Case study analysis of paul suffering from anxiety

This report will take the form of a written report of a case study transcript of a counselling session. The focus of this report is to evaluate the case study session of both the therapy and client. The report begins by a brief overview of the literature of counselling psychology framework that the therapy has used with the client. It will then go on to explain the type of issue the client present, and on the type of therapy that was being applied. Finally, evidence of assessing what the counsellor did well or badly in relation to counselling skills, process, theory, power, ethics and reflexivity, and what needs improvement.

Case study analysis of Paul

Paul is a 36 year old man who has presented having suffered from anxiety and depression for the past 6 months. He has been employed at an advertising agency for the past ten years and enjoys his job as a graphic designer but has recently been feeling under pressure at work and concerned that the current recession will affect his employment. Paul is concerned that there might be a possibility that he may lose his job and the thought of that and of being unable to provide for his young family, a wife, Kim, and two small boys aged 7 and 5, fills him with despair, hence his decision to present for counselling, this being his second of twelve sessions. Throughout the course of his interaction with therapist, Paul’s worries are seen to be the result of ‘irrational belief’s maladaptive cognitive processes that seem to be the source of the problem and Paul is also having difficult thinking. The therapist used several of approach’s methods of three types of counselling techniques to attempt to help Pauls.

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These counselling techniques include Person-Centred Therapy (PCT), Rational Emotive Behaviour Counselling (REBC) and Systems Therapy. Firstly, it is vital to think about the kind key methods of each approach to counselling engaged in the case study of Pauls in order to have a better understanding of what the therapist is trying to attain throughout the counselling sessions.

The Person-Centred Therapy (PCT), emphasis is on the here and now which was developed by (Rogers 1977). The PCT is focus on the notion that everyone has free-will and to be motivated to self-actualise or reach their full potentialities (Rogers, 1977). Rogers suggested that people’s behaviour is motivated by different kinds needs such as things to do with mental, spiritual aspects of living and emotional. Rogers interlink all these desires needs as the actualizing tendency. He suggested that the actualizing tendency enable individuals to be inquisitive and learn about their world, and allows people to value things like love and friendship. He also stated that actualizing tendency encourages healthy development enabling clients to have a better way of life.

The main centre focus of this approach is that it is more accepting people with their own phenomenal experience and personal meaning of the world, the client is equal with the counsellor and also are equal in the therapeutic relationship. This difference has been known as the ideal self and actual self. PCT believes is that the objective of therapy should be the client’s present life experience, instead of their past influences that could have led up to or which would be thought to explain their present position (Merry, 2002). However there is no formal ways of doing a PCT counselling session, it is necessary that the therapist avoids interpreting or giving an opinion in relation to the client’s distresses. PCT stresses the point that therapist should include helping the individual to see the worth of which they are and trust their own experience and conscious awareness to be who they are instead of whom they should be. In another word the therapist should value what the client says and make use of the three core conditions proposed by (Rogers, 1977) which includes empathy, congruence and unconditional positive regards (Merry, 2002). In addition, treatment is through the client’s needs instead of the therapists understanding or perception, which means it is to help the person to regain they own free will and choice in life (Merry, 2002). According to PCT emphases is that ‘the quality of the interpersonal encounter with client which is the most significant element in determining effectiveness ‘(Rogers, 1961). Restating what the client says is often used in such therapies in order to show a clear understanding of what the client says.

Now going back to Paul’s counselling session, it show that the therapist did takes advantage of the rephrasing techniques suggested by Rogers for the therapist to be able to understand and explain what the client is sharing about their issues that they are having. The therapist was effectively indicated empathy and understanding for the client’s worries through the use of emotionally expression such as ‘that sounds like a pretty big deal…’, ‘smiling warmly and encouragingly’. In addition by doing this can develop a trustworthy setting which could be seen as a way for the therapist to break the ice and create a non judgemental atmosphere for the client and to make the client feels that they are been take extremely seriously and to be understood. Also the therapist displays a focused listening skill to the client, which allows the client to be open about the situation that he is in and continue to talk which makes the information for the therapist to have a enrich discourse. Client’s maladjustment due to discrepancy between real self and ideal self, therapist providing unconditional positive regard, empathy, genuineness results in change in client

During the counselling session, it shows that the counsellor did give the client to take charge in some of the development of the therapy and allowing the client to discuss what he was concerned with. In which the therapist encourage Paul to be realistic and more able to overcome personal difficulties and the increase levels of positive self regard. In this way, the client is been able to take the therapy at his own convenes and to solve the issue. Through this way the counsellor will established an interpersonal relationship with the client which is in accordance to Rogers key to a successful therapy (Merry, 2002). It could be argued that on this circumstance, the client feel valued and take seriously which by this enabled a trustworthy interaction.

The second section of this essay is focuses on describing the techniques used in Rational Emotive Behaviour Counselling as this the other approach the therapist seems to be undertaking in the sessions.

