Cognitive Behavioural Therapy Case Study

Student Number - 12240294
Coursework Submission Cover Sheet
Student Number: 12240294
Words: 3832
Due Date: 10/02/2014
Programme: MSc Cognitive Behavioural Therapy
Module Title: Continuing With Clinical Supervision
Module Code: 0909
Assignment Title: Case Study 7HSK0024
Lecturer: Elizabeth Simon

Table of Contents
1.
Introduction...................................................................................3
2.
Presenting the case............................................................................3
3.
Rationale for the use of Cognitive Behavioural Therapy....................................5
4.
Learning Theories.............................................................................6
5.
Assessment and Measurement Tools.........................................................7
6.
Formulation..................................................................................12
7.
Problems and Goals.........................................................................18
8.
Interventions and Summary of Treatment Offered........................................20
9.
Literature Review...........................................................................25
10. Reflections...................................................................................28
11. Conclusion...................................................................................30
12. References...................................................................................32
13. Transcripts...................................................................................44
14.
Appendix (On Separate Pages)
1. Introduction
This case study aims to highlight the course of treatment offered to client AR. He is a
Caucasian male referred for Cognitive Behavioural Therapy (CBT) after receiving a
diagnosis of depression, and personality disorder traits specifically morbid anger and
jealousy. To date the client has had a total of ten weekly sessions. The sessions took place in a
private practice where the author works as a Trainee Cognitive Behavioural Therapist under
the supervision of a Counselling Psychologist.
Throughout this case study, the foundations for using CBT and learning theories were
highlighted. Additionally, the assessments, measurement tools and formulations that was able
to represent a treatment plan for challenging behaviours are explained. The selected model of
treatment deemed appropriate for this client incorporated cognitive, emotional and behavioral
features. This linked well with the client, as due to the co-morbidity of the presenting
problems the individual required varied treatment interventions. Discussions regarding the
use of negative automatic thoughts and faulty thinking were supplemented with the
implementation of cognitive restructuring. Additionally, assertive skills and anger
management techniques were taught. Throughout the case study these models are presented
which are then supported by a review of the literature. Additionally, a reflective account of
the authors experiences is presented.
2.
Presenting the case
AR is a 38-year-old male who was referred for CBT by his Psychiatrist after being described
as suffering with Depression and Personality Disorder traits of morbid jealousy and anger
(APA, 2006) (See Table 1.1). Due to his aggressive behaviours he was prescribed 20mg of a

mood stabilising drug to be taken daily. He lives with his wife and son in the family home.
The client reported feelings of intense jealousy and anger over both trivial and seemingly
important situations, which have resulted in him being very aggressive towards his wife and
physically violent on two occasions. He claims that due to his inability to control his anger it
makes him feel very depressed. Subsequently, he is reported to have experienced anxiety
when he does have social plans. Additionally, he has stated that he becomes worried about
situations that have not yet occurred which consume his mind and lead him to lash out. This
either leads him to isolate himself and ruminate his thought, which later leads to outbursts of
anger. Furthermore, he often contacts his wife and accuses her of situations he has no
evidence for. This has resulted in problems at work with colleagues, his wife and his son.
Table 1.1 Demographic details

Name
Gender
Age
Ethnicity
Marital Status
Diagnosis
Medication
Occupation
Table 1.1 - Demographic Details

AR
Male
38
White British
Married
Depression, Morbid Jealousy / Anger
Mood Stabilisers
Scaffolder
There are several aspects that appear to be contributing to the clients problems that were
highlighted through two generic formulations (Padeskey & Greenberger, 1995), an anger
specific formulation (Novaco, 1975) and a summary conceptualisation model with a
maintenance cycle (Kuyken, Padesky & Dudley, 2011). By using these formulations it was
easier to make a link between the clients problems. While he presented with classic
symptoms of depression his anger and jealousy complicate the overview of his treatment.
ARs main cognitions included feeling like he is inferior to others, feeling uncomfortable in

his own skin, feeling stupid and like other people cant be trusted. He has noticed
modifications in his body such as becoming restless, feeling hot and having racing thoughts.
Generally, AR believes that people cannot be trusted and the world is full of wrongens. As
a result, this leads him to isolate himself, ruminate his thoughts and have angry outbursts. The
onset of the existing problems of mistrust/anger/jealousy appeared to have stemmed from his
childhood where he had a very critical father who physically abused him. Additionally, he
was able to recall situations from his childhood that cause him distress. For example at the
age of 13, his girlfriend who ended their relationship over a microphone at a party had
publicly humiliated him. He claimed that due to these experiences he has developed a strong
mistrust for people leading to his jealous thoughts. The client has also reported that he feels
that his depressive symptoms are due to him feeling bad about how he behaves towards
others and his inability to control it.
3. Rationale for the use of Cognitive Behavioural Therapy

Due to the features of the clients presenting problems it was proposed that CBT would be a
useful intervention as recommended by the National Institute for Clinical Excellence (NICE,
2011 Guideline CG77). Within research CBT has been demonstrated as an effective
therapeutic intervention for both angels of the clients problems. There is extensive
substantiation that proposes that CBT is effective for the treatment of Depression (Beck,
Rush, Shaw and Emery, 1979). Previous literature by Dobson (1989) identified that CBT for
depression was as effective as medication. This was also supported by De Rubeis et al.,
(2005) & Stunk et al., (2007) who stated that CBT is "as effective as medication to alleviate
depressive symptoms". Past research has also been able to demonstrate the benefits of using CBT for
anger. Research by Novaco (1976) has shown the effectiveness of the CBT approach to anger

management. It has been proposed that this course of treatment can reduce anger whilst
improving motivation, self-esteem and interpersonal difficulties. This approach to an anger
management programme is able to fit well with the clients presenting problems. Generally,
research also demonstrates low drop out rates for CBT which makes it an appealing choice
for therapy (Covin, Ouimet, Seeds, et al., 2008; Hunot, Churchill, Silva de Lima, et al., 2007;
Haby, Donnelly, Corry, et al., 2006; Mitte, 2005).
4. Learning Theories
Cognitive Behavioural Learning Theories are able to provide a better understanding of the
underpinnings of ARs behaviour and how it has established throughout his life. Operant
Conditioning exemplifies that the process of behaviour occurs through learning by rewards
and punishment. This theory sustains that there is a crucial link between a persons behaviour
and the consequence that result from this behaviour (Skinner, 1953). The client appears to be
negatively reinforced to avoid social interaction after he has had an angry outburst. By
engaging in social interactions he feels he may be placed in a position where he was more
likely to express jealous thoughts, which could result in an angry outburst. This limited
interaction results in AR withdrawing and isolating himself from others which causes low
mood. As this avoidance removed the unpleasant angry outbursts it was reinforcing
avoidance behaviour. Although it increased feelings of low mood it became his preferred
method of coping when placed in this situation. Due to these experiences, the avoidance of
placing himself in social situations resulted in him withdrawing from seeing friends,
communicating effectively with his wife and working within a team at work making him feel
even more lonely, angry and depressed.

However, during the period of attending CBT sessions he demonstrated a shift in the operant
conditioning. He showed that by changing the negative thoughts of others cannot be trusted
to, its important to keep an open mind about others he was positively reinforced to discuss
situations calmly when he felt there was a problem. As he continued to put himself into social
situations where his problems may arise, he found the experience easier.
5. Assessment and Measurement Tools

The initial assessment was conducted over four sessions (See Table 1.2). This process
followed the strategies identified by Sanders & Wills (2005) and was complemented by two
disorder specific approaches, the Model for Depression (Becks, 1987) and the Model for
Anger (Novaco, 1975). In line with Sanders & Wills (2005), the initial assessment interview
included gathering information regarding the clients previous experiences of therapy and his
goals. By using an integrative methodology throughout, the significance of regulating
angry/jealous emotions, adapting thought processes and approaches for coping with
challenging situations was highlighted.
Table 1.2 Assessment Process

ASSESSMENT PROCESS
Session 1
Assessing diagnostic criteria for depression to see if clients features meet the
diagnosis.
Assess problems with anger and jealousy to see if clients features meet the
diagnosis for personality disorder or personality disorder traits.
Client completed psychometric assessment tools and take SUDS.
Gathering general information about client.
Explanation from client of what is causing his difficulties.
Expectations of the sessions and previous experiences of therapy were discussed.
Explanation of Cognitive Behavioural Therapy.
7
Discussed scepticism towards Cognitive Behavioural Therapy.

Instilling hope.
Provided information to read for homework on what Cognitive Behavioural
Therapy is in general.
Session 2
SUDS to be taken from client.

Gathering background information.
Completed a lifeline of significant life events.
Identified problems and goals.
Provide information sheet for homework regarding depression and anger and
how they can be linked.
Session 3
SUDS to be taken from client

Introduction to the five systems model
Completed a topographical analysis
What is depression is like for you and how does it feel in your body?
Explain functional analysis ABC and client this for homework
Session 4
SUDS and psychometric assessments to be taken from client.

