using the picture, Elizabeth had explained what was happening, and her performances to please Jodi. C
noticed the distance between Elizabeth and the rest of the people in the picture. When C asked about this,
Elizabeth said “they didn’t see me, I felt isolated.”

C used Solution-Focused therapy and asked Elizabeth what the picture would look like if she had a magic
wand and could change any of it. Elizabeth replied that she would be on the other side with the people in
the picture. Jodi would not be in the picture, and she would be independent and have a loving man at her
side.

Elizabeth’s admittance of jealousy opened another door for self-acceptance and she was able to talk
openly about this feeling. Elizabeth accepted that she was jealous because Jodi had found someone else
and it burned inside her. The kids liked his new partner and Jodi did not seem to suffer in any way because
of the break-up.

Jodi still had all their friends and family on his side. He still had control of her life through her children. She
had not found anyone else. Elizabeth was feeling guilty that she felt so resentful and jealous. These feelings
were contrary to the “nice” image she wanted to portray.

Together, C and Elizabeth worked to separate Jodi’s behaviour, from Jodi the person. Elizabeth came to
realise that it was his behaviour she hated – his controlling tactics most especially. And although she did
not like him any more as a person, she found that she did not hate him.

With further work on her acceptance of her situation, Elizabeth came to understand that her negative
emotions were common to all people, even nice ones. This revelation was quite a breakthrough for her.

Using the visual technique of drawing a situation gave Elizabeth the opportunity of exploring her feelings
through the picture. Thus the feelings became a tangible item to work with. C referred to the picture
constantly to draw out emotions. This was a less taxing and less obtrusive method, which gave Elizabeth
something solid to focus on, rather than just hear her words in the air.

To finalise the activity, C asked Elizabeth to draw a positive picture of herself in a new kitchen. The drawing
was different. This time she depicted many people, there was no distance and the smile, she assured C,
was real.

Paralleling

Despite the progress that Elizabeth was making and her growing acceptance of her feelings, she was
reluctant to let go of the feelings and move on with her life. C used a number of strategies and tactics to
encourage Elizabeth to let it go, but without success.

C was becoming frustrated with this situation and was considering approaching her supervisor for some
further input and advice. Before she did that, she tried a paralleling strategy.

C recalled some of Elizabeth’s experience as a successful businesswoman where she dealt with a range of
clients including suppliers and the general public. Elizabeth had been faced with a range of frustrating
experiences in her business and had coped with these problems and disappointments. C decided to ask
Elizabeth questions about her business, how she began it, what she needed to do to run it, what it meant
to her, how important it was for her to remain professional and focused, what was the most uplifting part
of her business.

When answering these inquires, Elizabeth became very animated and exited – and talked like a person
who was in total control of her environment. C used this strength to parallel as such:

Extract, Counsellor and Client

Counsellor: “So working with suppliers, they often let you down?”
Elizabeth: “Yes they often let me down.”
Counsellor: “Does that make you angry?”
Elizabeth: “Well yes, it is very frustrating.”
Counsellor: “Did you stop using them?”
 Elizabeth: “No, that would be silly, and very unprofessional, I get over it, and move on. I need them and
I know that it is not a deliberate act to hurt me. Most of the suppliers have problems of their own.”
Counsellor: “Were there many who let you down a lot?”
Elizabeth: “Yes, one or two”
Counsellor: “How did you cope with that?”
Elizabeth: “I let it go, I need to. I could not maintain my business if I held grudges.”

C asked many similar questions alluding to letting go of anger and frustration in her business world, the
message was always a resounding yes. Elizabeth had formulated strategies that she used to cope with the
disappointment.

C pursued the same line of questioning with Elizabeth’s experience of handling problems with the general
public. Elizabeth gave almost the same answers. It took about another three questions before the penny
dropped and Elizabeth realised that C was paralleling. She began to laugh, really laugh. It was a wonderful
sound for C to hear.

It was a big breakthrough for both Elizabeth and C. They spoke about applying her professional techniques
for letting go to her personal life. Elizabeth agreed that the skills could work in both her personal and
professional life.

Conclusions

In summary, C used a visual strategy, which gave Elizabeth an opportunity to express a feeling and to make
that feeling a concrete thing to refer to and address. It helped her to accept those emotions that for her
were not always acceptable. The second tool – paralleling – enabled C to highlight Elizabeth’s strengths
and to show her that she already had the tools to resolve her problems. She had used these tools
effectively in many aspects of her business life. The paralleling gave her an opportunity to see that she
could transfer these skills into another area of her life. Elizabeth progressed in leaps after this
breakthrough, attending sessions every second week for a month then once a month for two more
months. She has moved on and is enjoying a better quality of life.

2. A CASE OF STRESSFUL LIFE CHANGE

For ease of writing the Professional Counsellor is abbreviated to “C”.

In the first session, “C” asked some open questions to prompt Mary to start discussing her dilemmas. Mary
was able to convey the events leading up to her problems clearly, although was reduced to tears when
discussing her seemingly overwhelming feelings of being alone and unable to cope with her circumstances.
“C” allowed Mary the time to cry and acknowledged her need to release her feelings. When she was more
calm, “C” continued with gathering some of the background information.

Essential Case Information

Mary has been married for 13 years and has two daughters aged 9 (Christine) and 13 (Jennifer). About 9
months ago, Jennifer suffered a brain injury after a sporting accident. Since then, Mary and her husband
have had to teach Jennifer to eat, walk and talk again. They have attended numerous doctors, and
specialists appointments in regards to the treatment and rehabilitation of their daughter.
Jennifer is now able to talk again, however her speech is slurred and her vocabulary is still developing. She
has difficulty walking unsupported and Mary helps her to shower, dress, eat, go up and down stairs, get
out of bed, etc. Mary has quit her part-time work to stay home and look after Jennifer. Mary misses the
opportunity to work and have contact with her friends there. Phillip has cut his work hours to part-time in
order to help support their two daughters.

Mary states that she hardly recognises the girl that Jennifer used to be before the accident, the new
Jennifer is more demanding, throws screaming tantrums, and seems to resist Mary’s every effort to help
her. Mary grieves that she can no longer have the daughter she once had and she feels overwhelmed to
think that Jennifer will remain this way for the rest of her life.

Lately, Jennifer seems to favour Phillip’s efforts more than Mary’s. She said that Phillip seems more able to
convince Jennifer to shower and dress, whereas Jennifer has been refusing to dress or shower for Mary.
Jennifer would have a screaming tantrum, whilst Mary directed her towards the shower. She has started to
resent her husband’s apparent ability to control Jennifer and is very critical of her own ability as a mother.

Phillip had started to give Mary advice about how to handle Jennifer, to which Mary responded angrily. She
thought that he should be supportive of her efforts, not give her directions, and this further reinforced her
beliefs about being an inadequate mother. Mary feels that her husband is withdrawing from her, focussing
more of his attention on his two daughters and his work.

Mary has had little time for her friends and other family. She has been dismayed to find that many of her
friends and relatives have distanced themselves from her family. She hasn’t talked to her closest friends,
feeling that she doesn’t want to burden them with her troubles.

Mary has not been sleeping well, as she lies awake wondering whether her life will be this difficult forever.
She can’t see an end to the predicament and she is tired of feeling stressed, and having such conflict with
her family.

Session Details

“C” let Mary discuss her issues fairly openly for the first session. “C” used active listening skills to let Mary
know that her feelings and experiences were important. Mary had been experiencing insomnia and mood
swings for the last 4 months and due to this, “C” believed that she was suffering from chronic stress. Mary
described that initially she had coped well with the tragedy, as her attention was focused on the
rehabilitation of Jennifer.

At the end of the session, “C” commented that Mary was showing signs of chronic stress and explained
some of the symptoms to her. “C” validated Mary’s feelings of being unsupported, unable to cope and her
grief as being normal responses to the tragedy of her daughter’s accident.

Mary indicated that she was feeling a little lighter, after talking about her issues with someone. Mary and
“C” discussed some things that Mary could do before the next session to reduce some of her stressful
feelings. “C” suggested some relaxation strategies for Mary to use, such as deep breathing and listening to
meditation tapes. “C” also gave Mary some examples of positive affirmations she might use to calm her
thoughts, for example: by clearing her mind and saying, “I am relaxed” when she breathes out.
Mary decided to visit her G.P. to ask about medication (and alternatives) that may help her to sleep a little
better, as a short term solution. Mary also decided to organise some time to talk to a close friend about
her predicament, as a means to re-establishing a support network for herself apart from her direct family.

In the second session, Mary told “C” that she had talked for a long time with her friend. Her friend had
been very supportive and helpful, and Mary wished she had contacted her friend sooner. Mary’s friend had
suggested a herbal sleeping remedy that Mary should try and also gave her some relaxation music to listen
to before going to bed. Mary had been sleeping a little better since using the music and herbal remedy, so
she decided not to see her G.P.

Since Mary seemed less stressed in this session, “C” conducted a Personality Need Type Profile for Mary.
The test indicated that Mary was a type ‘B’. “C” explained about the high social needs of ‘B’s’ and Mary
thought that this was true of her personality.

Mary said that her husband was pleased that she was seeing “C”. She explained that they were still arguing
about Jennifer, as Jennifer was refusing to shower this week for Mary. Phillip had said to not push Jennifer
to shower when she didn’t want to. Mary felt that Jennifer was just trying to be disobedient and upset her.
Mary was visibly upset about the conflict with her daughter and husband.

“C” talked about some of the cause and effect relationships that were involved in Mary’s predicament,
such as:

Traumatic accident causing:

Grief about the obvious changes in Jennifer
Pressures on Mary’s ability to cope
Lack of contact with people, due to friends and family’s inability to relate to what had happened to the
family
Confusion for Mary about how to deal with an incident she has no experience
Change in lifestyle for Mary — having to quit her job and stay home as a full-time carer
Lack of social contact

Jennifer’s temper tantrums and refusal to be helped causing:

Feelings of frustration to accept Mary’s assistance

Feelings of inadequacy as a mother

Criticism / Advice giving from husband causing:

Feelings of inadequacy as a mother

Anger about the perceived lack of support from husband
Feeling alone in her attempts to cope with her situation

Feelings of inadequacy and inability to cope causing:

Hopeless feelings about the future for herself and her daughter

Attitude that she is alone in her predicament causing:

 Her B type personality needs to not be met
Stressful feelings

Separation from friends, social activities causing:

Her B type personality needs to not be met

These are some of the main cause and effect relationships that “C” outlined for Mary in her situation. “C”
then asked Mary what she wanted to focus on in the counselling process. Mary wanted to work on how
she could cope better with Jennifer and re-establish the bond between herself and her husband.

“C” explained to Mary that “C” was not qualified to give advice about how to deal with Jennifer’s
behaviours given that she had an acquired brain injury (ABI). “C” explained that damage to certain parts of
the brain can cause changes in behaviours, and Mary would require the advice of trained professionals (ie:
cognitive psychologists) to suggest appropriate behaviour modification strategies.

“C” provided Mary with a number of health and community organisations who specialised in treating and
providing information about ABI. “C” also suggested that Mary ask these organisations about support
groups for parents with children with ABI. “C” explained that as a type ‘B’, Mary would probably enjoy
being involved in such groups and it would enable her to have more social contact. Mary said she would
definitely try to find a support group to join and was planning to ask Phillip to attend them with her.

In the meantime, “C” talked to Mary about possible causes for Jennifer’s non-compliance. They discussed
Jennifer’s need to do things unaided and the effect of the disability on Jennifer. If Jennifer thought that she
wanted to do things unaided and Mary thought that Jennifer needed assistance, then the conflict may be
occurring over their differing attitudes. Mary and “C” discussed Mary’s attitude of what a good mother is.

“C” and Mary developed some mediating responses for Mary to use when her daughter did not want to be
assisted. Mary could say to herself “I am a good mother and I recognise my daughter’s need to do things
independently and when she wants” or “I love my daughter, I let her shower when she chooses”. “C” and
Mary also developed some visualisations such as: picturing herself remaining calm when Jennifer had a
temper tantrum and dealing with Jennifer’s issue when both were calmer.

“C” also suggested that Mary talk to Phillip about handling Jennifer if Mary did not feel able to remain calm
in the situation. In this way, Mary and Phillip could work together in parenting their daughter and help
ease Mary’s fears of being unsupported by her husband.

“C” also mentioned that Mary could try to praise and reinforce Jennifer’s attempts to do things for herself.

In the third session, Mary reported that she and her husband had, had a long discussion about Jennifer.
Mary talked to him about her changing her attitude about how she should be supporting Jennifer. She also
told him about her feelings of inadequacy and that she feared that he also thought she was a terrible
mother. She explained about her type ‘B’ needs for his company and attentions. Phillip told her he thought
she had always been extremely supportive of Jennifer and reminded Mary of all the effort she had put into
her daughter’s rehabilitation.

He had noticed lately how angry and critical Mary had seemed, when he had attempted to help her with
Jennifer. He thought she was trying to force Jennifer into patterns that Jennifer wasn’t happy about. He
also admitted that he didn’t really know how to cope with Jennifer’s behaviours all the time either. Mary
reported that Phillip was unsure as to how to help her, and was concerned about her stress. He had
withdrawn himself because he thought she did not want his opinions.

Mary stated how relieved she was to hear Phillip’s support for her and she understood why he had
distanced himself from her. She also understood how her anger and feelings of insecurity about her
capabilities had effected Phillip’s behaviour.

Mary talked to “C” about the possibility of having counselling for herself and her husband, to which “C”
agreed. Mary said that Phillip was interested in improving their communication with each other, however
he wanted to meet “C” before he committed to any counselling. Mary commented that Phillip expressed
interest in attending groups or courses to learn more about ABI. “C” reinforced to Mary that these
strategies would also help to fulfil her type ‘B’ needs for social contact.

In summary, “C” asked Mary about her current stress levels and what strategies she was using to combat
these. Mary said that sleeping was easier and she would continue to use her herbal remedy and relaxation
music. She was starting to develop quite a collection of tapes! “C” also suggested some exercise to help
combat the effects of the stress. Perhaps walking with her husband in the evening, as a means of taking
the time to talk to each other. “C” also reminded Mary to keep in contact with her friends and to try and
build up some social support for herself, in order to meet her personality, need for social contact.

In future counselling sessions with Mary and Phillip, “C” suggested they may like to discuss their feelings of
grief and loss about Jenny’s accident and the issues that it brought into their life. They could do this in
conjunction with improving their communication skills.

“C” also reinforced Mary’s decision to join a group of parents who had similar experiences in raising a child
with ABI. The group could provide her with support and understanding about the experiences she had. She
may also learn new strategies to cope with her daughter’s disability from those who were also in the same
situation. “C” also reinforced that Mary and Phillip should seek assistance from a psychologist to help them
develop strategies to manage their daughter’s behaviour.

Mary felt that she now had some direction to follow and did not feel so hopeless about the future. She
realised that she had been experiencing stress from the change in her daughter’s life and her perceived
inability to cope. Mary was still faced with the same struggles and problems in her life, though she realised
that she could change her approach to these, in order to reduce the stress, she suffered and to feel better
about herself and her family.

Case studies for homework:

3. COUNSELLING CASE STUDY: SOCIAL ANXIETY

Sasha is a 60-year-old woman who has recently retired from a career in teaching. Working for many years
in a secondary school environment, Sasha was confident, motivated and dedicated to her work, but at the
same time looking forward to retirement so she and her husband could travel and spend more time with
their adult children who lived nearby.
However, upon finishing work, Sasha found herself experiencing severe anxiety, particularly when around
other people, and began not wanting to leave the house or invite people into the house. She also
experienced bouts of crying when attempting to complete tasks such as housework and using the sewing
machine. Sasha found her symptoms eased when she and her husband went on camping trips in national
parks where they often did not see other people for days.

While working with Sasha, the Professional Counsellor adopts strategies from Cognitive Behavioural
Therapy and Gestalt frameworks in order to address any irrational thoughts and behaviours which may be
maintaining Sasha’s anxiety, and to complete any unfinished business which may have led to the
development of her anxieties in the first place. For ease of writing, the Professional Counsellor is
abbreviated to “C”.

Background

Sasha was an unplanned baby, born after her older brother. Her parents did not want a second child but
when they realised another was on the way, they hoped for another boy. As a child Sasha remembers
always being in the background and her brother and father being the ‘important’ ones.

Sasha reported a vivid memory of coming home from school one day and finding no-one home. Sasha sat
on the front porch and cried until her mother eventually came home and told her to stop being so silly. She
described her mother as being more concerned with the state of the house than with her young daughter.

Sasha’s father died when she was very young, and she remembers her mother not coping well for a long
time. During this time, she (but not her brother) was often sent to her grandparents’ farm to give her
mother a break. Here Sasha spent most days on her own. However, she remembers these visits fondly, like
‘a lull in the storm’.

When her mother died, she left everything to Sasha’s brother, who was by then a well- paid solicitor with a
young family. Sasha also had a young family but did not question her mother’s decision as she had been
conditioned from childhood to believe males were more important.

Issues identified

Sasha’s symptoms appeared to be those of social anxiety disorder. They included:

 An extreme fear of situations where she may have to meet new people or be scrutinized by
others.
 Social situations were either experienced with intense anxiety or avoided altogether.

When she did face these situations, she experienced physical symptoms such as sweating, shaking, tension,
shaky voice, dry mouth and a pounding heart. The main symptom of this disorder involves feeling extreme
anxiety in the presence of others. Sufferers often believe other people are very confident in public and that
they are the only ones who aren’t.

Almost everyone experiences some social anxiety now and then; however social anxiety disorder severely
limits the lifestyle of the sufferer, causing them to avoid making friends or miss important opportunities at
work.
Formulation

In the first session, Sasha described her current physical symptoms and her feelings of hopelessness that
she would never have the lifestyle she had dreamed of having in retirement. She was very tearful and her
voice was quite high and shaky. She stuttered occasionally and her hands moved constantly, tearing the
tissue she was holding to pieces.

She described trying to sew curtains and being overtaken by an uncontrollable fit of crying. She could not
explain why this had made her so upset. She had also avoided inviting former work colleagues to her house
for fear it would not be ‘good enough’. Her main concern was her daughter’s wedding, coming up in three
months. She became more tearful talking about this, saying she did not know how the bride’s mother was
supposed to look or act.

C then took a history of Sasha’s family background and noted that she had always been relegated to the
background, leading to the core belief that she was unimportant. Sasha then described her work history
which seemed to be in sharp contrast to her family experiences. C took some time to explore this with
Sasha.

Sasha described being in the classroom as ‘being in control’. She felt that she had a good rapport with
students and was good at her job. She often took on more than she could handle at work but somehow
managed to get through it and was praised by her colleagues when she did this. It appeared that the only
time Sasha had ever felt important was in the workplace.

However, while she got along with other staff, she had made no real friends and had never had any friends
throughout her life. C asked her why this was. Sasha became tearful again and said that she just wanted to
go and live somewhere she wouldn’t have to see anyone except her husband and her children. She
described her camping trips with her husband as being relaxed because she didn’t have to talk to other
people. She experienced particular anxiety when her husband’s family visited as she felt pressure to be a
perfect wife and housekeeper in their eyes.

Sasha mentioned that while she was working in the Education Department, she had been given a
personality test to complete which had told her she was an extrovert. She was puzzled by this because she
did not like people and clearly stated that it was not her goal in counselling to change this.

At this stage, C shared with Sasha her impression that Sasha appeared to have developed the belief that
her authentic self was unacceptable and had created a false self to present to the world. This created
intense anxiety because she was never quite sure who people wanted her to be from one situation to the
next, requiring her to constantly scan her environment for clues as to how to feel and behave.
Consequently, it was easier to think about going away to a place where she would not have to see anyone,
as she had done as a child at her grandparents’ farm. Only when she was away from people was she able
to relax and feel in control.

Also, because she had married an introverted man who indulged her need to avoid social situations, she
had learned to suppress her extroverted nature still further. It was no surprise that retirement was causing
her such distress, since the only time she had ever felt important and comfortable around people had been
in the work environment.
Session Content

Empty Chair

C decided to explore the unexpressed extroverted side of Sasha’s personality first. She asked Sasha what
she did that was fun. Sasha could only list one item, the morning walk she took with her husband in the
hills. Even this caused her concern however, because she felt she should be walking faster and further than
she was.

Using the Gestalt technique known as Empty Chair, C placed a chair opposite Sasha and asked her if she
would speak to the extroverted side of herself. Sasha found it difficult to stay in the first person and
avoided this by talking directly to C. C guided her attention back to the empty chair and suggested she ask
this part of herself what it would do if it could take over for a day.

When Sasha had done this, C asked her to move to the empty chair and reply as her extroverted self. Once
seated in the other chair, Sasha began to relax and freely spoke about wanting to go to Dreamworld and
wanting to make a quilt. When she returned to her original seat, C asked Sasha how she felt about allowing
this side of her to have some fun. Sasha appeared reluctant but agreed to ask her husband if he would go
to Dreamworld with her.

In the following session, Sasha reported she had not only gone to Dreamworld, but that they had
purchased season tickets. Throughout the course of the counselling sessions, Sasha and her husband began
visiting the theme park for half a day every week. She also started several creative projects, including hand
quilting and scrap booking. She found these activities extremely difficult at first, but utilising cognitive-
behavioural strategies to challenge her core beliefs, she was able to continue to the point where she was
able to enjoy herself for the first time in years.

Cognitive Restructuring

Challenging and modifying a client’s faulty thought processes is the basis of Cognitive Behavioural Therapy
(CBT). After Sasha had outlined several situations that were causing her anxiety, C helped her identify her
beliefs about these situations. Sasha was shown that it was her beliefs about these situations which led to
her bad feelings, and was encouraged to find more realistic alternative beliefs. Some of these processes
included:

Activating event (A) = sewing

Belief (B) = I can’t do it well enough, I might as well give up

Consequence (C) = crying, giving up, bored and depressed

Dispute (D) = I’ll do my best and focus on enjoying myself rather than focusing on the outcome

A = husband’s family staying

B = they’ll see the state of my house and be horrified

C = panic
D = I’ve got better things to do than clean the house and if they don’t like it, it doesn’t mean I’m a bad wife

A = attending daughter’s wedding

B = I’ll let her down and embarrass the whole family by saying or doing something wrong

C = panic

D = people will be focusing on the bride, not me, so I’ll focus on her too

In this manner, Sasha was asked to practice disputing her thoughts for homework.

C then asked Sasha to use the Empty Chair technique to complete unfinished business with her mother,
addressing her feelings about coming home to an empty house and then being told she was ‘silly’ for
crying. Sasha had always believed her mother had treated her as insignificant because she had been such
an inadequate child. Playing both roles, Sasha was able to see that her mother had her own agenda which
made it difficult for her to have time for her daughter. After Sasha told her mother via the Empty Chair
technique how she had felt in this situation, she realised the beliefs she had developed about herself were
not necessarily accurate or helpful and could therefore be challenged.

Again reverting to CBT techniques, C asked Sasha to look for disconfirming evidence for the belief that she
was inadequate. She was able to find many examples of this, chiefly in her work and as a mother to her
own children. Sasha was asked to continue noticing examples like this on a daily basis. She was also asked
to be aware of herself in the present moment as much as possible, rather than focusing on the past or the
future. This allowed her to enjoy what she was doing, rather than focusing on previous failures and
criticisms, or future ‘what ifs’.

Session Summary

Sasha’s counselling sessions focused on a number of issues:

 Integrating repressed parts of herself that were ‘unacceptable’

 Allowing her extroverted side to be expressed so she could take part in and enjoy pleasurable
activities which lifted her depression
 Completing unfinished business with her mother
 Challenging her thoughts and behaviours – the belief that she was unimportant and the need to
compensate by being perfect
 Learning to be present in the here and now, allowing her to focus on the activity at hand and
enjoy it, rather than worrying about the outcome Experimenting with relaxing her perfectionist
standards, which showed her that nobody else even noticed.
 Her daughter’s wedding – Sasha discovered that by distracting her thoughts about being around
so many other people in such an important role at her daughter’s wedding, and instead
focusing on the needs of her daughter and guests, her anxiety was no longer present.

Sasha’s experiments reinforced the fact that her thoughts were producing her anxiety, not other people.
She realised that when she wasn’t focused on herself, her anxiety was no longer there. When she couldn’t
distract her thoughts, she learned to modify them to something more realistic. By challenging her irrational
belief that if she wasn’t perfect she was inadequate, she began to enjoy everyday activities and became
much more relaxed. This was noticeable even in her voice, which lowered in tone, and in her generally
more relaxed nonverbal behaviour.

As a result of implementing these strategies, Sasha found it a lot easier to be around other people. By
learning to accept herself as she was, she no longer felt the need to guess what other people wanted from
her, and began to feel comfortable presenting her authentic self to the world.

4. A CASE OF MID-LIFE DIFFICULTIES

Fritz is 42 years of age and has been in Australia for the past 25 years. He migrated from Germany with his
immediate family, comprising of his mother, father and two sisters. At the age of 17 Fritz was filled with
great dreams and aspirations for his new life in a new country and until recently had been quite happy with
the life he had carved out for himself.

Fritz has sought counselling largely due to the persistence of his wife. Fritz does not really understand why
his wife is so upset with him but states that she thinks he is going through a “mid-life crisis”. For ease of
writing the Counsellor is abbreviated to “C”.

In the first session” C” focused on establishing a clear understanding of the presenting concerns before
moving any further with the client. Fritz was having difficulty explaining the details of the present situation
and why his wife seemed so concerned about him. Basically he didn’t see much of a problem and simply
wanted to try something new because he was feeling bored and restless. “It’s not like I’m having an affair”
he asserts. From this first session “C” was able to elicit useful background information and began to build
much needed trust and rapport with Fritz as he was quite sceptical towards the benefits of counselling.

Essential Case Information

Fritz is a Personality Need Type A with moderate to strong needs for self-recognition. He has been married
for 19 years and until recently has had a reasonably happy relationship with his wife Anna. “Of course we
have had the usual ups and downs like most couples”, Fritz explains, “but overall things have been all
right”. Fritz finds it hard to describe what the discord is about and simply states that “Anna believes I am
neglecting my family responsibilities and says that I appear distant and uninterested in her and the boys”.

Fritz has two boys, Ric (13) and Hans (15). Fritz describes them as generally good boys who are developing
their own interests and he feels that they don’t need him as much any-more. He believes that they would
prefer to hang out with their friends rather than their “old” dad anyway. Hans the oldest son has been
getting himself into a bit of mischief lately, not attending school some days, causing disruption when he
does attend and he has also been caught shop-lifting on a few occasions. Fritz dismisses this behaviour as
“kids’ stuff” and thinks that his wife is over reacting. He simply states that “Hans will grow out of it”.

When “C” encourages Fritz to discuss the situation with Hans further, Fritz states that he has more
important things to worry about. He goes on to explain that he is a Butcher by trade and runs his own
delicatessen. Business has been slow lately and he is afraid that the large chain stores are finally going to
ruin his business. Fritz has not discussed his financial concerns with his wife or the disappointment he feels
at never being able to achieve his long term dream of expanding and establishing other shops in the
surrounding areas. Rather he has decided to sell up and is thinking about moving away from the city.
Fritz continues to explain that when Anna found out that he had approached buyers for the shop she was
furious and could not understand why he had not discussed it with her first, after all it was her inheritance
money that enabled Fritz to purchase the shop in the first place and besides, he had always consulted her
in the past on important decisions. “C” clarified with Fritz that this was indeed correct, that in the past
both he and Anna discussed important decision and came to an agreement. Fritz replied “yes, that’s right”.

Over the past few weeks Fritz has been withdrawing more and more from the family hoping to avoid
further conflict, he has busied himself finalising details with the sale of the shop (he is determined to go
through with it despite his wife’s resistance) and arranging alternative plans. He does not see that such
avoidance behaviour is actually creating more conflict and simply asserts that “Anna will come round when
she gets used to the idea”. Anna has threatened Fritz with a divorce and states that she is not going to let
him drag the boys out of school and away from friends and family.

Fritz has entertained the thought that perhaps life would be much simpler if he did go it alone, shake off all
his responsibilities and simply do those things he has always wanted to. “It’s not too late” he stated “I’m
still young enough to enjoy myself”. However, Fritz knows that he still loves his wife and a divorce would
make him feel like an even bigger failure.

It is obvious to “C” the amount of stress that Fritz is under and the fact that he does not share his fears and
anxieties with anyone only heightens the sensation. At the conclusion of the first session “C” runs through
some relaxation techniques with Fritz which he can implement immediately to help alleviate some of the
symptoms of stress.

It is also apparent that Fritz needs to communicate with his wife and family, however “C” will endeavour to
teach him some effective communication skills in the next session. The reason for this is so that when Fritz
does begin to communicate with his wife it is constructive rather than destructive.

In the meantime, however “C” encourages Fritz to spend more time with the family instead of distancing
himself from them. It does not have to be anything too structured “C” explains, simply watching T.V. with
the boys or throwing a ball around with them after school. Even asking Anna about her day will show his
family that he is interested in them.

During the second session “C” focussed on teaching Fritz some effective communication techniques. “C”
begins to help Fritz convey his thoughts and feeling without projecting ridicule or blame, to listen openly
and not interrupt and most importantly “C” helps Fritz to begin to understand that it is OK to express his
insecurities and concerns.

For Fritz these are new ideas, a change that he will have to get used to in time as it goes against his earlier
learning. Fritz explained that he had not wanted to discuss the issues with his wife because he felt like such
a failure. His father had taught him that a man does not show any sign of weakness or people will lose
respect for you. “C” recognised that this attitude needed mediating as it was one of the underlying causes
of Fritz’s communication difficulties.

He was afraid to talk to his wife yet the apparent lack of communication was one of the causes of the
marital difficulties. “C” spent some time discussing with Fritz how communication can enhance a
relationship and that by talking about one’s fears, anxiety and failings can actually enhance intimacy. This
new information helped Fritz to see that improved communication may actually help iron out some of their
problems.

“C” helped Fritz to make up an affirmation he could repeat to himself when he began to fall back into his
old way of thinking, that “talking was no use and that he was responsible for working out his own
troubles”. Instead he would say to himself “I am an effective communicator” and/or “I am comfortable
sharing my thoughts and feelings with my wife and kids”.

Fritz later reported that the affirmations have made it much easier for him to talk to Anna and the boys
and he has also noticed the tension at home diminish. “C” offered encouragement and praise.
Reinforcement is critically important to achieve lasting behaviour change and “C” frequently asked Fritz to
discuss the improvement he has seen in the family relationships since he had adopted the new attitude. On
one occasion Fritz remarked how much Anna like his new “openness” and had actually thanked him for
making an effort to let her know what he was feeling rather than shutting her out.

In the following sessions “C” began to focus on another underlying cause of Fritz’s midlife dilemma, his
unfilled dreams. “C” began to explain that it is common for people around his age to look back over their
lives and assess their successes and failures. To see if they have achieved the dreams once set for
themselves early in life.

For Fritz the possible loss of his business is a terrible blow and he still feels like a failure even though he has
discussed some of this with his wife. He once dreamed of having a string of stores all named after him
“Fritz’s Delicatessen” and now he may lose the only one he has. He describes how people have been so
proud of him, “For a migrant who started with nothing Fritz sure has done well for himself!” they’d say. “If
I could start my own chain they would be even prouder” Fritz explains.

It is clear to “C” that the success of the deli has provided a great source of recognition for Fritz over the
years with friends and customers delighted with the gourmet foods he provides and now the fulfilment of
his personality need are being threatened. “C” is emphatic towards Fritz and the disappointment he feels,
but asks him to consider those dreams that he has fulfilled, for someone who started out with nothing Fritz
now has a loving family and a close network of friends and he has established himself financially.

A half smile appears on Fritz’s face as he begins to see the positives in his life that he has overlooked. “I
guess I have taken all those things for granted and focused on the one problem”. He is encouraged
immensely from this discussion and is inspired to sort out his current business situation.

At the conclusion of this session “C” sets some homework for Fritz. “C” suggests that throughout the
following week it would be extremely beneficial for him to make a list of all his achievements in life so far.
The rationale for this is to keep Fritz thinking positively, so he can see for himself how much he has
accomplished in life and that he is certainly not a failure.

In the next session Fritz states that he has discussed the business situation with his wife and they have
agreed to go ahead with the sale of the shop in order to start up a new business venture. Fritz is quite
excited about the prospect. After so many years in the same business he feels like he really does need a
change.
“C” asks about his original dream and Fritz admits that it was just that, a dream “I don’t think I ever really
expected it to happen” he explains and then continues “I understand now that having the deli is not the
only way I can meet my needs as I have achieved much in my life and will continue to do so in other areas
that will give me the recognition I desire”.

Fritz now has a thorough understanding of his personality needs and in time has been able to review his
dreams and expectations. In doing this Fritz has reduced the gap between his real and ideal self and has
therefore also reduced the amount of stress and anxiety he has been experiencing.

As Fritz is now beginning to see this stage of his life more positively, he sees a new set of challenges before
him rather than the problems “C” is confident that he no longer needs counselling and will be able to
navigate the new course set before him successfully.

5. A COUNSELLING CASE STUDY EXPLORING LOSS

Sue and Tom lost their child Jill to leukaemia approximately one year ago. Tom suggested that Sue attend
Professional Counselling because she still doesn’t seem to be able to cope with everyday living. For ease of
writing the Professional Counsellor is abbreviated to C.

In the first session C concentrated on building rapport with Sue and listening to her story. Sue felt that it
was the first time that anybody had really listened. She felt that her friends and family didn’t want to even
mention her daughter as they didn’t want to upset her. A lot of useful information was gathered
throughout this session.

Essential Case Information

Her husband Tom feels that she should be more advanced in her recovery because he himself is coping
much better and ‘getting on with life’. Sue is dwelling on guilt prone thoughts such as “Why her, she was so
young, I’m still alive”, “I didn’t tell her I loved her before she died” and “What did I do wrong”.