Cognitive behavioural therapy (CBT) stated that people are believed to experience emotional difficulties when they hold irrational beliefs about self and the environment. One of the key principles of CBT is that it focuses on the present rather than the past. Individuals with psychosis tend to be locked in unsupportive ways of thinking hence bias thoughts are distorted ( cited in McLeod, 2009)

Ellis (1989) the founder of Rational Emotive Behaviour Therapy (REBT), the approach principle was take from the originally in cognitive sciences as it emphasis is on behaviour, feeling and rational thought. There are three hypotheses proposed which is the ABC model, the model represents (A-) activating event interpretation or inference regarding what is going on in a person’s mind (B-) beliefs- is when people are evaluating their thoughts; rational or irrational which account for and (C-) consequences is emotional or behaviour, negative or positive. The thinking and emotion are coupled together which bring internalised self statement. Ellis (1991) propose that there is a very close line between thought, emotions and actions, which he argues that any one of them can triggers the other, for instant when someone is constantly making themselves to have irrational thought, they actions which can influence how they think and feel. Ellis says that they are three different type of cognition which is ‘hot cognition’ that contain strong to some feelings , ‘cool cognition’ that tend to be more expressive, including very little feelings, and ‘wear cognition’ this tend to be health state which is consist of rational beliefs and preferential thoughts, all this are mostly irrational and can become problematic.

Furthermore, Ellis (1977) stated that the aim of the ABC model of the irrational thinking is to explaining the underlying mechanisms that cause the behaviour; he also stated that C (emotional or behaviour consequences) is influence by A (activating events) and while B (Belief) are people who can act in accordance with A and B. Ellis (1977) points out that when an individual is constantly making themselves to have these irrational thoughts, these thoughts were originally coined earlier of their life and in order to change irrational thoughts the individual will have to challenge themselves to be able to change the irrational thought and not simply admit the existence of the problem. As a consequence those thought process can become the key factor to their existing behaviour response.

The Rational Emotive behaviour Therapies (REBT) focus is on thoughts such as inappropriate emotions and irrational beliefs that involved dichotomous thinking (which refers to the ‘must’, ‘could’ and ‘oughts’ that are present with people thinking processes) as in reality unpleasant demands could happened as a self defeat. Ellis (1962) state that the dichotomous thinking or beliefs may be of a better assistance if they were turned into preferential belief.

The goals of REBT is to find out irrational beliefs that the client is having, and by using the disputing styles which has to confront the client through the use of a scientific question (Ellis, 1962). The therapist may have to explain the illogically of the beliefs more explicitly, or even use ‘hot cognition’ (Zajonc, 1980) by arguing with the client, which required the client to use logic, facts and reason to support their belief and for them to see their cognitive errors.

In addition the therapist could self-disclosure they own situation which the therapist can describe how they dealt with a similar problem, or by the use of humour which often help the client feel more at ease. For example, ‘blimey, you are right, it is awful’, but the therapist has to be caution not laughing at the client, but making the client see their own irrational ideas which generally help reduce these imperfect ideas and thinking (Cited in Dryden and Mytton, 1999)

Relating to the case study of Paul, it shows that the therapist uses an evidence based approach proposed by Ellis (1977) asking the client to reflect on the questions he is being asked. For instance the therapy was using the disputing style Socratic questioning “Have you ever talked to your wife about your concerns, you know, about the recession, about the fact that you’re worried about the possibility of losing your job and all that goes with it…” or “So she stuck with you through all the hard times, when you were studying, looking for your first job…”, “And yet you seem to think that this time it will be different…” and “What makes you think that she’d leave you”? This demonstrates that the therapist is vigorously contributing to the client’s problem which may proofs to be related to the clients worry. Paul is obligate to detail the reasoning why he thinks that the wife will not support he when she as always been supportive with him before now. In this way the therapist is aiming at rationalising the client concerns with finding a new job and finance. In another word asking the client to deconstruct the meanings he has been giving to his circumstances in order to reconstruct a more health way of think about the job issues and the thought about the wife unable to support him this time round again.

In the counselling session, the therapist seek to have an impact on the client main demanding beliefs when the client was describe that he ‘I mean, I could lose everything…’. The word ‘could’ was change by the therapist, but this effort was no helpful to the client as it make the client even more depressed with the comment the therapist made. Froggatt (2005) suggest that the demanding beliefs can consequently cause ‘uneasiness disturbances’ and could bring dissatisfaction, this is means that the therapist has to be attended closely to the client statement. This could be argued that at this point that the therapist may have emphasise the client use of demanding expression and could be introduce by Ellis’ idea of preferential beliefs as an alternative.

Finally the last approach that the therapy used for Paul counselling sessions was the Systemic therapy, systemic approach deals with the family (Cited in Johnstone and Dallos, 2010). Systemic therapy is something that the therapist does with the family. Systemic approach looks at the issues of what is noticeable as the dilemma and the family effort trying to conquer the problem. Systemic approach sees the family as a system and individual distress as an expression of problems within that scheme. To some extent, instead of ‘blaming the families’ this widens the focus from any particular individual. Particularly the ways of communicating within families are especially associated with mental health problems (McLeod, 2009).