Discuss need to complete homework.
Continue with five systems model.
Completed a topographical analysis.
What is anger / jealousy is like for you and how does it feel in your body?
Socratic questioning to identify core beliefs, rules and assumptions.
Set homework of identifying how core beliefs have impacted behaviour.
Two different measures were used to assess the level of the clients problems and progress
during therapy, the Becks Depression Inventory Second Edition (Beck, Steer, & Brown,
1992) and Novaco Anger Scale and Provocation Inventory (NAS-PI) (Novaco, 2003). The
BDI is a 21-item scale that measures the severity of self reported depression in adults. ARs
scores on the BDI fluctuated over the ten-week period (See Table 1.3, 1.4 and Graph 1.1). On
average he demonstrated a moderate level of depression. The scores that AR demonstrated
are congruent to his presentation in the sessions and appear to reflect well on his current

situation. When analysing the items in more detail it can be observed that the areas in which
AR is experiencing the most difficulties includes agitation, concentration, self dislike, and
worthlessness and self criticalness.
Table 1.3 - Becks Depression Inventory Classifications
Score
Classification
0-7
Minimal
8-15
Mild
16-25
Moderate
Table 1.4 Becks Depression Inventory Results

BDI
Score
Classification
Week 1
22
Moderate
Week 4
21
Moderate
Week 7
18
Moderate
Week 10
14
Mild
Graph 1.1 Becks Depression Inventory Results
The NAS-PI tool was also selected; this is a self-report questionnaire that assesses an
individuals experience and expression of anger. An individuals score reflects their overall
level of anger, with high scores indicating relatively higher anger levels (See table 1.5, 1.6).
Table 1.5 Novaco Anger Scale and Provocation Inventory Classifications

Definitions of NAS-PI T-score Ranges
<29T
30T-39T
40T-44T
45T-55T
56T-59T
60T-69T
>70T
Very Low
Low
Low Average
Average
High Average
High
Very High
Table 1.6 - NAS-PI Results
NAS Total
Week 1
Week 4
Week 7
Week 10
Very High
Very High
High
High Average
10
Cognitive
Domain
Arousal
Domain
Behaviour
Domain
Provocation
Inventory
Anger
Regulation
High Average
High
High Average
Average
High Average
High
High Average
Average
High
High
Average
Average
High
High
Average
Average
Very High
High
High Average
Average
ARs scores fluctuated over the ten-week period. However, it was evident that in all areas his
anger levels had decreased over the course of therapy. Like with the BDI initially the scores
went up and then went back down. Overall, the NAS-PI suggests that the results obtained by
AR appear consistent in the way that he represents his anger. After taking all of these scores
together and analysing ARs current behaviour it could be suggest that AR generally does
experience deficits in his ability to regulate his anger.
In addition to these measurement tools, the Subjective Units of Distress Scale (SUDS) were
taken from the client to assess his level of anger over the previous week. The graph 1.2
demonstrates the results from the SUDS. Overall, his mood fluctuated over the ten-week
period.
Graph 1.2 SUDS Results
11
SUDS Results
6. Formulation
The initial part of the

10 formulation consisted of two Topographical Analyses, Cognitive ABC
(Pedesky & Greenberger, 1995) (See Fig 1.1, 1.2). From this aspect of the formulation the
9
therapist and client were able to begin to identify the thoughts, feelings, behaviours and
8
physical sensations when the client was placed in situations such as things going wrong at
7
work or being told that his wife has slept with someone else. These situations caused the
client to have angry6outbursts. He also stated that he felt sad much of the time because of
situations like
these. 5
Score
Fig 1.1 Topographical
analysis - Depression
4
3
2
1
0
12
Thoughts
Situation
"
"II
want to
to go
go
want
home"
home"
"I
"I cant
cant get
get
motivated"
"Why do i feel like
this"
this"
"What is going on
with me"
"Everything
"Everything bad
bad
always
always happens
happens to
to
me"
When a project at work

is not going to plan
Physical
Sensations
Emotions
Jealous
Jealous
Depressed
Depressed
Empy
like
Empy -- like
something
is
something is
missing
missing
Hot
Hot
Racing
Thoughts
Racing Thoughts
Tense
Heart
Heart rate
rate
increases
increases
Behaviours
Worrying about it
Moaning
Moaning
Withdraw
Withdraw
Dont
Speak
Dont Speak
Sulking
Sulking
Short tempered
Ring Wife
13
Fig 1.2 Topographical analysis Anger/Jealousy
Thoughts
Situation
"I dont
dont know
know if
if ii should
should
"I
believe
believe her
her or
or not
not"
"
When someone told

me that someone else
had slept with my wife.
It
It isnt
isnt ture"
ture"
"The
answers
"The answers that
that ii
am
am getting
getting from
from
her
arent good
her arent
good
enough"
enough"
"I
"I dont
dont believe
believe her"
her"
"Everything
bad
"Everything bad
always
happens to
to
always happens
me"
me"
Emotions
Physical
Sensations
Frustrated
Angry
Mixed up - dont
know what to think
Sad
Sad
Heart
Heart Racing
Racing
Feeling
Feeling uptight
uptight
Behaviours
Ask wife about it
Ruminate about
what she tells me
Withdraw
from
Withdraw from
everyone
Distant from wife
14
Following on from this generic formulation an anger case formulation (Novaco, 1975) was
completed (See Fig 1.3). Through this model the therapist was able to elicit the clients
cognitions, behavioural reactions, physiological arousals and what environmental
circumstances are likely to trigger this. For AR, often when he is at work and something went
wrong he called his wife to discuss it. If she is unable to answer the phone his cognitions
cause him to think negative thoughts such as what is she doing, who is she with. These
thoughts make him feel out of control and leave him feeling hot, sweaty, shaky etc. As a
result he often responds to such situations by accusing his wife of doing things that he has no
evidence for and shouting at her or at his colleagues. His wife then refuses to talk to him
when he is in this highly emotionally angry state and subsequently, AR begins to feel bad and
isolates himself.
15
Cognition: Structure & Processes

What is she doing
Who has she been with
Why would she love me when she can be with someone else
Everything I do makes her upset
I wont stand for her lying to me
No-one cares about me
Ive got no control over what I might do
II cant control my anger
Environmental Circumstances
At work something doesnt go my way call wife and she doesnt answer the phone.
ANGER
Behavioural Reactions
Shout at wife / colleagues

Avoid seeing / speaking to w
Wife is angry with me
Physiological Arousal
Hot
Sweating
Butterflies in stomach
Tense
Fig 1.3 Anger Case Formulation
16

Additionally, a collaborative case conceptualization model with a maintenance cycle
(Kuyken, Padesky & Dudley, 2011) was used to bring the two problems together. By
adopting the method of using an idiosyncratic longitudinal formulation process the
individuals life, presenting problems and CBT can be linked together. Its also able to
incorporate the early years of the individual and how these experiences developed into core
beliefs (See Fig 1.4). Some of the clients developmental experiences such as having a very
critical father who physically abused him led him to develop core beliefs such as I am
inferior, I feel uncomfortable in my own skin, and I am stupid. This led to AR
developing underlying assumptions such as If I take control then I can prevent bad things
from happening, If I want to be seen as competent then I must do everything well, If I
want people to love me I have to be able to do things well and If I prepare for the worst I
am never going to fail. The strategies that he uses to achieve this is to shout at his wife when
she doesnt allow him to be in control, work to a high standard, constantly worry about
making mistakes and avoid responsibilities when things go wrong or dont go his way. The
onset of the current emotional problems that he experiences are thought to be due to
challenges at work such as things going wrong or people talking about his wife. This causes
him to feel angry and low in mood. As a result he has thoughts of I feel out of control, I
hate it when people do things like this to me, Why does no one respect me, I am useless
and stupid. These thoughts originally cause him to confront his wife and individuals at work.
He then ruminates over what he has said to them and begins to avoid social situations. This
avoidance then maintains the negative thought processes leading to the cycle continuing to
occur.
17

Fig 1.4 Colaborative Case Conceptualization Formulation
Predisposing
Factors
Developmental Experiences
Critical Father
Physical Abuse
Difficulty making friends
Humiliated at school by his girlfriend who ended the relationship over a microphone at a party
Core Beliefs
I am inferior
I feel uncomfortable in my own skin
I am stupid
Underlying Assumptions
If I take control then I can prevent bad things from happening
If I want to be seen as competent then I must do everything well
If I want people to love me I have to be able to do things well
If I prepare for the worst I am never going to fail
Strategies
Shout at his wife when she doesnt allow him to be in control,
Work to a high standard,
Constantly worry about making mistakes
Avoid responsibilities when things go wrong or dont go his way
Onset
Work becoming more challenging which has resulted in him doing more things wrong, increasing alcohol consumption
Presenting Issues
Presenting Issues
Low Mood
Anger
Triggers
Something going wrong at work, people talking about or looking at his wife.
Maintenance
I want to go home
I cant get motivated
Why do I feel like this
What is going on with me
Everything bad always happens to me
cycles
If I carry on like this I am going to end up alone
Ruminate
Avoid People
Withdraw
Sad
Anxious
Low Mood
18
I dont trust my wife

What is she doing
its not just my wife nobody should be trusted
She doesnt give me the answers I want
I dont believe what she says
Ruminate
Confront people
Angry Outbursts
Angry
Frustrated
7. Problems and Goals

The clients problems and goals and appropriate interventions could be highlighted through a
9-box model (Thompson, 2012) (See Fig 1.5). When completing this, the client and therapist
ensured that they were in line with the SMART goals model (See Fig 1.6). These made it
easier to identify both long and short-term goals for therapy. Some of the main therapeutic
goals include improving reduction of avoidance and more effective processing and regulation
of emotions.
Fig 1:5 9 Box Model Problems and Goals

19

COGNITIVE PROBLEM
COGNITIVE GOAL
What is she doing, Who

has she been with, Why
would she love me when she
can be with someone else,
Everything I do makes her
upset, I wont stand for her
lying to me, No-one cares
about me, Ive got no
control over what I might
do I cant control my
anger.
FEELING PROBLEM
To be able to manage feel

comfortable around people
and manage my racing
thought.
Sad, Upset, Angry, Hot,

Sweating and Racing
Thoughts
To be able to manage the

feelings and symptoms of
anger, to feel more in control
and able to cope
BEHAVIOURAL
PROBLEM
BEHAVIOURAL GOAL
Shout at wife / colleagues,