Sue and Tom have a son David who is 12 and are currently divided on parenting styles, whereas before the
death they were fairly similar in their approach. Tom feels that David should be able to do what he wants.
He feels that life can be short and therefore doesn’t want to be restrictive. Tom feels that Sue is being over
protective whereas Sue feels that she has already lost one child and doesn’t want to lose another. She feels
that she couldn’t protect Jill and is now doing everything she can to protect David.

Jill was diagnosed with leukaemia only six months before she passed away. Sue was working part-time
before Jill was diagnosed but gave up work to be with Jill during treatment. Sue has not returned to work.
Before, when Sue was working part-time she was also doing all the housework, now Sue can’t “even” (her
words) get the housework done.

As Sue was very talkative and needed to get a lot of things off her chest in the first session C just focused
upon building rapport and trust by fully attending to what was said. Therefore, at the beginning of the
second session C started the process of establishing goals by asking the client what she wanted to achieve
out of counselling. It was also determined when and how Sue would know that counselling was no longer
required.
C then wanted to normalise some of Sue’s responses by providing her with some information about the
stages of Grief and Loss. C was careful to highlight that each individual moves through and expresses the
stages differently.

C then asked Sue if she could identify with any of the stages and what stage she felt she was currently in.
Sue felt she could relate to the first four stages and that currently she was in the Guilt stage. C then asked
Sue what stage she felt Tom was in. Sue felt that Tom was in the Acceptance Stage or may have moved on
to complete recovery.

Again C highlighted to Sue that it is normal for people to move through the stages of grief and loss at
different rates. C then spent some time examining how Sue felt about being in a different stage to Tom.

C also discussed the length of time (6 months) that Sue had to come to terms with her impending loss
before the loss actually occurred. Sue felt more relieved by discovering that it can be normal for someone
to become stuck in a stage when they have little time to come to terms with a death beforehand.

At the end of the session Sue left with an affirmation that she had constructed with the assistance of C to
affirm the normality of her current Grief and Loss behaviour. The affirmation Sue constructed was “The
feelings I am experiencing are normal for the stage I am in. I will progress to the next stage when I am
ready”. As Sue and Tom’s communication skills are quite good Sue is also going to discuss the stages of
grief with Tom and highlight to him that people progress through the stages at different rates, in order to
ease Tom’s concerns about Sue’s progress.

In the following sessions it was apparent that Sue was feeling more comfortable with the stage she was at
and was now accepting her feelings. Consequently, other issues could now be worked upon to assist her to
progress smoothly through the remaining stages of the grief process.

The first thing C wanted to know before further progress could be made, was Sue’s Personality Need Type.
The administration of the profile indicated that Sue was a Personality Type A with a score of 9,9. Sue was
amazed at the accuracy of the profile, although she felt that a lot of these behaviours had not been
displayed for a long time. This lead to a discussion about the effects of not meeting needs and how it might
contribute to her uncomfortable feelings at the moment. Issues that were discussed in detail included the
fact that she used to gain recognition within her work environment and from home entertaining as well as
by the praises she used to receive about being able to juggle raising a family, the housework etc.

The discussion then moved to ways that Sue could actually gain some need gratification now whilst she is
still grieving. C made a point of acknowledging that Sue is not going to be able to do all the things she used
to as of yet. This lead quite nicely into an awareness of the need for time management training. C
highlighted how a loss can upset routines and the loss of a routine can be a loss in itself. It was explained
that time management training may assist Sue in regaining a routine as people often need to relearn skills
they had previously in order to help them get back on track.

This left future sessions to explore the new parenting issues which the loss has created. Sue agreed for
Tom to join the counselling process at this stage to explore the differences. Once Tom and Sue
acknowledge each other’s thoughts and feeling about the loss of Jill and how this impacted on their
thoughts and fears regarding David they were in a better position to co-develop a suitable solution.
Once this issue was resolved there was no further need for counselling. It is important to note that Sue has
not finished the grieving process but now has more skills and resources to deal with the final stages
without continued counselling support.

Week 2 – Session 2 (180 minutes)

 Case study discussion (30 minutes)

 Class on Child Psychology (150 minutes)

Case studies on child concerns.

6. Case of behavioural problem

Child X is in the Year One class of a Primary School which is close to her home. Child X is one of eight
children, some live with their auntie and the rest live in the same house with their mother and father. The
child’s father is a double leg amputee, his first leg was removed before Child X was born and since Child X
was born he has had the other leg removed, as well as a thumb. The mother is out most evenings
socialising with friends and leaves the children at home with the father. They moved onto a local council
estate just as Child X was born, they moved from another council estate in the area. There is little routine
in the house, packed lunches not being made, tube of crisps given to the child for their dinner etc. Home
reading books are not given to take home as they are not brought back or are brought back damaged.
Social Services are heavily involved with the family as well as the staff at school. There is a lot of question
over the hygiene of the children, frequent head lice, same tights etc. for the whole week. Attendance and
punctuality of the child are above average with Child X being in school or on time eighteen out of twenty-
five days which is above the average for the class.

There is no fear in Child X, consequences do not work, the teacher confirmed this; detailing consequences
that have been tried in the past. Child X has numeracy help every day where a group of six children are
taken out to a small classroom and are given extra support with their work. This also happens on a Monday
where they are taken for social skills/ nurture. There is no parental involvement with the child’s school
work, when the reading book was allowed home it was not read and also homework, when given, is not
brought back, there should be no question as to stationary not being available as the children are provided
with pencils, rubbers and colouring crayons. Steer, 2009, “Evidence suggests that parental involvement in
the early years helps a child develop secure attachments, helping them to establish personal and learning
skills. Parents showing interest in their child’s education by talking to them regularly about their progress
appear to have a considerable effect their outcome.” (Steer, 2009, pg. 54) As this does not happen with
Child X there is a clear understanding as to why Child X is showing limited to minimal progression during
school. It is also evident that this has also affected the attachment bond with the child, with no skills being
transferred from the parents to Child X.

Observations in the classroom help to understand the child more as it is possible for the observer to see
what the triggers are with the child. Various observations were done on the child at various times; the
observations are included in the appendix.

The first of the observations was of Child X during a carpet activity (Appendices A) with the class, twenty-
eight children and four adults. The child was observed during the lesson talking out of turn, not putting
their hand up, even though there is a poster reminding the children to put their hand up. Rogers and
McPherson, 2008, pg. 12, suggests that a poster be used, “A visual poster cue can assist children’s short
term memory here. The poster is displayed on the board, able to be seen by all children. It illustrates how
children have their hand up (without calling out or click fingers.)” Although this method does work with the
other children in the class, it does not work with Child X; the poster was visible to the child during the
lesson. During the lesson the child was also rocking backwards and forwards on the carpet which was
disrupting the children that wanted to learn.

The second observation was whilst the child was playing with a small amount of children (Appendices B)
during this time the child was observed not joining in conversation with the other children, even though
this was fully expected and encouraged from myself. Under the Independent review of the primary
curriculum Rose, 2009, pg. 77, suggests that children are to be taught a range of social and emotional skills
this is because these skills are used a great deal in the education of the children and their development.
Also during the observation, the child snatched from another child and was very aggressive when doing so
this could be to do with rivalry and attention seeking at home, “A common description of such nuisance or
attention- seeking behaviours is: They fidget, tap rulers, pencils or feet, whistle or sing ostentatiously,
swing on chair tipped dangerously backward, roam around the room, crawl about under desks, snatch
others’ books and pencils.” (Cooper, 1999, pg. 165.) Child X displayed a lot of these behaviours during this
time; this could be to do with the amount of children in the house and the rivalry.

During the observation of the child during play time during their dinner hour (Appendices C) Child C was
observed to be looking sullen and upset whilst colouring in with her friend when another child come over
to the table to colour in. Duffy, 2003, pg. 15 describes how a child is seen to be saturnine, disengaged and
bemused this is because a child’s anger has been curbed. Child X was also observed to preferring to remain
alone, on the quietest table, the child also stated that they prefer to and do play on their own at home.
According to Schaefer and O’Connor1994, pg. 396, “The loner child is more often on of the younger
children in the family. This child is born into a family system with no place to fit. This child cowers from the
behaviour of the troubled child and withdraws into a world of fantasy, books and animals.” This is
appropriate as Child X is amongst seven other children and is amongst the youngest of the children with
two other children being younger. There is again an understanding that this could be because Child X has
to attention seek and be amongst a lot of rivalry at home so now shadows from others in order to no have
to do so. However, this is not beneficial for her education, “Classmate support, friendly socialising with
classmates is believed to influence students’ satisfaction with school because it may nurture the need for
relatedness. In addition to strengthening the bonding between students, positive student interaction may
nurture students’ need for competence and autonomy through a shared focus on learning activities.”
Danielson, 2009, pg. 305 if Child X defers from socialising with other children then the satisfaction with
school is degraded and the learning is then decreased.

During the observation of the child before going home (Appendices D) the most imperative behaviour that
was observed was the incessant daydreaming before going home, this was also observed at other times,
this affects their learning, “Similarly, a child’s daydreaming, passivity and under- performance in the
classroom could be dissocialise behaviour, or the result of limited intelligence and failure to comprehend
due to traumatic, neural pathway disorganisation.” (Hughes and Archer, 2003, pg. 137) The daydreaming
needs to be looked at in order to gain some strategies to curb this and enhance Child X’s learning in the
classroom and boost intelligence.

Child X was observed during their mathematics lesson which was in a small classroom with six other
children (Appendices E) during this lesson the children are given a biscuit if they have not eaten, Child X
misled the teacher by saying that they had not eaten even though they had. Lewis and Saarni, 1993, pg. 93
describe the behaviour of the children when they lie about food, “Children are not stupid nor are they
foolish. After only one or two interactions like this, the child discovers that if she admits to eating the
cookie she will be punished. She lies to avoid the punishment.” Child X lied to avoid the punishment of
eating a biscuit when she had already eaten.

The childhood experiences have affected Child X’s social and emotional development in a severe way,
which is imperative to their learning and development, “Childhood is a crucial stage in physical, intellectual
and psychosocial development, so children with mental health problems can struggle with their education,
social skills, general health and friendships.” (Honey man, 2007, pg. 39)

Child X is amongst a larger than average family and this could affect her social and emotional skills for a
variety of reasons, as described by Lask and Lask, 1982, pg17, “The most likely explanations are than in
large families the parents have less time to spend with each child and so may provide less stimulation and
education. Further, large families tend to be more disorganized, and so both verbal interchange and
discipline could be inconsistent and confused. Finally, discord and disharmony in large families are more
likely.” As Child X is part of a big family there is less time for the parents to spend time with her, which is
diminishing the chance for social interaction between parents and child. This is also affecting the child’s
behaviour as discipline is more than likely kept to a minimum due to chaos in the house as there is a lack of
routine. Jardine, 2008, [Online] explains that a child who is raised in a larger families’ benefits with their
social and emotional skills this is because they learn new skills, “Children from larger families get into fewer
fights, and are better at making and keeping friends. Through having siblings, children learn empathy, team
playing, gratification deferment, time-management and how to resolve disputes.” As Child X is in a bigger
family then she should have learnt emotional and social skills that will benefit her in her educational setting
and in her coming life.

Chid X has also grown up with her father being a double leg amputee, this surely will have affected her
emotional development in a positive way, Rogers believes that having a parent who is disabled strengthens
a child’s emotions, “Some children with a disabled parent were asked what strengths they got from having
a disabled parent and the responses included perseverance and ingenuity.” (Rogers, 2005, pg. 71) Child X
will have built the emotional skills to be able to persevere in things she does as she will have seen her
father do so with his disability. However, it is unknown for Child X to show the skills of ingenuity in the
classroom where there has been a lot of opportunity to do so. However, Byng-Hall considers that children
who live with a disabled parent may bottle up a lot of anger and may express it at any time, “A child might
start to express the feelings of the disabled parent or those of the parent who might now feel trapped by
their disabled partner. A child may give vent to the anger, frustration, and depression which are his or her
family’s as well as his or her own.” (Byng- Hall, 1998, pg. 266 Having observed and worked with Child X for
many months I believe that Byng- Hall is correct with the emotions of the child being angry and frustrated,
this is due to many possibilities of missed opportunities due to the father being in a wheelchair and the
apparent lack of the mother in the evening. These feelings are stopping Child X from developing both
emotional and in her education.

Not only have Child X’s earlier and current experiences affected her emotional and social development
they also are affecting her learning whilst in the classroom. The first one is the nutrition of the child, no
breakfast is given normally and when it is; it normally consists of a packet or tube of crisps not portion
controlled. This is affecting Child X’s learning in the classroom as deemed by Gurian, Henley and Trueman,
2001, pg 86 “If a five-year-old is under emotional stress, she has great difficulty controlling herself or
learning. If she is under emotional stress, the same is true.” As Child X has no breakfast some days this
could be a factor into the lack of learning and in-putt from the child. However Child X does sometimes have
a breakfast of crisps or sweets which is under some controversy with some practitioners believing that
children having fast food for their breakfast increases their results when doing examinations, could this
boost their learning in the classroom as well, “When given a pre-exam, fast-food lunch, which contained
eight per cent more calories than usual, the children’s grades were, on average, seven per cent higher for
maths and history, and four per cent for English.” (Hoe, 2005, [online]) There is a number of statistics that
show that consuming fast food does help to improve a child’s examination results, however this would not
be approved by the governing bodies for children to eat fast food every day to improve results. This is
because there is much research into the understanding that eating fast food and foods which contain high
numbers of additives are factors towards a child’s behaviour, “Diets high in processed foods are causing
bad behaviour and learning difficulties in children, scientists have warned. They claim junk food stops the
brain from working properly, leading to underachievement and a host of disorders.” Hope, 2005, [online]
During some of the observations Child X was seen to be day dreaming during the carpet work and
occasionally during independent work and at home time Brandell describes how certain types of children
can occasionally ‘go into’ a daydream and not pay attention to what is happening, “For example girls tend
to have more problems with attentions and may engage in daydreaming, may have difficulty processing
information and following directions, or may be shy and withdrawn. Girls with hyperactivity can generally
be hyper talkative.” (Brandell, 2010, pg 303) Brandell looks at the process of daydreaming as a symptom of
a child with ADD or ADHD, and that the child will be slow at processing the information. However, Fries,
2009, [Online] believes that children who do daydream are in fact intelligent and inventive, “For the most
part, children are natural, prolific, and happy daydreamers, and the process plays an important role in their
developing lives. Too often, however, parents and teachers are quick to label daydreaming as a symptom
of an Attention Deficit Disorder or the sign of a slacker in the making. A new study finds that “positive-
constructive” daydreaming, even when heavy in pattern, is not related to psychological disorders as some
have previously thought, but rather is a normal activity that reflects the daydreamer’s imaginative
tendencies and enjoyment of daydreaming.” When observing Child X daydreaming she seemed to be in a
happy daydream rather than a scary or withdrawing dream. However as with Brandell Child X displays
problems with attention, finds it difficult to follow instructions and can seem to be withdrawn when
around other children. Fries on the other hand has looked at this on a more neuro-scientifically way rather
than diagnostically.

There is there neuroscience theory of a child’s behaviour and then there is also the attachment theory
which does affect the way a child behaviours and learns in the classroom. “According to attachment theory
our first relationship with our carers acts as a lifelong template, moulding and shaping our capacity to
enter into, and maintain, successful subsequent relationships with family, friends and partners. It is
believed that these early and powerful experiences with the people who first looked after us will shape our
long-term emotional wellbeing.” (Hall, 2007, [online]) Having observed and worked with Child X for some
time it has come to my knowledge that she does have symptoms of reactive attachment disorder these
being,” Young children may seem withdrawn and passive. They may ignore others or respond to others in
odd ways. Some may seem overly familiar with strangers and touch or cling to people they’ve just met.
However, they lack empathy for others. Their behaviour comes across to others as needy and strange,
unlike the normal friendliness of children. Other symptoms of reactive attachment disorder in children can
include the following: inability to learn from mistakes (poor cause-and-effect thinking) learning problems
or delays in learning, impulsive behaviour, abnormal speech patterns, destructive or cruel behaviour”
(Bower, 2010 [online]) Child X displays many of these symptoms in the classroom, this could be a factor to
the behavioural issues that have happened in the classroom. Even though attachment disorders are
produced during the early stages of a child’s life, it stays with them throughout their life and affects the
people that they meet from teachers, bosses’ friends and future partners.

As Child X’s father was in and out of hospital during the early part of her childhood, there was little bond
formed with both Child X and her father, which could have a big impact on the child’s education. However
Bowlby implies that the primary caregiver and the person most receptive to creating a bond is the mother,
“The underlying assumption of Bowlby’s Maternal Deprivation Hypothesis is that continual disruption of
the attachment between infant and primary caregiver (i.e. mother)” Simply Psychology, 2010, [online] Even
though a father can contribute to the upbringing of the child, Bowlby believes that father is not a main
contributor and so is not a primary caregiver and so will not form a bond and her attachment and
behaviour will be challenged throughout her life.

However, upon looking at the behaviour of Child X further, their behaviour fits more with a child who has
Avoidant disorder attachment. “Extreme shyness, especially while facing a new situation, hypersensitivity
to criticism, rejection and other negative assessment, Avoidance of social as well as occupational
interaction and activities, especially if they require interpersonal contact, Low self-esteem, self-loathing
and a sense of inadequacy and inferiority, Fantasizing about the situations that they usually avoid in reality,
Keeping a certain distance even in intimate relationship, for the fear of being ridiculed.” Bora, 2010,
[online] Child X shows many of these behaviours in the classroom and other environments in the school
with a variety of people within the environment. The avoidant attachment is imperative to the lack of
parents that were and are around whilst Child X is growing up, the father being in hospital and the mother
socialising, there is also a number of other children who may take up a lot of attention from both parents.

As we as forming an attachment with their caregiver, Learning Theories, 2010, [online] understands that
children need a variety of different aspects fulfilled in their life to develop in life and in their education
such things are, for the child to have a sense of worth, accomplishment, and respect for others and
property it also includes care for others, acquaintances and possessions, etc. There are many other
requirements that are needed for the child to lead a successful and content life and education, upon
looking at the needs Child X seems to be unfortunate to not meet them all, such as having a sense of worth
and not taking ownership of their own work which is essential in their education.

However, as this area of needs is at the top of the ‘pyramid’ it could be seen as Child X has not progressed
to that level, although it is possible that she may not progress with limited to no structure in her home life
the safety needs area is not being met as this requires direction and permanence, with no organization and
the parents being in and out of the house the child may not gain a sense and understanding of this. On the
other hand, there is also and understanding that each child starts at the bottom and must progress through
each stage singly, though some of the needs do effect some of the other needs and so they can meet these
consequently which Maslow believes should not happen, so is this really the best theory to look at and for
educational leaders to follow?

It is more realistic to look at the effect that Bowlby’s attachment theory has on a child’s education, life and
behaviour as the way a child builds relationships holds a great deal of responsibility on the way a child’s life
is structured. This is because if a child feels loved and safe in their environment they feel content there is
no need for the fight or flight response as they are comfortable in their life. Looking at the theory of
Maslow’s hierarchy of needs there is problems and flaws with the way a child understands and develops
those skills and many of the skills learnt throughout a human’s life are needed during the early stages and
throughout the educational development stage.

Looking at Child X’s behaviour there is an understanding that it has effects on her education and social
development within school. Child X has numerous behavioural problems however there are four
imperative behaviours that are affecting her education. The first of these is the lack of respect and
understanding of the reality that her behaviour has consequences whether it is good or bad; Child X does
not react to consequences whether it involves staying in a playtime or the loss of ‘golden time’. The school
also hosts a traffic light system (Appendices F) which does not result in effecting Child X’s behaviour.

Child X also has behavioural issues when doing carpet work within the whole class, behavioural issues
during this time are ill-disciplined as the work done at this time assist the child’s independent work
subsequent to the carpet work. If Child X is behaving in a difficult way it is distracting herself from learning
as well as the other children who are also sat on the carpet, also the teacher’s attention is focused on her
rather than other children who may be struggling with understanding the work.

The behaviour that also affects Child X’s learning is the attention seeking from the child from both the
teacher and the teaching assistant’s in the class. After looking into the matter of the attention seeking it
has come to my knowledge that the behaviour of Child X could also be related to suffering from Attention
Deficit Hyperactivity Disorder (ADHD) Mellor and Weymont, 1997, pg. 19 discusses the indications of a
child with ADHD, “As a very rough way of distinguishing the two we can focus on the hyperactivity aspects
of ADHD and attention seeking. The child who displays a great deal of activity in the class as a way of
obtaining attention will almost certainly be happy to settle to work quite calmly with the teacher 1:1. If the
child continues to fidget and move all the time and you suspect ADHD discuss this with your special needs
co-ordinator and school medical officer.” However, Child X will fidget when working one to one with a
teacher it is no different to those who have acceptable behaviour in the classroom so ADHD will not be a
huge factor in the strategies that will be attempted with Child X.

The final crucial behavioural issues is the lack of socialisation skills from Child X with the other children, the
social skills are needed for the children to develop in their educational setting this is verified by an article
by Garner, 2001, [online] which states, “Teachers’ leaders warn that a growing number of pupils are
arriving for their first day at school without the social skills they need to get by. David Hart, the general
secretary of the National Association of Head Teachers, said: “I’m not in the least surprised about the
figures. They show primary school heads are having to deal with a growing number of children from
dysfunctional families, and it is clearly not reasonable to keep pupils in school who are damaging the
education of others.” The social skills are needed from each child to ensure that there are no
disagreements in the class and that the children can undertake simply group discussions without affecting
the education of the other children. Child X has great difficulty maintaining friendships and upholding and
having a view during discussions with the other children in the class, which in many ways is causing
classroom rifts which are leading to the teacher taking time out of a lesson to discuss the issues and
consequences of such clashes.

Now that we have defined the behavioural issues of Child X and the consequences on her education, it is
now time to look at the strategies that could be used within the educational setting which can then also be
used at home I shall look at these in a critical way looking at how they could be seen more as a hindrance
rather than a help to her education. The first strategy I shall look at is the lack of effect that sanctions have
in Child X, however Porter, 2008, believes in a scheme which does not involve reprimand or incentive for
children’s behaviour in the classroom. She believes that children should be taught behaviour as such like a
normal curriculum lesson in the classroom, using the same methods and resources as you would for any
other lesson. On the other hand, Wagner, 2002, how rewards can stimulate children in the classroom,
“Children like rewards, which keep their enthusiasm and willingness steady,” Like Wagner I do believe that
rewards help to enthuse and encourage the pupils to behave in the correct manner, but as seen with Child
X such rewards do not alter the way in which she behaves. Child X does have nurturing on a Monday with a
Special Support Assistant along with five other children, upon discussion with the SSA it is apparent that
Child X is making slow progression, but is ultimately making progress, this could be the method of teaching
children good behaviour that Porter was suggesting to do rather than rewards and punishment.

One strategy that has been research to combat the behavioural issues whilst Child X is doing carpet work,
with the rest of the class; is tactically ignoring the child. Rogers, 2007, pg. 144 examines the use of
tactically ignoring the child, “Tactically ignoring each student who calls out while responding to those using
the hands up rule. Tactical ignoring is only helpful if the students actually sense that the teacher is
conveying a message about selective attention to appropriate behaviour.” Ignoring the calling out of Child
X may trigger her to put her hand up when she wants to answer or ask a question; on the other hand,
tactically ignoring a child can be seen as a negative in the classroom as Westwood explains, “While it is
common to view the frequency of undesirable behaviour in a child as something to reduce, it is more
positive to regard the non- disruptive (appropriate) behaviours as something to reward and thus increase.
It is a golden rule to be much more positive and encouraging than be critical and negative in interactions
with students.” (Westwood, 2002, pg. 73) Westwood examines how rather than simply ignoring the inapt
behaviour as Rogers suggests doing, teachers should combine this with positive comments and praising the
child for the correct behaviour. Rewards could also be used, but as examined earlier Child X does not react
to rewards in the classroom.

There are many strategies to contest the attention seeking behaviour that Child X displays such as, “1. Give
the student a position of responsibility in the classroom and encourage him/her to set a good example for
others (e.g., passing out papers).2. Post a chart in the front of the room delineating the rules to be
followed when responding. For example: 1. Raise your hand if you wish to talk. 2. Wait to be called on. 3.
Listen while others talk. 3. Assign the student a special project of interest and let him/her present the
report to the class.4. Ignore the student’s annoying comments, but give praise when the student describes
his/her real achievements.” (Teacher Vision, 2010, [online]) Again focusing on the teacher is to ignore the
behavioural problems from the child; there is a further issue with this, which may lead to the child’s
behaviour exasperating, “Likewise, simply ignoring children’s early disruptive behaviour and offending is
linked to continued and more serious offending over time.” (Cipriani, 2009, pg. 162) As Cipriani suggests
the bad behaviour should be made clear to the child that it is un-acceptable behaviour; this will make clear
that such behaviours will not be tolerated in the classroom.

The final behavioural issue that needs further intervention is the lack of social skills displayed by Child X,
currently there is in place a special session where Child X is taken out of the class to go to a nurture group
with some other children, this last for an hour and it helps children to enhance their social and anger
management skills. There are reports which show that children in a nurture group have their social skills
and life skills dramatically improved, “The input is intense – praise and encouragement are constant – and
the rewards are high. The London borough of Enfield has had nurture groups since 1981, and now has 13,
which it supports with training. A study here in the Nineties showed that 83 per cent of children who had
been supported in a nurture group were able to later function in the classroom without additional help,
compared to only 55 per cent of children with similar problems who had not had the nurture group
experience.” (Wiles, 2007, online) There are radiant statistics there to inform those of the great help that
children in a nurture group receive, however there is accounts of the nurture groups increasing the bad
behaviour of the children, “There are for example, reports of very difficult nurture groups which actually
reach a crescendo of bad behaviour before calming down and consolidating” (Barnes, 1999, pg. 103) As the
nurture session is in the early stages, it would be more beneficially to allow Child X to continue in the
classes and monitor her improvement and development. There are future developments in the classroom
revolving around the social skills area according to OECD, 2010, “I remember being very impressed at the
time by the fact that teacher trainees in practice teaching not only has to have a curricular and didactic
understanding of how they were going to teach but also needed to show an elaborate and well developed
plan about how they were going to work with a specific diverse class to enhance social cohesion in the
classroom and to teach pro social values and social skills.” The author has seen trainee teachers in other
countries learning how to involve social skills into their teaching and to utilise any available resources.
There are plans to bring such teachings over to England in the upcoming years; this would allow children
such as Child X to gain and expand such skills whilst in the classroom rather than for them to be taken out
of the classroom.

Having observed Child X at various occasions and produced a case study, it was effortless to find out the
behaviours that were unacceptable. It was also looked into as to how Child X’s early life experience have
effected and continue to affect her education and her social and emotional development. There was also
the research into how Bowlby’s attachment theory could have also made Child X’s behaviour improper and
explain the lack of social skills. Having been able to understand the consequent behaviours displayed by
Child X it was then obtainable to develop strategies that could be used in the classroom to help deter the
behavioural issues; this was done in a critical way. After looking at the strategies critically it was clear that
there was no definite strategy to help Child X, although there are future developments into teachers being
able to involve social skills into curriculum lessons.

7. Autistic disorder

Tomeika is a three-year-old girl. She was recently diagnosed with autistic disorder. Tomeika is able to make
many vocalizations and is able to say one recognizable word. Tomeika will say “juice”, which she
pronounces as “oos.” Throughout the day, Tomeika cries and falls to the floor to gain access to food,
obtain a favourite toy, or when she wants to be picked up. Her parents, Mr. and Mrs. Williams, would like
for Tomeika to communicate her desires with words, but do not know how to help her. Tomeika recently
began attending an early childhood special education classroom for learners with ASD in the Hampton
County Public School System for six hours a day, four days a week. On Wednesdays, Tomeika and her peers
do not go to school. Instead, on this day, Tomeika’s interventionist, Mrs. Dell, has parent conferences in
her students’ homes. During the conferences, Mrs. Dell discusses educational programming, learner
progress, areas of concern, and also provides training to parents.

Step 1. Determine the Needs of the Family

During the first few weeks of intervention, Mrs. Dell has learned a great deal about Tomeika and her
strengths, learning style, and specific needs. As Mrs. Dell prepares for her first parent conference, she
decides she would like to learn more about the needs of Tomeika’s family. Mrs. Dell understands that
needs in the home may differ from those in other environments, so wants to take the time to get to know
about Tomeika’s home situation before providing input and training to her parents. During the first
conference, Mrs. Dell discusses Tomeika’s intervention program and progress she has made during the first
few weeks of intervention. Next, the three adults discuss home concerns. Mrs. Dell wants to ensure she
has an accurate and thorough understanding of the parents’ concerns and priorities, so she uses a family
information form (see Resources section) to interview the parents. While completing the interview, Mrs.
Dell focuses on gathering information regarding Tomeika’s strengths, parent-child interaction patterns, and
primary areas of concern. Additionally, Mrs. Dell gathers information regarding typical family activities and
daily routines. Once the interview is completed, Mrs. Dell observes Tomeika for approximately one hour.
She observes Tomeika eating lunch, playing independently, and playing with her father on the swing set.

Step 2. Selecting Goals

During the second conference, Mrs. Dell works with Mr. and Mrs. Williams to create appropriate home
goals for Tomeika. The three adults review the concerns raised at the previous conference. They prioritize
the goals and identify those that will have the greatest impact on family functioning. Mr. and Mrs. Williams
are most concerned about Tomeika’s ability to communicate her wants and needs consistently in the
home. Second, they would like to see her reduce the occurrence of interfering behaviour, including
screaming, crying, and falling to the floor. Once goals are identified, they write the goals in observable and
measurable terms so everyone has a clear understanding and can monitor the target skill accurately. The
following goals are developed by the team.

Tomeika will verbally request (one word) at least five desired items or activities at home each day for five
of seven days for two months.

Tomeika will verbally request desired items (one word) instead of exhibiting interfering behaviour (crying,
screaming, dropping to floor) and will demonstrate no more than three occurrences of interfering
behaviour per week for two months. Through discussion and observation, it was determined that Tomeika
would benefit the most from learning to request the following:

 up (for being picked up),

 chip,
 cookie,
 movie, and
 swing.

Additionally, Tomeika’s parents said that they would like to increase the number and type of interactions
they have with her. The following goals were developed by the team.

To increase number and type of interactions with Tomeika, Mr. and Mrs. Williams will:
 1. model language throughout the day by labeling objects and actions at least five times each day for
two months,

2. read bed time stories to Tomeika three times each week for two months,

3. play concept development games during bath time three times each week for two months, and

4. provide Tomeika with the opportunity to request a desired item a minimum of five times a day for
two months.

Step 3. Developing the Intervention Plan

Using information derived from the interview, observation, and ongoing discussions, Mrs. Dell creates an
intervention plan for Mr. and Mrs. Williams. She is particularly thoughtful about this step because Mr. and
Mrs. Williams both work and have another child. Mrs. Dell outlines a plan that provides a description of
when and where to provide instruction. Additionally, she provides step-by-step instructions on how
intervention is to be implemented.

Mrs. Dell believes the intervention should take place within the context of Tomeika’s natural routines.
Tomeika will encounter most of her target items on a regular basis allowing her parents to take advantage
of naturally occurring opportunities. Further, it will be easy for her parents to create additional requesting
opportunities throughout her day. Since the items are all motivational for Tomeika, Mr. and Mrs. Williams
believe it will be feasible to offer the target items at least 10 times per day within her daily routine.

Mrs. Dell decides that naturalistic intervention will be an appropriate instructional strategy to teach the
parents. Naturalistic intervention has been demonstrated to be an effective instructional strategy and
parents of children with ASD have used this strategy to successfully teach requesting. Additionally,
naturalistic intervention is designed to be conducted within natural routines.

Next, Mrs. Dell creates a data collection system that is succinct and easy to implement in the context of the
home. She decides to have Mr. and Mrs. Williams keep frequency data for both the requesting of desired
items as well as the occurrence of interfering behaviours. Mrs. Dell carefully crafts a data sheet for
requesting. She lists the five target items (up, chip, cookie, movie, and swing) and provides a column to
make a tally mark each time Tomeika verbally requests the item during the course of the day. Next, she
creates a data sheet for interfering behaviour. This data sheet is similar to the requesting data sheet
making it easy to implement. On this sheet, Mrs. Dell lists the problem behaviour and provides a column to
make a tally mark each time Tomeika demonstrates the behaviour during the day.

Step 4. Training Parents

Now that the intervention plan has been created, Mrs. Dell is ready to begin training Mr. and Mrs.
Williams. The three adults work together to develop an individualized training program that will result in
parent learning and implementation of the intervention. When creating the training program, the team
first considers the training format and location. They decide the Williams should receive individualized
training in their home since that is where the intervention will be implemented. Second, they consider the
amount and duration of training. The team outlines a training schedule that offers two hours of training
each week for four consecutive weeks. Once the four weeks are completed, the team will evaluate
progress and outline further training as needed. Lastly, the team considers training components. Mrs. Dell
provides a tremendous amount of input regarding how best to train Mr. and Mrs. Williams. She wants to
be sure the training components are appropriate for this specific intervention plan and also address the
Williams’ learning style. Mrs. Dell decides to provide approximately 30 minutes of training in a
conversational format to supply the parents with foundational information on the intervention strategy
and data collection system. All other training was conducted using a hands-on approach with Tomeika
present. This training consists of Mrs. Dell modelling the intervention, then providing opportunities for
both Mr. and Mrs. Williams to practice. Mrs. Dell provides coaching to the parents and gives immediate
feedback regarding tasks they performed correctly as well as areas needing improvement. At the end of
each training session, the three adults spend approximately 10 minutes recapping the day’s training and
identifying the training needs for the upcoming week.

