4. Development of the therapeutic relationship Show how you worked with aspects of the CBT relationship for the benefit of the client. Client Y and I had originally built up our therapeutic relationship using the core conditions and although this client has always been reluctant to talk she will and does work very hard answering open questioning. She knows she needs encouraging out of her shell and I feel she is grateful that I keep plugging away doggedly each week during our sessions, always gently encouraging her to come out of her shell and enlighten me to her world.
My clients patterns of behaviour are introversion, extreme shyness, fear of other people and being near them and so I know now how hard it must have been for her to pluck up the courage to come and help herself through talking therapies. She’d tried and ceased ordinary Person Centred counselling – this was too daunting and she hated the silences. This is where the CBT aspect really suited this client. The Formulation Sheet acted as a great tool to open up dialogue which she’d willingly give but because it could be done collaborative in open question form she felt safe with this.
This client had big trust issues but had been assessed by a psychiatrist who’d suggested talking therapy would help. She was re-assured by this professional opinion. This client exhibits no feelings of friendship or fondness towards me as she has the greatest of difficulties showing these to all but her late Father’s sisters. She has been an unusual client because of this barrier. I categorically know that she trusts me and values the work that we do, I completely understand how hard each week is for her and am very proud of the way she trusts me enough to tell me deeply hurtful experiences each session.
She has only welled up about 5 times and has never cried. I congratulate her often hoping to build her low self-esteem. She glows and smiles so beautifully when I do this. An example of how my understanding of her childhood enabled me to use a simile recently of how I saw her as a baby deer, who’d be suckling for milk and then for no reason her mother would bite her and hurt her teaching her to expect unexpected and un-predictable nurture.
As I teach her to be her own therapist through the CBT model I am also encouraging her to reach out verbally and emotionally to her younger brother and to open up a slither of a pathway between them – to let him know that she’s been brave enough to work on herself and that she’s feeling better for having done so, and if he ever wants to talk about his own barricaded grief over the loss of his Father, she’s there for him. It’s a useful exercise for my client to feel that she’s quantifiably feeling so much better that she’ll be able to help someone else through their psychological problems.
5. Use of self- awareness Reflect on how your self- awareness impacted on the therapeutic work. Being self-aware is essential for a therapist to avoid thinking I know what it’s like for my client to experience something similar in both our lives. Their journey to this point and my own are entirely different and both are unique and idiosyncratic. I need to empathise fully and put myself in their frame of reference to try and fully understand what life is like for them. Becoming self-aware is an integral part of becoming a counsellor.
Knowing your own triggers nd patterns of behaviour means you can spot them in a client. Some of the CBT concepts used to raise awareness of self in clients are Socratic questioning which helps focus on the problem definition, it exposes client’s core belief system and can challenge irrational beliefs while revealing the clients cognitive process. During our training we have done all this type of work on each other in groups, this allows us to critically reflect on our own process of working with clients and highlights how we respond personally to our clients and what impact this then has on the way we work with them.
I responded to client Y’s almost chronic shyness initially without knowing what had caused it. She was very much the wounded animal in the room and reading her body language I was aware from the start that this was not a confident young woman. Her nervousness has never totally disappeared as it’s like a favourite piece of clothing which she cannot shrug off. When I became aware of the depth of her low self-esteem it was an instinctive process for me to gently and carefully encourage her to come out of her shell enough to learn that she was going to be safe with me.
That I wasn’t going to hurt her unpredictably the way she’d learnt her Mother did. Being self-aware and knowing myself to be a nurturer it seemed a natural fit that if my client took to me, then I would be able to help to heal her in a caring way, teach her within the therapeutic relationship that not all people are erratic, cruel and out to hurt you. This awareness from myself that I needed to soothe and balm her with the kindness that can be therapy was an instinctive emotion from myself to the wounded animal in her, because of self-awareness I knew why I was responding in this way.
I am congruent with her also, I have long wondered and repeatedly asked “where is the anger? ” and tell her that I am feeling the anger by transference – but although she does feel very grumpy and cross at times in her life it’s not appropriately funnelled – it is channelled instead at herself and her own failings (as she sees them). This then is work to be done together.