Avoid seeing / speaking to
wife, Worrying about it,
Moaning, Withdraw, Dont
speak, Sulking, Short
tempered, Ring wife.
FEELING GOAL
Be able to attend the engage

with people at ease without
being worried about how I
may react or if I will have a
violent outburst.
20
COGNITIVE
INTERVENTION
Cognitive
Restructuring,
Analysing common faulty
thinking, Problem Solving define problems more clearly
and specifically with set
goals
and
develop
understanding as to why this
is
important,
Cognitive
Avoidance,
Safety
Behaviours
FEELING
INTERVENTION
Psycho Education anger
responses and the role of
avoidance in maintaining
anger, Relaxation techniques
progressive relaxation
BEHAVIOURAL
INTERVENTION
Thought Record, Anger log,
Avoidance Behaviours and
Rumination, Anger hierarchy,
Stress inoculation plans,
Assertive skills, Distress
Tolerance Skills and Coping
Strategies, Role plays
SMART Goals

Fig 1:6 SMART Goals
MEASURABLE my progress throughout the sessions will be measured using the ps
ACHIVABLE I
REALISTIC I am going to increase the amount of times that I practice, use and record the coping strategies that I learn each wee
TIME The short term plan is to increase the time sp
21

8. Interventions and Summary of Treatment Offered
The proposed treatment plan was informed by the Anger Treatment Protocol (Novaco, 1975)
and the Cognitive Therapy of Depression Protocol (Beck, Rush, Shaw, and Emery, 1979).
This was directed by the assessment, which highlighted two main difficulties; managing
emotional regulation and problem solving (See Table 1.7). After the completion of the
formulations the information was discussed with the client. From this a collaborative decision
regarding the treatment plan was made (See Table 1.8 & 1.9).
Table 1:7 Treatment Plans
Domain
Treatment Plan
Cognitive Domain
Cognitive Restructuring
Analysing common faulty thinking
Problem Solving - define problems more clearly and specifically
with set goals and develop understanding as to why this is
important
Cognitive Avoidance
Safety Behaviours
Psycho Education anger responses and the role of avoidance in
maintaining anger
Relaxation techniques progressive relaxation
Thought Record
Anger log
Avoidance Behaviours and Rumination
Anger hierarchy
Stress inoculation plans
Assertive skills
Distress Tolerance Skills and Coping Strategies
Role plays
SMART Goals
Review all of treatment programme
Blueprint skills and session content
Identify high risk situations
Identify most effective coping strategies learned
Encourage practice of skills for continual development
Feeling Domain
Behavioural Domain
Relapse Prevention
Table 1:8 Session Content

Treatment
Aims of treatment Session content

22

Session
Session 1
Assessing diagnostic criteria for depression to see if clients

features meet the diagnosis.
Assess problems with anger and jealousy to see if clients features
meet the diagnosis for personality disorder or personality disorder
traits.
Client completed psychometric assessment tools and take SUDS.
Gathering general information about client.
Explanation from client of what is causing his difficulties.
Expectations of the sessions and previous experiences of therapy
were discussed.
Explanation of Cognitive Behavioural Therapy.
Discussed scepticism towards Cognitive Behavioural Therapy.
Instilling hope.
Provided information to read for homework on what Cognitive
Behavioural Therapy is in general.
Session 2
SUDS to be taken from client.

Gathering background information.
Completed a lifeline of significant life events.
Identified problems and goals.
Provide information sheet for homework regarding depression and
anger and how they can be linked.
Session 3
SUDS to be taken from client

Introduction to the five systems model
Completed a topographical analysis
What is depression is like for you and how does it feel in your
body?
Explain functional analysis ABC and client this for homework
Session 4
SUDS and psychometric assessments to be taken from client.

Discuss need to complete homework.
Continue with five systems model.
Completed a topographical analysis.
What is anger / jealousy is like for you and how does it feel in your
body?
Socratic questioning to identify core beliefs, rules and
assumptions.
Set homework of identifying how core beliefs have impacted
behaviour.
23
Session 5
Take SUDS from client

Review homework and previous session
Feedback formulation to client
Complete Anger Case Formulation.
Set homework of keeping a diary of negative thoughts
Session 6

Feedback formulation to client
Complete Collaborative Case Formulation
Discussed treatment options and the rationale for each treatment
that was suggested as a result of the formulation.
Decided on SMART goals.
Complete pros and cons of having an angry outburst for
homework.
Session 7
Client complete assessment tools and take SUDS

Discuss anger as a normal emotion, what is anger and what
purpose does it serve?
Discuss relaxation strategies
Discuss self-monitoring of anger.
For homework ask client to describe their favourite relaxing,
calming image or picture.
Session 8

Discuss how high levels of stress affect thinking and behaviour.
The purpose of relaxation
Development of relaxation strategies
Provide client with anger log for homework to record any
situations where they feel angry.
Session 9

Anger treatment decision matrix
Cost benefit analysis
Building on an anger hierarchy
Review progressive relaxation and set this to practice for
homework.
24
Session 10

Continue to develop the anger hierarchy
Introduction to stress inoculation procedure.
Ask client to continue to complete the anger logs.
Table 1.9 Future Session Content

Treatment
Session
Aims of treatment Session content
Session 11
Client to complete assessment measures and take SUDS

Explain and carry out cognitive restructuring.
For homework review different situations where the client has felt
angry and make attempts to perspective take.
Session 12
Client completed assessment tools and take SUDS

Discuss clients faulty thinking
Discuss situations where faulty thinking occurs
Challenge NATs to make RATs
Identify ratings for how true the thoughts felt at the time of the
situation and at the time of cognitive restructuring
Connect cognitive restructuring with the clients formulation
Explain a thought record and provide for homework
Session 13
Session 14

Develop cognitive restructuring to include perspective taking.
Discuss scenarios with client and review how they might cope
successfully.
Discuss effectiveness of various coping strategies and role-play
these.
Positive self-talk set this to practice for homework.
Review and discuss problem solving
communication.
25
through
effective
Assertive skills, difference between passive and aggressive

For homework set the worksheet of effective communication in
angry situations.
Session 15

Review homework discussed why it is important
Work on 6 steps to problem solving method
Devise an action plan
For homework ask client to work on their action plan.
Session 16

Discuss dealing with rumination and escalation through attentional
focus.
Discuss why using coping strategies is more difficult in an
escalating situation.
Discuss strategic withdrawal
Ask client to practice coping strategies and record all those that are
used.
Session 17

Discuss dealing with repeat provocation
Review appropriate responses for repeat provocation
Review how to have less aggressive arguments within
relationships.
Ask client to complete the dealing with anger incidents personal
reminder sheet for homework.
Session 18

Discuss and role-plays saying no assertively.
Discuss unhelpful beliefs and ways of saying no
Discuss dealing with constructive and destructive criticism.
Role play giving each type of criticism
For homework ask client to review helpful and unhelpful thoughts
in relation to criticism.
Session 19
Client completed assessment tools and take SUDS.

Complete the relapse prevention plan
26
Session 20
Session 21

Make goals for the homework
Take SUDS from the client

Review homework and previous session.
Recap on generic formulation completed
Recap on some of skills learned including pros and cons, cognitive
restructuring, assertiveness
Identify high risk situations
Client completed assessment tools and take SUDS.

Complete the relapse prevention plan
9. Literature Review
The tempestuous emotion of anger is a feature of a widespread array of diagnoses (Koop &
Lundberg 1992; Novello Shosky & Froehlke 1992). The fundamental problem that
individuals tend to have when suffering with anger issues is the inability to regulate the
emotion meaning that the initiation, countenance, and consequences transpire without apt
controls (Goldstein & Glick, 1994). Due to anger often being intertwined with other clinical
issues, getting control for behavioural change can be an intangible target (Dryden, 1968).
Overall, as anger functions as a sentinel to self-esteem, it often results in interconnecting
negative responses and can cause the individual to experience depressive symptoms
(Renwick, Black, Ramm & Novaco, 1997 and Watt & Howells, 1999). Persistent anger is
often the result of difficult past experiences and can undoubtedly lead to dysfunctional ways
of apportioning with lifes encounters (Novaco & Taylor, 2004, Hanks, Temkin, Machamer &
Dikmen, 1999). These difficulties often cause individuals to have problems with personal
relationships, employment and physical health (McKay, Rogers & McKay, 1989). This was
clearly evidenced with client AR.
27
Through the six main meta-analyses that have been carried out for anger treatments in CBT a
moderate effect size has emerged (Tafrate, 1995; Edmondson & Conger, 1996; Beck &
Fernandez, 1998; DiGuiseppe & Tafrate, 2003; Del Vecchio & OLeary, 2004). This implies
that approximately 75% of people who undertake CBT treatment for anger demonstrate a
significant change compared to those in controlled conditions. However, when taking these
findings into account, further supportive research into this area would allow for a more robust
multi-model assessment design to be identified (Watt and Howells, 1999). Despite the limited
research there are several non controlled, case series and case study reports that have been
able to demonstrate effective CBT treatment for anger for individuals with multifarious needs
(Novaco, 1997 & Stermac 1986).
Research has also shown that individuals who have difficulties in regulating their emotions
have both cognitive and behavioural difficulties (Beck & Fernandez, 1998). Furthermore,
people with anger/jealousy problems often experience depressive symptoms in response to
their behaviours (Baker & Wilson, 1985; Battle, 1994). With the current client it was evident
that he had both cognitive and behavioural difficulties. However, with regards to the
treatment plan it was apparent that due to the risks that his behaviour posed it was felt that it
would be more advantageous to work on the behavioural element first. These models were
selected for the current client, as they were able to incorporate treatment interventions that
were able to meet the clients needs. It also allowed for elements of flexibility where parts of
the Becks Protocol for Depression could be introduced so that the client and therapist could
respond to all of the presenting problems. When reviewing the Becks Protocol for Depression
it was evident that aspects such as addressing faulty thinking and cognitive restructuring were
able to overlap with that of the Anger Treatment Protocols (Blashfield, 1990). The benefits of
28