Step 5. Implementing the Intervention

As the training sessions are provided, Mr. and Mrs. Williams diligently implement the interventions
throughout the week. They take advantage of natural opportunities when Tomeika desires one of the
target items and are able to provide many additional opportunities for her to request each day. They begin
modelling language by labelling a wide array of objects and actions Tomeika encounters. They add pleasant
bath time and story time routines. Over time, they begin to feel more comfortable with implementing the
interventions and are able to incorporate the goals seamlessly into their typical daily routines. As they
implement the intervention, they are careful to complete the data sheets and note major successes with
Tomeika as well as concerns and questions.

Step 6. Progress Monitoring

Mrs. Dell wants to be sure Tomeika’s parents are implementing the intervention with fidelity.
Approximately once a week, Mrs. Dell uses the “Parent Intervention: Fidelity of Implementation Form” (see
documents resource section) to evaluate and document their progress. Each time, she scores the checklist,
reviews the results with Mr. and Mrs. Williams, provides positive comments, and makes suggestions for
areas of improvement. During each training session, Mr. and Mrs. Williams show Mrs. Dell the data they
have collected and notes. The team analyses the data to ensure Tomeika is progressing. Further, Mrs. Dell
provides answers to their questions. After the four-week training period, Mr. and Mrs. Williams feel
confident about their ability to implement the intervention with Tomeika. The team agrees that training on
naturalistic intervention can be reduced to once a month. During the monthly training sessions, the
parents and team members review data and discuss progress and next steps.

Mrs. Dell wants to help the parents generalize this strategy and intervention plan to other behaviours.
Therefore, during the monthly training sessions, she discusses additional needs and concerns, outlines new
goals, and provides additional training to help them implement the intervention effectively. Additionally,
Mrs. Dell has made it clear that Mr. and Mrs. Williams can e-mail her anytime with immediate questions.

After eight weeks of implementing the intervention in the home, Tomeika is now consistently verbally
requesting “up,” “swing,” and “cookie,” which she pronounces as “oo-kee”. She will sometimes request
“chip,” but often requires her parents to provide a verbal prompt. During this time, her parents have seen
a significant decrease in the occurrence of interfering behaviour, as she now demonstrates this behaviour
on average less than two times per week. Her parents are thrilled with her progress. Because Tomeika has
shown progress on making verbal requests, the team has identified two additional items to target--ball and
bath. Her parents are eager to begin work on these new items.

8. Case on Communicating Emotions with ASD

Tait is a 12-year-old boy who was diagnosed with ASD at age 2. Tait is generally healthy although he has
recently been diagnosed with rheumatoid arthritis and is sensitive to pain. He has difficulty with small
spaces and “bottlenecks” where many people are congregated. Tait participates in special education at a
local elementary school. His strengths include being curious, social, and visually astute. His challenges
include communication, impulsivity, and behaviour that may include tantrums, aggression, and property
destruction. These challenges have made it difficult for Tait to participate in activities with peers.

Communication Profile

Tait has a positive-behaviour support team and receives speech-language intervention at the Schiefelbusch
Speech-Language-Hearing Clinic. He is a multimodal communicator whose verbal communication is not
understood by most people. He uses a Palm 3 (Dynavox Technologies), pictures, idiosyncratic signs,
gestures, and some words to communicate.

Assessment

Tait’s communication was assessed with the SCERTS® Assessment Process (SAP; Prizant, Wetherby, Rubin,
Laurent, & Rydell, 2006) in spring 2007. As a criterion-referenced, curriculum-based tool, the SAP
determines a child’s profile of strengths and needs based on his or her developmental stage in the domains
of social communication and emotional regulation. Tait was in the Language Partner stage of
communication. We collected data in three contexts: school, home, and an intervention session in the
Schiefelbusch clinic.

Social Communication

Tait’s strengths in the area of social communication included engaging in reciprocal interactions, sharing
attention to regulate the behavior of others, and using several modes of communication. His needs in
social communication included sharing a range of emotions with symbols and sharing intentions for joint
attention by commenting on objects, actions, events, or requesting information across partners and
contexts.

Emotional Regulation

Tait’s emotional regulation strengths included responding to assistance from a familiar partner that he
trusted, recovering from extreme dysregulation with support from a familiar partner, and using a
behaviour strategy (holding a block of wood) to remain focused and calm in some familiar environments.
His needs in the area of emotional regulation were seeking assistance with emotional regulation from
others, responding to assistance across contexts, and responding to the use of language strategies across
environments.

Transactional Support

Transactional support was strong in some areas. For example, all of Tait’s partners wanted him to learn
and communicate more conventionally and he had consistent, responsive communication partners at
home. Tait needed the same responsive style across all partners and the consistent use of visual and
organizational supports as well as his AAC system to enhance learning and comprehension of language and
behaviour.

Intervention

Goals included:
Increased use of emotion words on the AAC device.
Commenting on objects, actions, or events.
 Choosing what he needs to calm himself from choices offered (from an adaptation of the 5-point
scale by Buron and Curtis, 2003).
Transactional goals included:
Using augmented input (Romski & Sevcik, 2003) with redirection, expansion, and modelling by
Tait’s partners.
Providing a binder with a schedule and social stories (Gray, 1995) for preparation for activities.
Making an AAC device always available and using an interactive diary developed by his mother.
These supports were implemented in activities of interest to Tait such as holidays, his life in photo
albums, tools, and events at home.
9. 9-year-old girl has difficulties with concentration and fine motor skills.

Issue, Concern or Learning Difficulty

Difficulty getting ready for school – being at least 45 minutes late to school every day. Frequent
meltdowns over hair being not perfectly done. Anxious nature and unable to speak in front of the class
or ask for help.

Demographics – Age, Gender, Family Structure

Nine-year-old girl living with parents and younger sibling. Both parents working, occasionally cared for
by maternal grandmother.

What the Therapist Found

Difficulty with planning and organization skills. Low self-esteem and lack of confidence.

Types of Treatment

Initially attended weekly sessions for 4 months. Then fortnightly sessions for 2 months. Provided
strategies for understanding emotions in self and others, self-regulation, modifying negative (red)
thoughts into helpful (green) thoughts using “Fun Friends” training. Sensory diet. Turn taking and
interactive games to develop organizational skills. Sensory motor activities to develop core strength
and upright posture. Self-reflection encouraged to increase ability to cope with challenging situations.

Outcome and Timeframe

By discharge, the child always reached school on time and started participating in dance and drama.
She was elected for the student executive where she had to organize multiple activities with other
children at school. She could also wear her hair in multiple ways without stress

10. 7-year-old girl with concentration and behavioural difficulties.

Issue, Concern or Learning Difficulty

12-month history of difficulty concentrating in the classroom, occasionally leading to behavioural

difficulties.

Demographics – Age, Gender, Family Structure

 7-year-old female, from a family of 5 (Mum, Dad, older sibling, younger sibling).
What the Therapist Found
Assessment revealed specific learning difficulties were present which were leading to frustration and
subsequently, difficulty concentrating and behaviour difficulties in the classroom.

Types of Treatment

Liaison with her school to discuss assessment findings and arrange additional support at school.
Discussion with parents and teachers in relation to strategies to support the child, adaptations to be
made to activities and materials given to the child at school and at home to best suit their needs.
Individual sessions with the child to help them understand their strengths and areas of difficulty and to
improve their self-esteem.

Outcome and Timeframe

Child is doing much better at school both behaviourally and academically and is attending well in the
classroom. Parents and teachers report a much better understanding of the child and feel much more
confident in managing the child’s behaviour.

Week 3 - Session 3 (180 minutes)

 Case study discussion (30 minutes)

 Class on Clinical Psychology

Case studies on clinical concerns.

11. COUNSELLING CASE STUDY: MANAGING ANXIETY

Leah is a 24-year-old woman who was recently discharged from the Army on medical grounds. During her
four years in the Army, Leah experienced high levels of stress and anxiety which she coped with by drinking
heavily. When she presented for counselling, Leah had been sober for 55 days and was seeking strategies
to cope with her anxiety that didn’t involve drinking.

While working with Leah, the Professional Counsellor adopts a case management model in order to assist
her to build a network of supports within the community, enabling her to maintain her sobriety and
prevent recurrence of the factors which contributed to her high levels of stress. For ease of writing, the
Professional Counsellor is abbreviated to “C”.

Background

Leah was an only child whose parents separated during her teen years. She felt isolated and was often
bored at school. Her love of art was the only thing that gave her any enjoyment and she expressed this by
covering the school buildings with graffiti after dark. Already in conflict with her mother due to her poor
school performance, the involvement of the police after she was reported for vandalising public property
further worsened their relationship. Her father had moved away and was no longer involved in Leah’s life.

Leah left school intending to train as an ambulance medic. On being told she lacked the life experience
required for this work, Leah joined the Army on a four-year contract hoping to address this requirement.
However, the Army turned out to be a repeat of the constrictive structure within which she had struggled
both at school and at home.

Being obligated to complete the full four years, she began to feel increasingly trapped and was often
anxious and depressed. She was introduced to alcohol by her fellow recruits and began using this as a
means of deadening her overwhelmingly negative feelings about the course her life was taking. After three
years in the Army, Leah was discharged on medical grounds, having become dependent on alcohol and
unable to control her intake.

Issues identified

A case manager’s initial function is to develop an understanding of the client and help build a resource
network that the client can later access on her own. In this role, C performed an examination of Leah’s
environment, behaviour and immediate needs which identified the following issues:

 Career indecision – although still wanting to be an ambulance medic, Leah had lost confidence in her
ability to achieve this or any other career goal.
 Unsuitable accommodation – Leah was sharing a flat with a young man who yelled at her if she
smoked and often made unwelcome passes at her.
 High levels of stress and anxiety – Leah continually craved alcohol during her period of sobriety and
began using Valium to replace the role alcohol had played in deadening her feelings
 Large amounts of unstructured time – Leah had no other strategies in place to cope with her
negative thoughts and feelings and, now she was no longer working, found herself with large
amounts of time during which she had nothing else to do but think.
 Lack of a personal support network – Leah was estranged from both her parents, had no siblings,
and felt unable to contact any of her former Army colleagues because she felt inadequate due to the
manner in which she had been discharged.

Plan

Following an identification of issues needing attention, the case manager then coordinates a plan to enable
the client to access needed assistance within her community. In this role, C worked with Leah to outline a
plan which involved the following strategies:

 Schedule pleasurable activities

 Obtain suitable accommodation
 Increase support networks
 Contact a supported job training network
  Access Centre link benefits
 Undertake a drug and alcohol rehabilitation program
 Cognitive restructuring
 Medication monitoring
 Ongoing support

This plan was designed to utilise Leah’s strengths and was later outlined in clear measurable terms that
allowed for periodic evaluation of her progress. This is particularly important when the client is becoming
disillusioned as it illustrates to her that while she may not yet have reached her goals, she has made
significant progress towards them. Leah’s goals were developed with her input to encourage her to feel
ownership of them, increasing her motivation.

Barriers

The following barriers to the above plan were identified:

 Craving for alcohol – Leah had used alcohol as a way of coping with overwhelming feelings,
consequently she had strong cravings whenever she was feeling particularly stressed and anxious
 “Doctor shopping” – Leah had discovered that Valium served a similar purpose to alcohol and when
her GP refused to give her any further prescriptions, she simply went to another doctor.
 Misinterpreting anxiety and stress symptoms – Leah had become hyper vigilant towards her
physical symptoms of anxiety (breathlessness, increased heart rate, hot flushes, dizziness),
interpreting them as medical problems resulting from her drinking, which further increased her
stress and anxiety levels
 Pessimism – Leah exhibited this internal barrier through her belief that she was solely responsible
for the things that had gone wrong in her life and that because of this, there was no way for things
to change and nobody would be able to help her. This left Leah feeling helpless, overwhelmed and
at times suicidal.

Goals

Leah’s goals were written in specific behavioural terms as follows:

 Schedule enjoyable activities – C asked Leah to make a list of five activities that had either given her
pleasure in the past or were things she would like to try in the future. She listed jogging, calligraphy,
painting, reading and walking on the beach. C asked Leah to carry out at least one of these activities
every day.
 Obtain suitable accommodation – C asked Leah to contact a former Army colleague who had always
been very caring towards Leah and who had previously invited her to share her home. Leah did this
and, upon moving in, she and her new flatmate bought a new puppy, providing Leah with further
enjoyable activity on a daily basis.
 Supported employment / job training – C accompanied Leah to an appointment with a supported
employment service run by the state government. This service aimed to support Leah in regaining
 her confidence in returning to the workforce, providing her with vocational counselling to guide her
career choices and ongoing support when searching for and commencing employment. They were
also able to provide funding for retraining.
 Centre link benefits – C helped Leah obtain and lodge necessary forms to help her transition to New
Start Allowance once her Army benefits had run out.
 Rehabilitation – C connected Leah with appropriate contacts to commence drug and alcohol
counselling and to undergo residential rehabilitation if needed.
 Cognitive restructuring – C provided short-term intervention aimed at identifying Leah’s irrational
thought processes and replacing these with a more functional belief system. Here C took on the
counselling function of the case management role and centred the work around Leah’s belief that
she was a failure and would never get her life together. This process utilised Rational Emotive
techniques such as Examine the Evidence and Thinking in Shades of Grey (Ellis as cited in Dryden &
Golden, 1986).
 The Gestalt technique ’empty chair’ (Perl’s as cited in Patterson, 1986) and aspects of Dialectical
Behaviour Therapy (Linehan, 1993) were also used to address Leah’s unresolved feelings towards
her parents and to teach her to tolerate distress without having to escape through the use of drugs
or alcohol.
 Medication monitoring – C arranged for Leah to be seen regularly by a psychiatrist in addition to
her local GP to ensure she was receiving the correct medication and to facilitate hospital admission
should the need arise. She was also educated about the fight or flight response that was leading to
her physical symptoms.
 Ongoing support – C provided Leah with contact names and numbers for local chapters of
Alcoholics Anonymous and, following successful completion of her immediate goals, C referred
Leah to her local community health clinic for ongoing monitoring and medical follow-up.

Session Summary

C has provided a combination of case management and counselling functions while working with Leah. As
counsellor, C has used Cognitive Behaviour Therapy, Dialectical Behaviour Therapy and Gestalt Therapy
techniques to facilitate achievement of the client’s goals.

In reducing her high levels of anxiety and stress, Leah was able to address her more practical needs, for
example challenging her beliefs about what her former colleagues thought of her enabled her to contact
one of them to follow up on the offer of accommodation. While C provided education and support in this
regard, Leah carried out most of the practical tasks herself, thereby building on her strengths and further
increasing her confidence levels and reducing her pessimism.

This process occurred over a three-month period, during which two progress reviews took place between
C, Leah and her psychiatrist. At this time, Leah was able to see the progress she was making and was also
able to draw attention to any areas with which she was experiencing difficulty or concern.

Upon completion of the above plan for meeting Leah’s immediate needs, C has referred her to services
able to provide her with ongoing but less intensive support. With Leah’s written permission, C provided the
community health centre with a referral form outlining Leah’s history, medication regime, and a summary
of the work undertaken with C, which C had documented following each session with Leah.

C maintained contact with Leah on a weekly basis during the transition to the new service and while she
became comfortable in her local AA support group. In taking this step, C has ensured Leah has acquired the
necessary skills for maintaining progress on her own, with assistance available to her as needed

12. A COUNSELLING CASE STUDY USING CBT

Jocelyn works as a Human Resources Manager for a large international organisation. She is becoming more
and more stressed at work as the company is constantly changing and evolving. It is a requirement of her
job that she keeps up with this change by implementing new strategies as well as ensuring focus is kept on
her main role of headhunting new employees.

She finds that she is working twelve-hour days, six days a week and doesn’t have time for her friends and
family. She has started yelling at staff members when they ask her questions and when making small
mistakes in their work. Concerned about her stress levels, Jocelyn decided to attend a counselling session.

Below is an extract from Jocelyn’s first session with her counsellor:

Transcript from counselling session

Counsellor: So Jocelyn, let’s spend a few minutes talking about the connection between your thoughts
and your emotions. Can you think of some times this week when you were frustrated with work?
Jocelyn: Yes, definitely. It was on Friday and I had just implemented a new policy for staff members. I
had imagined that I would get a lot of phone calls about it because I always do but I ended up snapping
at people over the phone.
Counsellor: And how were you feeling at that time?
Jocelyn: I felt quite stressed and also annoyed at other staff members because they didn’t understand
the policy.
Counsellor: And what was going through your mind?
Jocelyn: I guess I was thinking that no-one appreciates what I do.
Counsellor: Okay. You just identified what we call an automatic thought. Everyone has them. They are
thoughts that immediately pop to mind without any effort on your part. Most of the time the thought
occurs so quickly you don’t notice it but it has an impact on your emotions. It’s usually the emotion that
you notice, rather than the thought. Often these automatic thoughts are distorted in some way but we
usually don’t stop to question the validity of the thought. But today, that’s what we are going to do?

The counsellor proceeds to work through the cognitive behaviour process with Jocelyn as follow:

Step 1 – Identify the automatic thought

Together, the counsellor and Jocelyn identified Jocelyn’s automatic thought as: “No-one appreciates what I
do”.

Step 2 – Question the validity of the automatic thought

To question the validity of Jocelyn’s automatic thought, the counsellor engages in the following dialogue:
 Counsellor: Tell me Jocelyn, what is the effect of believing that ‘no-one appreciates you?’
Jocelyn: Well, it infuriates me! I feel so undervalued and it puts me in such a foul mood.
Counsellor: Okay, now I’d just like you to think for a moment what could be the effect if you changed
that way of thinking
Jocelyn: You mean, if I didn’t think that ‘no-one appreciates me’?
Counsellor: Yes.
Jocelyn: I guess I’d be a lot happier in my job. Ha, ha, I’d probably be nicer to be around. I’d be less
snappy, more patient.

Step 3 – Challenge core beliefs

To challenge Jocelyn’s core belief, the counsellor engages in the following dialogue:

Counsellor: Jocelyn, I’d like you to read through this list of common false beliefs and tell me if you
relate to any of them (hands Jocelyn the list of common false beliefs).
Jocelyn: (Reads list) Ah, yes, I can see how I relate to number four, ‘that it’s necessary to be competent
and successful in all those things which are attempted’. That’s so true for me.
Counsellor: The reason these are called “false beliefs” is because they are extreme ways of perceiving
the world. They are black or white and ignore the shades of grey in between.

Applications of CBT

Cognitive approaches have been applied as means of treatment across a variety of presenting concerns
and psychological conditions. Cognitive approaches emphasise the role of thought in the development and
maintenance of unhelpful or distressing patterns of emotion or behaviour.

Beck originally applied his cognitive approach to the treatment of depression. Cognitive therapy has also
been successfully used to treat such conditions as anxiety disorders, obsessive disorders, substance abuse,
post-traumatic stress, eating disorders, dissociative identity disorder, chronic pain and many other clinical
conditions. In addition, it has been widely utilised to assist clients in enhancing their coping skills and
moderating extremes in unhelpful thinking.

13. COUNSELLING CASE STUDY: USING REBT

Thomas is a 33-year-old married man, who has recently become a father. He explains that he feels his self-
esteem has been gradually deteriorating ever since he was married. He says that he can’t find reasons to
enjoy life with his wife due to feelings of inadequacy as a husband.

In his new role as a father, Thomas had hoped to find the happiness that he was looking for; however, this
has not been the case. He mentions that his relationship with his wife’s family is strained and thinks that
this is the root of his problem. In this scenario, the Professional Counsellor will be using a Rational Emotive
Behavioural approach with Thomas.

For ease of writing the Professional Counsellor is abbreviated to “C”.

Background Information

Thomas was married 4 years ago to Helen. They met after leaving school and have been in a continuous
relationship since that time. Thomas describes his relationship with Helen as a strong friendship, but also
explains that they have experienced recurring problems in their relationship.

Thomas feels that the main problem is the interference of Helen’s family in their partnership. Helen has
had a close relationship with her mother and father and had been living with them up until 5 years ago.
Neither Helen’s mother or father approved of her relationship with Thomas, since their first meeting.
Thomas is at a loss to explain their disapproval of him, and it appears that he has tried in many ways, to
gain their respect.

Initially Helen was hesitant to continue a relationship with Thomas, due to her parent’s strong reaction to
him. At times they even carried on their relationship in secret to avoid her parent’s reaction. It became
more apparent to them that they would eventually have to overlook Helen’s parents’ opinions of their
relationship and follow their own wishes.

Finally, Helen and Thomas moved into their own apartment and became engaged to be married. Since
becoming married and having their first child, Thomas has continued to extend himself to great personal
lengths to maintain any of his parents-in-law’s support. It is his belief that if he extends himself enough,
that they will come to love him as much as they love their daughter.

He finds this position very demanding. Of particular difficulty is that Helen’s parents expect to be visited on
a weekly basis, by their daughter and new grandchild. These weekly meetings are very draining for Thomas
as his parents-in-law are still openly critical of him. At best, he says, they ignore him. In these situations, he
finds that Helen is quite passive, though she tells him that she wishes her parents were less critical. Helen
has said to him that it is usually best to just let them have their way, and this appears to reflect her pattern
of coping with the situation.

Session Content

“C” firstly aims to assist Thomas to understand his feelings and beliefs about the current difficulties. They
discuss Thomas’s beliefs and feelings about his relationship with his wife and parents-in-law. It appears
that for a long time Thomas has held the belief that if he just tries hard enough, Helen’s parents will stop
their criticism and come to respect him. He also thinks that without their approval, he will never
completely gain the full respect of his wife.

“C” used humour to begin to challenge Thomas about his views. The use of humour in REBT is a strategy to
reduce the importance and value that clients place on certain irrational beliefs. This strategy does need to
be balanced with sensitivity and timing, to ensure clients do not become offended by the counsellor’s use
of humour. Humour is most effective when the client is also able to enter into the joke and it shouldn’t be
used to belittle the client or their feelings.

“Thomas it seems to me that you have been seeking the approval of these people, since the first day that
you met them. In that time, you have been ignored, belittled, backstabbed and denied respect. Even after
your public declaration of love to their daughter, their behaviour towards you has not changed. Under
these trying circumstances, I must congratulate you on your undying loyalty to your wife and her family!”
Thomas reacted well to the humour and responded with a joke about his wedding vows, “On my wedding
day, I never realised that I also had to love, honour and cherish my wife’s mother and father!”

“I am absolutely certain that you never would have vowed that on your wedding day. After all, a marriage
is the unity of only two people”, replied “C”. “This leads me to wonder about your reasons for continuing
to appease Helen’s parents, in what appears to be beyond the call of duty and in the face of such
adversity.”

Thomas responded to “C’s” confrontation. “I’ve always felt this need for their approval. To me, it is all
wrapped up in my role as a husband. It is my duty to be a good son-in-law and I’ve just hoped that they’ll
come to accept me in time.”

“C” asked Thomas about how he would prefer to be treated by his parents-in-law. Thomas replied that he
wanted a friendship with his new family and to be respected by them. He wanted them to be less pushy
and more cooperative with himself and Helen.

“C” spent some time then explaining the nature of irrational beliefs with Thomas. “Due to certain learning
experiences in our lives, we come to accept certain beliefs about ourselves and others. These beliefs may
be inappropriate for us if they don’t allow us to realise happiness or acceptance of the disappointments in
life. Our beliefs are reinforced by particular thoughts that we should behave in certain ways.

If our thoughts and behaviours are more concerned with the welfare of others, rather than ourselves, this
can lead to lowered self-esteem and further self-condemnation. The task that all of us face at some time, is
to realise that some of our thoughts and behaviours are not healthy and to replace these with more self-
appreciating thoughts and behaviours.”

From this discussion, Thomas came to understand that he had control over his own beliefs and therefore,
control over his behaviour and a chance to improve his self-esteem. The first step, “C” explained, was to
identify the irrational beliefs that were controlling his life. The irrational beliefs that “C” and Thomas
identified are listed below:

a. “I must have the respect of my parents-in-law”.

b. “It is my duty as a good son-in-law and husband to meet the approval of my wife’s parents”.
c. “My wife will never completely respect me if her parents do not respect me”.
d. “If I keep trying, they’ll eventually accept me”.
e. “My need for happiness is secondary to the needs of my in-laws”.

“C” said, “Thomas, you said before that you want Helen’s parents to be less pushy and more respectful of
you. I would challenge you that these are preferences that you have, which you have little personal control
over. You cannot expect to change another’s behaviour. Instead I would like you to think about your own
behaviours and how you might have more control of them, by changing your irrational beliefs. We can do
this through a process of debate, where we weigh up the pros and cons of your beliefs”

“C” began the debate by challenging Thomas about his beliefs through a series of questions. “Why do you
need your parents-in-law approval to be a good son in law? What constitutes good parents-in-laws? If you
had a son-in-law, how would you treat him? At what point do parents need to reduce their control of their
children? Do you expect to be meeting your parents-in-laws demands for the rest of your married life?
Where did you learn that you have a duty to obey Helen’s parent’s wishes?”

Through open debate and discussion of these questions, Thomas was able to view his irrational beliefs
from different angles. He was able to see how his belief impacted on his own wellbeing, and that his future
happiness was dependent on his ability to change his belief and subsequent behaviours.

The next step involved identifying and constructing new, more appropriate beliefs with Thomas. “C”
encouraged Thomas to rethink alternatives to the irrational thoughts that he identified earlier. Instead of
the belief, “I must have the respect of my in-laws,” Thomas was encouraged to rephrase this as a
preference. “I would like to have the respect of my in-laws.” To this belief he also added some other
preferences such as “I would like to be able to respect my in-laws in return.” Other modified beliefs for
Thomas included:

a. “It is not my duty as a son-in-law to accept personal criticism or being ignored”.

b. “It is my duty to be respectful of my wife’s family, though not to the point of sacrificing my
happiness”.
c. “My wife respects me as her husband and partner”.
d. “My wife’s love is not determined by the influence of her parents”.
e. “My wife and I have the right to determine how we will be involved in the life of our families”.
f. “My priorities for happiness begin with myself, my wife and my son”.
g. “I accept that my in-laws may never accept me for who I am”.

“C” and Thomas also listed behaviours that could increase his personal happiness and reflect his new
beliefs about himself:

a. Personally invite his parents-in-law around for visits, instead of visiting them.
b. Address any demands from parents as requests and notify them that the matter will be
discussed by Helen and himself in private. With Helen, redefine boundaries between couple
issues and family issues. For example, discuss the amount of time that should be spent with
various family members.
c. Expect parents to be more respectful of him and do not tolerate criticism. Determine the
consequences if this behaviour is not forthcoming, i.e.: politely leaving, hanging up the phone or
ending conversations if no respect is shown to him. Encourage ways in which Helen could also
expect more respect from her parents.
d. Discuss his personal changes with Helen and talk about the implication of these for both of
them.

In summary of the session, “C” expressed enthusiasm at Thomas’s willingness to explore his irrational
thoughts and self-condemning behaviours. “C” recommended a further discussion of Thomas’s self-
statements and establishment of a program of behaviour change, structured on his new beliefs.

For homework, Thomas was required to identify other problems and self-defeating beliefs that were
affecting his life. For each of these, he needed to challenge their rationality and record these thoughts in a
personal log book. The log book would act as an inventory of all of Thomas’s irrational thoughts and
beliefs. He could refer to this book as a reminder to himself of the beliefs that he was challenging.
“C” also suggested that he could begin to identify more appropriate thoughts to supplement his irrational
thoughts and record these in his log book. “C” highlighted to Thomas that disputing irrational beliefs was
something that required practice and to not expect this to happen automatically.

Thomas also suggested inviting Helen to take part in counselling with him, so that she would be more
aware of his new beliefs and for them to discuss mutual strategies for managing their family problems.

At the end of the session, “C” reminded Thomas of the presence of irrational and self-defeating beliefs that
he holds and how these impact on his opportunity for personal happiness and self-confidence. The
challenge for Thomas was to continue to become more aware of the presence of self-defeating beliefs in
his life and to energetically replace these with more personally satisfying thoughts.

End of Session

Some points to consider with Rational Emotive Behaviour Therapy are as follows:

People have the capacity for rational and irrational thoughts and beliefs. Irrational beliefs can also be
described as absolutistic cognition’s. Absolutistic cognitions by nature demand that certain situations or
behaviours should, or must occur in order to meet certain standards that the client believes to be
necessary.

REBT proposes that humans are fallible and imperfect and endeavours to help clients realise and accept
their fallibility and construct more satisfying thoughts and beliefs. We often seek counselling due to the
consequences that we are experiencing because of our irrational thoughts and beliefs.

The focus of REBT is to help the client to understand the connection between their irrational beliefs and
their present problem. The counsellor aims to expose the irrational and self-destructive beliefs and to
challenge their value to the client. For example, if a client thinks that they need the approval of everyone
around them, then the REBT therapist will identify this belief and dispute the client’s reasons for holding
this belief.

Once exposed, the therapist and client can then work towards identifying more appropriate and rational
beliefs. From these beliefs it is hoped that new feelings and thoughts will arise for the client. This process is
known as the ABC theory of personality where:

(a) The activating event or stimulus, paired with the

(b) belief about the activating event, causes a
(c) consequence (the emotional and behavioural response)
(d) is the disputing intervention that is introduced to change the (b) belief. After which a new
(e) effect (more appropriate belief) becomes associated with the original (a) activating event. Lastly
new
(f) feelings arise which are associated with the new beliefs about ourselves.

The methods involved in REBT include:

a. Disputing irrational beliefs in a systematic and logical way.

b. Changing one’s language from should, oughts’ and musts to preferences.
c. Using humour to reduce the exaggerated effects of irrational thoughts and beliefs.
 d. Doing cognitive homework to identify absolutistic beliefs behind their problem. This can include
assignments to observe their self-fulfilling prophesies, reading self-help books and listening to tapes
of earlier counselling sessions to critique their original self-defeating beliefs.
e. Using modelling and role play in the session to encourage the client’s use of more rational thoughts
and beliefs.

14. A CASE OF USING A PERSON-CENTRED AND COGNITIVE-BEHAVIOURAL APPROACH TO BURNOUT

Brett is a 36-year-old man who works as an accountant for a small family business. The business is failing
and Brett will probably have to begin the process of “winding it up” in the near future. His commitment to
the business and his friends, the business owners, has intensified the level of stress he is feeling as a result
of the business collapse. He has taken a week off work on sick leave and feels too “stressed” to return to
work.

In this scenario, the professional counsellor uses a Person-Centred/CBT approach. For ease of writing, the
Professional Counsellor is abbreviated to “C”.

Background

Melinda, Brett’s wife, contacted C because she was greatly concerned for her husband. She was worried
that Brett was depressed as he was refusing to go to work. She stated that he had agreed to attend
counselling if she organised an appointment, however he did not think it would help him.

Brett had worked as an accountant in small businesses for the last twelve years. About eight years ago he
was working with another business that required him to close it down. He described that experience as
extremely distressful. He felt that the process had involved a loss of loyalty from organisations associated
with the business and that he saw this as a “personal attack” against him. He also felt he had been exposed
to people who would do everything they could to get as much as possible from a “crumbling company”.

Brett reported the following symptoms: decreased motivation particularly in relation to his work, unusual
outbursts of anger, anxiety whenever he thinks about his work or attends his workplace, and difficulty
sleeping. He stated that these symptoms commenced when he realised that the business he was working
for might begin to fold and have increased to the point that he is finding it difficult to complete his usual
tasks and “doesn’t want to do anything”.

Brett attended four appointments with Cover a ten-week period.

Session Details

In the first session, Brett reported that he felt he was “depressed” (using his own understanding of the
term). He stated that the depression began as the retail business he was working for started deteriorating.
He also described feeling depressed in the past on about 4 or 5 other occasions when he had experienced
significantly negative events in his life.
One of these events was that while he was working for a printing firm six years ago, it began to fold and he
was required to do the work to “wind it up”. During that time, he felt betrayed by people he had trusted
and he felt “conned” and tricked by many “colleagues”, and as a result, he had felt like a failure. He stated
that he was now experiencing an extreme fear of having to go through the same experience again.

Brett described working at least a sixty-hour week every week and that his whole life revolved around his
work, in fact, he had not had a holiday for at least four years. He said that he measured his success in life
by the quality and quantity of his work rather than by any other measure, including the income he earned.
He talked about how his family of origin had in the past told him to work elsewhere, as he would earn a lot
more money. Brett knew that they were right, but he preferred to be involved in the development of a
small company, and money was not very important to him.

Brett reported that he felt “a bit silly” having such a big psychological reaction to something that he
thought should not affect him at all. C identified his symptoms as a burnout-type of reaction and gave Brett
some information, including the causes and symptoms of burnout, to take home and read. C identified the
seriousness of the events that had led to his level of stress and normalised Brett’s reaction. Additionally, C
reality-checked Brett’s feeling of ‘failure’ and his high level of concern for not letting his friends, the
business owners, down.

To manage the current level of stress that Brett was experiencing, C recommended he continue his
temporary respite from work (Brett had stated that he would not be able to cope with returning to work)
and that he implement some relaxation strategies. The strategies included:

 Regular exercise (Brett had explained that he liked to walk regularly but had not done so for
some time)
 Doing things that he enjoys and things that he finds relaxing
 Use of a relaxation tape each evening (provided by C)

Brett was very concerned about what he should do about his return to work. He said that he did not feel
that he could go back. C suggested that he try not to think about the decision concerning his return to work
until our next appointment in two weeks, at which time we would work out what his strategy would be.
Instead, he should focus the next two weeks on relaxation and self-care. C encouraged Brett to keep any
return to his workplace to very brief periods over the next two weeks, and to use his relaxation tape before
and during that time if necessary.

In the following session, Brett reported that he felt “more relaxed”, although he continued to feel
unmotivated to return to work. He described walking regularly and avoiding worrying too much about
work. He also said that he had gone into work for two brief periods during the two weeks and had
experienced a high level of stress and frustration when he did, although he reported some comfort from
the use of the relaxation tape. This experience reinforced to him that he was unable to return to work in
his previous capacity. C used a four step decision-making model to assist Brett to come to a decision about
his work.