Systemic therapy takes is to understand the organisation and pattern of communication in a family sub-systems, limitations, and a formal agreement between the family members. The strategic approach to family therapy grew out of pioneering research carried out by (Gregory Bateson, 1950) this practice is to reoutlining direct the family to bring about change in symptoms and the collective construction of a family reality through shared beliefs, and supposition. According to the systemic approach family relationships and specific traumatic events are not the only factor in creating problematic life circumstances. Social and economic factors also shape people’s life experiences. Smail (2005) argues that these factors are actually more important in shaping our experiences in understanding the world as ‘self as centre’.

In this case going back to Paul counseling sessions with the therapy, it shows that the therapist uses evidence based approach proposed by (Dallos and Draper, 2005; Cited in McLeod, 2009) asking the client to reflect on the questions he is being asked. For example the therapy asked or suggested Paul to communicated with his wife, because it seem that Paul is having ineffective communication with his wife or some distortion of the structure of his family. Example likes “It sounds like quite a responsibility, you know, to have so many people depend on you…”, “It doesn’t really sound fair to me, you know, everything falling on your shoulders, what about your wife – couldn’t she get a job instead of just expecting you to do everything”? and “Have you ever talked to your wife about your concerns, you know, about the recession, about the fact that you’re worried about the possibility of losing your job and all that goes with it…”. This could mean that the fact that Paul has not talk to his wife about the fears and worries he has about lose his job, disappointing his wife and a failure, in which as a result could make he to have a different belief or though According to Proctor (1981) illustrates families that share different beliefs maintain the patterns of relationships in the family. This could help Paul to maintain his family situation.

Although in the counselling session with Paul it seems that the counsellor did not invite Paul’s to come with he to the session.

Furthermore, the therapist was successful assessed Paul behaviour understood in terms of subjective experience of Paul own world how he sees it. Although the therapy seems to have been impenitent with the client, for example the therapist was “Glances at watch” during the sessions with the client and also saying to the client “Yes, doesn’t get much worse… ” and “Quite consuming…”in accordance with Rogers (1957) congruence commands enthusiasm from therapists to express acceptance or positive regard. Rogers believed that it is vital for the individual to feel acceptance of self positive regard. In here one could think that the client may not have been able to be comfortable with them he self or be able to be free.

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In addition the therapist was able to be effectively to assess Paul faulty cognition as most of the distortion of realities and irrational beliefs have been solved and for Paul understand all the cause of those dysfunctional thoughts. Nevertheless more work should been carried out for example the therapist could have suggested may be Paul and his wife could come together for a session so that she may understand more the way Paul is feeling and also if the wife is having some worries as well which is possible. Also to find out more about Paul’s anxiety comes from if it is from his personality, or repression of memories that as a man he must be good at every thing because of his ego cannot cope with his demands of Id and superego.

In conclusion the evidence for the three approaches shows that they are all effective in their own right of methods. The case study of Paul counselling sessions with the therapy with the uses of different approaches such as Person-Centred Therapy (PCT), Rational Emotive Behaviour Counselling (REBC) and Systems Therapy all work equally well. However, they all do have their own limitation and method that could be improve.

Dallos, R. & Draper, R. (2005) An introduction to family therapy: Systemic theory and practice, Second Edition. Maidenhead: Open University Press.

Dryden, W. & Mytton, J. (1999) Four approaches to counselling and psychotherapy. London Routledge.

Ellis, A. (1962) Reason and emotion in psychotherapy. New York: Lyle Stuart.

Ellis, A., & Grieger, H. (1977) Handbook of rational-emotive therapy. New York. Springer.

Ellis, A. (1989) The history of cognition in psychotherapy. In A. Freeman, K. M. Simon, L. E. Beutler and H. Arkowitz (eds) Comprehensive handbook of cognitive therapy. New York: Plenum Press

Ellis, A. (1991). The revised ABC’s of Rational-Emotive Therapy (RET). Journal of Rational-Emotive and Cognitive Behaviour Therapy, 9, 139-72.

Froggatt, W. (2005). A brief Introduction to Rational-Emotive Behaviour Therapy. [online]


Johnstone, L., & Dallos, R. (2010) Formulation in psychology and psychotherapy: making sense of people’s problems. Routledge.

McLeod, J. (2009). An introduction to Counselling. 4th Edition. Buckingham: Open University Press.

Merry, T. (2002) Learning and being in person-centred counselling, 2nd Edition, PCCS Books

Proctor, H. (1981) ‘ Family construct psychology’, in S. Walrond-Skinner (ed.) Family therapy and Approaches, London: Routlege.

Rogers, C. R. (1977) Carl Rogers on personal power. New York: Delacorte. (Currently Published by Constable).

Rogers, C. R. (1961) On becoming a person. Boston, MA: Houghton Mifflin.

Rogers, C. R. (1957) The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95-103.

Smail, D. (2005) Power, interest and psychology: Elements of a social materialist understanding of distress. Ross-on-Wye: PCCS Books.

Zajonc, R. (1980) Feeling and thinking: Preferences need no inference. American Psychologist, 35, 151-75.



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