using two different protocols with co-morbid clients allows for more problem directed
solutions (Cain 1987; Paykel, et al., 1999; Scott et al., 2002).
In line with this, it should also be noted that whilst the client demonstrated with a co-morbid
problem the underline issues that emerged through the longitudinal formulations suggest that
his problems were all in some way connected. As a result it was hypothesised that as one
aspect of the problem is treated it will also help to alleviate other presenting symptoms
(Hunsley, Crabb, & Mash, 2004). This explains why it is not necessary to complete two full
treatment protocols for each presenting problem as not only would it be repetitive but may
not be any more effective (Mahoney 1993; Lochman 1985).
Although the development of the client over the past ten sessions of therapy was evident and
it was apparent that the correct protocols were followed, there were other noteworthy models
that were not used. For example the Unified Protocol for the Transdiagnostic Treatment of
Emotional Disorders (Barlow et al., 2004). A fundamental feature of this model involves the
use of underlying treatment ideologies of change that overlap different treatment styles and
diagnostic classifications (Boswell & Goldfried, 2010; Norcross, 2005). More specifically,
this transdiagnostic ideology is focused on emotion and can be applied to any disorder that
encompasses a protuberant emotional constituent for example mood disorders (Barrett,
Mesquita, Ochsner & Gross, 2007). The aim of this type of therapy is to focus on deficits in
emotional regulation (Mennin, Heimberg, Turk, & Fresco, 2007; Greenberg, 2008). As a
result, this type of therapy aims to increase individuals awareness of their emotions and how
this awareness can change behaviours (Greenberg, 2002a). Although some aspects of this
model would appear to benefit the current client there were also aspects of it that did not meet
29

the clients needs. Whilst more recently, the evidence base for CBT has been critisised
(Nathan & Gorman, 2007), their effectiveness in treating specific disorders is very good
(Tafrate, 1995; Edmondson & Conger, 1996; Beck & Fernandez, 1998; DiGuiseppe &
Tafrate, 2003; Del Vecchio & OLeary, 2004).
With regards to particular interventions used with the current client, one of the main focuses
was on stress inoculation for anger control (Meichenbaum, 1985). The concept of this
involves teaching cognitive behavioural coping techniques
(Ekman, 2003). During this
training the individual learned to identify their own triggers for anger and how to deal with
this effectively when it occurs (Shapiro, 1994; Lindsay, Overend, Allan, Williams, Black,
1998). This process is similar to that of social skills and assertion training (Liberman, DeRisi
and Mueser, 1989). By expending a methodical approach to problem solving when
experiencing anger individuals are more able to effectively manage situations (Novaco,
1978). In summary, the stress inoculation approach to treatment has been found to be
effective with a wide range of populations (Novaco 1994b, Tafrate, 1995, Edmondson and
Conger, 1996, Beck and Fernandez, 1998, Taylor, 2002; Siddle, Jones & Awenat, 2003).
10.
Reflections
Over the course of therapy that has been carried out with AR so far, significant time has been
spent reflecting on the content that has been covered. One of the main points that emerged
during my own reflection was that it was very important to distinguish the link between the
two presenting problems of the client and how these can be connected over the course of his
life span. Overall, the clients responses to situations, which cause him to become angry, have
30

changed and he has been able to learn more effective skills for regulating his emotions. As a
result this has decreased his depressive symptoms.
During therapy there were some problems that were encountered. Throughout the sessions the
client appeared to be reluctant to complete homework. Some of the reasons that he provided
for not completing the homework were that he found it too difficult, he did not find the time
within his week or that his handwriting was not very good. These issues were then raised
during the therapy sessions. I found that by addressing this within therapy we were able to
develop an action plan to work on this. By doing this I was able to help overcome this
problem collaboratively with the client whilst still allowing him to understand the benefits of
completing homework. Initially I found that I was getting frustrated when the client was
attending sessions without having completed the homework previously set, by working
through this problem, I could deal with my own frustrations as well.
Additionally, within therapy at times I found it difficult to empathise with the client. I found
that when he was justifying some of his behaviours such as verbal aggression towards his
wife these ideas contradicted with my own personal values. I found that my personal feelings
towards him at times were very negative and this was something I was able to work on within
my supervision. By bring this to supervision I was able to develop ways of communicating
my views to him in a constructive manner. I also found that by keeping a diary about my
experiences I was able to vent my frustrations and express my thoughts about our sessions,
which helped immensely. I also was able to realise that I could complete effective CBT even
when I did not personally like the client.
31

With regards to my overall practice, when reflecting on my work, I was able to identify that
during the concrete experience stage of Kolbs Learning Cycle (1984), I was able to apply my
academic understanding into practice by adapting theories to ensure the therapy carried out
was individualised. Following on from this, during the reflective observation stage I was able
to identify both the positive and negative aspects of the therapy, which contributed to the
formation of the sessions. For example, after completing the formulation stage with the client
I was able to identify that anger, jealousy and depression were the problems that were causing
the client the most concern. By using this information when I reviewed the literature, I was
able to classify models for therapy that applied to the clients needs. During the abstract
conceptualisation stage of my learning I found that reviewing aspects of the sessions that
could have been carried out differently was very helpful. Additionally, throughout the course
of the clients therapy I found that I was using reflection through active experimentation. I
discovered that by regularly reviewing my practice allowed me to generate ideas for how to
improve my competencies in carrying out CBT with clients.
11.
Conclusion
The wide-ranging conclusion regarding the outcomes of CBT for Anger and Depression
based on models by Novaco (1975) and Beck (1979) propose promising results. More
recently, researchers have begun to divert their attention towards CBT as a treatment for
anger and have been able to support CBT as effective in this (Edmondson & Conger, 1996;
Renwick et al., 1997; Beck & Fernandez, 1998; Watt & Howells, 1999; Dyer, 2000;
Deffenbacher et al., 2000; DiGiuseppe & Tafrate, 2003; Siddle et al., 2003; Del Vecchio &
OLeary, 2004). A review of the literature by Tafrate (1995) demonstrated that of 50 studies
of 1640 participants an effect size of 0.70 was establish. This suggested that overall,
moderate treatment gains were accomplished within therapy. Within these studies a very
32

diverse group of people were used. Subsequently, the effectiveness of CBT for anger can be
generalised across several populations (Fernandez & Boyle 1996; Glass McGaw &
Smith 1981; Rosenthal 1991). These outcomes are consistent with further meta-analyses
authenticating the effectiveness of CBT (Dobson 1989; Van Balkom et al. 1994). In line
with these research findings, the current case study followed these CBT models of treatment
in order to overcome the clients problems.
Whilst recognising the positive results demonstrated by the current case study so far, the
limitations of the treatment cannot go unnoticed. The treatment aims to last for twenty-one
weeks of one-hour sessions rather than the recommended twelve weeks of an hour and a half
for this protocol. This is due to the functioning level of the client, elements of two different
protocols being used and the complexities of the comorbid problems that the client presents
with. Moreover, as the treatment has not yet been completed no relapse prevention plan or
follow up sessions have been arranged. However, at the current stage it is apparent that the
clients views of himself, others and the world around him are beginning to change.
For future research regarding CBT and the treatment of anger, principally by Deffenbacher et
al., (2000) & Lochman & Lenhart (1993) it is likely that further developments will enhance
the effectiveness of the programmes that are made available. Specifically, when evaluating
their effectiveness it may be interesting for future studies to pay focus to particular variables
such as self-efficacy ability to control urges and impulsivity. By focusing on specific
variables within treatment it would allow for more specialist programmes to become
available, which would be able, to focus more directly on individuals needs. Generally, ARs
diagnosis deemed him suitable for CBT. The therapy appears to have had a positive impact
on the clients thoughts, feelings and behaviour. Throughout the initial sessions, the most
33

important maintenance factors regarding the clients problems were emphasised; which was
able to formulate the treatment applied. This has been able to contributed to the client
beginning to achieve his goals for therapy.
12.
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13. Transcripts
The first five minutes of the session were spent completing the psychometric assessments
T = Therapist
C = Client
57 minutes and 44 seconds plus 5 minutes complete the psychometric assessments before the
session.
Speaker
Session Verbatim
CTS-R
Skills
Ok alright so should we start by maybe setting an

agenda for todays session
Go on
so just that we kind of know where we are going with it.
Erm is there anything that you wanted to bring to the

erm session
46
Comments / Reflections
Agenda
Setting
By starting the session

setting an agenda it gives
structure to the session.
Collaboration
By asking the client if there

is anything they would like
to bring I was able to ensure
that it is not just me

engaging in the session.
C
No not today sorry
Nothing in particular
No
Ok so maybe you could have a think about that
ok so maybe we can have a look at the homework
No I havent dont it I have been naughty
Ok so we can talk about that
Right
So we can talk about that, that can be the first thing we

talk about
Erm and maybe look over what we did last week do you
remember do you remember what we did last week.
Erm yeah and no to be honest
Ok well we can look at that
Yeah
And I was thinking of erm continuing on with the

formulation stage where we were making a picture,
making sense of what we have been doing
So last week we spoke about the depression side of

things so maybe this week we could look more on the
jealousy, angry sort of side
Do you think that would be ok?
Yeah that is fine
Then we can talk about the homework and see where we Homework
are with that, thats fine
setting
By placing the setting of the