Step One: What is the problem?

 Brett is extremely stressed when he considers returning to work and does not think he can do it.
  He does not want to let his friends, the business owners down.
 He wants to fight through his anxiety (not be a coward) and return to work

Step Two: What are the options and what are the relevant issues associated with each one?

 Resigning from his work – he would feel that he let the owners down and that he might ‘run
away’ at the next sign of stress he experiences.
 Remaining in the position as he was before his recent leave – he felt he could not cope in this
scenario.
 A balance between the two previous options: sharing the position’s responsibilities with a
colleague, delegating the tasks that he finds most stressful, and working from home as much as
possible.

Step Three: What is the best option?

 The third option, to take back the work on a different basis.

Step Four: What do you need to do to implement the best option (include possible contingency plans)?

 To continue with leave from work for the next two weeks with only a minimal work
involvement.
 To gradually increase his workload particularly on a work-from-home basis, and to continue to
use relaxation strategies when needed to assist this process.
 Balance his life better, that is, focus on other things as indicative of success, including:
o good relationships with wife and family
o improved health
o developing hobbies
o taking enjoyable holidays

C suggested that Brett develop a written plan for managing and balancing all the aspects of his life
(relaxation, enjoyment, hobbies, family relationships, and work) that would be reviewed at the next
appointment.

In the third session, Brett explained that he had taken a holiday for a week with his wife and had returned
“refreshed” and with new insights into his life. He also stated that his stress continued to reduce. He
described a “new conviction” to balance his life more.

C and Brett reviewed his gradual plan for return to work on a work-from-home basis and his delegation of
tasks to other employees. Brett had also decided to undertake this plan for another month and then
review it again to see if his decision had changed. At that point, he felt he might be able to return to the
workplace full-time, or he might decide to resign from his position and move to another area to start again.
He said that he realised that when he has no clear direction and feels out of control, he gets very stressed.

He described these things as the triggers for the stress he has felt in this situation and similar situations in
the past. He therefore decided to ensure that he always has a sense of direction and control in the whole
of his life by taking the focus away from work. C supported and encouraged his continued self-reflection
and determination.
One month later, Brett attended a fourth and final appointment. Brett described the stress as almost
completely gone. He was working half the time at home and the other half at the workplace, and the
business owners were happy with his return. However, Brett had also decided to move to a more rural area
in three months and continue to work in the position predominantly from home.

This move is based on his decision to balance his life more and he was excited about his family’s plans. He
had commenced playing a sport with friends one night a week and was walking regularly. He stated that he
had realised it would take some time to change his measure of success/failure, however, he would
continue to address it.

Key Concepts of Person-Centred/Cognitive-Behavioural Therapy Applied

 Developing a positive therapeutic relationship using unconditional positive regard and empathy.
 The assumption that, given the right environment, the client will strive towards self-
improvement and self-actualisation.
 Providing education on burnout and managing symptoms.
 Reducing the overwhelming nature of the problem by identifying it specifically. This made the
problem something that could be addressed more readily.
 Normalising the client’s reactions and behaviours.
 Implementing a problem-solving/decision-making model.
 Application of relaxation techniques.
 Reducing sources of stress by prioritising them and delegating them where possible.
 Gradual exposure to the stressor (return to work).
 Reality-checked cognition’s (letting friends down, being a failure).
 Fostered insight into key issues and their possible causes.
15. COUNSELLING CASE STUDY: RELATIONSHIP PROBLEMS

Mark is 28 and has been married to Sarah for six years. He works for his uncle and they regularly stay back
after work to chat. Sarah has threatened to leave him if he does not spend more time with her, but when
they are together, they spend most of the time arguing, so he avoids her even more. He loves her, but is
finding it hard to put up with her moods. The last few weeks, he has been getting really stressed out and is
having trouble sleeping. He’s made a few mistakes at work and his uncle has warned him to pick up his act.

This study deals with the first two of five sessions. The professional counsellor will be using an integrative
approach, incorporating Person Centred and Behavioural Therapy techniques in the first session, moving to
a Solution Focused approach in the second session. For ease of writing the Professional Counsellor is
abbreviated to “C”.

Background

After leaving school at 17, Mark completed a mechanic apprenticeship at a service station owned by his
uncle and has worked there ever since. His father died from a heart attack when Mark was six years old
and his uncle, who never married, has been a significant influence in his life. He is the youngest of three
children, and the only boy in the family. One sister (Anne) is happily married with two children and the
other (Erin) is single and works overseas. Mark and his mother have a close relationship, and he was living
at home until his marriage.

Some of Mark’s friends are not married and say he was a fool for ‘getting tied down’ so young. Mark used
to think that they were just jealous because Sarah is such a ‘knockout’, but lately he has started to wonder
if they were right. In the last couple of months, Sarah has been less concerned about her appearance and
Mark has commented on this to her. Sarah had been looking for work, but doesn’t seem to do much of
anything now.

Three months ago, Sarah found out she can’t have children. According to Mark, she hadn’t spoken about
wanting kids so he guessed it wasn’t a big deal to her. When she told him, Mark had joked that at least
they wouldn’t have to go into debt to educate them. He thought humour was the best way to go, because
he had never been very good at heavy stuff. Sarah had just looked at him and didn’t respond. He asked if
she wanted to go out to a movie that night, and she had started to shout at him that he didn’t care about
anyone but himself. At that point, he walked out and went to see his brother-in-law, Joe and sister, Anne.

Since then, he and Sarah hardly spoke and when they did it often turned into an argument that ended with
Sarah going into the bedroom, slamming the door and crying. Mark usually walked out and drove over to
Joe’s place. When Anne tried to talk to Sarah about it, Sarah got angry and told Anne to keep out of it, after
all what would she know about it. She had her kids. Joe and Anne had kept their distance since then. Mark
talked to his mother, but she said that this was something he and Anne had to work out together. It was
she who suggested that Mark come to see C.

Session One

When Mark arrived for the first session, he seemed agitated. C spent some time developing rapport, and
eventually Mark seemed to relax a bit. C described the structure of the counselling session, checked if that
was ok with Mark, then asked how C could help him.

Mark: “I really wanted Sarah to come; my wife, but she said that I need to sort myself out. I have to tell
you, I don’t think counselling is really for men. Women are the ones that like to talk for hours about
their problems. I only came here because she insisted and I don’t want her to walk out on me.”
C: “Your marriage is important to you.”
Mark: “Yeah, sure. We’ve had fights before, but they weren’t anything major. And we always made up
pretty quickly. But this is different. It seems like whatever I say is wrong, you know? Lately, I haven’t
been able to concentrate properly at work and I wake up a lot through the night. I’m feeling really tired
and I wish Sarah would get off my case.”
C used encouragers while Mark described what had been happening over the past few months. When
he had finished ventilating his immediate concerns, C, moving into Behavioural techniques,
summarized and asked Mark to decide what issue he wanted to deal with first. “Mark, you have
discussed a number of issues: you are concerned that communication between you and Sarah has been
reduced to mostly arguments; you’re unsure how to deal with the fact that Sarah cannot have children;
you want to improve your relationship with Sarah; you are worried that Sarah might leave you, and you
are feeling very stressed out. What area would you like to work on first?”
 Mark: “I just want her to talk to me without arguing. All this is making it really hard for me to
concentrate at work, you know.”
C: “Sounds like two goals there, to reduce your stress and to improve communication between Sarah
and yourself.”
M: “Yeah, I guess so. If she would just talk to me instead of crying.”

C used open questions and reflections to encourage Mark to look at his feelings. “How do you feel when
she goes into the bedroom and starts crying?” Mark: “Well, she’s never been a crier, and I don’t know what
to say to her. If I mention not having children, she will probably cry even more.”

C: “So you feel confused about what to do, and anxious that you may upset her even more.”
Mark: “Yes, I just can’t seem to think straight sometimes. Like, I want things to be the way they were,
but it’s just getting worse.”
C informed Mark about the use of relaxation techniques to reduce his stress and checked out if he
would like to give it a try. “Mark, you appear to be having difficulty coping because you are feeling very
stressed. I believe that learning relaxation techniques would decrease the level of stress and help you
think more clearly. How does this sound to you?”
Mark: “I’m not into that chanting stuff if that’s what you mean.”
C explained that there are many forms of relaxation and described the deep breathing and muscle
tensing method; Mark agreed to do this for 10 minutes twice a day.
As the first session drew to a close, C reviewed the relaxation technique and asked Mark to practise it
as often as possible. A second appointment was arranged for the following week.

At the next session, C asked Mark how the relaxation exercise had helped. “I forget to do it some mornings,
so I did it for twenty minutes at night instead. I told Sarah what I’m doing and she just leaves me to it. Not
sure if it’s making any difference but I’ll keep doing it. It’s nice to have twenty minutes of peace and quiet.”
At this point, C moved into a Solution Focused approach.

C congratulated Mark on commencing the relaxation practice, then checked out if it was okay to ask him
some different types of questions. Mark agreed and C asked a miracle question. “Imagine that you wake up
tomorrow and a miracle has happened. Your problem has been solved. What would other people notice
about you that would indicate things are different?”

Mark looked at C, who waited in silence. Eventually Mark responded. “Ok, they would see me and Sarah
talking a lot more, without arguing.”

C: “What else would they notice about you?”

Mark: “I would probably be spending more time at home. You know, not staying back so late at work.”
C: “What would they notice that was different about Sarah?”
Mark: “That’s easy. She wouldn’t be crying and yelling all the time.”
C: “So what would she be doing instead?”
Mark: “I guess she would be talking to me, and smiling.”

After spending some time exploring what would be different if the miracle happened, C asked Mark what
he had tried in the past to improve communication. Mark revealed that he bought Sarah some flowers and
a box of chocolates (his uncle’s suggestion) but it hadn’t really made any difference. C complimented Mark
on his efforts and continued with an exception question.

“Can you think of a recent occasion, when you would have expected a quarrel to start and it didn’t?”

Mark furrowed his brow and appeared to be thinking deeply for some time. C waited in silence. Finally,
Mark answered. “Actually, about a week ago, I was a bit late home from work and I was expecting another
tongue-lashing, but it never came.”

C asked Mark what was different about that night.

Mark: “Well, Sarah was happier.”

C: “How did you know she was happier?”
Mark: “She talked to me, you know, just talked about something she had seen on the telly or
something like that.”
C: “And how was that for you, Mark?”
Mark: “Not bad. Actually, it wasn’t too shabby. We did get to chat, and we haven’t done that for ages.”
C: “Can you explain, “Wasn’t too shabby”; I haven’t heard that term before?”
Mark: “Oh, it means it was all good, you know, it was okay.”
C: “So you came home and chatted with Sarah over a cuppa and you found that wasn’t too shabby?”
Both smiled
Mark: “I really liked it. I remember thinking I would have come home earlier if I had known it was going
to be like that.”
C: “If I was to ask Sarah what was different about that night, what do you think she would say?”
Mark: “Boy, this is getting weird.”
C waited.
Mark: “Let’s see. She would probably say, “He actually sat and had a cup of coffee with me, instead of
just flopping in front of the telly. She’s always griping about that.”

At the appropriate time, C called for a break. “I’d like to take a break and give us both time to consider all
the things we’ve talked about. After that, I will give you some feedback.” After the break C summarized
what had been discussed and complimented Mark on the work he had put into exploring his problems. He
seemed less stressed and had shown that he was committed to improving his relationship with Sarah.

Counselling continued for another three sessions, by which time Mark’s stress had reduced considerably,
he was coming home from work earlier and making an effort to talk more to Sarah. The arguments were
less frequent and not so heated.

Session Summary

The Person Centred approach allows the client to take the lead and discuss issues as they see them. This
encourages the client to talk openly, which was especially useful in this instance since the client showed a
reluctance to do so at first.

The Behavioural technique of goal setting is used to clarify what the client wants to achieve out of the
sessions.
Solution Focused Therapy, this approach acknowledges that the client has the ability to solve his own
problem.

Miracle questions assist the client to examine how they and others would be behaving if the problem were
already dealt with. This helps the client to look at their current behaviour and see what they can do to
bring about the required change. Exploring what the client has tried in the past highlights that the client is
committed to solving the problem. Exception questions help the client to see that there are times when
the problem does not occur, and that they have contributed to that situation. This shows the client that
they have control over the problem.

Clarifying client’s words, e.g. “Not too shabby” shows respect for the client’s language and emphasises that
the client is the expert.

Week 4 - Session 4 (180 minutes)

 Case study discussion (30 minutes)

 Class on Sports Psychology & forensic psychology (150 minutes)

Case studies on sports concerns.

16. CLIENT: MINOR LEAGUE HOCKEY TEAM (GTHL- AAA)

SEEKING SUPPORT

This newly formed team came from the select level and moved up to their first year at the AAA level, for
their Minor Atom year.

The coach’s goal was to recruit and build a strong group of players, and provide the best development
program in the league. In doing so, they believed they would give their team the best shot at success, with
the goal of a championship in mind. They had high level coaching and on ice development in place, as well
as a strength and conditioning program.

The head coach wanted more. He wanted to develop the ‘complete’ player, both on and off the ice, and
give his team every competitive advantage possible. This is where mental game training and our services
came into play. A unique and valuable addition to their training program with high level development-
their program stood out. This helped in their recruitment phase and with attracting players and families.

Once the team was put together, the coach’s next goal was to help build team cohesion and get all of the
players functioning as a solid team unit. He also wanted to make sure they had good mental fitness to
complement them on ice skill, development and game play.

The first thing to be done was a needs-based assessment in order to understand team goals and objectives,
and have a clear vision of what the team wanted to accomplish. From there, the program was developed.

THE DEVELOPMENT PLAN

Baseline Concussion Testing: A neuro-cognitive baseline test was done for all players to establish current
functioning. Having a proper assessment and understanding of overall functioning could later be used as a
measure if a concussion was suspected, and also for the purpose of return to play objectives if a
concussion had been sustained.
Mental Game Training was provided through team workshops to help bring the team together, help
players manage pressure, and learn how to rebound from mistakes and adversity.

A Workshop on Effective Sports Parenting was given to all parents on the team to help them understand
how to best support their youth athletes.

Mind Gym/Sports Vision Training Program A neuro-cognitive team training program was run with the team
to help them gain the 1 second advantage - see more, think quicker and react 1 second faster.

A baseline test for each player was conducted to establish a starting point and assess their overall visual
and cognitive processing skills. From there, a customized training program was developed.

Plus, 10 session training program designed to enhance the following:

 Peripheral awareness
 Anticipation timing
 Reaction timing
 Decision making under stress and pressure
 Focus and concentration
 Target accuracy
 Ability to multi-task
 Memory recall
 Reduce injury occurrence
 Improve eye hand co-ordination

RESULTS

1) A unified and cohesive group

2) Able to manage pressure in playoffs and bounce back when things were not going well

3) Toronto Marlboros Tournament Champions

4) Barrie Colts Remembrance Day Tournament Champions

5) VK Bio Steel Classic Tournament Champions

6) 1st place finish in the GTHL Regular Season, Kraft Cup Champions

7) 1st place finish overall, GTHL Scotiabank Playoffs – Champions

17. CLIENT: NCAA DIVISION 1 ATHLETES

SEEKING SUPPORT

This case study represents individual coaching done with 3 different athletes, each preparing for their
rookie year in the NCAA, from 3 different sports as follows:

Harvard – Hockey
Yale – Track & Field
University of San Francisco – Tennis
Each of the athletes above were struggling with the following common themes:

 Managing high levels of stress associated with the pressures and expectations of being such a high
level athlete, at an elite and prestigious academic institution.
 Time management – being a student athlete at such a high level, comes with extensive training
hours, travel, and hectic schedules, along with the need to manage a rigorous academic course
load. There is no doubt it takes extreme discipline and time management skills to manage this
workload.
 Pre-competition & competitive anxiety
 Confidence
 Transitioning into a new school, new stage of life (college), and a new team

The first step begins with a one-on-one, 1-hour comprehensive mental game assessment in order to better
understand each individual athlete. The assessment evaluates the overall mental game and level of mental
toughness of the athlete, establishing a mental aptitude profile. Key components such as overall
confidence, focus, motivation levels, emotional control and regulation, thought patterns, and behavioural
patterns were assessed. Based off the assessment, the development of a customized training program
designed specifically for each of the athletes was developed to strengthen their overall mind-set (both on
and off the ice or playing field), and build mental performance skills to allow them to break through
barriers inhibiting peak performance.

THE DEVELOPMENT PLAN

10 Session Mental Game Training Program

Each of these clients completed a customized 10-session mental game training program, followed by
ongoing in season support over the course of their school year and season.

The initial 10-session program focused on understanding and effective management of anxiety, developing
life skills, such as time management, self-care, and self-compassion in sport, and developing a mental
performance skill set/toolbox such as self-regulation skills, self-motivation, and goal setting, attitude and
self-talk, performing in the zone, managing pressure and adversity, developing proactive confidence,
mental imagery, and the development of a present and process oriented focus.

In Season Training and Support

Following the 10 sessions of mental skills training, all of these athletes received ongoing support
throughout the season and school year. These interactions varied from quick support calls and text
messages to full sessions via Skype or FaceTime where we had the opportunity to deal with and manage
issues, concerns or stressors as they arose, and work at applying and implementing the skills we covered in
the initial 10-session program into action as they moved through their seasons.

RESULTS

 A shift in overall thinking patterns and the development of a stronger and more productive mind-
set

 The ability to self-manage and reduce levels of stress and anxiety

  Increased levels of focus and confidence

 Ability to manage pressure and bounce back quicker from mistakes and adversity

 The ability to manage both self-oriented and other oriented expectations

 Smoother transition into the school year and team for their rookie year

 Ability to manage heavy academic workload and demanding training schedules, by mapping out
study, training and sleep schedules, and knowing how to prioritize

 Ability to self-advocate and take care of individual needs

 Ability to shift perspective in difficult times and enjoy the journey

18. CLIENT: SAM SCHACHTER

Professional Beach Volleyball Player 2018 World Ranking – #9, Canadian National Team, Commonwealth
Games 2018 (Silver medal), Olympic Games Rio, 2016, Pan Am Games, 2015

SEEKING SUPPORT

GOAL: Medalling at the 2021 Tokyo Olympics

1) A competitive advantage in preparation for the 2021 Olympics in Tokyo

2) Mental preparation

3) Development of intense levels of focus, resilience, adaptability, and ability to manage high levels of
stress and pressure.

The first step was a 1-hour comprehensive mental game assessment, evaluating the overall mental game
strengths and needs of the athlete. Key components such as overall confidence, focus, motivation levels,
emotional control and regulation, thought patterns and behavioural patterns were assessed. Based off the
assessment, the development of a customized mental game training program was developed in order to
help prep this athlete for the 2021 Tokyo Olympics.

THE DEVELOPMENT PLAN

Sport Psychology Training Program

Customized sport psychology mental game training sessions to develop performance readiness with a
focus on the development of a championship mind-set, including preparation, mindfulness, resilience,
adaptability, confidence and emotional control.

In Season Training and Support

Training will be ongoing with support provided through both competition and training leading up to the
Olympics, as well as throughout the Olympic games.

Mind Gym/Sports Vision Training program

To help the athlete gain the 1 second advantage – the ability to see more, think quicker and react one
second faster – giving him a performance edge over his competitors.
This part of his training began with a baseline test to assess his overall visual and cognitive processing skills,
followed by training in our Mind Gym, working to strengthen the following:

 peripheral awareness

 anticipation timing

 reaction timing

 decision making under stress and pressure

 focus and concentration

 target accuracy

 ability to multi-task

 memory recall

 reduce injury occurrence

 improve eye hand co-ordination

RESULTS

Stay tuned for the 2021 Summer Olympics in Tokyo!

19.
20.

Case studies on Forensic concerns.

21. Case on Delusional disorder; drug-induced psychosis or intoxication

Anthony, a 36-year-old man, was given a mandatory death sentence after being convicted of two offences
of murder. He was not assessed psychiatrically pre-trial.

On the evening before the offences, he and his co-accused purchased two containers of gasoline from a
petrol station. Early the next morning, armed with wooden posts and manufactured torches, they entered
a cathedral where a communion mass was being celebrated. They lit the torches and sprinkled gasoline
over members of the large congregation, beating those who attempted to disarm them. The two men then
walked towards the altar. An elderly, frail, male priest approached them carrying a silver cup, as if to offer
them communion. Anthony threw gasoline over the priest and said: ‘Don’t do that!’ A few seconds later,
he set the priest alight, who later died of severe burns. An elderly female nun then ran towards the men,
and Anthony turned to face her and said: ‘Don’t do that, don’t do that!’ He then struck the woman with a
wooden post he had with him, causing three deep lacerations to the head, which led to her death.

Both men were arrested at the scene. At trial, the prosecution described Anthony’s actions as being
premeditated and wilful, a cold-blooded attack on the worshippers at the cathedral.

Anthony has lodged an appeal against both his conviction and sentence. He has recently produced a
witness statement in which he states, regarding the attack: ‘I wanted to burn the Vatican and the demons
there…I wanted to destroy the Cathedral…I thought this would bring about the destruction of the Pope and
the Queen of England...which would have been a punishment for their crimes committed against the
humanity of black African people…I told lots of people what my plan was…I was surprised that people were
shocked.’

A probation report prepared at the time of sentencing contained some background information:

‘Anthony had an abusive childhood… he passed the Common Entrance Examination and gained
admission to secondary school, where he was disruptive and engaged in fights using dangerous
weapons, such as knives. He was defiant and refused to accept school rules. He was suspended for his
aggressive behaviour and later expelled… he shows absolutely no remorse...indeed, Anthony feels
pleased with his actions, claiming that he has been appointed to destroy the oppressors, the church and
the government… they are both convinced that their actions were justified and that they should be
allowed to continue their mission...they are happy that their deeds will be recorded in the annals of
history…’

You are asked by Anthony’s current lawyers to provide an opinion on whether Anthony was insane at the
time of the offence in order to assist with an appeal. You are told that the jurisdiction in which he
committed the offences does not allow the defence of ‘diminished responsibility’.

Case – unfit for punishment

Phillip & John v The Queen – St Lucia [2007] It is necessary to prove first that the defendant suffered from
a delusion or delusions, as defined by the medical witnesses in this case, not shared by any significant
group such as the adherents of a religious sect. The second criterion is that the delusion must be of such a
nature as to render him an unfit subject for punishment of any kind. The latter in their Lordships’ opinion
carries the connotation of a delusion of the presence of some outside influence which operates upon the
defendant’s mind in such a way that he is impelled or persuaded to commit acts which he knows to be
forbidden. The threat of punishment would have no deterrent effect, one of its main objects. The object of
retribution would be repugnant to the conscience of the ordinary citizen. Accordingly, punishing such a
defendant with ordinary criminal sanctions would be both inappropriate and pointless

Clinical (There is no recorded history of mental illness, so how could you approach determining whether
Anthony was mentally ill at the time of the killing?)

This will be a complex and time-consuming task, given the length of time since conviction.

Information from other than Anthony

Interviewing Anthony will be necessary. However, before doing so, you will need to gather as much
background information as possible about Anthony in order to try and piece together his life story, from his
childhood, with the help of his lawyers. The probation report gives some details, but more will need to be
known about his personality, including his capacity to form relationships, and his general propensity for
violence. School records, if available, might explain something of the nature of the abuse Anthony is said to
have suffered. Given the nature of the offence, his religious views will be important to understand. And any
material that helps determine his likely mental state during the months leading up to the offence will be
particularly useful.

Even in the absence of a documented history of mental illness, it will be essential to read his medical
records, both primary care and hospital records – for example, there might be symptoms of mental illness
that were complained of, or described, but not recognised as such, or responded to, at the time. If Anthony
was the subject of any ‘care proceedings’ as a child, or other social services intervention, then you should
read the relevant files. His educational records should also be sought.
The witness statements gathered for the original trial should be scrutinised for evidence of Anthony’s
thought content specifically at the time of the killings; his remarks to the victims give some evidence
relevant to retrospective reconstruction of his likely mental state. However, it will be important to
determine whether these are consistent with things he may have said to others, including friends and
family members – possibly including members of the church congregation where he may have worshipped,
if he did. If such accounts are not available, then Anthony’s lawyers could assist by taking statements from
those to whom he was close. However, interviewing informants from a detailed clinical perspective will,
almost certainly, be necessary, or at least beneficial. Although it would be ideal to be able to interview
individuals who were present at the commission of the offences, they will have been prosecution witnesses
and will, almost certainly, not be available to you. Also, if there had been previous criminal offending by
him, it will be necessary to review the detail of this in order to determine whether this was likely – or not – 
ever to have been influenced by mental abnormality.

How should an interview with Anthony be conducted?

It will be important to take a detailed history of any mental symptoms or distress that Anthony may have
experienced from childhood, including both their nature and their association with drug or alcohol
ingestion, if any. It will be important to gain a picture of the pattern of Anthony’s mental functioning
unconnected with the index offence, as well as any association of such symptoms with violent behaviour in
the past. That is, first try to gain evidence that might point towards a diagnosis, and/or formulation, in
relation to his mental functioning unconnected with the index offences. And clearly close attention should
be paid to his religious beliefs, both during childhood and later, in regard to whether these changed at
some point.

Any remarks made by him at all suggestive of symptoms of mental illness – especially psychotic illness –
should be followed up closely and meticulously, in terms of both their form and implications for any
possible diagnosis. If he offers nothing suggestive of illness, it will still be necessary to ask ‘direct questions’
concerning whatever range of diagnoses you consider could be possibly valid from what he says at
interview or from what he said during commission of the offences. Given that – unless you have discovered
evidence suggestive of illness from records and informants (see above) – you will likely be reliant
substantially upon what you gain from Anthony in clinical interviewing, it will be important to include in
your manner of interviewing him, and interpreting the results of the interviewing, consideration of the
possibility of ‘faking’. That is because under cross-examination, you will likely be challenged that your
diagnosis is simply based upon what the appellant told you (assuming you come to an opinion that lays a
foundation for an appeal).

If you have come to a provisional view concerning a possible diagnosis of mental illness being present
prior to commission of the index offences – whether ‘drug-induced’ or not – then this will provide a
foundation for asking Anthony in detail about his mental functioning, and likely mental state, at the time of
commission of the offences.

However, in any event, the interview with Anthony should then become focused upon trying to establish
his ‘most likely’ mental state at the time of the offence (any defence that might, on appeal, be available to
him will be tested by the court to the standard of ‘on the balance of probability’ and not ‘beyond
reasonable doubt’), based on a background understanding (hopefully already achieved) of his mental
functioning at other times. Beyond taking a standard psychiatric history, you will need to try to establish
from Anthony a detailed timeline of events prior to the offences: was there any change or development of
his mental functioning during the weeks and days prior to the killings?; was any change associated with
ingestion of drugs or alcohol?; when did he first think of committing the offences, and why?; why did he
purchase the gasoline the evening before?; why target the cathedral?; why the two particular victims?;
why that day?; and why not flee the scene afterwards? Essentially, the questions asked need to be posed in
such a way that any information gained can, if relevant, be mapped onto the potential psychiatric defence
that you have been asked to comment upon. In respect of the defence of insanity, you will need to have
asked sufficiently detailed and specifically oriented questions for you to be able to take a view not only on
the nature of any abnormality, if any, of Anthony’s mental condition per se at the time of the offences but
also how any symptoms he likely experienced were linked causally to his actions. The specific legal criteria
for a finding of insanity must be directly referenced when providing an opinion on this issue.

An added issue is the relationship between Anthony and his co-defendant, who appears to have taken a
lesser role in the offending. You will need to address with Anthony directly the nature of their relationship
prior to committing the offences, as well as how it was they came to offend together. This will include
trying to address whether there is any evidence that his co-defendant was mentally ill, and how this
related, or not, to any symptoms in Anthony. For example, you may need to address whether Anthony was
in a ‘folie a deux’ and, if so, who was the dominant partner in the illness Ideally, you would wish to
interview the co-defendant, either to gain further information about the relationship between the two of
them or to gain information from him of Anthony’s functioning. However, he is unlikely to be available to
you.

Finally, Anthony’s current mental state will not only be important in terms of its potential relevance to
what might have been his state when he killed – and whether he continues to exhibit symptoms of illness
he may have experienced prior to the offences – but it may also be relevant to a re-sentencing hearing, in
the event that he is found insane (you will need to be advised whether a finding of insanity infers an
automatic or discretionary disposal) or, in the event that the appeal is unsuccessful, to a ‘mercy hearing’.

Legal

The defence of insanity, unlike the partial defence of diminished responsibility,9 is not limited to the
offence charged of murder. The threshold is, ubiquitously across jurisdictions, both narrow drawn and
high, since a successful plea of insanity amounts to a ‘full defence’, leading to a verdict of ‘not guilty’, or
‘guilty but insane’. And neither a prison sentence nor the death sentence is mandatory in any jurisdiction
upon a finding of insanity.

Although the definition of insanity varies somewhat between common law jurisdictions, the essence of it is
that it is written in terms solely of disabilities or abnormalities of ‘cognition’ so that, for example, disorders
of emotional regulation or expression are irrelevant to it.

It will be necessary for you to receive detailed advice from counsel for Anthony as to what is the precise
definition of insanity in the jurisdiction relevant to his trial and appeal. Do not simply assume that it is ‘the
same as in England’, or in other jurisdictions with which you are acquainted.

Assuming, however, that the relevant definition is identical to that in England and Wales, in order to
succeed in the defence, a defendant first needs to prove (sanity is presumed) that, on the balance of
probability, s/he was suffering from a mental condition – in England, a ‘disease of the mind’, that seriously
affected their ability to reason, defined in terms of ‘a defect of reason’ – the result being that they either
‘did not know the physical quality of their actions’ or, if they did, they ‘did not know that what they were
doing was legally wrong’.

Most commonly, a delusional disorder will be required in order to meet the very narrow and high
threshold definition of insanity – although some have argued that other forms of psychosis can deprive
sufferers of the ability to concentrate and retain information to such a degree that they cannot make
reasoned decisions in terms of their defence. In regard to ‘knowing’ that what they were doing was legally
wrong, some jurisdictions may adopt, or might be encouraged to adopt, a somewhat flexible
interpretation. So, for example, being capable of knowing that what they were engaged in were they to
have been interrupted might not make the defence unavailable to them if, at the time of the offence, they
were (for example) so ‘psychotically driven’ that they did not ‘appreciate’ that what they were doing was
legally wrong while they were doing it.

Most commonly, it is defendants who express delusions of persecution and/or control that can
convincingly succeed in arguing their actions followed from such disordered reasoning as to qualify for the
defence. But, even here, the detachment from reality needs to be severe; for example, it is not enough
simply to feel compelled to attack another because of a delusional idea. Rather, for the defence of insanity
to succeed, the defendant needs to prove that they believed that they were acting in self-defence (in other
words, in their mind their actions were lawful). Alternatively, those with bizarre delusional beliefs focused
on the victim of the offences can sometimes successfully argue insanity; for example, if it can be shown
that they did not believe that the victim was human but understood them to be a robot, or the devil, and
hence did not know that their actions were unlawful.

Clinico-legal (How would you address the defence of insanity?)

In Anthony’s case, if clinically you have come to the conclusion, for example, that it seems more likely than
not that he harboured religious – and possibly grandiose and persecutory type – delusional beliefs in
relation to members of the church, particularly focused upon priests and possibly nuns, then this may lay a
foundation for supporting a defence of insanity. However, it will be necessary to establish the ‘full detailed
content’ of his beliefs. For example, you might discover that, in his mind, he was acting in ‘self-defence’,
believing himself to be under imminent threat from a powerful external morbid force, and that the two
victims had physical powers beyond their objective power. However, if, on the other hand, you find that he
harboured resentment – even ill-feeling based on pathological feelings of persecution towards the church
– it would be hard to see this as being enough to satisfy the legal test of insanity (although it might do so
for a defence of diminished responsibly in a different jurisdiction that allowed this defence).

If you conclude that Anthony had a psychotic illness at the time of killing that, given its specific symptoms,
does satisfy the terms of the insanity defence but was precipitated by drugs, then there will be likely be
dispute over whether the appellant’s mental state was indeed one of ‘psychosis’ or whether it reflected
‘intoxication’. So, for example, if you were to conclude that Anthony was in a drug-induced psychosis, then
you will need to be able to distinguish this from ‘self-induced intoxication’, which would not, of course, lay
the foundation for the defence – albeit it could possibly lay the foundation for ‘incapacity to form the
specific intent for murder’, if his state was so disordered as to come within the terms of this alternative
defence.

What would be the likely challenges to a defence of insanity?

In every case where a psychiatric defence is proposed, it is important to consider whether other
hypotheses might explain the offending concerned, including those suggesting no connection with mental
disorder.

In this case, the lack of prior medical evidence of mental illness is likely to be emphasised, as is Anthony’s
antisocial behaviour as an adolescent. So the lack of any medical evidence having been offered at trial will
need to be explained; for example, was this because Anthony, in hindsight, was not properly able to
instruct his lawyers, or because he was not adequately assessed clinically pre-trial? And the suggestion
might be made that Anthony harboured ill-feeling towards the church that had little to do with mental
illness; for example, he may have expressed angry beliefs about the church that were ‘extreme’ but not
apparently related to symptoms of illness.

Even if it is accepted that Anthony acted in a general sense ‘because of delusional beliefs’, the specific
reasons why he assaulted the two elderly victims who posed no threat to him will need to be carefully
explained. Indeed, the lack of any ‘rational’ explanation may assist the defence.
Finally, if you express the opinion that Anthony was in a drug-induced psychosis when he killed, then
undoubtedly the prosecution will suggest that he was ‘merely intoxicated’.

Ethical and professional issues (One of the challenges in this case is the need to reconstruct Anthony’s
mental state 10 years after the offences. Can and should you do this?)

