Category: Individual Treatment

Fictional Case Study

Demographic Data

Client Description

A 45-year old Male, his family has no particular religious affiliation but he believes he has Christian based values and is more inclined than not to believe there is a creator.

Relationship Status

Married and reports that his marriage is very stable and his wife is understanding and supportive; the family dynamic is egalitarian. They have two children.

Occupation

Client is self-employed in the business of marketing. His business is maintaining, but he has concerns the future.

Parents / Siblings

Clients mother is deceased; father is still alive. He has one younger male sibling. Client stated that he was never close to his brother, and has very little contact with both him and his father. The client has no contact with other extended family in NZ.

Treatment History

Client has had previously seen by a psychiatrist who suggested a diagnosis of a Major Depressive episode with associated features of anxiety, the client was prescribed medication. Both the client and his GP decided an appropriate adjunct to the medication would be talk therapy.

Presenting Problems

Problem:

Client said he has self-doubt and a growing lack of confidence in work and social situations when trying to develop relationships. In business and social interactions, he becomes anxious and believes he is unlikable and not good enough. Client believes people will notice his anxiety and lack of confidence, and think he is incompetent, defective or weird.

The client stated that he continuously worries about failing and how catastrophic his future will become. Client is less active and has reduced social contact with his friends.

Cross-sectional details:

1)

• Situation: Socialising with friends and acquaintances.
• Thoughts, Beliefs: They think I am boring, I have nothing interesting to say, they don’t really like, I sound stupid
• Feelings: Depression, Anxiety
• Biology: (sensations) Tension, breathing rate increases, upset stomach.
• Behaviour: Reduce eye contact, go quiet and withdraw, drink more to reduce the anxiety, leave early.

2)

• Situation: Presenting my products at a conference of 50 people.
• Thoughts: I can’t do this, I’m a failure, I’m not good enough to present to these professionals, they can see I’m anxious and lacking confidence, this is terrible, I am so ashamed.
• Emotions: Depression, anxiety
• Biology: Racing heart, flushed face, dry mouth, racing thoughts.
• Behaviour: Focus on notes, focus sensation, speak fast, and plan on ways to shorten the presentation, look for ways to escape.

Brief Historical Context of the Clients Problem

Client said he has believed for most of his life he is not good enough and less worthwhile than others.

He stated that during his young adult years he was shy and remembers feeling sad and anxious a great deal of the time; he didn’t have many friends. Client said this was mainly due to believing that he was fundamentally flawed, different from others and didn’t fit.

Over the past twenty years he had worked for a variety of companies with varying success. He said he mainly worked behind the scenes where there was less pressure to perform and less risk of failure.

Client reported that although he has a low opinion of himself, he has friends who like him, and have shown concern for his wellbeing. He said he has strengths that he is reluctant to acknowledge; he is polite and personable, has a good sense of humor, and in spite of his belief, he has good social skills.

Early Developmental Life History

Client described his father as being highly critical, unaffectionate and distant. He said his father was prone to mood swings and was often angry and unpredictable. Client said he felt very anxious around his father and would avoid being in his presence. He said his father told him to never get above his station or that he would never amount to much. He said he believed his father did not love or care for him.

Client said his mother was a frail vulnerable person who was loving and tried to be happy. He believed that she loved him and would always be there for support.

Client said his parents seemed indifferent towards each other and has no memory of them showing affection to one another. Although his father was not physically violent Client said he constantly intimidated the family verbally with critical angry outbursts about not behaving the way he thought he should.

Clients mother became unwell and died of cancer when he was in his late teens. The gap between his father, his brother and himself grew to the point where hardly a word was spoken and as soon as possible client moved out of the family home.

Clients Goals for Therapy

• Reduce symptoms of depression and anxiety.
• To increase pleasurable activities both individually and socially.
• To decrease procrastination and avoidance of work issues. To decrease anxiety and increase confidence when socialising and making important work related presentations to prospective clients.
• To develop self-acceptance, self-positive regard and change absolute beliefs such as Failure, Defectiveness & Shame and Unrelenting Standards (the need for perfect performance).
• Reduce the need for approval.
• Learning to be more assertive

A diagnostic assessment, and outline of a Conceptualisation.

The diagnosis and conceptualisation are based on clients self reporting and objective measures: Questionnaires: Multimodal Life History Questionnaire, Dysfunctional Attitude Scale, Fear of Negative Evaluation Scale, Depression and Anxiety Inventories and the DSM-IV-TR. DSM IV: Diagnosis: Major depressive disorder – recurrent, with a co-morbidity of Social anxiety with associated features of GAD

 Conceptualisation

 ELH

Father: Rejecting, Critical, uncaring and Threatening

Mother: Vulnerable, fragile, loving and unwell. Died at a relatively young age, when Client was in his late teens.

Development of Schema (core beliefs)

Self: I am a failure. I am worthless, defective and incompetent. Vulnerable to harm

I must have approval from others to be of value

Others: Others expect me to be perfect and will condemn me when I am not.

World: My world is overwhelming and is a dangerous place

Future: The future is bleak and terribly unpredictable, things will never get

better, feeling hopeless

Assumptions & Rules

If I can get others approval, then I am safe and a good person of value

I must always perform perfectly

I must always be confident

I should never be anxious or show vulnerability.

Precipitating Events

Dealing with clients when the running his business and

Social situations, or public speaking

Negative beliefs

I wont be able to cope, I will be overwhelmed by my anxiety

I am not competent enough to succeed

I am a failure

Symptoms of depression and anxiety

Thoughts, Emotions, Physical symptoms, Behaviour

 Interacting in a vicious cycle