homework on the agenda it
ensures that it is completed
Ok so first thing, what what happened with the

homework what went what went wrong
Highlighting to the client

the first item on the agenda
Erm I dont know to be honest I didnt think about

47
Homework
Review the previous weeks

homework.
Agenda
Setting
Prioritising what order

things will be done in
Feedback
By asking the client their

opinion regarding what has
been said I am able to
confirm that they agree
Agenda
setting

doing it, I dont know why I just, I dunno
T
Ok, erm do you remember what it was?
No I dont to be honest I havent looked at it
You dont remember what it was
If I said to you an ABC would you what would you
Yeah an ABC yeah thats something to do with it
Ok so when I say ABC to you what does that mean
I learned it when I was two
(Laugh)
Ok so you brought the sheet with you thats a good

things so you havent lost it
I put it on the side and to be honest I just left it look at it

a couple of times probably looked at the paper not
opened it up and just thought Ive got to do it but
What do you think made it difficult to do it
Erm I dont know I probably didnt know what to put

down
Not really sure what to put
Yeah yeah
Ok
We can look at that
Erm (pause) I know you said before we left last week

erm you were a bit kind of anxious a bit worried about
doing this
Yeah yeah
Was it because it was a bit too it felt a bit too much what
was it that made you feel anxious about it.
Erm dont know I just felt anxious about it, I felt a but
silly last week to be honest because you was talking and
I was listening but I wasnt and I
That sometimes happens to us though
Yeah yeah it happens quiet a lot
48
Interpersonal
effectiveness
Providing the client with

positive reinforcement

C
(laugh)
Which is exactly why you are here
Yeah
So did you find what so lets stick with that for a minute
did you feel you were beating yourself up about it or
what
Erm probably for a little while but
What, what were you doing in that little while
Just dont know just feeling a little bit silly and a little
bit uptight and then as fast as I felt a bit silly and uptight
I just dont know I just blanked it out and tried not to
think about it to be honest
Was there any part of you that was thinking I shouldnt

be feeling this way there is no reason for me to feel this
way or was it more that you were just kind of trying to
blank it out and avoid it.
Erm I think probably I just blanked it out and avoided it
Ok how difficult (erm) would it be for you now to think

to think it didnt really matter, it wasnt a significant
part of my life, it wasnt going to make any difference
how difficult is it for you to think like that?
Sometimes it it I can think that way and other times I

cant it just plays on my mind and plays on my mind and
I dont know why
Ok
(erm) what do you think was triggering you having that

kind of blank mind last week and not being able to focus
too much.
Probably when you are talking to me I probably had

something to say but I didnt manage to get it out and
then it was just going over and over in my head
What was it that made it difficult for you to get it out
I dont know probably didnt feel as though it come up

in the right conversation to be able to bring it in
Ok
Do you know what I mean
49
Eliciting key
cognitions
Establishing what the client

was feeling when in an
anxious situation
Eliciting
behaviours
Establishing what the client

was doing at the time of
feeling anxious
Eliciting key
cognitions
Asking the client about their

thoughts

T
Yeah that makes sense
Rather than just be talking, and then ill go totally off

about something else and then just felt a bit silly and
then trying to get it in to
I think it is really important for us to be able to hear

everything that you have got to say as you are the expert
of your problem and actually what you have got to say
is really really important
Yeah
So I think maybe we could come up with some

strategies where if you think you have something that
you
Really I should write it down but I am not always in the

position to be able to do that I might be up a scaffold
and I am working away and sometimes my mind is
doing a hundred miles an hour and im with it, I wasnt
really with it today this afternoon so I made a couple of
silly mistakes, nearly fell off a couple of times
When, what was making you aware that you wasnt

really with it today
I dont know, it was, (erm)
What did that feel like what was going through your
mind
Just as though I wasnt concentrating on the task that I

was meant to do and normally I am pretty focused at
work and I am really careful
Why do you think it was that you couldnt concentrate
(erm) dont know may probably anxious about coming

here on my mind
Ok
Erm that I hadnt dont this was probably there and that
and obviously like today is like that day like d day
Yeah I mean one thing about the homework is that the

reason we give homework is because practicing these
things makes perfect
Yeah yeah
50
Interpersonal
effectiveness
Building a rapport with the

patient
Guided
discovery
Asking the client questions

to help them understand
what was going on with
them.
Eliciting key
cognitions
Helping the client to

recognize their thoughts
Homework
setting
Discussing the benefits of

homework setting

T
So for us it is you are able to move a lot quicker in the

process if you practice them I mean you know that in
your job you must have had to have done a lot of
practice to get to the stage that you are at now
Yeah I only (erm) I have been collage for two weeks and
then for 4 days to do what I am doing now
So mainly all of it is practical practice
Yeah yeah and in I cant I cant go no further than what I

am, well I can just go in the office or supervising but I
am as good as you know like that
Yeah
But
I mean it sounds like you are very knowledgeable about

your job and you know what you are doing and you are
focused
Yeah
I am entitled to be I have been doing it for long enough
Exactly
I have been doing it for 27 years
27 years so you must know a few loop holes to do

things quicker and all these different things
Yeah
Right so that is the same thing with the homework here I

mean I dont want you to feel pressured to do it, I think
maybe as well that was a bit too much but sometimes
when we when we discuss like decide on some
homework it is just literally to reiterate some of the
things that we have been talking about in the session so
I think I think the reason why I am not very forward in

the reading and writing is because I dont have to do it
in my job
Yeah so it is a bit alien really
Yeah on the odd occasion, yeah it is to me it is really

alien because today I had to just write out a variation
sheet of what I had done and I got someone to sign it
and my handwriting is terrible, and like iits where I have
just finished work and I dont know you, your
adrenaline is still going as though like I am writing and I
51

have got really no control so its like a little kid is doing
it
T
Yeah
I can write alright if I am just sitting there and chilled

out and writing but its just where you have been
working and your adrenaline is going and you have been
working its
I was going to say the last homework you did your

writing looked really really neat
It can be but it can be really thingy it all depends
Do you think that is you putting a negative spin it again
Maybe (erm) I dont know I probably put the negative

spin on a lot of things I suppose like make things into
bigger issues than what they really are
What does it feel like to thing about that
I dont know, sometimes I get my head around it and

think why was I worrying in the first place and then
other times it really gets to me and really plays on my
mind really and just and then everything just escalates
and then something else will give me and then I when
you are feeling a bit down it just gives me the hump and
it just escalates and evolves from there and its turns into
a big thing when really I should have just dismissed it
and (pause)
what does it feel like for you to hear me say well

actually your writing is really good and it is completely
illegible and
Yeah I know I can write its just when I put my heart to

it, its the same like at school
Like under pressure
Yeah yeah I could write when I wanted to but I dont

know its being lazy I suppose
Sometimes that could be the case
I mean everyone is lazy in there own little way
Ok so if we look at the second thing that we put onto the Agenda

agenda it was to review last week
setting
52
Pointing out to the client

that we are moving onto the
next agenda item

C
Yeah
What do you remember about last week, what we did

last week
(erm) (pause) I cant
Its kind of gone out of your mind
Yeah
Thats ok
If I show you this this formulation
Yeah I remember that
So we had about certain times of the day that you are

doing a job and it does go to plan, so that was kind of
our focus of a situation that makes you feel depressed
sometimes
Yeah
So that was an example
Or I feel as though I have too much of a conscious at

times when I should when I look at other people and
they dont seem to hold things they just like
Explain that to me a bit more what do you mean by that
I dont know (pause) I dont know its just like leaving

stuff and it might be for being tidy or having things
done a certain way or something like that but
So you feel you do more than others
(erm) I feel as though I do but I probably dont its

probably just me thinking out I dont know I dont know
That makes sense (erm)
When you feel like you do more than others when you
are in a situation and you think I am going to see this
out see this through to the end
Yeah try and do it try and do a bit extra try and do it the
best I possibly can
53
Conceptual
integration
Reviewing the previous

formulation that has been
completed.
Guided
discovery
Asking the client questions

in a Socratic way to help
develop a deeper level of
understanding into their
problems.
Feedback
Summarizing what the

client has said

T
What does that make you think about the other people
Dont know like they have got a bit of a blaze attitude

towards things
So they are not as dedicated
But at the end of they day they are still getting paid so
whats so I think to myself so whats the why am I
getting myself in a state when they are not worried
So they are not worried about it so why am I
Yeah why should I be worried about it
So when you think that thought of there not worried

about it why should I be what behaviours do you do
what does that lead you to do
(erm) for a little while have a little bit of a blaze attitude
So you are kind of like oh what the hell
Yeah yeah
And does that lead you to stop working or take a break

or what do you do
Yeah just like anything or just (erm) but then I think to

myself why have I got to be like them and then not care
and that but at the end of the day (paurse) there is not a
lot of caring in the world sometimes and some of us
have got to care do you know what I mean
Is it bad to care
Not its not bad to care its not but we can probably care
too much I suppose and let it play on you
So it is like trying to find a balance
Yeah a happy medium with it and I obviously havent

got it.
Ok so that is what we are looking at
So
(erm)
54
Guided
discovery
Helping the client to

understand how they view
the world.
Feedback
Repeating to the client what

they have said to ensure
clarity.
Eliciting
behaviours
Asking the client to identify

what behaviours they show
in certain situations.