It is an accepted legal maxim ‘absence of evidence is not evidence of absence’. Hence, the fact that no
evidence of Anthony having had a record of mental illness was discovered at the time of his trial, or of him
having acted upon delusions (beyond the rather odd things he said to both victims), does not amount to
evidence that he was not mentally ill or driven to kill the victims by delusions. Much of the preceding
section amounts to a description of how it is possible – and correct – to do one’s best clinically to
reconstruct Anthony’s ‘most likely’ (not ‘possible’) mental state at the time of the killings, plus establish
linkage of this to the killings. For example, Anthony’s memory for events and symptoms might have been
poor or inaccurate even quite soon after the killings – many defendants, even those who are not suffering
a mental illness, such as a psychotic illness, fail to recall the circumstances of their crimes even soon after
their offences. This is aside from being unable to do so many years later, for example, because psychosis
concurrent with commission of an offence can affect the registration of data sufficient for subsequent
accurate memory. This can be for a variety of reasons, including being in a high state of arousal, or being
subject to intrusive hallucinations, at the time of their offending.

A number of issues are likely to be closely examined at appeal, including evidence of consistency, or of
inconsistency between: accounts by Anthony on different occasions; the account of others and Anthony’s
account; Anthony’s present account and his account at the time of the offences; and the symptoms
described by Anthony and typical symptoms of mental illness. And it is likely that a major focus of
prosecution attack will, indeed, be framed in terms of: ‘Doctor, your opinion is based upon what the
appellant told you, now, after time for reflection and discussion with others in prison … he is making it all
up.’ The proper response to this, both technically and ethically, is to explain that determining a diagnosis,
or its absence, requires looking at all of the information available – as it they are pieces in a jigsaw – in
order to see whether there are sufficient pieces (of evidence in fact) to give a ‘picture’ of the diagnosis, or
mental state at the relevant time, and the absence of pieces that would be inconsistent with the picture.

22. Case on depression with psychosis; diagnosis of children and adolescents

Radhika is a 17-year-old girl charged with the murder of her two-year-old child. She is alleged to have
drowned her child in the bath at home. Her mother was at home at the time and discovered the child’s
body. Radhika then said that she had taken an overdose. She was admitted to hospital but suffered no
harm from the overdose. Radhika has only patchy memories of what happened.

Radhika was treated for depression after the birth of her child when she was 15, from which she recovered
fully. However, eight weeks before the killing she again began to feel low in mood. She stopped going out
and her mother became concerned that she was not feeding her child regularly. Radhika also started to say
some strange things about how she felt – such as like she was dead and that her baby was dead. Her
mother had therefore not left her alone with the baby.

After the killing, Radhika was admitted to hospital and diagnosed with ‘depression with psychosis’, and
treated with antidepressant and antipsychotic medication. She disclosed that she had believed that she
and her child had died, and were about to go to hell unless they killed themselves again. She said that she
drowned her child in the bath because her child was already dead, and she needed to save her from going
to hell. She had then tried to kill herself so that she could be with her daughter in heaven.

Radhika was sexually abused by an uncle between the ages of five and eight years. She started to cut
herself on her arms from the age of 12 years, but this had ceased two years ago, and she had never
seriously injured herself before taking the overdose. Her mother also has a history of depression. She has
never used any drugs.

You are asked to assess Radhika and to give an opinion on whether she was suffering from ‘a mental
disorder’ at the time of the killing, and on whether she was insane at the time.

Clinical (What is depression with psychosis?)

Depression is a mental illness characterised by the presence of symptoms that include low mood, loss of
interest or pleasure, feelings of worthlessness, poor sleep, poor appetite, poor concentration, low energy
levels, thoughts of lack of self-worth, plus sometimes suicidal thoughts. Depression, in its most severe
state, can be accompanied by delusions and/or hallucinations; such psychotic symptoms are often
congruent with other symptoms of depression, and commonly involving themes of guilt, nihilism and
death. In some cases, however, they are not ‘mood congruent’. Depression, including psychotic
depression, is more common after childbirth.

To what should you pay particular attention when assessing someone under the age of 18 years?

In most developed countries, psychiatrists subspecialise, and child and adolescent psychiatry is one of
these subspecialties. There are, therefore, psychiatrists who specialise in the assessment and treatment of
people under the age of 18 years. In larger countries, there may also be specialists who have trained in
both child and adolescent and forensic psychiatry, and are therefore highly specialised in this field. The
gold standard for a case involving a person under 18 years of age is the instruction of one of these highly
specialised professionals. However, where this is not available, the appropriate expert will depend upon
the particular nature of the case and of the mental disorder that is suspected.

Some of the key reasons for the use of child and adolescent psychiatrists in clinical and clinico-legal
practice are that there are diagnoses particular to those not yet adult; presentation of diagnoses that can
occur in both adults and children can differ; and diagnosis of mental illness in those not yet adult can be
made difficult because the person is still developing, and that such that aspects of such development can
be confused with symptoms of mental illness (for example, ‘adolescent turmoil’ may be mistaken for
illness).

This case involves a 17-year-old with a mental disorder that can affect adults, and in many ways is
indistinguishable from its presentation in an adult. Hence, it may be reasonable for the expert appointed to
be an adult psychiatrist, particularly bearing in mind that most adult psychiatrists will properly have
undergone some training in child and adolescent psychiatry during their postgraduate psychiatric training,
prior to being appointed as a consultant. However, any expert appointed should pay particular attention to
aspects of Radhika’s presentation that may arise from her youth – taking particular note also of her history
of self-harm, which is not uncommon in adolescents. There will be other circumstances where the mental
disorder falls much more naturally within the expertise of a child and adolescent psychiatrist, so an adult
psychiatrist should be very wary indeed in accepting instruction. Finally, in some circumstances the
involvement of two professionals from differing specialties might be necessary.

Are there any diagnoses that cannot be made in people under the age of 18 years?

DSM5 incorporates definitions and criteria that attempt to include the way in which children experience
symptoms of mental disorder, and most mental disorder diagnoses can be made in children. However,
personality disorders are not usually properly diagnosed in children, given that children are still forming
their personality, and can also exhibit symptoms suggestive of personality disorder that are, in fact, a
representation of developmental turmoil. This heavy caution is based upon an understanding of the way in
which personality develops and the need to observe stability in the observed personality traits before
personality disorder can properly be diagnosed; many traits observed in children do not persist into
adulthood. Guidance suggests children can rarely be diagnosed with personality disorder, with the
exception of antisocial personality disorder.

What attention should you pay to the diagnosis already made by the treating clinicians?

An expert will properly pay attention to the diagnosis made by the treating clinician. However, it is very
important that you do not assume that the diagnosis is correct. Your role is to give your opinion based
upon your own assessment, albeit using all of the data available – including those originating from the
treating clinicians – rather than to seek to confirm (or refute) the diagnosis already made. This will involve
pursuing an ordinary, comprehensive approach to assessment. Crucially, approach the case without any
pre-conceptions about it, including in regard to diagnosis.

Legal (Insanity)

In regard to the terms of the legal definition of insanity, which can vary somewhat between common law
jurisdictions, see Case 7 (also the Handbook). In essence, however, the defendant first needs to prove
(sanity is presumed), on the balance of probability, that she was suffering from a ‘defect of reason’, arising
from a ‘disease of the mind’, such that she ‘did not know the physical quality of her action’ or, if she did,
that she ‘did not know that what she was doing was legally wrong’.

Clinico-legal (How should you approach the question of insanity?)

The questions in your instructions include whether the defendant comes within the insanity defence –
although, where available legally within the relevant jurisdiction, ‘diminished responsibility’ is also likely to
be under consideration (‘infanticide’ will not be in contention, since this requires not only that ‘balance of
the defendant’s mind was disturbed’, but also that this arose from failing to get over the results of birth or
lactation, and that the killing occurred within a year and a day of the birth of the child). However, the role
of an expert is to describe the defendant’s likely mental state at the time of the killing and its likely causal
relationship to the killing, and not to opine definitively upon whether the insanity defence is satisfied. To
do so could infer taking a view on the legal meaning of elements of the defence – although courts not
uncommonly do ‘ask the ultimate question’ of an expert, without reference to the distinction between
medical description and legal interpretation of that description.

The approach should include breaking down the insanity test into its individual components, and
describing the way in which any mental state abnormalities present at the time of the killing ‘map onto’
each of those components. For example, if you are satisfied that there was psychosis present – in the form
of delusions – then explanation of what these delusions likely were and how they might map onto the legal
term defect of reason is required. Also, description of the underlying diagnosis – and the status of the
diagnosis medically as a recognised disorder – that might go towards the legal requirement of disease of
the mind, will also be necessary.

The greater potential complexity comes in explaining the ways in which the symptoms might have affected
the functional abilities of the defendant ‘to have known the nature or quality of her actions’ or ‘to have
known that what she was doing was legally wrong’. The diagnosis and description of the symptoms is
‘ordinary psychiatry’, but description or explanation of how these symptoms likely operated in relation to
the killing, and might map to aspect of the legal definition of insanity, is more complex and often uncertain
– as well as requiring strict boundary-keeping between psychiatry and law.
Ethical and professional issues
(Should you raise with defence lawyers the possibility of an alternative plea of ‘diminished responsibility’?)

The nature of the relationship between lawyer and expert is in terms of the former ‘instructing’ the latter,
including which legal questions the lawyers wish addressed by way of expert opinion. However, sometimes
lawyers are ill-informed, or can think in ‘simple straight lines’. So, for example, in Radhika’s case, it is
possible that, because they have read medical records suggesting that she was ‘psychotic’ when she killed
her child, they assume that this must infer legally ‘insanity’. However, of course, there is no necessary
relationship between any particular medical diagnosis and any given legal defence.

Also, the lawyers may be ‘going for broke’, in terms of achieving a ‘not guilty’ (‘by reason of insanity’) result
(if that is the terms of the defence in the relevant jurisdiction), and be unwilling to ‘muddy the waters, or
to raise any possibility in the mind of the prosecution that the defence of insanity might not be a robust
one to run. Also, they may not have ‘thought through’ that ‘psycholegal mapping’ of their client’s mental
state when she killed onto the insanity defence may not be robust, so they should consider a ‘fall-back
position’. An experienced expert witness psychiatrist will be aware of subtleties at the interface between
psychiatry and law that may not be appreciated by the defence lawyers – especially as they may come
across a case of possible insanity only once in several years. Therefore, it can be reasonable to ‘raise’ with
instructing lawyers the question ‘Would you wish me to address also the partial defence of diminished
responsibility?’ and to explain, in whatever of the above terms that may be relevant, the reason for
sensibly doing so.

How can you approach a case such as this objectively and minimise bias?

Cases involving the death of children can be emotionally highly affecting and poignant, and also appear
‘beyond comprehension’, so the aim of objectivity can be especially difficult to achieve. There is no clear
direction in which expert opinion might be affected by such factors; for example, the apparent horror of a
case of this nature might invoke feelings of retribution or anger, which may then be expressed in the
medical opinion offered. Or the opposite might occur – trying to make sense of the apparently ‘unnatural’
nature of the killing of her child by a mother, by assuming there ‘must be’ a mental disorder explanation.

As with any case, you should attempt to anticipate your own likely responses to it, and actively to consider
alternative explanations of the killing, plus alternative opinions that might properly be offered to the court.
Drawing a clear boundary between medical description and legal interpretation (see above) will serve
further to protect you, and the court, from the impact of your own ‘values incursion’.

More generally, both your clinical practice and your medico-legal practice should be subject to peer
review, which should include case discussions, so that your practice is subject to some form of informed
appraisal ex post. However, asking for colleagues to review your report before a trial can be more difficult
to justify, since the opinion must be yours and not a ‘joint’ opinion. As a result, it can greatly assist you to
engage, for yourself, in actively considering the ‘opposite’ opinion, and then questioning why you hold
your opinion and not this ‘opposite’ one. Doing so will also ‘protect’ you, and your opinion, within cross-
examination, since you should know better than the opposing counsel what the ‘counter points’ are to the
opinion you express, and have already worked out for yourself why they do not, on balance, overturn the
opinion to which you have arrived.

23. Case study on sexual assault:

Andrew is fifteen. He has been accused of sexually assaulting his younger sister and may be charged with
this in the near future. Some of his family have a history of mental disorder and he has a history of learning
and behavioural difficulties, as a result of which he has been attending a residential special school.
He does not acknowledge the accusations against him and is reluctant to discuss them.

INFORMATION FROM INTERVIEW -

Andrew presents as a tall, slim-built youth who is restlessly anxious, looking away for most of the
interview, and repeatedly yawning in an exaggerated manner to indicate how little he wants to be involved
in the discussion. Despite this he is essentially polite in manner and answers all questions, at least in some
measure. His apparent level of intelligence puts him in the mild range of impairment, and he is also very
sensitive to anything that he thinks puts him at a disadvantage or makes him look "thick". He has some
social skills, although these are not always used and sometimes he appears socially disinhibited.

He has a reasonable vocabulary and powers of speech. There are no behavioural stereotypies (repetitive
apparently purposeless movements) and no perseverative behaviour (continuance of behaviours after
their original purpose has been served). However, his powers of concentration are limited and he is easily
distracted from discussion. His attention is focused on his perceived likelihood that he will automatically go
to prison, regardless of whether he is charged or not. He hopes that a combination of his medical history
and denial of the allegations will be enough to get him through any legal processes.

Andrew says he hasn't been charged with anything "because I ain't done nowt". Nevertheless, he is able to
say that 'sexual assault' means "trying to make somebody do something - have sex, how to make babies"
and that 'penetration' means "putting a finger up someone - up (the) clitoris of women".

He has already been officially asked on one occasion about "for what's going on now basically" but can
describe no details and says that he "ain't bothered because I haven't done it".

CURRENT CIRCUMSTANCES -

Andrew has his own room at his special school and has made one or two friends. The activity that he
enjoys most, and gets most from, is "studying motor vehicles" and he has developed an ambition to
become a mechanic.

He comes home for some weekends and for holiday periods.

At present he feels he "hasn't got a life anymore". This is both because of the possible pending charges and
because he feels "people are dropping dead around me". A "close friend (female)" of his died recently, and
his life has not felt the same since his father died unexpectedly the day before his birthday four ago, and
his paternal grandmother died about a year afterwards.

He would like to become a motor mechanic, but thinks this will not be possible, unless he can get training
in prison, because of his possible court case.

PERSONAL AND FAMILY HISTORY -

He is the youngest member of his family, although his own list of his siblings and half-siblings is slightly
different to that provided by his family.

His father died from a heart attack and his mother has a lot of problems with her health.

He was excluded from his first school for "throwing a brick at a teacher or something like that - they were
doing my head in all the time".

MEDICAL HISTORY -
He has been diagnosed as having "ADHD" (Attention deficit hyperactivity disorder), and says that this is
why he is at boarding school. He says that he "used to get all mad and hate people and take it out on
them" but that this has improved more recently.

Two years ago he tried to hang himself with two belts because he "just felt like it - I couldn't be bothered
living anymore - I did it for fun - I thought it was funny". He also tried to cut his wrist, and still has a faint
scar from this. He continues to have periodic thoughts about a quick premature death as a way of not
having "to put up with living anymore". Although these thoughts reflect a depressed view of life there is no
indication that he currently has a depressive illness.

He has previously taken the anti-hyperactivity drug Ritalin, but has now discontinued this and describes it
as "doing my head in".

SEXUAL DEVELOPMENT HISTORY -

He first became sexually aware at a very young age, as a result of being given information either by one of
his sisters or a friend. His father told him not to have sex until he was older so as to avoid having children.

His strongest sexual experience so far has been with a girlfriend who he described as "the nicest person
you could meet - even though my sister called her a 'smack head'".

He denies the allegations about his sister and describes them as "all lies".

Questions -
What identifiable risks, giving your reasons, does Andrew present a) in the short term and b) in the longer
term? Rank them once in their order of certainty, and again in their order of importance.

Construct an interview strategy to help investigating police officers further question Andrew about the
allegations regarding his sister, explaining your rationale.

24. Case Study on behavioural problems

Background
Early Childhood
Mr D was born to a 16-year-old mother and conceived following a one-night stand. Mr D recalled an
unsettled childhood due to his mother handing over his care to her parents. Mr D described how he liked
living with his grandparents, however he also described how his grandfather frequently used alcohol and
his grandmother was strict and did not allow him to socialise with other children. Behavioural problems
were noted from the age of 4.

Throughout this time period Mr D began having severe tantrums which involved hitting and kicking and Mr
D was referred to the Children's Hospital at the age of 8. This followed a severe attack levied against his
grandfather involving a knife. Throughout the interview process Mr D remained closed about his
relationship with his grandfather. Later reports indicate he was sexually abused by his grandfather but Mr
D refuses to discuss this subject.

Mr D was taken into care at the age of 8, where again he reported an unsettled period of time
characterised by isolation and bullying. Mr D was able to live with a foster family whom he described as
supportive for the next two years and it is of note that there were no behavioural difficulties noted for Mr
D within this time period. Mr D appeared to settled with this family and their two sons, which allowed him
to form secure attachments with this family. Unfortunately, the family needed to emigrate to South Africa,
and although he was asked to go with them, Mr D chose to remain close to his grandparents.
Mr D spent the next five years in Children's homes, interspersed by foster placements which broke down.
Mr D returned to live with his grandparents following this period. Previous reports indicate conflicting
points of view about this time period, some indicating that Mr D had more positive relationships with his
grandparents and mother at this time, but with others highlighting that his grandparents did not really
speak to him.

Education and employment

Mr D attended approximately five different schools as he was moved due to his living situation changing.
Mr D recalled an unsettled period of time at school as he was bullied. He also described himself as 'hyper, I
would scream and shout a lot' and recalled finding lessons boring. Records indicate that Mr D began
refusing school at the age of 4 and has a significant history of truancy throughout his education. Mr D left
school with no qualifications but school reports describe him as exceptionally bright.

Mr D has never been in formal employment. After leaving school he was unemployed for 2 years as he
reported he could not find a job that interested him and he was having difficulties with his mental health.
Following this, Mr D has been detained due to the conviction for his index offence.

Substance and alcohol misuse

Mr D reports a substantial history of cannabis use and a history of binge drinking.

Psychiatric History
Mr D first came into contact with mental health services at the age of 8 when he was admitted to the
Children's Hospital for 6 weeks following a violent attack on his grandfather. An ECG and neurological
examination at the time were found to be normal, however Mr D's mother recalled a 'black patch' being
found. Following this Mr D was referred to an Adolescent Unit at the age of 14 due to behaviour problems
such as refusing to attend school and standing naked in the window. Later that year, Mr D was admitted to
the hospital and was described by the doctor as an 'isolated and withdrawn individual, having no self-
confidence who responded with aggressive outbursts when frustrated'. Mr D self-harmed by cutting his
arms with a piece of glass.

After being convicted of two incidents of indecent exposure at the age of 17, Mr D received outpatient
treatment initially, but following another charge for indecent exposure Mr D was admitted as an inpatient.
At this point he was talking about injuring people before they had the chance to injure him.

On the 9th April 1987 Mr D was again charged with indecent exposure and was remanded under section 35
of the Mental Health Act (1983). During his assessment there, it was noted that he was hearing voices
telling him to commit acts of violence. No specific diagnosis was made at this time, although a condition of
residence and psychiatric treatment was made. Following his 18th birthday he was moved to Arnold Lodge
Hospital. Whilst there it is reported that Mr D's mental health appeared to deteriorate and violence
towards others increased. At the age of 20 Mr D was transferred to a Hostel in Liverpool as it was thought
that he would benefit from integration with other people, however three months after this he was
discharged after assaulting another resident.

Mr D managed to live in the community on his own for approximately two and a half years before he
committed his index offence. At this point he was remanded to HMP Hull for approximately 2 months. Mr
D attempted to hang himself during his first night in custody. He was then transferred to Wathwood
hospital due to him exhibiting paranoid ideation and experiencing auditory hallucinations commanding him
to harm a female prison officer.

Whilst at Wathwood Hospital, initially Mr D's presentation seemed to improve to the point that he was
granted conditional discharge by a Mental Health Review Tribunal, however at this point Mr D's fixation
with a female member of staff began to cause concern. Mr D began exposing himself to female members
of staff and his mental health deteriorated. Mr D's presentation continued to decline over the next two
years in terms of incidents of violence, aggression and sexually inappropriate. His mental health also
fluctuated with episodes of paranoid ideation, delusions, thoughts of harming himself and incidents of
aggression.

Forensic History
Mr D has three previous convictions for offences of indecent exposure. There are seven previous
convictions for driving offences (e.g. driving whilst under the influence, reckless driving, driving without a
license, insurance and MOT) and 4 convictions of acquisitive offending (2 offences of shoplifting and2
burglary offences). Mr D has no other convictions for violent offences apart from the index offence,
however there has been other violence evident in Mr Driver's past when he has been a patient in hospital.

Index Offence
Mr D was convicted of the murder of his neighbour. The offence occurred in the context of ongoing
difficulties Mr D was experiencing with his neighbours in terms of loud music they were playing in the early
hours of the morning. Mr D had raised this problem with his neighbours and it is reported that they
responded to this in a less than positive way. Mr D then tried to involve the council to alleviate the
problem, however this appeared to have had no effect. On the day of the index offence, the victim was
taking his rubbish out and Mr D approached him from behind and struck him once in the back with a 5-inch
bladed knife. Mr D immediately ran away from the scene and made his way to the Family and Community
Services Department with whom he was in regular contact and the police were contacted and Mr D was
subsequently arrested. The victim had removed the weapon himself and in the meantime had made his
way to nearby premises to seek assistance. He later died of his injuries in hospital.

Mr D's account of the offence is that he had been living next to neighbours who were 'noisy'. He said he
had lived next to them for about six months and 'I kept knocking, asking them to turn it down, they just
said it was their house'. When asked how many times this had occurred Mr D said, 'probably approached
them about 5 or 6 times'. Mr D stated that he didn't phone the police at all, but that he did phone the
housing association. He said that nothing happened as a result of this and the music continued.

On the last occasion that Mr D asked for the music to be turned down before he committed the index
offence Mr Driver stated 'he started threatening me and said 'I'm not turning the music down' and was
arguing. I can't remember what was being said, but I just kept asking him to turn it down. He was shouting
and I think I hit him first, we had a scuffle and the police were called. The Police told me to get in touch
with the housing association'. Following this incident Mr D said that a few weeks passed and the music
continued. Mr D stated that he had been going out shopping he had been carrying the same knife that he
eventually stabbed the victim with.

On the day of the index offence, Mr D reported being woken at 9am by music being played. He stated, 'I
felt really stressed and angry. I got up, got dressed, I was standing in my kitchen and could hear it (the
music) and I saw him going to the bin. I'd come to the end of how I was feeling and looking for a way out'.
Mr D stated, 'I got a knife and stabbed him in the lower back. When asked what might have happened to
resolve the situation had the index offence not occurred Mr D said, 'If I hadn't seen him, I probably would
have gone on carrying the knife and gone round to his house'. In terms of why Mr D felt he committed the
offence, he stated, 'I couldn't stand them playing loud music'. Mr D went onto say 'Yes I regret it, its led to
me being kept in hospital. There is nothing else I could have done. He deserved it because he wouldn't turn
down his music'.

Assessments
Wechsler Adult Intelligence Scale -3rd edition (WAIS III)

This assessment examines general cognitive abilities, specifically thinking and reasoning skills. It explores
non-verbal reasoning skills, spatial processing skills, visual-motor integration, attention to detail and
acquired knowledge such as verbal reasoning and comprehension. Mr D presented with a full scale IQ of
130.

International Personality Disorder Examination

Mr D was assessed for personality disorder using the International Personality Disorder Examination (IPDE:
Loranger; 1999). The IPDE is a semi-structured clinical interview developed to assess personality disorders
defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV; American
Psychiatric Association, 1994) and the International Classification of Diseases, 10th revision (ICD-10; World
Health Organisation, 1992). Mr D's current presentation indicates that definite diagnoses of Antisocial and
Narcissistic personality disorders are warranted. The Antisocial features most relevant in Mr D include a
lack of concern for the feelings of others, reckless behaviour, consistent irresponsibility, disregard for rules
and punishment, low tolerance to frustration leading to acts of aggression and violence, and a proneness
to rationalise and blame others for his own behaviour. The Narcissistic features which Mr D presents with
include a grandiose sense of self-importance, a belief that he should be treated differently, an overinflated
sense of self-entitlement, arrogance in his behaviour and attitudes, a persistent pattern of taking
advantage of others to achieve his own ends and an unwillingness to recognise or identify with the feelings
of others.

Psychopathy Checklist Revised (PCL-R)

The Hare Psychopathy Checklist Revised (PCL-R, Hare 1991, 2003) is a rigorous psychological assessment,
widely regarded as the standard measure of psychopathy in research, clinical and forensic settings. It
measures different aspects of a person's emotional experience, the way they relate to others, how they go
about getting what they want and their behaviour. High levels of psychopathic traits as measured by the
PCL-R are associated with high rates of re-offending and future violence (however a low PCL-R score alone
does not imply low risk) and can impact on responsivity to therapeutic intervention. Mr D presented with
moderate levels of psychopathic traits which fell just below the diagnostic cut off for psychopathic
disorder. Items that he scored on include failure to accept responsibility for his actions, irresponsibility,
lack of remorse, callous disregard for others, grandiose sense of self-worth, manipulation and early
childhood problems.

Presentation in interview
Mr D presented as a difficult and challenging patient to interview. He was dismissive at times, questioning
my experience, qualifications and competence. He stated that psychology was not a proper science and
would prefer to talk to the 'proper doctor' i.e. the psychiatrist. Mr D appeared to have some knowledge of
psychiatry and psychology and used technical terms throughout. He appeared to have little insight into his
mental disorder stating that he does need to take medication and that everyone is like him. Mr D stated he
does not understand why anyone would think he poses a risk to people and that he should be discharged
from hospital immediately.

Questions:

1. Describe the type(s) of mental disorder Mr D may be suffering from

2. Consider whether those disorders are likely to contribute to the risk he poses of future violence
3. Identify those risks that Mr D poses to himself and others
4. Consider whether you would discharge Mr D from hospital at this time and give your reasons why
 5. (Point 5 is optional) Highlight what challenges Mr D may pose in treatment and how you might
overcome them.

25. Case Study on psychosis

Background
Early childhood
Ms W was the eldest child of three, the other two children being boys. Ms W recalled an unhappy
childhood due to the sexual abuse she experienced from her father (for which he received a conviction)
and then the emotional detachment that was apparent between her mother and herself. Social services
records support Ms W's account of her early childhood. In addition to being sexually abused by her father,
Ms W also reported being sexually abused by an uncle and a next door neighbour.

Ms W also reported that the relationship between her mother and father was a turbulent one and
although she did not witness any physical violence, she did hear arguments which resulted in her
repeatedly banging his head against the wall through the stress this caused. Ms W's behaviour became
uncontrollable both within school and the community, in terms of fighting at school and committing petty
crime such as shoplifting.

Whilst still living with her parents, at the age of 14, Ms W became involved in a relationship with a man
who was much older than her, in his 60's. This further contributed to the deterioration between Ms W and
her parents, and her parents subsequently placed her in care. Ms W remained in care until the age of 17,
and upon leaving she was given support from social services and moved into independent housing in which
she was happy on her own.

Education and employment

Ms W reported that her school performance was average; teachers would not have found her a
management problem, but that she did get distracted easily. Whilst at school she was subject to bullying
from peers and this resulted in her engaging in fights outside of school. Ms W left school with no formal
qualifications.

Ms W obtained employment as soon as she left school and worked as a 'packer', a cleaner and in a pet
shop. All of the employment she engaged in was in a short period after school, with her last job being held
at the age of 20. Ms W reported that the last job she had needed to leave because her mental health was
causing her difficulties and she needed to attend various appointments.

Following this period of employment, Ms W was unemployed for the next 16 years due to mental health,
drug and alcohol difficulties. Ms W claimed incapacity benefits and before coming into custody she
reported having an income of approximately £800 per month.

Substance and alcohol misuse

Ms W reported that she began drinking at the age of 14 or 15 as she would visit pubs with her partner at
the time. She suggested that she became a heavy drinker at age 20 and that she needed alcohol every day
as otherwise she would suffer with withdrawal symptoms. Ms W would consume approximately 12 cans of
Stella a day or 2 bottles of 2 litre Cider. Ms W's drinking caused her health problems in the form of liver
failure and pancreatitis. Ms W was under the influence of alcohol when committing the index offence and
this followed a period where she had tried to go through a detoxification process without medical support.
It is of note that Ms W reported hearing voices whilst she completed this 'home detoxification' process.

In terms of drug use, Ms W remembered beginning to use substances at around the age of 18. She reports
using acid tabs, microdots, magic mushrooms, speed, heroin (smoking) and cannabis. She also reported
that she would take prescription medication if the opportunity arose. Ms W recalls that she would use
whenever she had the money to do so and that she would frequently take drugs and drink at the same
time. She estimated that she would spend approximately £14 per day, but that this would depend on what
funds she had available at the time. In the early 1990s Ms W was diagnosed with drug induced psychosis.

Psychiatric history
Ms W first recalled being in contact with psychiatric services in her 20s. She was first seen by a psychiatrist
due to the hallucinations she was experiencing and she voluntarily stayed in hospital for a few months. Ms
W had spent time in group mental health homes and has had support from psychiatrists, CPNs and social
workers.

Ms W had attempted to commit suicide on a number of occasions through taking overdoses. She was
diagnosed with depression in her late 20s and has been on a number of anti-depressant drugs which she
combined with drink and non-prescription drugs.

Whilst in custody Ms W was taking antidepressants, anxiolytics and anti-psychotics. The latter were
prescribed due to Ms W experiencing hallucinations and also mood instability. Ms W had most recently
been diagnosed with 'Generalised Anxiety Disorder with features of depersonalisation and derealisation'.

Forensic history
Ms W had three previous convictions. Two were received in 1989 which were both fraud offences, and
then the third in 1990 for burglary and theft of a non-dwelling. Ms W cannot recall specific details
regarding the situations. Ms W had no other convictions for violent offending, apart from the index
offence, but there has been other violence present in Ms W's past especially within interpersonal
relationships.

Index offence
The offence occurred in the shared home of Ms W and her partner. Two weeks before the index offence
occurred, police had been called to the home after Ms W had taken an overdose of her partner's
medication. When Ms W's partner had attempted to summon help, Ms W threatened her with a knife to
try and prevent this. On the 10th June 2006 when the offence occurred, it was alleged that Ms W had been
drinking cider from the early hours of the morning. Ms W insists that she was so drunk that she has no
recall of the stabbing which then occurred and all that she remembered was seeing the blood on her
partner's stomach. After stabbing her partner in the stomach she then threatened to cut her throat with
the knife. The stab wounds caused a near fatal injury. The victim was able to summons help by activating
the emergency pull cord for the accommodation's warden.

Assessments
Wechsler Adult Intelligence Scale -3rd edition (WAIS III)

This assessment examines general cognitive abilities, specifically thinking and reasoning skills. It explores
non-verbal reasoning skills, spatial processing skills, visual-motor integration, attention to detail and
acquired knowledge such as verbal reasoning and comprehension. Ms W presented with a full scale IQ of
75. The assessment showed that Ms W processes information more effectively when presented visually
rather than verbally and that she struggles to concentrate for long periods of time.

International Personality Disorder Examination - Screening Questionnaire (IPDE-SQ)

This assessment is a screening questionnaire which indicates whether there are certain personality traits
which need further investigation using the full International Personality Disorder Examination assessment.
The IPDE-SQ indicated the possible presence of paranoid, schizotypal, emotionally unstable, avoidant and
dependent personality disorders but this should not be considered as a formal diagnosis.

Millon Clinical Multiaxial Inventory III (MCMI-III)

This assessment is used to evaluate elements of personality and also pathological syndromes within
psychiatric populations. On this occasion the MCMI- III was used to provide a more comprehensive picture
of Ms W's personality and presentation in combination with the outcome of the IPDE-SQ. This measure
was not used to diagnose personality disorder but to contribute to the understanding of Ms W's
presentation. The Millon highlighted that Ms W presented with anxiety, drug dependence and post-
traumatic stress disorder and may possible present with thought disorder and major depression.

Presentation in interview
Ms W presented as a shy, pleasant individual with very low confidence and who suffered with anxiety. It
was evident that she was lacking in confidence in terms of speaking to people and being sure of her own
opinions. She had also seemed to struggle in terms of her level of concentration.

Over the course of the sessions Ms W's mood could be quite volatile, changing from happy to depressed in
the period of a couple of hours. Ms W consistently spoke of thoughts of self-harm throughout the sessions
and when feeling depressed would project these feelings onto others as having caused them. Ms W also
presented at times as quite paranoid in terms of thinking that people were talking about her. Ms W also
disclosed that she was experiencing visual hallucinations particularly when she felt stressed.

Questions:

1. Describe the type(s) of mental disorder Ms W may be suffering from

2. Consider whether those disorders are likely to contribute to the risk she poses of future violence
3. Consider what techniques/strategies/considerations you would use when interviewing Ms W
4. Highlight what further areas of work you may wish to undertake with Ms W (concentrating on what
areas of her presentation you would like to explore/assess further and why)

Week 5 - Session 5 (180 minutes)

 Case study discussion (30 minutes)

 Class on Health Psychology (150 minutes)

Case studies on health concerns.

26. Case study explores the impact of conversion disorder resulting from a workplace injury and the
resulting delicate psychological condition of the patient.