6. Theory underpinning skills Work within a coherent CBT framework of theory and skills in the counselling process. The CBT theoretical framework that underpins my practice comes from the blending together of the Becks cognitive therapy devised in the 60’s and behavioural therapy by Wolpe and others, to become the most empirically proven therapy working on a goal-orientated treatment for clients that takes a hands-on, practical approach to problem solving. It aims to change patterns of thinking or behaviour that are behind peoples’ difficulties and so change the way they feel. (Internet) I share research facts with clients about its efficacy and give research findings for facts.
CBT’s use of tools such as the Formulation Sheet, Thought Record as homework, NAT’s & EMS psycho-education will form the mainstays of integration for me. I have used all of these with client Y. I have found the EMS psycho-education of particular relevance to evidence facts. It wasn’t until some evidence came to light a long way into our sessions together – the loss of twin boys many years before my clients birth – that for me the missing part of the jigsaw was found logic wise.
I feel I counsel better if I can logically follow the main player’s motives and I feel this is akin to detective work and part of the appeal. When I critically evaluate my work at level 5 with this client within a CBT approach I can see that her vulnerability is that she only had one secure attachment figure and the second attachment was of an unpredictable and abusive nature. This led to an Early Maladaptive Schema of erratic parenting – very loved by her Father and mostly unloved by her Mother. This may well have been caused by the loss of the male twins 5 or so years before my client was born.
My client being a girl and preferring her Father was enough to produce un-diagnosed mental illness in the Mother and due to typical family collusion to ‘cover-up’ this level of dysfunctionality my client learnt the core belief that she was unlovable to her Mother. This core belief undermined her self-confidence at school and coupled with natural shyness my client became avoidant of all social interaction at school. She actively shunned friend making and got the label of ‘weird’ by her peers. This Maintaining factor fed into what she knew of herself through her EMS.
Her ‘current problem’ is that now at 18 she still ‘avoids’ socializing and only has one girlfriend whom she is not very close, she still has a core belief that she is weird and somehow different but she is learning that it was an in-secure attachment to her Mother that made her feel unloved rather than through any fault of her own. I am very hopeful that by September when she starts University in London that she will feel more secure.
7. Use of supervision Critically reflect on your use of supervision. I enjoy supervision as my supervisor has a vast wealth of knowledge; she has spent the last 30 years studying many theoretical models and is extensively read. She has a very grounded and holistic approach to her own clients and her supervisee’s clients. This constantly gives me inspiration and alternative ways of looking at counselling. She is always encouraging and has been interested to refresh her old knowledge of CBT tools and update them. I have used supervision to investigate my non-comprehension as to why my clients Mother would be cruel and abusive to her.
Yes, understood – if she was psychotic; but this was so random and sporadic and clinically unproven that it didn’t make sense to me. I would tell my supervisor that I just couldn’t get a sense of why my clients Mother behaved in this way? My supervisor and I discussed it, was I missing something? Why was I getting such a sense of transference via my client about her? I would congruently tell my client that I just couldn’t work her Mother out and I remember her smiling and saying that nobody had ever been able to do that.
Then the session recently when my client said she’d been wondering whether or not to tell me something for some time and had finally decided she would tell me – that she’d located her mother’s medical records and found that she’d lost twin boys at 19 years old in Australia. This was a great find. It literally was the missing piece of the puzzle. My client’s Mother had come home from Australia, married a different man and had wanted to replace the children she’d lost. My client was the wrong sex and favoured her Father.
That’s why her jealousy was so intense and had caused a level of mental illness possibly post-natal. I took this back to supervision and we discussed its relevance. I also spoke to her about the fact that my client had been wondering whether to tell me about it for some time before actually saying anything? We discussed the possibility of trust and the loyalty she felt towards her Mother in not wanting to admit she’d had children so young. I haven’t had the correct opportunity to ask my client about my ruminations on this but my supervisor has encouraged me to bring it up if there is one.
For further learning on my part in case I’d communicated an unintentional air of judgement about this fact??? Unknown on my part but if that’s the case I must address it. From a CBT framework point of view this would go nicely in the Critical incidents section of the Formulation of client problem list and a useful illustration to show how a) it’s not possible to fill it all out immediately as this info came very late in the day and b) what a useful bridge the therapy the Formulation sheet can be.