T
Go on
Over the last week I havent had a bad week to be

honest its been quiet good I have had a couple of
moments, a few moments but
Do you remember what those moments were
Just generally worrying about things (erm) just getting a

bit anxious then I think why am I worrying or letting it
play on my thing I am doing as much as I can so no one
can ask any more of me
Yeah that is true
And I dont know I didnt feel as though it was right or

it was wrong the way I was feeling, do you know what I
mean
Yeah that makes sense
What things have you worried about can you pin point
any
No I dont just in general just any simple thing I dont

know just
It doesnt matter if you cant remember
Yeah just because obviously I am at work a lot and its

the only thing I can really relate to, at home it has been
lovely its like my son has been really lovely and a
couple of times we have had to tell him off but at the
end of the day he is a teenager
Yeah that going to happen
Yeah he is going to push his luck but overall he is lovely

he is he is a really good kid, and my wife has been fine
and been really helpful and understanding and this and
that and so
What has she been understanding about
Just the way she knows I am obviously feeling down

and obviously feeling depressed and that and obviously
she just keeps saying the sooner you sort yourself out
everything will be lovely because like she was saying
we have got a lovely relationship it just needs to for you
to sort yourself out
And how does that make you feel

55
Eliciting key
cognitions
Aiding the client in

identifying what their
cognitions and thoughts are.
Eliciting key
Identifying the individuals
It makes me feel lovely but if I could flick a switch and

it would be done that would be great but its not like that
You feel like it is quiet a long time
But I probably I think it is going to get to stage where I

am doing it without even realizing it and then I dont
know and then I think to myself how do I know I am not
going to be doing this for the rest of my life I am going
to have to try and find a happy medium yeah but (pause)
I dont know
I think you are right in questioning am I going to be

doing this for the rest of my life and the thing is with the
skills that you are going to learn through CBT you will
be doing those for the rest of your life but they will
become a part of your life
Yeah Yeah
So changing the way that you think about things and

changing the way that you behave
Yeah your whole attitude towards things
Yes that change will be a positive change for the rest of

your life, it wont be this is a real drag like being on diet
ive got to stick to this, it will be a part of your life that is
making your life better
Yeah
So thats probably a when you think of is this going to

be me for the rest of my life you need to think of the
good things about it so it is going to make you feel a lot
better.
Yeah yeah
Ok so if we just (erm) review again, (erm) finish

reviewing what we did last week, we came up with lots
of different thoughts that were going through your mind
so when you are in this situation where things are not
going to plan at work you want to go home, you cant get
motivated
Yeah
You are not really sure why you feel the way that you do
or what is going on and these and that makes you
behave in ways that where you start to worry about it,
56
cognitions
feelings
Feedback
Reviewing what was

completed in the previous
session.

moaning, you kind of withdraw and go into yourself
C
Yeah yeah
Ring your wife, think the worst of everyone and get

quiet short tempered.
Mmm
(erm) And then in your body it feels like your heart rate Feedback
increases your get kind of racing thoughts and hot and
that leads to feelings of jelousey so when you are calling
your wife you are wondering what she is doing, where is
she
Yeah yeah
Kind of feel empty inside maybe like something is

missing
Mmm
Can you relate to that?
That is me down to a t
Weve got that, ok so that is the depression side of

things
Right
So if we can maybe look at the anger and jealousy can

you think of any situations in your mind now that where
you have felt angry or jealous that you can talk about.
(erm) (pause) to be honest I have had a couple of jealous

thoughts lately but not to any extreme
Thats fine
Compared to what it has been
So would you prefer to talk about an extreme time or

one of the ones that you have had more recently, it is up
to you, you can decide
(erm) (pause)
What ones have caused you the most problems
(pause) loads
Try and maybe pin point a specific situation
Feedback
Feedback
57
Paraphrasing what the client

has said.
Repeating what the client

has said.
Asking the client if they

agree.

C
(pause) (erm) when someone at work (erm) said their

friend had slept with my wife
Ok
That caused a big problem
So the situation was someone at work (pause)
Said that there friend had slept with my wife
Ok
(pause) in what context was this was it in a jokey

context or was it that they had pulled you aside
No no no just said
So where were you
I dont know I cant remember now
A the time what thoughts were going through your mind
I dont know I didnt know weather to believe it or not
Right I dont know weather to believe this or not what

else
(pause) (erm) frustrated (erm)
Eliciting key
cognitions
Asking the client what

thoughts were going
through his mind at the time
of the identified situation.
Feedback

has said for clarity.
So that would probably be a feeling or emotion

frustrated so I will put that in that box (erm) what else
were you thinking at the time, how did you know you
were frustrated, what was going through your mind?
Eliciting
emotional
expression
Allowing the client time to

identify emotions
experienced.
So we have got I dont know weather to believe this or

not
Feedback

has said.
I dont know I was just angry I suppose
Ok so you felt the feeling of anger
And when you feel angry what do you think?
Eliciting key
cognitions
Paraphrasing what the client

has said to help them to
identify their thought
processes.
(pause)
Often when we are in these situations are minds are

really really busy and lots is going on you have even
58

said that you experience the racing thoughts
C
Your head is doing overtime
So you have to try and grab one of them and figure out
what is it that is going on, what am I thinking, (pause)
maybe even now if you think back and reflect on the
situation what do you think about it?
(pause) I dont think nothing about it, I dont think that

it is true
So it might not be true
Mmm
(pause)
Or it isnt true
Mm (pause)
What else is going through your mind
I dont know
It is quiet tricky to capture what is going through our

minds
I asked her weather it was true and she (erm) obviously

denied it and (erm) I dont know I didnt think that that
answer was good enough
Ok so your thought was the answers I am getting arent

good enough
Yeah
Ok yeah that is good
Its like disbelief
I dont believe her
Mmm (pause)
Ok so some of the thoughts that you have come up with

are I dont know weather to believe her or not, it
isnt true, the answers I am getting arent good
enough, I dont believe her. So it is kind of a mixture
of all the different things that are happening in this
intense situation, (erm) if you could think back to that
situation and the feeling of jealousy with 0 not being
59
Eliciting key
cognitions
Repeating the questions

asked to gain more detail
from the client.
Eliciting
emotional
expression
By asking the client to rate

their emotions it
demonstrates how intense
the emotion is currently and
at the time of the situation.

jealous at all and 10 being very jealous where would
you say that you are
C
10 yeah
10 out of 10 right
(erm) so you heard this news, somebody at work said

that there friend had slept with your wife what
behaviours did you do, what did you do in that instance
So you said that you asked your wife if it was true
Yeah it just played on my mind I didnt say anything to

them
So you kind of ruminated it
Yeah and it just played on my mind and played on my

mind and played on my mind and I was just going into
myself and brain had a shut down
So you kind of withdrew from everyone
And was just thinking over and over and over
Was you doing all this at work
Yeah while Im still at work I was just carrying on with

normal things because it really does my head in I just,
all this was going on in my head but I can still carry on
do my work and carry on carry on living a normal life
well it aint a normal life just going through the motions
of, of leading a normal life but deep down theres
something obviously wrong
Ok so you feel like there is something wrong
And is that something wrong with you or something

wrong with other people?
With me
Ok (erm) ok so thinking back to this situation (pause)

what did you do when you went home, what was your
behaviour?
(erm) a bit distant (pause) as though like I am picking

for an argument or
This is with your wife
60
Eliciting
behaviours
Identifying what behaviours

the client expressed in
response to his thoughts and
feelings.
Guided
discovery
Using specific questions to

get a deeper understanding
of the clients views.

C
Yeah yeah yeah
How did you tell her
I asked her weather it was true
What out right you just said this is what you have heard
Yeah yeah
And is this true
Mmm
And then what happened
She was obviously denying it and and er we wil go and

see the person and this and that so I said why involve
other people in their argument I want to sort it out
between us
Mmm
And erm she was going off her head and
And how did that make you feel
(erm) I dont know really just frustrated and mixed up

and (pause)
Ok what does mixed up feel like
Just not knowing what to think, weather it is true,

weather it is false so like its
Yeah that makes sense (pause) (erm) ok so we have got

quiet a lot of behaviours, we have got that you asked
your wife if it was true, you were kind of ruminating
with it, it was playing on your mind, thinking about it a
lot, withdrew from everyone else and quiet distant from
your wife and picking arguments with her. When you
had these thoughts that we have got and these
behaviours what was going on in your body, what did it
feel like?
(pause) obviously the heart racing again
Yeah
And feeling uptight and (pause)

61
Eliciting
behaviours
Attempting to identify what

it is they client did when
placed in situations that
made him feel angry
Eliciting key
cognitions
By asking the client how it

made him feel we were able
to get to a deeper
understanding of what was
going through his mind.
Feedback
Summarising what has been

said.