Ms. P reported that she suffered a workplace injury in 2003 by way of a heavy fall, on a slippery walkway,
in which she injured her spine and knee, five weeks after commencing new employment. A worker’s
compensation claim was implemented and accepted. She reported that following her fall she spent 5½
months in hospital and stated that during her rehabilitation she lost significant motor skills, specifically in
her lower limbs initially. Her rehabilitation was conducted at various facilities including a regional hospital,
and city hospitals and rehabilitation facilities. Multiple and repeated tests were undertaken, which did not
reveal a physical diagnosis. Ms P was ultimately diagnosed with a conversion disorder. A further diagnosis
of Dupuytrens contraction was identified, affecting both hands, and in this patient’s case, likely caused
from weight bearing on her hands when transferring in and out of a wheelchair and propelling herself in a
wheelchair. Her condition has deteriorated to a stage where she can no longer sit up, or hold her head up
and she suffers phases where she cannot speak.

She is treated by a health psychologist who has diagnosed a chronic adjustment disorder, arising from her
severe and increasing conversion disorder, which has emanated from her workplace injury.

Ms P has been compelled to reside in a nursing home since 2010, as a consequence of her substantial loss
of upper body strength and increasing incapacity. Such deterioration has involved loss of neck muscle
strength; causing profound head instability. Her presentation is indicative of severe quadriplegia. Her
upper body regression has caused added symptoms of increased and ongoing pain in her shoulders,
elbows, wrists and hands with sciatic pain in her mid to lower back and buttocks. She is unable to manage
without intense nursing and is now bed-ridden mostly. She requires full-time carers to assist her at all
times and when she occasionally goes out of the nursing home she must be accompanied by two carers
with her mobilisation in a specialised electric wheelchair. Ms P utilises a wheelchair which requires
extension to almost a fully reclining position, necessitated by the patient’s inability to sit up or control her
head. This wheelchair, however, is unstable and dangerous and has caused Ms P numerous falls from the
chair as it is prone to tipping over.

Of psychological necessity, Ms P needs to reside in her own purpose-built home with full disability aids
tailored to her needs. In her psychologist’s view, an aged care facility designed for residents until their
death is inappropriate for Ms P at age 43. Further, Ms P reports that the aged facility are short staffed and
she reports neglect regarding hygiene needs.

To sustain such independent care, she requires two carers during the day with a carer at night to turn her
every two hours due to her inability to turn herself. This is essential to reduce pulmonary compromise and
bed sores.

Ms P requires a minimum of 30 carer hours per week while she resides in the nursing home. Without carer
assistance Ms P is isolated and bed 24-hour day. The impact psychologically to this patient cannot be
overstated and will, in her psychologist opinion, provoke and engender significant depression and anxiety
and increased psychological crisis.

Ms P reported that she is required to take an extensive array of medication to relieve her condition. She is
prescribed venlafaxine for depression, with analgesics and anti-inflammatory drug therapy.

Psychological treatment intervention is comprised of CBT, cognitive reconstruction, psychotherapy and

strategies to engender distraction with modalities incorporated in therapy to assist the patient in coping
with a devastating disability. Ms P, in her psychologist’s opinion, suffers from a chronic and severe
adjustment disorder with depression arising from a maladaptive response to the ongoing stress of having a
chronic disability with such disability incorporating a chronic complex regional pain syndrome arising from
a workplace injury on 14 May 2003 with ongoing sequelae diagnosed as conversion disorder in 2006.

Symptoms of conversion disorders may appear suddenly after a stressful event, or with emotional or
physical trauma. Conversion disorder is still a poorly understood diagnosis in adult patients and even more
so in children. The term ‘conversion disorder’ refers to the conversion of emotional stress to physical
symptoms. However, these same kinds of physical and sensory problems can occur with or without known
psychosocial or traumatic stressors. An adjustment disorder can arise from maladaptive ways of coping
after a stressful event or events.

Discussion questions

 How significant is the stress or emotional or physical trauma in understanding conversion

disorder?
 What is the relevance of an adjustment disorder in this case study and how does such a
disorder impact on treatment efficacy?
 Some symptoms of conversion disorder, specifically, if not treated, can result in substantial
disability and impoverished life quality, similar to chronic medical pathologies. How do health
psychology interventions on adjustment disorder provide better health outcomes for such
individuals?
 Are women more likely than men to develop conversion disorders?

27. Case study on seizure disorder

A 64-year-old man with a number of health issues comes to the hospital because he is having trouble
breathing. The care team helps resolve the issue, but forgets a standard treatment that causes
unnecessary harm to the patient. A subsequent medication error makes the situation worse, leading a stay
that is much longer than anticipated.
Mr. Stanley Londborg is a 64-year-old man with a long-standing history of a seizure disorder. He also has
hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD). He is no stranger to
the hospital because of his health issues.  At home, he takes a number of medications, including three for
his COPD and three — levetiracetam, lamotrigine, and valproate sodium — to help control his seizures.

Mr. Londborg came to the emergency department (ED) because he was wheezing and having trouble
breathing. The physician in the ED conducted a physical examination that yielded signs of an acute
worsening of his COPD, which is known as COPD exacerbation. (In many cases, COPD exacerbation is the
result of a relatively mild respiratory tract infection, but could be due to something more serious, such as
pneumonia.)

The physician in the ED ordered a chest x-ray, which did not show any signs of pneumonia. He admitted
Mr. Londborg to the hospital for treatment of acute COPD exacerbation, resulting from a relatively mild
respiratory tract infection. Before leaving the ED, Mr. Londborg also underwent routine blood work, which
showed an elevation in his creatinine, a sign that his kidneys were being forced to work harder due to his
infection.

On the medical floor, the care team treated Mr. Londborg with oral steroids and inhaled bronchodilators
(standard medical therapy for his condition), which resulted in a gradual improvement in his respiratory
symptoms. Nurses also gave him IV fluids for the issue with his kidneys, which slowly resolved.

Mr. Londborg was steadily improving, so it seemed this visit to the hospital would be one of his shorter
ones.

But on his third morning in the hospital, Mr. Londborg complained to the intern (a first-year resident) on
the care team about acute pain in his left leg. This symptom, potentially indicating deep venous thrombosis
(a blood clot in his leg commonly known as DVT), prompted the team to order an ultrasound of Mr.
Londborg’s lower extremities. (A primary concern with DVT is that blood clots in the legs may dislodge and
travel to the lungs, causing a pulmonary embolism, which could be deadly.)

The resident on the care team (who oversees the intern) then checked Mr. Londborg’s medication orders
and was surprised to see that the admitting doctor had not ordered prophylaxis for DVT (i.e., blood
thinners, such as heparin or enoxaparin). The resident was surprised because patients admitted to the
hospital typically receive this treatment to prevent blood clots from forming while they lie in their hospital
beds. Further, nothing about Mr. Londborg’s medical record suggested he shouldn’t have received this
treatment as an important precautionary measure.
The ultrasound, unfortunately, confirmed the presence of a blood clot in Mr. Londborg’s left calf. Due to
his impaired kidney function, treatment for the blood clot required him to remain in the hospital on IV
medication.

Mr. Londborg’s stay was going to be longer than expected.

At 10 PM on his eighth day in the hospital, a member of the environmental services (also known as
housekeeping) staff found Mr. Londborg on the floor of his room. She immediately alerted the nurses on
the ward. The nurses noted seizure activity and called the overnight medical team to Mr. Londborg’s
bedside. The team responded quickly and gave him intravenous medication that stopped his seizure.

Because no one witnessed his fall and seizure, Mr. Londborg underwent an emergent CT scan of his head
to check for any sign of bleeding. After his mental status improved (it is common for patients to be
confused for a time after a seizure), he complained of pain in his left shoulder and elbow, but x-rays of
these joints showed no evidence of a traumatic fracture from his fall.

After ensuring that Mr. Londborg was stable, the overnight care team reviewed the chart and the
medication history to try to determine the cause of Mr. Londborg’s sudden seizure. They found that one of
his seizure medications, levetiracetam, had not been given earlier in the day when it should have been.
There was a notation in the medication administration record from the daytime nurse indicating that the
ordered dose was not available in the automatic medication dispensing system on the floor earlier in the
day.

Further discussions the following day with the daily care team of doctors and nurses revealed that the
nurses didn’t notify the physicians or the pharmacy that the essential medication was not administered.
The medication system didn’t include an automatic alert, either.

Fortunately, the overnight physicians restarted Mr. Londborg on his medication, and he suffered no
apparent permanent harm. Mr. Londborg was discharged after 10 days in the hospital. Most
hospitalizations for COPD are far shorter. In fact, many last only a couple days.

Discussion
questions

1) Unfortunately, Mr. Londborg suffered a seizure, a complication that could likely have been avoided if
he had received all of the ordered anti-seizure medications. Identify at least two specific errors that
contributed to this mistake.
1. His medication wasn't available.
2. The physicians weren't notified that the medication wasn't available.
3. The pharmacy department wasn't notified that the medication wasn't available.
4. The overnight care team wasn't as familiar with the patient and thus it took some time to realize a
medication error was responsible for Mr. Londborg's seizure. (This likely delayed other therapy to
prevent additional seizures and could have led to unnecessary testing.)
2) Based on the types of errors you just identified, can you identify systems issues/failures that affected
Mr. Londborg's hospitalization?

Communication failures:
 Though unclear why, the message that a medication wasn't available didn't reach either the
physician on the daily care team or the pharmacy.
 In this case, a limitation in transferring care to physicians on the overnight care team became
evident in the delay that occurred before recognition of the error. There are handovers in hospitals
among all professions – physicians, nurses, pharmacists, and other team members – to provide 24-
hour care to patients. This means that teams caring for patients overnight often are not as familiar
with individual patients and rely heavily on ''sign out,'' a practice where physicians relay
information about their patients, including current and anticipated problems, to other physicians
providing care overnight or on weekends and holidays. It also means that after a critical event, it
may take the team longer to identify the potential causes for a particular complication.
Technology failure:
 The advent of electronic ordering and dispensing has reduced the chances of medication errors
reaching the patient, but as with many improvements, it has not been perfect. (Sometimes
improvements lead to other potential sources of error.) The pharmacy wasn’t automatically alerted
that Mr. Londborg's anti-seizure medication wasn't available, and the physicians weren't alerted
that an alternative medication might have been needed. In an era where most hospitals face the
challenge of significant medication shortages of all types, preventing these sorts of errors becomes
even more critical.

3) Identify at least one thing that went well during Mr. Londborg's visit to the hospital.

1. The fact that a member of housekeeping was appropriately trained to alert nursing staff to Mr.
Londborg's condition is a great example of how everyone in a hospital plays a role in providing care.
This staff person responded quickly and got the patient the attention he needed.
2. The nursing and medical staff responded quickly and treated Mr. Londborg's seizure rapidly,
providing medical stabilization. They also evaluated him for potential trauma and other
complications of his seizure and fall.

4) Pretend you are the nurse manager on the ward where this adverse event occurred. (In most
hospitals, the nurse manager is responsible for daily operations on a given floor or ''unit,'' including the
nurses and others who work there.) How would you run a meeting to debrief team members in the days
after Mr. Londborg's seizure?

Most importantly, you wouldn't want to assign blame to the individuals who were directly involved. This
error stemmed from problems with systems of care. You should emphasize the critical role communication
plays in providing care and avoiding the type of complications that affected Mr. Londborg. (This might
involve working with a team of nurses and doctors to improve communication, possibly to include times
each day where nurses and doctors talk directly about their mutual patients.)

You might build a team of people from the professions involved (pharmacy, nursing, physicians, hospital
administration, and quality improvement departments) to review the specifics of the case, and work to
identify and implement changes to prevent similar errors in the future.

Recognition of staff for responding to a critical situation well is always warranted, including the
housekeeping staff member.
Lastly, it's important to discuss that the error was never disclosed to the patient. By acknowledging the
error and offering a plan to prevent such errors in the future, hospital staff could have helped Mr.
Londborg feel more confident in the hospital and his care teams. In addition, it may have been appropriate
to offer to let Mr. Londborg participate in the evaluation of the error that affected him and plans to
prevent future errors.

28. Case on identification (multi-morbidities):

Presentation
Barbara is 42-year-old woman presenting at your surgery for a routine appointment. Three years ago she
was diagnosed with early stage (stage 3a) chronic kidney disease associated with hypertension. Her kidney
disease and hypertension are managed by a combination of drugs that includes an ACE inhibitor, and
dietary restrictions. Barbara is complaining of ‘these heads of mine’ that she says make her feel poorly, and
a discomfort in her back and abdomen.
Medical history
Her notes show that a previous doctor has prescribed Barbara benzodiazepines for nervous complaints.
You have treated her mother in the past for depression.
On examination
Barbara describes her symptoms in a flat, monotonous voice and looks anxious and ill at ease. You find that
she uses vague phrases such as “these heads of mine” without properly describing them. During the
consultation she attributes her symptoms to her chronic kidney disease. Further exploration reveals that
Barbara is describing headaches which she attributes to her kidney problems.
Establishing a diagnosis
Question
What else might you look for to help with establishing a diagnosis?
a) Non-verbal cues may be helpful, for example, Barbara may fidget and may have restless movements.
She might avoid eye contact, and her posture might be collapsed. A person’s voice - in this case Barbara’s
monotonous and uninflected tone - could also provide another cue to help you as a GP in establishing a
fuller picture of a person’s situation.
b) Picking up on Barbara's earlier mention of her feelings could be useful, for example: ‘You mentioned
earlier that your headaches make you feel poorly. What do you mean by that?’ Also, try asking Barbara
how things are at work and at home.
c) When you obtain an accurate description of Barbara's head pains she describes bilateral mild to
moderate pain, which feels like a tightening or pressing (but not throbbing) and you establish that is not
aggravated by routine activities of daily living. The headaches happen about twice a week and based on
this description11 Next steps for diagnosis you diagnose this as an episodic tension-type headache. You ask
Barbara to keep a headache diary should further management be needed.

What else could help you to establish a diagnosis?

Ask the questions below.
In view of Barbara's worry and restless movements (using the GAD-7):
a) Have you recently been feeling nervous, anxious or on edge?
b) Have you not been able to control worrying?
In view of her flat monotonous voice (using the PHQ-9):
c) Have you recently felt down or depressed for most of the time?
d) Have you recently experienced much less interest or pleasure than is usual for you?
If there are any positive replies, you will need to investigate further.
Next steps for management
If Barbara's replies lead you to suspect depression, what should you do next?
Ask Barbara how she is feeling, and if she is affected at all by her symptoms, for example:
• have these problems prevented you from doing any of your usual activities?
– (if yes) has this been more than one activity?
– (if no) have you been able to carry on with your usual activities, but only with increased
effort?
This additional questioning will help you to establish the severity of Barbara's depression, and to help with
formulating a diagnosis – which will then be based both on the number of depressive symptoms and the
extent of any associated impairment.

Effective delivery of interventions for depression

All interventions for depression should be delivered by competent practitioners. Psychological and
psychosocial interventions should be based on the relevant treatment manual(s), which should guide the
structure and duration of the intervention. Practitioners should consider using competence frameworks
developed from the relevant treatment manual(s) and for all interventions should:
－ receive regular high-quality supervision
－ use routine outcome measures and ensure that the patient with depression is involved in reviewing the
efficacy of the treatment
－ engage in monitoring and evaluation of treatment adherence and practitioner competence – for
example, by using video and audio tapes, and external audit and scrutiny
where appropriate.

Case identification and recognition

• Be alert to possible depression (particularly in patients with a past history of depression or a chronic
physical health problem with associated functional impairment) and consider asking patients who may
have depression two questions, specifically:
－ During the last month, have you often been bothered by feeling down, depressed or hopeless?
－ During the last month, have you often been bothered by having little interest or pleasure in doing
things?
Low-intensity psychosocial interventions
For patients with persistent subthreshold depressive symptoms or mild to moderate depression and a
chronic physical health problem, and for patients with subthreshold depressive symptoms that complicate
the care of the chronic physical health problem, consider offering one or more of the following
interventions, guided by the patient's preference:
－ a structured group physical activity programme
－ a group-based peer support (self-help) programme
－ individual guided self-help based on the principles of cognitive behavioural therapy (CBT)
－ computerised cognitive behavioural therapy (CCBT).

Treatment for moderate depression

For patients with initial presentation of moderate depression and a chronic physical health problem, offer
the following choice of high-intensity psychological interventions:
－ group-based CBT or
－ individual CBT for patients who decline group-based CBT or for whom it is not appropriate, or where a
group is not available or
－ behavioural couple’s therapy for people who have a regular partner and where the relationship may
contribute to the development or maintenance of depression, or where involving the partner is considered
to be of potential therapeutic benefit.

Antidepressant drugs
Collaborative care
Consider collaborative care for patients with moderate to severe depression and a chronic
physical health problem with associated functional impairment whose depression has not
responded to initial high-intensity psychological interventions, pharmacological treatment or a
combination of psychological and pharmacological interventions.

29. Case study on diabetes: Identification and assessment (comorbidities)

Presentation
Paul is a 52-year-old self-employed builder who has diabetes. He presents to his GP complaining that he
has been feeling increasingly tired for the last 4 months. His sleep is poor and he says he can’t be bothered
to shave in the morning. He says that the practice nurse was unhappy with his diabetic control and his wife
has now insisted that he see a doctor.
Medical history
Paul smokes around twelve cigarettes a day, mostly at work, with his mates. He has hypertension and has
been receiving an antihypertensive drug for the last five years. He takes an oral statin to lower his
cholesterol and an oral antidiabetic drug for his diabetes. He also takes an ACE inhibitor for treatment of
hypertension and prevention of diabetic complications, and aspirin for the prevention of cerebrovascular
events. Paul does not regularly use alcohol, and reports drinking a couple of pints’ maximum, if he is out
with his mates, after a football match.

On examination
Paul looks overweight and has a body mass index of 32. When last seen by the practice nurse his HbA1c
Establishing a diagnosis had increased from 8% to 9.2% and his cholesterol level is 5.8mmol/l. His current
blood pressure is 145/85 mm/Hg. He appears low in mood, is avoiding eye contact and has lost his usual
jocular manner. He is speaking quietly and describes his mood as ‘fed up’. He is blaming himself for not
being able to ‘pull himself together’.

Establishing a diagnosis
Question
As Paul’s GP, what should your next steps be?
The GP should ask Paul about his appetite and his sleep patterns over the past month, as this will help to
reveal symptoms of any depressive disorders. Paul informs the GP that he has lost his appetite, and he is
finding his eating is ‘all over the place’. He is usually in bed by 10pm, and has no problems with getting off
to sleep but has begun to recently experience sleep disturbance as he wakes once or twice at night to use
the toilet. Paul reports that he has also recently begun to wake about an hour earlier than usual (at 5am)
feeling stressed, and finds he cannot get back to sleep. The GP then asks Paul if he felt refreshed on waking
in the morning, and he replies that he “feels tired and finds it hard to get out of bed”.
How could you build up a full picture of the impacts on Paul, including those affecting his psychological
functioning?
a) The GP asks Paul how his concentration has been over the last month or so, and for example, whether
he is able to concentrate on reading a newspaper (these questions will help to test Paul’s psychological
functioning). Paul feels his concentration is okay, and he is able to read the headlines of the newspaper,
but doesn’t read much more because he feels there is too much bad news in the papers.
b) The GP then asks Paul if he can test his concentration, by asking him to name today’s date, and his own
date of birth. Paul is able to correctly name his date of birth and the month for today’s date, but appears to
be struggling to identify the actual date within the month.

What risk factors should you consider with Paul?

a) The GP asks Paul if he has had any suicidal thoughts, for example, has he ever wished when he went to
bed at night that he would never wake up. The GP also asks Paul directly about whether he has ever
thought of harming or killing himself. Paul is adamant that he loves his wife and children too much to do
that to them, and confirms that he has never had any ideas or plans to harm himself.
b) The GP also asks Paul if there have been any problems with his diabetes medication, as he has noticed
his diabetes is not as well controlled as usual. Paul states that he is still taking his medication, but that he
has been a bit forgetful regarding taking it over the past six weeks, and has ended up skipping some doses
as a result.
c) The GP also asks Paul if he is still smoking, and Paul confirms he is still smoking about twelve cigarettes a
day, but he feels too stressed to stop at the moment.

Next steps for diagnosis and management

What would your next steps be in establishing a diagnosis for Paul?
The GP asks Paul some further questions about the management of his diabetes and whether - apart from
the practice nurse - he has seen anyone else about it. Paul confirms he has had appointments with the
diabetic nurse at the surgery every six months and thinks he last saw her three months ago and that he has
a target of 7.5% for his HbA1c.
The GP probes further, to try and discover why Paul thinks his HbA . 1c The GP explains that because of
Paul’s current weight, his HBA1c and the level of his cholesterol that if he met with the practice nurse at
this point it may trigger an intensification of his treatment.
The GP thinks that an escalation in Paul’s diabetes treatment could potentially risk denting his self-esteem
at this point in time, and it could also introduce further medicines whereas behaviour change support may
actually help Paul to get his diabetes management back on track. As Paul had managed his diet previously,
his GP encourages him to set some realistic goals for his diet for the next fortnight, for example by trying to
avoid the café for at least a couple of days a week, and if he does go to try and opt for a healthier option.
He also asks Paul to keep a food diary. has risen to 9.2%.
Paul confirms that over the past month he has often forgotten to take his medicine during the day. He then
admits that he has also struggled with keeping to his diet plan and has had a few days in a row where he
has been for all-day breakfasts with the lads from the building site at lunchtime.

What else could you ask, as Paul’s GP to help establish a clearer picture of his psychological functioning?
a) The GP asks Paul if he has ever suffered from depression, but Paul doesn’t think that he has. The GP says
to Paul that he wonders if he is experiencing symptoms of depression, and asks him what he thinks about
this. Paul states that his wife had suspected this, and that is why she had encouraged him to visit the GP.
b) The GP asks Paul if his work has been affected since he has been feeling this way and Paul confirms that
although he is still working – he is a builder, and he says that work is becoming scarce - he is often feeling
really tired at work.
c) The GP asks Paul about his home life, and whether the way he has been feeling recently may have
affected things at all. Paul discloses that his wife has seemed annoyed with him at times, as he is often
sitting around and she says it is like he is moping all the time and he can’t even be bothered to go to watch
the football with his friends anymore.

As Paul’s GP, how should you negotiate the diagnosis with him?
a) The GP informs Paul that from what he has mentioned so far, it appears that Paul is moderately
depressed, that it seems to be beginning to affect his work and how he feels at home, and that this could
also be having a knock-on effect on his diabetic control. He asks Paul what he thinks about this diagnosis
and Paul replies that he feels okay to take any actions the GP recommends, especially as he can see that
the depression is now affecting his relationship with his wife.
b) The GP gives Paul some leaflets on depression so that he can understand it better, and asks Paul if he
would like to be referred for counselling from a therapist who can see him at the surgery. Paul agrees to
this referral, and says he thinks it would be good to start to try and tackle his symptoms.
c) The GP also asks if Paul would like to attend a follow-up appointment with his wife, so that they can
together explain Paul’s issues and his planned treatment. Paul agrees to this course of action.

Next steps for treatment

Question
What would the best approach be for both the management of Paul's diabetes and the treatment of his
depression?
a) The GP makes a follow-up appointment to see Paul and his wife together in two weeks’ time so that they
can explain to her what is happening with Paul, his plans for treatment and can answer any questions she
may have.
b) The GP also asks Paul to complete a PHQ-9 questionnaire – explaining that it is so Paul’s progress with
his depression symptoms can be monitored. Paul’s PHQ-9 score is 14 which equates to moderate
depression. His GP explains to him that this score, along with the other factors they have discussed today
indicates that he is moderately depressed.
c) Towards the end of the consultation the GP makes a referral for Paul to the surgery’s IAPT therapist and
reminds him of his follow-up appointment with the GP in two weeks’ time.
d) The GP also asks Paul to let him know if things get any worse, and to come back and see him straight
away if they do. At the end of the consultation Paul asks the GP whether he thinks he needs tablets for his
symptoms of depression. The GP asks Paul why he suggested this and they discuss his symptoms again and
how to manage them. They agree that Paul will continue to see the GP regularly in order to monitor things.

30. Case study on psychoeducation and active monitoring:

Presentation
Jerome is a 35-year-old welder who lives with his partner and two children aged 3 and 5 years. Jerome has
come to see you at your surgery as he is feeling tired all the time.
Medical history
Jerome has a history of anxiety and depression. He joined your surgery 5 years ago, at which time he was
taking sertraline for moderately severe depression and associated panic attacks. This was prescribed by his
previous GP. The sertraline was effective and Jerome stopped taking the medication after 6 months of
treatment. He has not returned to the surgery since that time. Jerome is otherwise physically fit and well
and is not prescribed any medication.
On examination
Jerome describes a lack of drive and energy for the past six weeks. He feels stressed at having to face his
job but is still going to work. Jerome admits trying to cope with disrupted sleep patterns by drinking more
alcohol than usual during the past fortnight. He is now drinking 3 pints of beer every night instead of only
twice per week as he used to. His physical examination is normal but he appears in low mood.

Next steps for diagnosis

Question
You suspect depression. What would you do to investigate this?
a) You should ask Jerome the following questions:
• During the last month, have you often been bothered by feeling down, depressed or hopeless?
• During the last month, have you often been bothered by having little interest or pleasure in doing things?
b) If Jerome answers yes to either question then this should be followed up using a validated scale and the
9-item Patient Health questionnaire (PHQ-9) or Hospital Anxiety and Depression scale would be
appropriate.
c) As part of the consultation you should explore possible life triggers for Jerome’s depressive feelings and
the functional impact that these are having on Jerome’s life, as well as the risk of self-harm or suicide.
d) You should compare Jerome’s current presentation with any record on his notes of his previous
presentation (when he had been diagnosed with moderately severe depression).

Next steps for management

Jerome scores 11/27 on the PHQ-9 and he has no thoughts of self-harm and is still functioning at work and
home with his family. As a result, you diagnose a mild depressive episode. However, there is also
associated anxiety and excess alcohol use.

What should your next step be?

a) You should use the step 1 interventions of active monitoring and psychoeducation, providing
information and leaflets or web links on depression and discuss some effective approaches for Jerome to
use to manage his depressive feelings. In addition, you should provide information about both depression
and the role that excess alcohol use has in exacerbating a depressed mood, as well as its contribution to
poor sleep. Written information and web links could be used to supplement the information that you
provide to Jerome.
b) You should advise and collaboratively agree with Jerome that he reduces his alcohol intake to below 21
units weekly, or to cut alcohol out completely
c) Jerome should be asked to come back in two weeks so that you can reassess the effect on his mood.
Jerome returns to see you after 2 weeks. He reports that with support from his partner, he has significantly
reduced his alcohol use to around four units per week. However, he has found that his mood is no better.

What should you now advise?

a) Follow the step 2 interventions
b) Discuss Jerome’s use of alcohol, and advise him to try and continue to reduce his alcohol use – aiming to
reach abstinence from alcohol.
c) Discuss the treatment options with Jerome, taking into account his preferences and previous response
to treatment. These include:
• individual facilitated self-help based on the principles of cognitive
behavioural therapy (CBT)
• computerised CBT
• a structured group physical activity programme
• antidepressants
d) As this is a recurrence of depression and Jerome previously had a good response to sertraline, he could
restart medication and continue for 6 months after recovery (alone or in conjunction with the treatment
options above).
e) You should outline the principles of CBT and offer an information about CBT.
Jerome chooses individual facilitated self-help using CBT, and agrees to return to see you to reconsider
talking sertraline if non-drug approaches are not effective.

Further management
a) Over the next 2 months, Jerome receives a mixture of face-to-face and phone consultations as part of
his low-intensity treatment plan. This also means he does not have to miss work.
b) Jerome’s treatment includes the following interventions: explanation; monitoring of risk and alcohol
consumption; activity scheduling and goal setting; challenging of unhelpful and extreme thinking; and
written 'homework' diaries.
c) Over time, Jerome’s depression and associated anxiety resolves. He also creates a written Staying Well
(relapse prevention) plan with his mental health worker for the future.

Week 6 - Session 6 (180 minutes)

 Case study discussion (30 minutes)

 Class on Educational Psychology

Case studies on students concerns.

31. Case Study: Behavioural Problems

Alphonse is often a behavioural problem in Ms. Stewart's tenth-grade classroom. Throughout the school
year, she has tried to ignore his behaviour in an effort to not reinforce it and avoid giving him an audience
for his acting out.

She has given him swift and immediate consequences for his inappropriate behaviour, progressing from
school detentions to in-school suspensions. Alphonse's grades in Ms. Stewart's class are almost failing,
and he seems to have given up hope.

Alphonse is oppositional and moody, and Ms. Stewart doesn't look forward to seeing him each day. Most
of the comments she has given Alphonse have not been positive. She has called his mother several times,
but has been unable to reach her.

One day in May, Alphonse comes into the classroom with his hood up and headphones on, and he
immediately puts his head down on his desk. Ms. Stewart goes over and taps him gently on the shoulder,
firmly telling him to remove his hood and sit up. Alphonse becomes upset, cursing and throwing his books
onto the floor, creating a huge disruption in the classroom. He then storms out of the room.

Strategies to Help the Situation

After the incident, the vice principal gave Alphonse a one-day suspension. Ms. Stewart felt she had failed
Alphonse because neither his academics nor his behaviour had improved during the year—in fact, they had
gotten worse. After this incident, Ms. Stewart decided that trying to deescalate Alphonse's behaviour by
ignoring him had been a mistake. She also realized it hadn't been wise to enter Alphonse's personal space
when he wasn't expecting it.

When Alphonse returned, Ms. Stewart asked him to stop by for a visit after school. She made sure she had
snacks available to create a comfortable environment in which to talk. Calmly and professionally, Ms.
Stewart asked Alphonse what was going on. It wasn't long before the floodgates opened: Alphonse was the
oldest of five siblings. His single mother worked at night, and it was Alphonse's responsibility to feed,
bathe, and take care of his other four siblings. He often did not get much sleep.

As a result of his at-home responsibilities, Alphonse was not able to play basketball for the school's team
this year—a fact that he resented strongly. He was angry that he was not able to enjoy his teenage life like
his friends could, and that anger manifested itself in class.

Ms. Stewart immediately notified the school social worker so that Alphonse could discuss his problems
with a professional on a regular basis. She then told Alphonse about a weekend basketball league. She
contacted the coach and explained Alphonse's situation.

Very quickly, Alphonse began to see his teacher as an ally. Ms. Stewart lamented the fact she waited so
long to build a relationship with Alphonse. She saw a marked improvement in both Alphonse's behaviour
and his academics. Although he sometimes still lost his temper, the incidents were more infrequent, and
Ms. Stewart was almost always able to calm and redirect him.

When school starts in September, Ms. Stewart plans to follow up with Alphonse, his social worker, and his
new teachers so that he can continue on the road to success.

32. Case on temper tantrum and behavioural problems

Chuck lived with his parents and younger brother in a small rural community in Oregon. Shortly after his
fifth birthday, Chuck’s parents enrolled him in a general education kindergarten class at a nearby
elementary school.

Chuck had several behavioural challenges in kindergarten. His teacher reported that Chuck frequently had
difficulty following directions and would sometimes throw a tantrum when he did not “get his way.” He
also had problems getting along with his peers. Chuck did not like to “wait for his turn” or “stand in line”
with his class. Chuck’s mother reported that he displayed similar behaviours at home. For example, his
mother was concerned that Chuck often “did not listen” to her or her husband. He often tried to “be the
boss” with his brother—both at home and during family outings in the community.

Chuck’s problem behaviours continued and escalated in first grade. For example, he repeatedly defied his
teacher and refused to follow her instructions. Loud verbal arguments led to fistfights with other boys, and
occasionally girls, at lunch or recess. Given the increasing frequency and severity of these and other
problem behaviours, Chuck was referred to the school’s Individual Education Program (IEP) team, assessed,
and identified as a student with behaviour disorders.
At the beginning of second grade, Chuck’s principal, his teacher, and his parents decided to enrol Chuck in
a special program called First Steps, an evidenced-based behavioural intervention program for young
children developed by researchers at the University of Oregon. The intervention had school and home
components.

• At school. Chuck’s second grade teacher used a “token economy” program to positively reinforce
his appropriate behaviour. The teacher set clear behavioural expectations for Chuck’s behaviour in
the classroom, hallway, lunchroom, and playground. Chuck received “tokens” for appropriate
behaviour (e.g., waiting quietly in line), but lost tokens for misbehaviour (e.g., talking out of turn or
leaving his desk without permission). Chuck turned in tokens for special prizes. He could choose
something fun for himself (e.g., extra library time) or the whole class (e.g., playing Simon Says or
extra recess). He could also earn special time with his mom or dad (e.g., go for a walk in the woods).

• At home. A First Step interventionist visited Chuck’s home once a week for six weeks. The
interventionist taught his mother to play short games that would help Chuck be more successful at
school. His mom really liked the games; she even modified some of them so that they could be
played with both Chuck and his brother. She said that she felt more empowered as a parent. She
felt the First Step activities offered her a structure and helped her learn how to interact with her
children in a positive way.

The First Steps intervention was effective with Chuck. His third grade teacher reported that Chuck focused
on his schoolwork, was near grade level academically, and especially enjoyed reading. His soccer coach
reported that he followed team rules and got along with his teammates.

33. Case on social behaviour

Juanita lived with her father, mother, and five siblings in a large city in Arizona. She was enrolled in a
general education first grade class at her local neighbourhood school. Juanita qualified for Title 1 supports,
including the free and reduced-price lunch program, but did not receive special education.

Juanita’s first grade teacher reported that she was an average student academically. The teacher reported
that Juanita generally paid attention and tried hard to complete her seatwork and other academic
assignments each day. Juanita’s reading and math skills were near grade level and similar to those of most
of the other students in her class.

However, her teacher also reported that Juanita had several behavioural challenges at the beginning of
first grade. Her teacher indicated that Juanita shy and timid, often refusing to “stand up for herself” when
interacting with her peers. She rarely volunteered to participate in group activities in class or on the
playground. Instead, Juanita would often avoid or withdraw from social situations, especially those
requiring her to work together with other students.

In response to Juanita’s behavioural challenges, her first grade teacher referred Juanita to a new
behavioural intervention program at her school. The program was based on behavioural studies of young
children like Juanita conducted by researchers at Arizona State University.