T
Anything else, anything else happening in your body
No no
Ok so I have been writing down a few feelings and

emotions that you have been saying as we have been
going along so you have got frustrated, angry, mixed up
because you are not really sure, not knowing what to
think really, have you got any other emotions or
thoughts going on with the jealousy?
Obviously angry but not in a violent way
What way is it?
I dont know I, just storming around and just trying to

show that I am angry and not happy
Ok yeah
But to be honest I just go in myself and dont speak and
Was there any sadness
Yeah obviously a lot of sadness I feel as though I am sad

a lot of the time and I dont know why just go in myself
and (pause)
Ok
(erm) when you came here you said one of the biggest
problems that you had was jealousy when is this the first
situation that you can recall being jealous
No there is loads
When was the first time that you can recall feeling like
jealousy was a problem for you
(erm) probably all through relationships with other

people paying attention to who ever I am with and
obviously them paying attention to them back and
obviously if it keeps occurring the attention I just cant
understand and it makes me feel jelous
So
It makes me, (pause) I dont know
Does this happen with your wife that you are with now?
Yeah yeah yeah
And did this happen before this situation

62

C
Yeah yeah yeah
So even before this situation there were times were you

were out and people were paying her attention
This has happened a few times yeah
So other people paying your wife attention
(erm) because the only thing I am quiet mindful of is

that this situation so someone at work saying that your
wife has slept with someone else, it would probably
depend on the context but it would probably be quiet
normal for you to be jealous of that situation
Yeah of course yeah
It depends on the context though so if it were maybe in

a jokey way not so much as someone confidentially
telling you a situation
Yeah yeah yeah
Do you remember anything about the context that it was

in?
No I cant remember not really it happened a little while

ago to be honest and I try not to think about it
So if we stick to like maybe other people paying your

wife attention rather than you does that happen now
(erm) er (pasue) I suppose it does like when she goes

out or what
Any times that you can think of
Yeah but sometimes it seems a little bit more, more I

cant put it into words
More prominent?
Yeah more prominent sometimes like obviously people

are going to smile at each other and just but sometimes
it tends to go on a lot more
Do you think it is going on a lot more or you are

noticing it a lot more
You are noticing it a lot more
Ok (erm)
But I say to my wife about it and she says there is

nothing there or she is not doing it and I dont know
63

why
T
So if you think of yourself in this situation, so you have

got other people paying your wife attention and she is
paying it back to them what thoughts are going through
your mind then
(erm) angry, hurt
Ok so they are the emotions, good
The emotions are that you are angry and hurt (pause)
yep, what are the thoughts what are you thinking at the
times, so you have got this situation where you feel like,
that your, there is somebody looking at your wife and
your wife is looking back at them, what is going through
your mind?
I dont know I cant really put my finger on it
You cant really put your finger on it, thats ok
So we have got your feelings as being angry and hurt

what when that happens what do you do, you said to me
that you speak to your wife
Yeah but she just denies it and then I question myself

weather I am reading more into it or I dont know
So you question yourself you might say something to

her, what sorts of things might you say to her
(erm) challenge her on, on the attention that she is been

giving someone else
So you challenge her, can you think of what you might

say?
No no
No
(erm) do you think that you would do it in an aggressive

way or not
Yeah probably a little bit aggressively
Ok and then what happens does she get defensive
Yeah yeah
Does that end up in an argument?
Yeah it just escalates and then just goes all up in the air
64
Eliciting key
cognitions
Identifying the clients

thoughts

and..
T
How does it disappear
(erm) just (erm) we dont talk about it and then just

blank it
So you kind of avoid it
Yeah avoid it
Ok so what would it mean to you if other people were

looking at your wife
(erm)
And she was looking back at them
In a way it is just being friendly but sometimes I dont

see it as that I dont know what I see it as
But what would it actually mean to you?
I dont know really
So imagine this situation were true, we are in a

situation, we are in a bar your wife there is a guy across
the room who smiled at your wife and you wife smiles
back, what does that mean to you.
(erm) nothing because obviously people are smiling but

if it keeps happening and I dont know it just
What is it about the situation that makes you feel uneasy
(erm) I dont know it could be that I feel a bit inferior

that I feel a bit (erm) I dont know
Yeah that makes sense, that makes perfect sense
(erm) do you think it is true that you are inferior?
No but that is probably the way that I feel a little bit I

dont know as though they have got something that I
havent, it looks like
Ok so they might have something that you havent
Ok so there is thoughts going on that they might have

something that I havent what if they have, what if they
have got something better than you. What would that
mean
65
Guided
discovery
Understanding the deeper

meaning behind the clients
core beliefs.

C
(erm) (pause)
They are quiet tricky questions
Mmm
Well they have obviously done (erm) well it all depends

if it is material or or I dont know or they are better
looking or whatever and that I dont know
What would it mean to you though
(erm)
So we have got that it might make you feel inferior

anything else
(pause) yeah I would just feel inferior to them, that is all

like just
Ok so imagine that you are in this situation where there

is a guy looking at your wife and your wife is looking
back at them, you feel inferior because of that situation
what does that say about you
That I am not comfortable in my own
So you dont feel comfortable in yourself or
Ye ye in myself in my own skin if you know what I

mean like
(pause)
Ok, how are you able to recognize this this so this feel
of inferior and this feeling of not being comfortable
when do you think that started? Where did that come
from?
I dont know I really dont know, I probably felt like it

for a really long time to be honest
So as a child or more as an adult
Probably more as an adult
Can you recall any situations that might have led you to
feel that way in the past other than the ones that you
have mentioned so far
Can you think of any
No
66

T
Not really
Thats fine
Ok so this belief of being inferior, feeling uncomfortable

in your own skin is that something that you feel all of
the time is it
No no just
Or is it in certain situations
Yeah probably in certain situations and I cant and thats

across the board not necessarily just with my wife its
probably dealing with situations and probably not being
able to answer or answering in the right way
Tell me a bit more about that, what do you mean?
(erm) (erm) somebody will say something and I should

have an answer and about five minutes later I have
thought of the answer but its probably too late
Why
Im probably a bit slow
Why should you have an answer?
(erm)
Is that a rule for living that you have?
No its just I feel as though I need to
So when somebody speaks to me I have to answer

them? Or I have to have the right answer
No no
What is it
Just I cant put my finger on it
Thats fine
If for example I asked you a question now and you

didnt have the right answer or you didnt have an
answer to give how does that make you feel
Erm ok because I know you will write about it (laugh)
(erm)
Guided
discovery
67
Identifying rules and

assumptions

T
So what is it about this situation and other situations that

is different?
This is, I am here for you to train me to think otherwise
Ok
And obviously I am going to make mistakes I am going

to be this I am going to be that and until I can grasp it, I
am not going to feel the way that I should do
Ok so it is ok in some situations not to have the answers
Yeah yeah
But the rest of the time you should do
Mm
Ok
My wife is really quick like we went to lakeside last

night (erm) went in a shop and I wanted to get a case for
my phone because (erm) I lost my other one and there
was a case there for 3.99 and I thought yeah I will get
that and I took it to the man and he said 6.99 but it was
priced up wrong and I challenged him and said it was
3.99 and er he said no they they are 6.99 when really
I should have had that or at that price because it was
priced up and I just said well if I wasnt rude or
anything I just said if it was 6.99 I wasnt going to
have it and I said erm goodbye and thingy and I said it
to my wife and she said oh you should have said this
and that but at the time I probably didnt think of it I
probably didnt want to be rude to him or thingy or try
not to be rude to him
Yeah
But thinking about it after I should have been quicker

but I wasnt
Ok so it sounds like that you felt like you should have
Yeah I dont know I felt a little bit silly and she will be
on the phone and will think quicker on her feet and
Some people are a lot more assertive than other people
Yeah
Which is definitely something that we can look at as

well
68

C
Yeah yeah
(erm)
And I think if I was a little bit better at that I could be a

lot happier as well
So maybe looking at some assertive skills
Yeah yeah
That is definitely something we could do, maybe we

could do some role plays on how we can get you to act
more assertively in certain situations particularly ones
that make you feel a bit uncomfortable
Yeah and I, I was thinking about it and thinking about it

and then I said oh I am being silly really, and this and
that and I tried to dismissed it, I mean I ended up buying
one at 6.99 anyway so it was just something and
nothing really do you know what I mean
Yeah
Ok well we can definitely look at that
Yeah
So if ok so just thinking about that situation quickly

what thinking back on it how would you behave
differently what would you have done
I would have said it is priced for that I should be able to

buy that at that it is not my fault it is your problem
obviously say that without being rude obviously get
your point across
So not aggressive not
Yeah yeah
Yeah just getting the point across, that sounds like a

good idea
I can be like that but I can probably sound aggressive
I think getting in between the line of being passive and

aggressive and then getting to the in between bit which
is assertive is really difficult
Yeah and I havent mastered that
I think it is a real skill
Conceptual
integration
69
Making goals and plans for

following sessions.

C
And I beat myself up over that to be honest and I think

about it
So that is another thing that you might beat yourself up

about
Yeah
What, when you think about not being able to be

assertive what does that make you feel? What does it
make you think of yourself
(erm) its silly really a bit stupid
So I am stupid
Yeah yeah
So its like I cant do that I must be stupid
Yeah yeah just putting myself down
Yeah ok so putting yourself down about it (erm) ok we

have come up with quiet, with regards to like the anger
and jealousy it fits really well with the depressed stuff
that we were doing last week it kind of all connects
together and links up because we get the feelings of
sadness when you do have these situations where you
feel jealous which can probably lead to acting in the
depressed ways that you do
Yeah yeah
And in the same sense you said that when things arent
going well at work you might call your wife and if she
doesnt pick up you get jealous which leads to the other
things
Yeah I try not to call her now unless I can be happy and
chatty and that because a couple of times I have spoken
to her and she has said oh (erm) saying oh youre her
being sarcastic and saying oh you have cheered me up
no end with her being all nice and chirpy but sometimes
we cant be chirpy all the time
Yeah we cant be happy all the time
And obviously it is nice to hear a friendly voice and like

and a friendly and understanding voice and like I try not
to give her a feeling that Im a little bit shitty and that
So you might try and avoid talking to her
70