Juanita’s behavioural intervention had two main components:

• Social skill instruction. Her teacher explicitly taught Juanita specific social skills in targeted areas
such as answering questions, controlling her anger, and getting along with others. For each target
 skill, Juanita learned how to perform the skill effectively as well as when to use the skill in what
social situations.

• Cooperative learning groups. Juanita participated in a small cooperative group with three other
students who behaved properly at school. Her cooperative group provided opportunities for Juanita
and the other students to model and role-play target social skills.

In addition to her behavioural intervention, her teacher positively reinforced appropriate behaviour by
Juanita and her classmates. Her teacher also provided opportunities for Juanita to observe and learn how
her classmates behaved in different social situations during class, in the hallway, at lunch, and on the
playground.

By the end of first grade, Juanita’s social behaviour had changed dramatically. Juanita had gained self-
confidence when interacting with her peers in class, during lunch, or on the playground. She began making
friends with other students, including asking her mother to arrange for “play dates” with her friends after
school or on weekends. No longer socially isolated, Juanita and her family looked forward to her continued
learning and achievement in second grade and beyond.

34. Case on difficulty in learning and speaking

Fred lived with his family and attended his neighbourhood school in a suburban community in Oregon.
Fred was seven when he was hit by a car—an accident that left him with reduced use of his right leg and
arm, difficulty speaking, and even more difficulty learning. Fred’s learning and behavioural challenges
continued through elementary school and into middle school.

By sixth grade, Fred frequently misbehaved at school. When presented with a complex or difficult task,
Fred would frequently whine and stomp his feet. When particularly frustrated, Fred would run out of the
room and, on several occasions, left the school grounds without permission. After Fred threw a typewriter
through a classroom window, his principal considered asking the district to place Fred in a special school
for students with severe behaviour challenges.

Fortunately, his teachers and family asked behavioural researchers at the University of Oregon to help
them design a new behaviour management program for Fred. The team analysed possible reasons for
Fred’s problem behaviours, including identifying environmental events (e.g., transitioning between class
periods) that triggered his outbursts. The team also planned how to positively reinforce Fred for displaying
appropriate behaviour in different situations at school.

Fred’s new behaviour management program had several interrelated components, including:

• Academic Instruction. Fred was provided an adapted curriculum for his academic instruction. For
example, Fred learned functional skills, such as reading lunchroom menus or shopping at a nearby
grocery store. Fred received individual (one on one) tutoring. He also received integrated academic
instruction in small groups of students, including instruction with both special education and
general education classmates.

• Self-Monitoring Strategies. Fred was taught specific strategies to help him resolve difficult social
situations. For example, Fred learned how to (a) interact properly with his peers, (b) tell his
teachers when he was frustrated, and (c) initiate self-imposed “breaks” rather than becoming
violent. Fred’s teachers recorded data on the frequency of his use of (and his success in using) these
strategies in different school environments.

Over time, Fred’s behaviour management program led to the creation of a social network to support Fred.
Key members were Fred’s mother, his special education and general education teachers, and his middle
school principal. The network coordinated systematic positive reinforcement and support for Fred in
displaying appropriate behaviour at school and home.

The last two years of middle school were a great success for Fred, his teachers, and his family. Fred
continued to progress in each academic subject. His behaviour also improved. For example, the number of
classroom disruptions requiring the principal’s attention dropped from 40 episodes in seventh grade to
only four minor events in eighth grade. Best of all, as Fred learned to monitor and manage his own
behaviour, he began displaying a renewed interest in learning. Fred entered high school with a newfound
pride in himself and what he could do independently.

35. Case Study on conduct disorder.

An 11-year-old boy, Jake, was referred to an inpatient unit of the Children’s Hospital for further diagnostic
evaluation and treatment by the paediatric liaison team on call. He was socially isolated at school and in
the rural community where he lived. He had behavioural difficulties at home and difficulties in adhering to
the boundaries set by the parents. His mother labelled him as a “troublemaker” and he was oppositional at
school with inappropriate behaviour. He was frequently interfering with teaching in the classroom.
Although he wanted to socialize with other children, he was clumsy and aggressive in his attempts to
initiate contact. Teachers and other children’s parent’s complaints objectified the presence of behavioural
problems. His behaviour was described as aggressive and violent. His play and his reactions were often
inappropriate and fear-provoking to others—i.e., he performed animal amputations, made and collected
poisons, destroyed objects, and set fires.

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his
mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no
friends and, on occasions, he has been victimized by bullying at school and in the community. His father is
44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent
to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The
mother is 41 years old, and describes herself as having a close relationship with her children and
mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts.

Treatment

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and paediatric
assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was
started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his
behavioural problems prevailed and thus were the main target of treatment. In addition, his behavioural
problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings,
peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe
profile and fewer side effects. Family meetings were held regularly, and parental and family support along
with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying
them to others as well as in learning how to recognize the emotions of others and to become aware of the
consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his
discharge, he received regular psychiatric follow-up and continues with the medication and the
occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has
been noticed regarding his social behaviour and behaviour during activity as described by all concerned.
Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more
manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying
by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors
relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after
intervention, the child’s encouragement and support from parents and teachers, and the improvement of
parental relations as a result of parent training and family support by mental health professionals. Taken
together, it appears that also in the case of psychiatric patients presenting with complex genetic
aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can
lead to a decrease of symptoms and improved functioning.

Week 7 - Session 7 (180 minutes)

 Case study discussion (30 minutes)

 Class on Geriatric Psychology & Maternity counselling (150 minutes)

Case studies on geriatric concerns

36. Case study on Post Traumatic Stress Disorder

A 90-year-old woman has been a patient of the Beacham Ambulatory Care Center since 2000.   Chronic
conditions are pernicious anemia, osteoarthritis, and urinary incontinency.  She is fully functional and fully
independent.  She provides care for the homebound husband who has severe COPD.  They live in a row
home specifically “close to the hospital” to ensure access to house calls for her husband.

In September 2000, the husband dies as a result of respiratory arrest.  Her only relative is a nephew who
talks with her about once a month.  In October 2002, her home is broken into and our patient is raped and
robbed.  She was taken to a local hospital specializing in rape.  Here, she is distressed, delusional, and is
reported to be very emotionally distraught.

Presentation and Examination

We see the patient about 3 weeks after the rape in a community nursing home, where she was moved
after a 4-day stay at the hospital.  She was very distressed, delusional and confused.  She slowly improved
over 2 months and was discharged to a senior living building in a community in eastern Baltimore County. 

In March of 2003, the patient is seen in the office. She is still very ill emotionally.  She is crying, depressed
(not suicidal), and stressed about her new home.  She wants to move to a new Senior Housing unit because
it would be on the bus route making it easier to get around.  She has also hired a middle aged woman as a
caregiver.

In November 2003, 9 months after moving to a new facility, she becomes acutely ill with psychotic
symptoms and severe paranoia.   She hallucinates that men and women are in her bed and calls others all
hours of the day.  She is hospitalized on a psychiatric unit and improves over about 14 days without
antipsychotic medication.

One week following discharge from the hospital, symptoms rapidly recurred when she returned to the
senior apartment.  She was disruptive and threatened with eviction unless something was done rapidly. 
An emergency petition was prepared as she refused medical care.  With the help of her companion, we
were finally able to persuade her to take a neuroleptic drug (Haloperidol 0.025 – 1.0 mg/day) for her
recurrent incapacitating hallucinations.  Our office nurse and staff called her daily to guide her through the
process of taking her medicines.  She slowly but steadily improved and became stabilized.

Diagnosis: Post Traumatic Stress Disorder

Case Discussion
Basic Facts on Elder Rape

 65% of rapes are associated with burglary

 73% occur in the victim’s home
 300,000 Elder Abuse reports in 1 year in the U.S.; 9,000 were sexual assault
 Study:  28 rapes/year in Massachusetts 
     -Victims were ages 65-101
     -50% were committed by a relative

Treatment
PTSD is a treatable condition and therefore it is important to recognize.  Without treatment, PTSD is
disabling in 50% of cases. Slightly less than 50% of patients are untreated.  Informing the patient about the
illness and its course through educational counselling help patients and their families cope.  Cognitive
therapy (a specific form of interactive counselling) requires referral to a psychologist experienced in this
form of counselling. SSRIs (antidepressants) may be necessary. 

1. Remain compassionate

When suffering from PTSD, seniors can relive episodes of traumatic events through flashbacks. Though
they're perfectly safe, they may suddenly feel like they're in terrible danger and start acting erratic and
strange. This can be scary for caregivers, so it's important to remain compassionate, understanding, and
empathetic.

Though it's impossible to know exactly what the senior is going through, it might help you to research what
goes on in the mind of someone with PTSD. This will help you remain empathetic and understand that they
can't simply "snap out of it." They need loving support and professional help.

2. Understand co-factors

PTSD is a serious condition for people of all age levels, but there are some special considerations for
seniors. For example, a senior might also have Alzheimer's disease or dementia, which could worsen
symptoms and increase confusion.

In other cases, medications taken to manage other health conditions can exacerbate emotional outbursts.
Coping with a myriad of different health conditions and mental disorders is one of the unique challenges
of being a caregiver. If you accompany your loved one to doctor's appointments, it's important to keep
these contributing issues in mind.

3. Embrace Therapy

Though there are many different therapeutic approaches available, cognitive behavioural therapy has long
been considered the most effective. It works by changing an individual’s thought and behaviour patterns
surrounding an event.

Cognitive behaviour therapy might involve interventions like exposure therapy, in which an individual is
gradually taught to face the triggers that cause them fear. It can also use techniques like cognitive
restructuring, which helps seniors fight feelings of shame and confusion they may be carrying from the
past.

4. Explore alternative therapies

While it's important to work with medications, therapy, and official support groups, there are also some
alternative therapies that can be very helpful in supporting those with PTSD. For example, you might want
to explore:

 Mindfulness meditation
 Breathing techniques
 Gentle yoga practice

These gentle techniques can not only help your loved one establish coping mechanisms for their PTSD
symptoms, but also help provide good lifelong habits that can support better quality of life.

37. Case on Depression in Patient with Dementia

The patient is a 77 year old man with past medical history significant for dementia, hyperlipidaemia,
coronary artery disease (CAD), s/p coronary artery bypass graft (CABG) and aortic valve replacement  (AVR)
who was referred to the Memory Clinic for agitation.

According to the patient’s family member, he started having memory problems in 2002, which worsened
significantly after his CABG and AVR in 2004. At the time he presented to the clinic, he had functional
deficits in the following instrumental activities of daily living (IADLs) – handling finances, driving, cooking
and shopping.
The patient was noted to be easily agitated and irritable for some time, and was referred to the Memory
Clinic for exhibiting verbal and physical aggression towards his wife as well as others. The patient was
recently seen by his primary care physician for this issue, and all of his laboratory exams were normal, and
subsequent MRI of the brain was also unremarkable.

The patient noted good appetite and denied problems with sleeping or weight changes. He also denied any
suicidal ideations and visual/auditory hallucinations. However, he stated that he was depressed because he
was worried about his memory problems.

The patient’s Mini-Mental State Examination (MMSE) was 16/30, and Cornell Scale for Depression in
Dementia was 8 for the patient and 14 for the wife. 

Assessment and Plan

The patient had few typical symptoms of depression, however had agitation and irritability noted by his
wife in addition to depressed mood expressed by the patient. In this case, the patient may be minimizing
or is unaware of his symptoms due to his dementia. The patient was started on 25mg PO qD of a Selective
Serotonin Reuptake Inhibitor (SSRI) which was increased to 50mg PO qD after one week. The patient’s wife
was also instructed on behavioural management of agitation and aggression, and was encouraged to
contact the Alzheimer’s Association for caregiver support group.

Follow up
The patient and his wife returned four weeks later. The wife reported complete resolution of the
symptoms, and the patient denied feelings of depression, stating “I am a happy man.” The patient’s wife
also noted that she had contacted the Alzheimer’s Association, and joined a caregiver support group. She
learned about different strategies to care for her husband to minimize his symptoms.
Diagnosis of Depression in Patients with Dementia

Patients with Dementia May Have Different Clinical Manifestations of Depression

In a study comparing major depressive features between patients with Alzheimer’s disease (AD)* and
cognitively normal older adults, several significant differences were noted in the study. Patients with AD
had significantly diminished ability to concentrate or indecisiveness, less disturbances in sleep, and less
reports of feelings of worthlessness or excessive guilt. However, patients with AD were noted to have
higher rates of delusions and hallucinations. There was also a trend towards higher rates of psychomotor
agitation/retardation and fatigue/loss of energy in more advanced AD patients.

*AD is the most common cause of dementia in the older population.

Screening Tools for Diagnosing Depression in Patients with Dementia

While a screening tool such as the Geriatric Depression Scale (GDS) is commonly used to screen for
depression, there may be an underreporting on the part of the patients with dementia as they are unable
to recall or are not aware of the depressive symptoms reported by the caregivers. The reliability of GDS
diminishes with MMSE below 15. Input from caregivers become more important as the patient’s cognitive
status declines. Therefore, an assessment tool that incorporates caregiver input such as Cornell Scale for
Depression in Dementia (CSDD) may be more appropriate in patients with dementia. CSDD scores above 12
requires treatment, and above 8 requires more close follow up and possibly treatment.

Treatment of Depression in Patients with Dementia

Depression can be a contributing factor in functional decline in dementia, and treatment of depression
may improve functional levels in these patients.

Non-pharmacological Intervention

Non-pharmacological methods should be the first-line intervention in treatment of depression in patients

with dementia. Interventions targeting the patient as well as the caregiver are important. These may range
from arranging a day care for the patient to participate in activities to educating the caregivers on different
care giving skills.

Physical Exercise

The benefits of physical exercise for depression are many. From improving self-esteem and sleep habits to
increased energy levels, exercise can clearly benefit people with dementia. As an added benefit, some
research has shown that physical exercise may also improve cognitive functioning for those with dementia.

Meaningful Activities

For some people, part of depression is a lack of purpose. Giving people the opportunity to do something
that is important to them and related to their interests can be therapeutic for their emotional and mental
health.

Group Music Therapy

Some research conducted with older adults who were diagnosed with both depression and dementia
found that depression decreased after group music therapy sessions.3 Additionally, a slight improvement
in cognition—specifically in short-term recall ability—was also noted following the music therapy sessions.
Adding Structure to the Day

Having a routine and a schedule for the day can foster a feeling of control for people. Additionally, a
scheduled mental activity such as a game or a class may provide something to look forward to during the
day. For those with mid-stage dementia, sometimes the structure of an adult day-care centre can be
beneficial.

Individual Counselling

Especially for those in the early stages of dementia, therapeutic counselling can be very helpful. There may
be feelings of grief and loss after a diagnosis of dementia, and counselling can assist one in processing
those feelings and in developing ways to cope with the challenge of dementia.

Social Interaction

Some people with dementia tend to isolate themselves, which can increase the likelihood of developing
depression or exacerbate a mood that's already low. Although social interaction has the potential to be
tiring for some people who are depressed, positive social stimulation can also benefit and encourage those
with dementia and depression.

Support Groups

Support groups can be beneficial for people struggling with the adjustment of a new diagnosis of
dementia. Sometimes, it can be encouraging to hear from others how they're coping with the challenges of
dementia. Interacting with others in a group can also decrease feelings of loneliness and isolation.

Depression in people living with dementia is not uncommon, but there are some non-pharmacologic
approaches as well as medications that may be helpful to improve quality of life. Be sure to report feelings
or observations of depression to the physician in order to discuss possible treatment and support.

38. Case on mental disorientation in old age(Delirium)

Ann is 81-years-old and lives in upstate New York with her dog Margaret. She has been widowed for the last 15 years. She
lives alone in her own home across the street from the house she grew up in. Ann has a few close friends and three
granddaughters that live far away but call her often and visit when they can. Her only child Tom, and his wife Lynn, live
about 5 miles away. They see or speak with Ann daily. Ann has recently entered remission from a two-year battle with
Myeloma. She no longer drives and has lost about 25 pounds in the past year and most of her front teeth. She has become
frailer in the last three years, but is much stronger now that she is in remission and no longer has to take the bone
strengthening and anticancer medications.

For the 3-4 weeks Ann has complained about “losing time.” When speaking on the phone she repeatedly forgets what day
it is and has to look up the date on the calendar. One day, she frantically called Tom wondering why he had not picked her
up for her doctor’s appointment yet. He had to explain that the doctor’s appointment was not for another 4 hours. Ann
had thought it was 2 in the afternoon, when it was only 10 in the morning. Ann has also left the stove on three times in
the past 2 weeks and has taken to unplugging the television at night. When asked why, Ann states that she believes
Margaret is turning the set on in the middle of the night because when she gets up in the morning, the TV is on. She insists
that she has mailed her granddaughter Becky a news clipping from the local paper – but it never arrived. She has
complained to her granddaughters that she keeps forgetting the date, time and day of week. Last week, when talking to
her family on the phone she began to repeat herself. She also insisted that a strange man with a hat was looking in her
window from the street. This has not been verified. Her family is worried that she is going to burn the house down, forget
to take her daily pills or forget to feed the dog (or over feed the dog).

What are some diagnostic possibilities? What is your hunch?

What further assessment information is needed?

39. Stress experienced as a result of caring for aging mother

Rosa, 72, is brought to therapy by her daughter, Maria. Maria has been visiting her mother every day
for five years, ever since Maria’s father (Rosa’s husband) died, leaving Rosa alone. Maria helps Rosa
shop and cook and clean and keeps her company. But lately, Rosa needs more and more help, and
Maria feels she cannot meet her mother’s needs anymore. Rosa is irritated by this and angrily tells
her daughter, “You don’t even care about me.” The therapist takes a thorough personal history of the
family and comes to suspect that Rosa is suffering from a form of dementia. The therapist refers Rosa
to a physician, who confirms this. The therapist then works with Maria to find appropriate, affordable,
professional services for Rosa, including an adult day centre and an in-home nurse that Rosa’s
insurance covers. The therapist also helps Maria and Rosa understand the symptoms of Rosa’s illness,
helps Maria deal with feelings of guilt as well as communication difficulties , and facilitates joint
sessions to help the two talk about what Rosa is going through.
40. Therapy to assert independence with well-meaning family: 
Tobias, 64, enters therapy, discouraged and distressed by his family. He tells his therapist that he lives
alone in a small house, but his family has been encouraging him to sell his house and move into an
apartment complex for senior citizens so he can be near "other people his age" and so he does not
"get lonely." Tobias tells the therapist that he is happy on his own, that he has plenty of friends, and
that he has no desire or reason to make any changes in his life. The therapist asks if his family has any
reason to be concerned about him, and Tobias admits that he recently had a few accidents due to
vision changes but that since he has begun wearing glasses, he has experienced no more difficulties.
The therapist affirms Tobias' right to make decisions for himself, and together they explore ways that
Tobias can assert himself with his family. Tobias continues in therapy for several sessions, and the
therapist helps him work through his frustration with his declining vision and his fear of other changes
related to aging.

Case studies on maternity concerns

41. CASE STUDY ON YOUTH AND SEXUAL HEALTH

Nita is 21 years old and lives in Toronto, where she attends university and works part-time as a waitress.
Her studies keep her busy, and she is doing well. As often as possible she returns to see her family in her
community north-east of Montreal. On a recent trip home, she makes an appointment to see a family
doctor at the community health centre, which she prefers to the university clinic. She sees the visiting
family physician, Dr Pear, at the clinic, where she presents with vaginal discharge and itching, but is
otherwise healthy and physically active. She has no fever or urinary symptoms and has normal bowel
movements. She lives with her boyfriend and is taking birth control pills as prescribed.

Scenario 1 Dr Pear prepares to examine her. It is a busy day in the clinic and he is running behind schedule.
He asks if she is sexually active, but does not take a full history. He proceeds to examine her without much
interaction and recommends doing a Pap smear. He does not realize that she has regular examinations, is
in a stable relationship, and is taking good care of herself. After finishing the examination, he says that the
exam is inconclusive and he is not sure what is going on. He suggests that she might have an STI, does not
explain other possibilities, and says that the nurse will call her when the results are back. He arranges for
the nurse to come in and talk to her about birth control.

Scenario 2 Dr Pear greets Nita and asks her a few questions about herself. She tells him how she is doing in
university, that she is in a happy and stable relationship, and about her symptoms. Dr Pear explains that he
is going to do an examination to see what is going on. He leaves the room so that she can undress and asks
her to drape herself so that she will feel more comfortable. He returns and prepares to examine her, going
slowly and gently, and explaining what he is doing as he goes along. After finishing the examination,
including taking a sample and examining the slide, he tells her that it seems she has bacterial vaginosis. He
explains what this is and that it can be easily treated. He gives her a prescription for antibiotics and
reminds her hat if she has a Status card, she should show it to the pharmacist since her medication is
covered.

Dr Pear asks Nita if she has any questions. He also asks if she has regular health checks and if she has ever
had a Pap smear. Nita explains that she has regular examinations and knows the importance of staying
healthy, but that she doesn’t really like going to the clinic on campus. Dr Pear lets her know about
Anishnawbe Health Toronto, an Aboriginal community health centre.

Learning Points

• Do not make assumptions about a young woman’s sexual activity, such as that she has multiple
partners or dysfunctional relationships.
• Always explain what you are doing during procedures and why.
• Ask about Status as it relates to medication coverage. Be familiar with the medications that are
covered by the NIHB, or have a reference readily accessible.
• Ask open-ended questions, since these often give patients the opportunity to disclose things they
are uncomfortable with.
• Ask the patient if there is anything else you should know or anything else they would like to talk
about.
42. CASE STUDY ON ADOLESCENCE AND PREGNANCY— MIDWIFERY CARE

Tracy is a 16-year-old woman from a semi-remote First Nation community. She is 36 weeks pregnant and
attending a prenatal visit with her community midwife. This is her first pregnancy and she has attended all
previous visits with her mother and/or Frank, the father of her baby. Tracy is very quiet and makes limited
eye contact during these visits. Tracy’s pregnancy has been fairly uneventful. Her weight gain has been 23
pounds. Laboratory values and blood pressure have been within normal limits. A 20-week ultrasound
found no abnormalities of fetal anatomy. At her last visit the midwife told her they would be discussing
place of birth today. Tracy’s options are to deliver in one of two tertiary care centres in a large city 9 hours
away, or at a hospital in a smaller city closer to home. Tracy arrives for her visit with her mother and her
midwife notices that they seem to be more serious than usual today.

Scenario 1 Her midwife Mandy quickly asks them what is wrong. When there is little response, she asks if
Tracy is starting to experience some fears around labour and birth, and quickly goes on to reassure Tracy
that they will discuss all the options for coping. Tracy does not make eye contact. After an uncomfortable
silence Mandy begins to enquire about fetal movement, changes in vaginal discharge, whether Tracy is
taking her prenatal supplement, headaches, etc. Tracy answers with yes or no. Mandy explains Tracy’s
options for delivery, and asks her whether she has thought about which hospital she would prefer to give
birth in. After a moment, Tracy’s mother replies that she will give birth at ______ tertiary care hospital and
that she will be escorting Tracy. Tracy’s mother informs Mandy that Tracy is upset because she does not
want to leave Frank behind when she flies into the city to give birth. Mandy asks Tracy how she feels about
that and she shrugs her shoulders. Mandy proceeds to explain the next steps in setting an appointment
with a referral physician and arranging transportation.

Scenario 2 Although her midwife Mandy suspects that there may be something bothering Tracy, she begins
the appointment by asking about Tracy’s sister and her 1-year-old son, who she helped to deliver. Mandy
casually asks whether there are any plans yet for who will be able to attend Tracy’s birth, knowing that the
family is very close and Tracy would like more than one person to be there. There are some vague
responses. When Mandy asks a question, she speaks directly to Tracy’s mother until Tracy initiates eye
contact. She goes on to ask about fetal movements and jokes about how active the baby is at 1:00 a.m.,
saying that the baby is just like her mother. Tracy smiles a little and makes brief eye contact with Mandy,
which Mandy sees as an indication that she is ready to speak about today’s concerns. When she feels that
Tracy has relaxed, she asks about Frank and how they are doing as a couple. Tracy answers that she is
worried about having to choose between bringing her mother or Frank with her to the city to give birth.
Tracy’s mother then asks when Tracy will be “sent out.” Mandy reviews Tracy’s options for where to give
birth and asks them if they have discussed their plans and considerations. Tracy’s mother replies that Tracy
will give birth at ________ tertiary hospital and that she will be escorting her. Mandy glances at Tracy to
see how she reacts. She reassures them that she will request funding for Frank to be able to accompany
them. The referral appointment is booked for one week from the current visit. The day following Tracy’s
scheduled appointment in the city, Tracy calls Mandy to tell her that she has noticed blood in the toilet and
that she is still in the community.

The midwife arranges to meet Tracy at the clinic to assess her. Frank comes with Tracy to the clinic.

Scenario 1 A medivac flight is organized to transport Tracy to the hospital to query early labour. Her
mother arrives at the clinic with a suitcase and escorts Tracy. There are vague plans for Frank to travel later
with Tracy’s father.

Scenario 2 Mandy comments on how Frank and Tracy are treating each other well and how important this
is for Tracy and the baby. A medivac flight is organized to transport Tracy to the hospital, to query early
labour. Her mother arrives at the clinic with a suitcase and escorts Tracy. There are vague plans for Frank
to travel later with Tracy’s father. Mandy asks Tracy and her mother to keep in touch.
Learning Points

• Indirect questioning about feelings is often more effective, allowing the underlying story to
emerge.
• Noticing eye contact is an important aspect of reading body language since it is an invitation to
communicate. Young people may initially hesitate to make eye contact.
• When accompanied by her mother or another Elder, a young woman will often defer to her
mother or Elder when questions are asked. Politely address the Elder directly in the conversation
and respect and recognize her role as decision maker while carefully considering the patient’s
perspective.
• When a mother has to leave her community to give birth it can cause considerable stress in her
intimate relationship. This stress can sometimes present as conflicted feelings about being with the
partner or complying with guidelines and recommendations for leaving. This is especially difficult
for young women in new relationships, and it is important to recognize that they are not
deliberately being irresponsible; they are generally willing to be guided by caring adults in making
significant decisions in their lives.
43. CASE STUDY ON PREGNANCY AND BIRTH EVACUATION POLICIES

Marni is 31 years old and 35 weeks pregnant. She was initially seen in the emergency room of the hospital
in her community and was referred to a tertiary care centre in the city after being assessed by the family
doctor, who was concerned about preterm labour because of clear changes in her cervix. Marni arrives at
the tertiary centre escorted by a nurse who reports that she was comfortable and had no contractions
during the transfer. She reports that Marni has had no fever, urinary symptoms, nausea, or vomiting and
that her bowel movements have been normal. Dr Green, the on-call obstetrician, proceeds with a medical
history. Marni is a grand multipara, gravida 5, para 5, delivering at 37 to 38 weeks. She has not had any
terminations, miscarriages, or stillbirths and has had 5 live births, all vaginal with short, uncomplicated
labours and uneventful deliveries. She had gestational diabetes in her last 2 pregnancies and her antenatal
visits for this pregnancy were unremarkable apart from the diabetes, which is being well-controlled with
insulin.

Being away from home, Marni is concerned about her other children and is eager to get back home. Since
her contractions have settled down, Marni asks if she can go home. She tells Dr Green that there is a family
doctor who comes to her community to deliver babies. She wants to be close to home for the birth so that
she can be with her family.

Scenario 1 Dr Green explains that given her history, there could be complications. She tells her it is not safe
for her to give birth in her community and that she will have to be flown out for delivery. Her husband will
be able to accompany her, but not her children. Dr Green sends Marni home to prepare.

Scenario 2 Dr Green is worried that given her family concerns, Marni might present very late in her labour
so that it would be too late to fly her out. She tells Marni that her reasons for wanting to give birth in her
community are good reasons. Dr Green takes some time to explain why she thinks it is important for Marni
to deliver in a tertiary centre, explaining the risk of delivering in her community in easy-to-understand
language. She also gives her some information about things the hospital can do to support her through the
labour and help honour the birth of her baby even though she will be away from her family. She gives her
the contact information of the liaison officer.

Learning Points

• Consider the reality of living in rural locations, and the complex and multiple considerations a
woman must make in leaving her community.
• Familiarize yourself with the services available in rural areas.
• Communicate with the mother about the plans she will need to make to leave her community.
• Appreciate the cultural significance of birth to the family and community.
• Acknowledge and validate the concerns of your patient; do not dismiss concerns beyond the safety
of the unborn baby.
• Be familiar with the programs and services available at the hospital to better support the inclusion
of families.

44. A case of first-trimester vaginal bleeding with abdominal cramping

Mrs. M, aged 24 years and 11 weeks pregnant, presented to the emergency department (ED) with
abdominal cramping and heavy vaginal bleeding and clots. Over the past two days, she had experienced
light spotting, which had increased in severity that morning. Mrs. M reported no fever, chills, burning on
urination, nausea, or vomiting. Her past obstetric history was gravida 4 para 2 abort 1. She was sexually
active and receiving prenatal care from her obstetrician/gynaecologist. The patient was otherwise healthy
and had no significant medical problems.

Physical examination

Mrs. M’s BP was 124/84 mm Hg, heart rate 83 beats per minute without ectopy, respiration rate 18
breaths per minute, oxygen saturation 100% on room air, and temperature 98.3°F. Lungs were clear on
auscultation in all fields; S1 and S2 were normal with no murmurs, gallops, or rubs. The patient’s abdomen
was slightly distended, and mild tenderness was present over her lower pelvic area. During pelvic
examination, moderate active bleeding was noted in the vaginal vault with the cervical os open. No cervical
motion tenderness or adenexal tenderness was observed. Blood clots or tissue were noted on a per iPad.
The remainder of the patient’s physical examination was unremarkable.

Diagnostic workup

Laboratory findings showed WBCs 10,000/uL (normal 4,500-11,000), haemoglobin 13.7 g/dL (normal 12.1-
15.1), and haematocrit 39.7% (normal 36%-44%). Chemistries and urinalysis were within normal limits.
Mrs. M’s blood type was B-positive. Beta-human chorionic gonadotropin (b-hCG) level was 9400.0 mIU/mL,
which is elevated and suggests a gestational age of three to four weeks, according to the lab report.

Transvaginal ultrasonography showed what appeared to be an abnormal gestational sac within the cervical
canal. The findings were suggestive of a threatened abortion in progress. Transvaginal ultrasonography is
very reliable for finding remaining tissue or content of conception with 100% sensitivity and 80%
specificity.1 When transvaginal ultrasound shows a vacant uterus and the qualitative b-hCG level is >1,500,
an ectopic pregnancy should be considered and ruled out.2

After reviewing the findings of the abnormal gestational sac, it was apparent that Mrs. M did not have an
ectopic pregnancy.

Diagnosis

First-trimester bleeding has a number of differential diagnoses that must be reviewed along with a
complete history and physical examination. The relevant differentials for this case are cervical
abnormalities, including excessive friability, malignancy, polyps or trauma; ectopic pregnancy; idiopathic
bleeding in a viable pregnancy; infection of the vagina or cervix; molar pregnancy; spontaneous abortion;
sub chorionic haemorrhage, and vaginal trauma. 3

Upon review of her history, physical exam, and diagnostic workup, Mrs. M was diagnosed with incomplete
spontaneous abortion. In an incomplete abortion, some (but not all) of the products of conception have
been passed. Usually the patient has heavy bleeding and cramping with dilation of the cervix.

Treatment

1. Make them Understand That It Not their Fault. ...

2. Make them Understand the Grieving Process They Are Going Through. ...

3. Try Not to Close Themselves Off From Others. ...

4. Look After Self-Physical health. ...

5. Writing Out Present Feelings Can Help. ...

6. Understanding Anxiety and PTSD Can Occur After a Loss.

45. Case on postpartum depression

Maya is a 32-year-old fit, vibrant lawyer. She had been married for more than two years and was expecting
her first child, a baby boy. She had a history of depression and generalized anxiety disorder.

She had been doing well with a combination of medication and cognitive behavioural therapy (CBT) for
many years. Maya had decided in the months leading up to getting pregnant that she wanted to be off
medication and worked with her psychiatrist to carefully get off medication. She continued weekly therapy.
She was mostly active, upbeat and cheerful during her pregnancy. She gave birth to a healthy 7.3-pound
baby boy. After the delivery, she started to feel sad, overwhelmed and consistently tearful. She frequently
felt irritable and on edge. This feeling persisted for the first 10 weeks after the baby was born. She had
limited support—her parents were divorced and her mother was living in another state and helping her
sister’s family as a full-time babysitter. Her in-laws were much older with numerous health complications
and couldn’t help regularly.

Maya went to see her psychiatrist. She was quite tearful and felt she was a "failure as a mom." Her baby
cried incessantly and she could barely get sleep. She struggled with getting the baby to latch during nursing
and didn’t want to have to give him formula. She was upset that she had to "resort to getting an epidural,
even having to get induced." She had been fixed on giving birth the "natural" way and was lamenting on
how things didn't turn out the way she wanted. The baby had high level of bilirubin and had a bit of
neonatal jaundice and she blamed herself for it. After being monitored in the NICU, he was sent home.

Maya felt utterly incapable of soothing her baby and would get frustrated and tearful. She was so afraid of
what she had learned about sudden infant death (SIDS), that she would barely allow herself to sleep. She
felt that it was a constant race against the clock—with nursing, pumping and changing. She was always
cleaning bottles and diapers. She felt horrified with how she looked. She had expected to wear pre-
pregnancy clothes immediately after childbirth. She hadn't had a meal in peace or gotten her hair or nails
done and couldn't even think about having sex with her husband. He tried to be supportive, but also felt
overwhelmed by it all. He felt she was inconsolable and they both felt at a loss.

They went to see Maya’s psychiatrist as a couple and to get advice regarding her current mental state.
They talked about a variety of tools, including CBT, incorporating 15-20 minutes of daily relaxation,
mindfulness skills, hiring help, getting her mom to stay with her for a few weeks and other support. Her
husband understood the urgency of the situation and offered to take time off work and to do some of the
overnight feedings. Maya decided to get back on her previous antidepressant as it was extremely beneficial
in the past. She also joined a new moms support group and continued CBT weekly therapy. Over the next
few months, she was exercising more and getting more sleep and support and had significant improvement
in mood and energy. She received some sleep training tips from her paediatrician as well.

Maya and her husband shared with her psychiatrist that they were feeling significantly better. They were
excited to share that they found a series of self-help parenting books to be particularly helpful and had
gotten some helpful tips from others in the mom’s group.
"Wow-it really does take a village to raise a child, doesn't it," Maya commented to her psychiatrist. They
spoke about how in previous generations new couples could rely on extended family support and how that
support often doesn’t exist now. Also, inaccurate beliefs, such as babies are easy and infancy should be a
happy time for parents, add to stress, conflict and guilt. Being able to normalize the stress of adjusting to
parenthood was extremely helpful for Maya and her husband.

Managing after childbirth

Here are some tips that can help you cope with bringing home a new-born:
 Ask for help. Let others know how they can help you.
 Be realistic about your expectations for yourself and baby.
 Exercise , within the limits of any restrictions your doctor may place on your level of activity; take a
walk, and get out of the house for a break.
 Expect some good days and some bad days.
 Follow a sensible diet; avoid alcohol and caffeine.
 Foster the relationship with your partner -- make time for each other.
 Keep in touch with family and friends -- don’t isolate yourself.
 Limit visitors when you first go home.
 Screen phone calls.
 Sleep or rest when your baby sleeps.

Week 8 - Session 8 (180 minutes)

 Case study discussion (30 minutes)

 Class on Psychotherapy (150 minutes)
Case studies based on psychotherapy use:

46. Case on experience of panic use of CBT

Joe is a 34-year-old forestry worker. One day he had a panic attack out of the blue while queuing in a
supermarket. He started sweating, his heart was beating very fast and he was extremely dizzy. He was
convinced he was going to pass out and so he ran out of the supermarket, leaving his shopping behind. As
soon as he got out of the shop, he felt better. Joe was very confused about why that had happened to him,
and also embarrassed that he’d had to run out of a shop. He began to worry that he might have another
panic attack and started to feel anxious at the thought of going to supermarkets. He decided that there
was no need to go to supermarkets and instead went to his local shop when he needed something. A
couple of weeks later, Joe was driving to work on the motorway when he started to feel anxious and
panicky. As he was scared he might lose control of the car and cause a crash, Joe came off the motorway
at the next junction. Joe felt better straight away and decided that from then on he would not risk driving
on the motorway. Joe reasoned that since he might have a panic attack and need to leave places suddenly,
it would be best to avoid busy places where it might be difficult to get out such as supermarkets, shopping
centres, lifts, cinemas and the motorway. Joe’s wife began to get annoyed with him because the whole
family had to make allowances for his anxiety. In addition, Joe was becoming worried because he was
avoiding more things over time and he wondered where it would end, and so he made the decision to
come for a psychological assessment.

During the assessment, Joe and I discussed how his difficulties had progressed. We talked about what he
wanted to gain from attending therapy and set his therapy goals, which included things like gaining
confidence, using the motorway again and going for a date to the cinema.

Cognitive behaviour therapy (CBT) has a strong evidence-base for panic disorder and is recommended by
the National Institute of Clinical Excellence (NICE) as the treatment of choice for this condition. This
approach was discussed with Joe and we agreed to meet for 8 sessions of CBT.

1) Understanding the problem and what keeps it going

We began by considering what was causing and maintaining the panic. We went through Joe’s experiences
of panic in detail and learned that his panic attacks consisted of a) physical sensations and b)
misinterpretation of those sensations as dangerous (this is called catastrophic thinking). More specifically,
the first time Joe had a panic attack, he was in a busy queue in a supermarket. He was feeling stressed at
the time because he had left work late and was worried he was going to be late home again, possibly
resulting in an argument with his wife. He was thinking about how he needed to get out of there as quickly
as possible and he began experiencing a number of physical symptoms associated stress and anxiety, such
as increased heart rate and sweating and dizziness. When this happened, Joe started to think about how
faint he felt and how embarrassing it would be if he did so in front of the other people in the supermarket.
These thoughts resulted in increased anxiety, further physical symptoms and further catastrophic thinking,
with Joe thinking he was going to pass out for sure. In order to prevent this happening, Joe left the
supermarket and found that he felt better immediately, as he was no longer at risk of passing out and
embarrassing himself. While getting out worked to decrease his anxiety in the short-term, Joe then began
to worry about going back to the supermarket, and so in the longer-term, the avoidance only served to
increase his anxiety levels and likelihood that he would panic. Therefore, the areas we identified as
important for intervention were catastrophic thinking and avoidance.

2) Managing catastrophic thinking

We began by getting Joe to identify his thinking processes when he was stressed and anxious. By doing so,
Joe was able to recognise that when he noticed symptoms of anxiety, he started having a lot of
catastrophic thoughts such as, “I am going to pass out”, “I am going to lose control”. Next we looked at
these thoughts in detail and considered how accurate these were. For example, Joe was worried he was
going to faint because his heart rate had increased and he felt dizzy. We investigated fainting and learned
that people faint when their heart rate decreases and therefore it is almost impossible to faint when you
are anxious and your heart rate is elevated (the one exception to this is blood-injury injection phobia so
contact me if you wish to discuss this). As well as information about anxiety and panic, Joe was provided
with techniques to help him evaluate his thinking and come up with more balanced alternatives and test
these alternatives out. Joe said he felt more in control as he realised that anxiety is a normal part of life
and panic only occurs when thinking about sensations becomes distorted.

3) Tackling avoidance

Now Joe had the necessary information and skills to manage his thoughts, the next step was for him to
start doing the things he had been avoiding. Joe was very anxious about the idea of this and so he did it in
a graded way. Joe was asked to think about all of the things he was avoiding and rate how anxious each
one made him feel. These were then placed on a list and Joe tackled them one at a time in order of
difficulty. Before doing each one, we would use the session to prepare for the task by predicting what he
thought might happen and how he would manage if it did. As a result of this preparation, Joe had the
confidence to try things out as he had a detailed plan of what he would do to cope if he did become
anxious. He began by going into supermarkets when they were quiet and when he coped well with this, he
went in at busier times. Joe kept a record of his progress which also helped increase his confidence and
spurred him on to try the next item on his list. When doing the early tasks, Joe continued to feel anxious
but he learned that he could cope with anxiety and that it did not harm him. By repeatedly doing the
tasks, he became more confident in his ability to manage anxiety and panic and the sensations gradually
reduced.

Joe attended 8 sessions in total and had achieved all of his goals by the end of treatment.

47. Gerry’s experience of bi-polar disorder

Gerry was 21 when he experienced his first episode of mania while at University. After a night out, he was
unable to switch off and found it difficult to get to sleep. Over the next couple of days, his friends noticed
that he was becoming more and more hyper in that he was very excitable and was speaking really quickly
about all sorts of plans and ideas. Gerry’s friends began to get worried on the third day when Gerry came
to chat to them about his ideas at 4 in the morning. By the following evening, Gerry was becoming
increasingly paranoid and began accusing his flatmates of spying on him. Gerry’s flatmates called his mum
who in turn called their GP. Gerry was referred to a psychiatrist and it was agreed he needed an in-patient
admission to stabilise his mood. Gerry spent two weeks in hospital where he was treated with medication
and his mood stabilised. After a couple of weeks, he felt ready to return to University but things began to
get difficult again. He was struggling with motivation and was unable to keep up with the workload. His
friends were managing well and he began to feel like the odd one out. Over the next few days, his mood
became lower and so he went back to see his GP, who prescribed a course of anti-depressant medication.
The period of low mood lasted three to four months and eventually lifted. Over the course of the next four
years, Gerry had a further two episodes of mania and one episode of depression and was diagnosed with
bi-polar disorder. He was becoming increasingly worried that he might lose his job in sales as he had had a
number of periods of absence, and this is the reason he sought psychological help.

When I met with Gerry, he outlined his experiences with mood instability and we discussed his current
mood, which was stable. The National Institute of Clinical Excellence (NICE UK) recommend a combination
of cognitive behaviour therapy (CBT) and medication for the treatment of bi-polar disorder. I outlined the
CBT approach to Gerry and I highlighted the treatment rationale, namely that the aim of treatment is not
to eliminate the condition but to help reduce the likelihood of relapse and minimise the impact of an
episode should one occur. Gerry understood this and we agreed to meet for 16 sessions of CBT.

Understanding the difficulties

We began by developing a psychological understanding of the difficulties Gerry was experiencing. We

discussed predisposing factors (such as a family history), current stressors that increased the likelihood of
having an episode of mania or depression (such as a heavy workload in University and relationship
problems) and poor coping strategies that further increased the risk of having an episode (such as staying
up all night to catch up on work and drinking alcohol to forget about relationship problems). This was
important not only because it helped Gerry to understand why he was experiencing these episodes, but
also because it identified areas that required attention during therapy.

Liaison with other professionals

Since bi-polar disorder requires a multi-professional approach to manage medication, psychological

therapy, mood monitoring and possible in-patient stays, an important aspect of the treatment is close
working between professionals. With Gerry’s permission, contact was made with the other professionals
involved in his care and a co-ordinated care plan was developed. Once Gerry had developed his relapse
prevention plan, this was circulated to the other professionals in his network with his permission.

Gaining insight into the signs and symptoms of a manic or depressive relapse

The next step was to gather information to develop detailed insight into the signs and symptoms of an
episode of mania and depression. In order to do this, Gerry had to think about his episodes in detail and
list all of the thoughts, feelings, behaviours and physical symptoms he noticed during an episode. In order
to make this more comprehensive, Gerry asked his girlfriend and family members for their recollections.
Once this was complete, we outlined in detail what a period of wellness looks like and then considered the
period in between wellness and an episode, from the first signs that something is changing to the period
just before an episode. By doing this, Gerry was able to track a number of behaviours across the mood
spectrum. For example, when Gerry was really depressed, he didn’t care at all about his sales targets and
often didn’t attend work, when he was well he wanted to achieve the targets which had been set and so
worked from 9-5, and when he was going high, he became obsessed with being the best performing
salesman on the team, meaning he stayed late most nights and skipped meals to ensure this happened. In
this way, Gerry was able to monitor 4-5 activities which would give him insight into his mood at the time. If
Gerry noticed that things were changing, he would then be able to take the appropriate action.

Providing a range of skills to manage signs and symptoms of a relapse

Once Gerry had a clear sense of the signs and symptoms of a relapse, we discussed and practiced a range
of psychological strategies which he could use to manage these symptoms, including mood monitoring,
behavioural activation and deactivation strategies (depending on whether Gerry was going low or high)
and cognitive techniques to manage unhelpful thought processes. When Gerry noticed changes in his
mood, he was able to use these techniques to manage these changes.

Developing a relapse prevention plan

The next step was to draw all of the information together in a relapse prevention plan. This took the form
of a traffic light signal, with green meaning Gerry was well and what he should keep doing to maintain this,
amber indicating that things were changing and what he could do to manage these changes and red
indicating that he was in an episode and what he could do to manage this. This plan was printed out for
Gerry and sent to other professionals involved in his care so that everyone in his network were aware of
what Gerry could do at different stages.

At the end of therapy, Gerry reported feeling more confident in his ability to recognise signs of a relapse
and more confident in his ability to manage these symptoms should they arise. As a result, he reported
feeling more confident and in control of his future.

Attending for top-up sessions

While Gerry had the necessary understanding and skills to manage his condition, at times when he felt at
risk of relapse, he requested a top-up session to refresh his skills. Having these top-up sessions meant that
Gerry could revise his skills and ensure he was using all of the skills available to him to manage his
symptoms.

48. Couples Therapy Case Study: Anna and Brian

Helping Brian and Anna to Build a Happier Future Together

Anna and Brian came to Couples Therapy with Linsey, our Relationship Psychotherapist at Evidence-Based
Therapy Centre, on the verge of a relationship breakdown.

Why Anna and Brian came to Couples Therapy

Anna felt that she was doing everything to keep the relationship going, and that Brian took her for granted.
Brian felt isolated and neglected, and often found himself lacking the motivation to do the things he felt
Anna nagged him to do.

Anna was thirty and worked full time as a personal assistant while completing a Master’s degree part-time
in the evenings. Brian was also thirty and had completed his degree. Since graduating five years ago, he
had held a variety of temporary jobs and was unemployed when the couple first scheduled an
appointment with Linsey. Although she wished Brian would put efforts into finding a job, Anna noticed that
he spent most of his day playing video games.
The couple had not had sex for over four months; Anna would attempt to initiate sex, but Brian did not
have the desire. The couple were engaged to be married, and had set a date for their wedding six months
from when they first contacted Evidence-Based Therapy Centre. Anna would like children, but she was now
feeling that Brian would not be a fit husband or father.

Working Together to Uncover the Issues

In Couples Therapy, Linsey began to explore the couples’ backgrounds.

Anna was the eldest of four children. Her father died suddenly of a heart attack when Anna was twelve,
and her mother became depressed following his death. Anna looked after her younger siblings, and was
responsible for completing the majority of the household chores. She worked very hard academically
because she saw this as a way to eventually support her family financially.

Brian was raised by a single mother. He had no ongoing relationship with his father, who left when Brian
was one. He was close to his mother when he was little, but as he grew up his mother had to spend more
time working outside of their home in order to support them both. She trained as a nurse and did shift
work. Brian was often left to fend for himself in the house while his mother was working.

Putting the Pieces of the Puzzle Together

Over the course of their work together, Linsey helped Anna and Brian to notice ways in which their early
lives were now shaping their current relationship patterns. They came to the conclusion that the couple
were repeating different aspects of their pasts unintentionally, and each were feeling resentful about it.

Anna found herself in a position where she was once again under pressure to provide and care for her
loved one. She had not been able to express her upset at her family of origin because her mother was
depressed and her siblings were younger than her, and she felt responsible for keeping them from any
further hurt or distress. Anna had experienced rage at her experience of growing up that it was not
possible for her to express or work through safely at the time, and this was now being experienced and
expressed in Anna’s relationship with Brian.

Anna was also scared that she was marrying into the difficult family situation she had grown up in, as she
was worried that Brian, like her mother, was depressed. As Linsey helped Anna to make sense of her
experiences and her emotional responses, Brian began to understand some of Anna’s frustration with him.
As they explored Anna’s early life and experiences, Brian was able to view Anna’s reactions to his own
behaviour in the context of what she had been through previously, helping him to be more understanding
and sympathetic when she felt threatened.

During the work together, Linsey discovered that what Anna perceived as Brian’s “depression” had first
become apparent around the time that Anna had started her Master’s degree. Brian remembered that
while his mum was away working when he was a child, he occupied his time mostly by playing computer
games and eating frozen pizza; a pattern of behaviour he now repeated while Anna was out in the
evenings.
Brian recalled his experience of sadness at his mother’s working hours despite his understanding even at
the time that she was working hard so that he could have a better life. As a child, he was often lonely, and
felt that his mother didn’t want to spend time with him. Brian admitted to Anna that he felt she preferred
her work to spending time with him.

Brian also acknowledged that he was angry at Anna about her decision to apply for her Master’s, which he
felt she had chosen seemingly without considering the impact this may have on Brian and their
relationship. Anna had learned from her experiences that others were unreliable – something which her
discussion with Brian and Linsey helped her to realise – she was used to making decisions by herself and
rarely relied on anyone for advice. Anna admitted that she hadn’t considered talking to Brian about
applying for the Master’s, and she began to understand his experience of neglect.

Building connection through understanding

Working together over a number of sessions, Brian and Anna began to develop a better understanding of
their own and each other’s perspectives. When placed in the context of their past experiences, the ways in
which they each responded to the challenges in their relationship seemed more understandable and
relatable.

Once they began to understand their own and each other’s behaviour, and how it had functioned for them
in their lives up to that point, they were able to think more practically about how to address their
relationship issues in ways that were more considerate and functional. Linsey set about helping the couple
to identify ways of working through their differences that felt respectful of both partners’ needs.

Making Meaningful Changes

Anna and Brian both agreed they wanted to stay together, and recognised that they would need to commit
to ongoing maintenance of their relationship. They spent time giving serious consideration to what they
needed to change in order to improve the relationship. A first step that they agreed to was reconnecting to
each other by spending more time enjoying each other’s company. They started by scheduling a regular
“date night” each week, which they both began to look forward to.

After highlighting some of the barriers to his job search together with Linsey, Anna began helping Brian to
look for suitable employment. Brian recognized how his behaviour contributed to the strain on Anna’s
resources – her little free time was often being spent tending to things Brian had been distracted from, so
she had limited energy left to address his need for companionship when she was home. Brian began taking
responsibility for more of the household chores, freeing up Anna’s energy to enjoy their time together.

Looking to the Future

The couple noticed improvements in their relationship, including fewer, more productive arguments and
an increased experience of intimacy and mutual regard. They decided to continue working together with
Linsey following their agreed sessions to explore the possibility of starting a family together.

Thinking that Couples Therapy may be right for you and your partner?

You can learn more about Couples Therapy with Linsey’s helpful guide here, or contact our receptionist
Jennifer to book an assessment with Linsey.
49. Case on Severe Growing-Up Phobia

The patient is a 14-year-old adolescent whose problem started two and a half years ago due to an
excessive fear of growing. He does not eat much because according to his own research food contains
nutrients needed for physical development; in addition, he adopted a stooped posture to hide his height
and began to distort his voice, using lower volume and higher pitch than usual, and he has also been
searching the Internet to learn how not to ejaculate. He is greatly concerned with the development of
secondary sexual characteristics. Every time he notices a physical change that indicates that he is growing,
he feels fear and anxiety, to the point that has considered undergoing multiple surgeries to hide it. If
people tell him that he is taller or older, he becomes extremely upset and cries. Due to the restriction in
food intake, he has a weight loss of more than 12 kg. He is currently in the 25th percentile, according to the
BMI for his age; however, he does not perceive any alterations in body image. Other discrepancies with
regard to his physical appearance also coexist; he has Latin American features but his ideal of beauty is
that of a Caucasian, “like Hollywood stars,” according to his own definition. He admires everything related
to the United States. He has never been there but has plenty of information collected through the media.
Although he believes that this fear is grossly excessive, he argues that the expectations that adults face are
excessive: getting a partner, being independent, and having more responsibility and financial solvency. He
also believes that once he reaches that age, he is more likely to get sick and die, all of which are very
overwhelming.

Due to this problem, two years ago he consulted with a psychologist who treated this intense anxiety with
cognitive behavioural therapy, gradually exposing him to the feared stimuli and using relaxation
techniques; however, desensitization/habituation when facing his fears was not possible. After a year of 2-
3 sessions per week his therapist together with his parents decided to refer him to our institution to
continue his therapy, since it has a specialized area for treating adolescents and children.

With regard to his medical history, at age 5, he was diagnosed with separation anxiety disorder, for which
he received psychotherapy once a week for a few months. The results were good and he achieved total
remission. At age 6, he was sexually abused. A neighbour, 16 years of age, made him look at and touch his
genitals and the neighbour also touched the patient. The parents noticed an emotional change in their
child with a greater tendency to cry and later he also avoided going over to play with the neighbour’s
brother, who was his age, but it was not until he started treatment with the psychologist two years ago
that he was able to talk about the sexual abuse he received during his childhood. He does not remember
how long this went on, but he did recognize that the incident was repetitive. In sixth grade, he was a
frequent victim of bullying (2-3 times a week). As for his family, his mother is an anxious person with
dependent characteristics, while his father is rigid and often makes comments in a tone that the child sees
as judging.

The rest of his development was normal. His mother had a normal pregnancy, planned and desired, with
adequate prenatal care. There were no peri- or postnatal complications. The child was born at term by
vaginal delivery with a birth weight of 3,950 g. He was discharged the next day with his mother and was
breast-fed for 1 year and was weaned at 6 months. In the first months of life, he is described as calm. He
was always under the care of his mother, who devoted all her time to the home. Psychomotor
development was as expected: he sat at 6 months of age and walked and said his first words when he was
1-year-old. The mother denies problems in movement coordination. He was toilet trained at the age of 2
years and 1 year later he also had nocturnal control. He slept with his parents until the age of 4 and in the
same room until he was 6.

On arrival, the Birleson Depression Scale was applied and the child had a score below the cut-off; the
Anorectic Behaviour Observation Scale (ABOS) screening was positive; on the Body Shape Questionnaire
(BSQ), a mild body image dissatisfaction was detected; a very high fear of maturity and interpersonal
distrust (both in the 95th percentile) were identified in the Eating Disorder Inventory (EDI). Accordingly, he
had a significantly higher score in anxiety (4.6) and avoidance (3.5) in the Attachment Scale. On the
Rorschach test, an elevated Armstrong and Lowenstein Trauma Content Index and Perry and Viglione
Critical Content were found.

Regarding parental attitudes towards the problem, excessive care was provided by the mother, responding
to changes in the patient’s behaviour with an attitude that corresponded to that of a much younger child:
she would sing lullabies so he could sleep, chose the clothes that he would wear each day, combed his hair,
and answered the questions that he was asked, not giving him the chance to answer. During consultations,
she would cry when talking about the problems they faced as a family and openly expressed her despair
and feeling that this was something that could not be fixed.

The father was angry with this scenario. He believed that his son was doing this to annoy or to get back at
him for having been away such a long time due to his work. He tried to solve the problem by putting
corrective posture belts on him and squeezing the curvature area tightly with his hands. The parent-child
conflicts were constant until both chose to maintain a greater distance, further reducing communication.
They even went so far as to avoid being in the same room.

As for treatment, since arrival at the institution and to date, psychotherapy has been provided. For one
month and a half a crisis intervention model was used, attending with a frequency of 2-3 times per week.
Retrospectively, a metallization-based [17] approach has been used that has continued to this day with 50-
minute sessions once a week.

From the beginning, the therapeutic alliance was prioritized because it is within a safe relational context
where people can think, feel, and talk about traumatic events and thus reduce dissociative strategies;
cognitive affect-regulation strategies identifying and naming emotions, being able to tolerate those which
are dysphoric and favouring the pleasant ones have been modelled; the patient's affections have been
validated, empathizing with him; situations are clarified, developing thoughts/feelings; feelings are related
to the circumstances and emotions/reactions of others; exercises where he could practice the process of
“reading minds”, which means perceiving and interpreting human behaviour, considering mental states
(Metallization). Thus, an autobiographical narrative has been built where the meaning of mental states
may reflect and explore past and present issues. Now the young man has a greater ability to understand
that his reactions are based on something, which is the result of what happens to us in relation to others.

He was trained to know that what people think/feel is not obvious and other people may not know how he
feels.

Fluoxetine 20 mg/day was started, increasing the dose to 40 mg/day after 6 weeks, obtaining an
improvement of symptoms. He is currently seen with an upright posture and a natural tone of voice with
no problems detected in his eating pattern. He has recovered 6 kg of weight; the ABOS scale is below the
cut-off point for eating disorders. Mild body dissatisfaction persists in the BSQ and in the EDI great
improvement is observed in almost all areas (obsession for thinness, body dissatisfaction, perfectionism,
interpersonal distrust, and interceptive awareness), except fear of maturity. The most obvious difference is
in interpersonal distrust, which is currently in the 50th percentile. He attends school and has good
performance. He has friends and participates in extracurricular activities (English classes). He does not
show anxiety due to the presence of body hair or when he wears clothes that correspond to his age. He is
able to imagine the future, living on his own and working as an actor, and this is an idea he likes; however,
he continues to express a fear of commitment and responsibilities that he feels will be required of him in
adult life.

Because the parents were overwhelmed and were not able to contain the patient, they were suggested to
enter the family-to-family course created by Dr. Joyce Bourland, founder of the National Alliance for the
Mentally Ill, and they accepted this recommendation. This course is led and taught by trained family
members of people living with mental illness and addresses biological/physical, psychological/emotional,
and social/occupational aspects. The parents and the sister attended the 12 sessions, which are held once
a week and have duration of 2.5 hours each.

Here, issues such as psychosocial disabilities and brain function are addressed; problem-solving skills and
dealing with crises and relapses are learned; rehabilitation, expressing emotions at home, empathy, and
techniques to improve communication are also covered, as well as WHO recommendations for addressing
mental illness. At the end, his good performance/understanding was clearly seen; therefore, they were
offered to be instructors of this movement.

Also, systemic family therapy was simultaneously carried out, lasting 60 minutes, once a week, for a total
of 12 sessions. Therapy was aimed at improving family functioning, increasing the understanding and
support among its members, unfocalizing the symptomatic patient, and increasing the skills of problem
solving and coping techniques. Emphasis was placed on the strengths that the family has and the
interactions that occur between its members. The mother tended to infantilize the patient, while the
father tried to get away from him.

50. Clinical case study: CBT for depression in a Puerto Rican adolescent: challenges and variability in
treatment response

The patient was a 15-year-old Puerto Rican adolescent female living with both her parents and a younger
sibling. Her parents presented with significant marital problems had been separated several times and
were discussing divorce. Her mother reported having a history of psychiatric treatment for depression and
anxiety and indicated that the patient's father suffered from bipolar disorder and had been receiving
psychiatric treatment. He was hospitalized on multiple occasions during previous years for serious
psychiatric symptoms.

The patient was failing several classes in school, and her family was in the process of looking for a new
school due to her failing grades and difficulties getting along with her classmates. She presented the
following symptoms: frequent sadness and crying, increased appetite and overeating, guilt, low self-
concept, anxiety, irritability, insomnia, hopelessness, and difficulty concentrating. In addition, she
presented difficulties in her interpersonal relationships, persistent negative thoughts about her
appearance and scholastic abilities, as well as guilt regarding her parents' marital problems.

The patient's medical history revealed that she suffered from asthma, used eyeglasses, and was
overweight. Her mother reported that she had been previously diagnosed with MDD 3 years ago and was
treated intermittently for 2 years with supportive psychotherapy and anti-depressants (fluoxetine and
sertraline; no dosage information available). This first episode was triggered by rejection by a boy for
whom she had romantic feelings. Her most recent episode appeared to be related to her parents' marital
problems and to academic and social difficulties at school.

DIAGNOSIS

A diagnosis of MDD was established using the Diagnostic Interview Schedule for Children (DISC-IV).16 In
addition, according to the DISC-IV, she also met criteria for generalized anxiety disorder, separation anxiety
disorder, and attention deficit disorder. Symptoms of depression were assessed every 2–4 weeks
throughout therapy using the Children's Depression Inventory—CDI17.

TREATMENT

The patient was treated using a manual-based CBT, which has demonstrated success in treating depression
in Puerto Rican adolescents. She participated in a research project on therapy for depression in
adolescents, which compared a standard 12-session “dose” of CBT only, with CBT enhanced with a group
psycho-educational 8-session parent intervention. She was randomized into the CBT only condition of the
study. As part of a supplemental research project, additional sessions (up to a maximum of 12) were
offered to adolescents whose depression did not remit at post treatment to examine the optimal dose
needed for complete remission as well as characteristics associated with treatment response. Five
adolescents agreed to participate in this study and received an average of seven additional sessions. The
adolescent chosen for the case study had a therapist who was a doctoral level graduate student in clinical
psychology trained in CBT who received weekly supervision from a licensed clinical psychologist with a
Ph.D. Qualitative data for this case study were analysed by reviewing progress notes and video recordings
of therapy sessions.

SESSIONS 1–4

The first four sessions focused on teaching the patient about the influence of thoughts on mood and
strategies to debate dysfunctional thought patterns and increase positive thoughts. During the week, the
patient was asked to complete a daily mood thermometer, which was discussed at the beginning of every
session. Homework assignments such as keeping a daily log of positive and negative thoughts and
identifying and challenging dysfunctional thoughts were some of the homework assignments that the
patient completed between sessions.

The patient's mood fluctuated widely during these first sessions. She cried several times and verbalized
feelings of sadness, guilt, and low self-concept. The main dysfunctional thoughts identified and challenged
during these sessions were mostly about herself (I'm ugly and stupid; People look at me because I'm fat),
anxiety over not being able to fit in at a new school (I won't know anyone; I'll be far away from my friends;
It'll be too hard), and guilt about her parents' marital problems (My parents fight because of me; If I had
better grades they wouldn't fight). By the fourth session, she succeeded in rationally challenging several of
these negative thoughts (I can make new friends; I have a chance to start over at a new school; I am good
at drawing and I have a good sense of humour). Nonetheless, many negative thoughts persisted, mostly
surrounding her parents' relationship. By the end of this therapy module, the patient began to share some
of her artistic talents with the therapist and her self-concept appeared to be improving.

SESSIONS 5–8

The following four sessions worked with increasing pleasant activities, time management, and goal setting
to improve mood. Homework assignments in this module involved keeping a daily log of pleasant activities,
completing a weekly planner, and establishing specific goals and steps to complete them.

By the 5th session, the patient's mood improved significantly, most likely due to having a positive
experience at her new school; she had made new friends, her grades had improved, and she was getting
along well with her teachers. She also reported a decrease in depressive symptoms (Fig. 1). This positive
experience at school was used in therapy to help the patient challenge negative thoughts and expectations
by providing evidence that disqualified them (i.e. she is likeable, she can cope in a new school).
Consequently, the number of negative thoughts she had decreased markedly, and this reduction was
reinforced verbally by the therapist.

The patient recognized that one of the barriers to enjoying pleasant activities, particularly social activities,
was her negative thoughts (I'll make a fool of myself; I won't do it right; I'll be rejected by others) and her
parents (obtaining permission for certain activities). The patient kept track of her pleasant activities and
began to organize her time better to accommodate her homework and chores by using a weekly planner.
This allowed the patient and therapist to evaluate whether she had an adequate balance of pleasant
activities in her schedule that helped improve her mood and make adjustments accordingly. Role-playing
exercises were used to help the patient learn to negotiate permission from her parents to participate in
social activities. Her self-concept continued to improve as evidenced by her verbalizations (Sometimes I
feel pretty) and her physical appearance (increased confidence, better posture, and grooming). The
therapist reflected these observations back to the patient. She was also handling stressful situations better
as evidenced by her reaction to being teased at school; she simply ignored it instead of feeling sad and
having persistent negative thoughts about herself, which would have typically been her response. This
suggests that the patient was internalizing skills learned in the first few sessions, such as thought-stopping
techniques to decrease negative rumination.

SESSIONS 9–12

The last four sessions worked on the ways in which interpersonal relationships affect mood and focused on
increasing and maintaining social support, as well as improving assertive communication skills. The patient
reported having a good social support system, but complained about one of her close friends who would
often put her down; this would activate negative thoughts about her abilities and attractiveness. This
relationship was examined in the context of adequate expectations for friendships. The patient presented
a passive communication style, which was contributing to feeling hurt frequently and having her emotional
needs unmet. Thus, the focus of two sessions was to work on developing assertiveness through role-
playing exercises. She reported some upsetting incidents at school between her new and old friends but
appeared to be handling them well using cognitive strategies learned in the first module.

However, during the last few sessions of this module the patient was still experiencing feelings of guilt,
anger, and sadness about her parents' marital problems. Notably, she was disturbed by significant
communication problems between her parents who often spoke negatively about one another in her
presence and used her as a messenger to communicate with each other. She confided in the therapist
about having witnessed physical and emotional abuse between her parents, as well as living through
several separations over the previous 10 years. The therapist explored the possibility of having a session
with her parents to discuss how their problems affected the patient, and she agreed. During this session
the therapist discussed with the parents how their behaviour was contributing to the patient's depressive
symptoms and recommended marital therapy. The parents admitted to having significant problems and
agreed to seek couple’s therapy.

ADDITIONAL SESSIONS (13–16)

On completion of the standard 12-session “dose” of CBT, the patient was still presenting symptoms of
depression in the severe range and continued to meet criteria for MDD; hence, she received additional
sessions of CBT until her symptoms decreased and she no longer met MDD criteria according to the DISC-
IV, as established by the study's protocol for additional sessions. These four sessions worked mostly with
the patient's feelings and thoughts surrounding the possibility of her parents' divorce or separation. The
focus was on how to manage these feelings in order to decrease their impact on her mood and daily
functioning.

The patient's main negative thoughts were mostly related to fear that her father would leave and never
contact her, and that he would remarry and have another family with whom she might not get along.
These were challenged in therapy by asking the patient to find evidence that these thoughts would actually
come true. The patient realized that most of her friends whose parents had divorced had good
relationships with them and their new families, and acknowledged that although her father had often
threatened to leave, he had also told her that he would always be there for her. She also realized that it
was possible that things would be better if they separated and that their fights might even decrease. In
addition, role-playing exercises were used to practice talking to her father about her fears and worries
regarding the possibility of his leaving and how it would affect their relationship.

On termination, the patient's depressive symptoms were in the moderate range and she no longer met
criteria for MDD according to the DISC-IV, which was one of the study's criteria for ending therapy. In
addition, her self-concept had improved, and the therapist observed decreased dysfunctional attitudes and
suicidal ideation. These improvements were maintained at 6 and 12-month follow-up assessments, and her
depressive symptoms decreased to mild by the last three follow-up assessments.

During the last session, the therapist worked on closure with the patient, reinforced improvements in the
patient's mood and coping skills, and counselled the patient on relapse prevention strategies. Relapse
prevention strategies include monitoring depressive symptoms and recognizing the need for treatment if
they worsen or recur, and using cognitive-behavioural strategies to manage her mood (i.e. debating
dysfunctional thoughts, planning pleasant activities). The therapist also counselled the patient's mother on
how to monitor her daughter's residual symptoms and the importance of seeking treatment if symptoms
worsened. She also reiterated her previous recommendation that the parents seek couples counselling,
which they had yet to do.