C
Yeah and I try and avoid talking to her and just talk to
her when it is nice so it is a nice memory for her
To think about
Yeah to think about rather than just being all doom and
gloom
Yeah no that would make a lot of sense, I think it has

been really good for us to get to the core of some of the
beliefs that you have so you have all these different
thoughts and behaviours and feelings going on but the
reason why you are having those there always has to be
like a central point of where those come from and for us
I think today we have kind of come up with that you
feeling inferior in situations and you feeling
uncomfortable in your own skin and sometimes feeling
stupid in situations is probably where it routes from I
mean there is probably lots more as well
Yeah
But that is some of them, would you agree that is some

of them
Yeah yeah erm my left eye is been a problem from when

I was younger and I have got lazy eye and that really
plays on my mind like confidence
So because of your lazy eye what do you think
Erm I dont know I dont know as though people take

the micky out of me and like just I dont know I (pause)
Have they taken the mickey out of you for it
And then other times, yeah yeah and then other times I
can just dismiss it and just get on with it and not but this
is just I cant think
When people have taken the mickey out of you what

have they said
(erm) (erm) (pause) I dont know
Not really sure
Yeah I dont know or maybe it is just me being paranoid

or I dont know
So you cant really think of anything it might be you just

being paranoid
71

T
I will be honest I did not notice at all and I still cant

notice now
Yeah
So it might be you being paranoid or
Yeah might be yeah
You cant remember anything someones said
I spoke to my wife about it and she said dont worry it is

this and that I have even er gone to er gone to go private
to have it done but they said it is not bad enough for
some reason
Yeah
But obviously when I am tired or I have had a drink it

comes out more
Yeah ok but you havent had a drink still
No on Sunday no on Saturday we went out Saturday I

went out and had a couple of pints of shandy but I
wasnt drunk
What was it like to drink
(erm) it was alright we had a bit of a late night, I woke

up with a bit of a headache and that and to be honest it
wasnt very nice and I was thinking you know what I
am not really missing a lot so
(laugh) ok I think although you have struggled with the

homework. (erm) sorry is there anything you wanted to
add to this what we have been through so the angry
slash jealous situation we said that we had kind of got to
some of the core beliefs (erm)
(erm) just (erm) my wife had a lie detector test and

passed it but erm I still didnt believe that
Ok so you was it you who told her to have the lie

detector test?
Yeah yeah yeah (pause) it cost a lot of money as well
So she had a lie detector test, passed it and you still

dont believe that?
Well I didnt but I do and I dont know
You still feel a bit confused about it

72

C
Yeah yeah yeah
So sometimes you feel like you do and sometimes you

feel like you dont
Yeah and the fella that she even phoned the fella up that
done it but said the fella who done it is not going to say
its not because he has had our money and
So you are kind of doubting the situation kind of trying

to put a negative spin on that
Yeah yeah
I dont know
Thinking the man wouldnt tell you if it wasnt real
No course he aint because he has had your money and
So can people not be trusted
Yeah yeah
(erm)
Yeah I am not a very trusting person to be honest
So you kind of see others as people who cannot be

trusted
Yeah yeah
How do you view the world
(erm) I dont know there is a lot of wrongens out there

in my eyes but in other I see a lot of nasty things during
the day and a lot of things that people are doing and that
you have got to open your eyes but to be honest nothing
really shocks me because (pause) it dont surprise me I
just think thats just people thats just the society that we
live in
That is quiet negative but thats fine we can look at that, Homework
ok so I do want to ask if I will I have got an idea of how
we can set some homework that might be kind of related
to what we have done in the session today
Right so
I was thinking maybe you could write about how your

core beliefs affect the way that you behave, just a little
paragraph so some of the core beliefs that you came up
with were that you feel uncomfortable in your own skin
73
Discussing the homework

ideas with the client and
how they relate to the
session.

so if I put them on her
C
Yeah then I can relate back to them
Even if you can just bullet point it (pause) dont feel

pressured
Right
(laughs)
Dont feel pressured to write so much because I know

that writing is obviously not something that you like
doing
Yeah sometimes I can write a lot and then other times it

is just the bare minimum and thats it
(pause)
And I feel stupid so what I have done I have written

down some of your core beliefs there and what what I
thought would be a good idea is for you to look at the
ways that these core beliefs have affected the way that
you behave do you do you understand what I mean by
that
Yeah yeah
Have you got anything that you think might stop you
from being able to do the homework
Yeah that I cant be bothered
So motivation might stop you from doing it
Yeah
So what can we do to make sure that you feel more

motivated can we set maybe a specific time
Beat me with a stick (laugh)
I wouldnt be able to do that I am afraid (laugh)
So do you think we could set maybe aside a bit of time

for you to be able to find a bit of time for you to be able
to do it
Maybe if you could think of a day you might have less

on that you might be able to spend even five minutes
just thinking about it
74
Homework
Discussing any problems

that the client might have
with completing the
homework.

C
Yeah I can take time out to do it if I aint doing anything

I am just sitting watching telly
Ok so even if you think just five minutes of an evening

just have a reflect on what we have spoken about and
how that these beliefs that you have have affected the
way that you behave and just get those down because it
can really help us in erm the next bit that we do when
we are trying to look at your goals for therapy and what
it is you want to achieve
Yeah
And I think next week it would be a really good idea if

we can kind of put these two big pictures that we have
got together and bridge the gap and see how the
different problems relate to each other
Yeah does it all evolve from one thing or is it separate

things
Its likely to come from, I mean even now the core

beliefs that we have got we have three different ones
here so it is likely that a bit of this and a bit of that have
all resulted in the way that you are feeling now
Yeah
But I am more than sure that if we work together we can

get through some of these thoughts and feelings and
behaviours that you are having and the impact that they
are having on your life, we can
I can get frustrated indoors as I can get home and I have

got a lot to say and but I dont get a chance because I
cant I and then (pause)
so that sounds like some real assertive skills are really

going to be helpful for you
Yeah and when I do get a chance to speak I feel as

though I cant just bring that conversation in because it
doesnt
Flow
Yeah
Does it have to flow
Well no but it just seems a bit random to me because it

has just been going around and around
75

T
Kind of a bit like what you were saying at the beginning

of the session that it doesnt fit well I want you to know
that in here you are open bring up anything we can just
pop it onto our agenda
Yeah yeah
And speak about and find a place in our session to speak

about it because here we need to speak about all of the
things that you are thinking about
Yeah I have got loads of things going on in my head and

because I dont want to I dont know it seems though it
is weird like you talk about something and then you go
on about something else
Yeah
Or just coming in saying like a random thing I have got

a dog and like if it was it feels like that situation
Yeah but you know what that is ok right and we will

write that down right
Yeah
So you have got a dog and we will get to that
Yeah but I havent got a dog
Yeah I know that was just an example
Yeah its just obviously
How that impacts on why has that come up for you and
why is that a significant thing and we are able to look at
those things and we can teach you ways to be able to
open yourself out and be able to speak about that when
you are with your wife
Yeah
(erm) yeah so there is the dreaded homework
(laugh)
Is there anything that you want to ask about it, is there

anything that you think might make it difficult for you
to do other than your motivation levels that would make
it difficult for you to be able to do it
(pause)
No it is ok
76

T
No
No it is fine
Ok so todays session obviously we looked at some of

the reasons why you were not able to do the homework
which is fine that I know you said writing is sometimes
quiet difficult
Mmm
(erm) we looked at the previous session so all about the

depression situations where you felt depressed and how
that had impacted on your thoughts, your feelings and
your behaviours and then today we kind of looked at the
anger and jealousy side of things and different situations
with that and with that we were able to come up with
some of your core beliefs
Also I am doubting myself about being feeling mad

because the way I feel and like doing this but (pause) I
dont know like what is made I dont know
What do you mean by that
I dont know I dont know it is hard to explain
Yeah it sounds it
Yeah
What you mean you are doubting coming here or
No I am not doubting coming here but I have just I feel

as though I am mad like I dont know
That you shouldnt be feeling this way
Yeah yeah
I dont know but I cant really put my finger on it
Ok so you shouldnt really be feeling this way
No yeah
Ok
So that is probably a common feeling in this sort of

situation where you have got lots and lots going on
Yeah and there has been a lot of things (erm) going on at

the moment about mental health issues and Ive
obviously listened to them and this and that and I dont
77
Feedback
Summarising on the session

know I just
I think the reason that you are hearing so much about it
is because it is so common
C
Yeah yeah yeah even just watching the something

obviously 999 emergency the other night it was erm
they was dealing with mental health patients and they
are just sitting here taking loads of tablets in front of
them and they are hearing voices and I dont hear that
but I feel as though like because the way I am I feel as
though I am classed as the same as that person
Ok so there is a lot of stigma around it
Yeah yeah like that
I mean like it is the same as like when like if you look at

it in terms of criminals there is a massive long spectrum,
you see it as they are all criminals but then you could
see it as this person has done this to get out of what they
have done or they have finished their treatment so does
that still make them a criminal it is just the way that you
are looking at things
Yeah it is just the way that I interpret it
Yeah interpret the situation
Yeah interpret
(erm) there isnt there we cant get away from the fact
that there is a stigma around mental health
Yeah yeah
But
The nurses are definitely the ambulance staff are

definitely not trained for it and they shouldnt be put in
that situation to be honest its terrible
Yeah I mean we have come a long way but there is

obviously more that needs to be done as well
Yeah yeah yeah
(erm) ok so is there anything that you feel we havent

touched on today that you wanted to speak about
anything that we have missed out from the session, we
have kind of run through what we have done today and
we have really been able to formulate like get a real
picture of where we are so next week when we can feed
78

all that back we can start with some of the interventions
C
No after I have done my homework
Yeah after you have done your homework
Yeah ok so thats good.
79

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Student Number - 12240294

Coursework Submission Cover Sheet

Student Number: 12240294

Due Date: 10/02/2014

Programme: MSc Cognitive Behavioural Therapy

Module Title: Continuing With Clinical Supervision

Module Code: 0909

Assignment Title: Case Study 7HSK0024

Lecturer: Elizabeth Simon

Student Number - 12240294

Presenting the case............................................................................3

Rationale for the use of Cognitive Behavioural Therapy....................................5

Assessment and Measurement Tools.........................................................7

Problems and Goals.........................................................................18

Interventions and Summary of Treatment Offered........................................20

Appendix (On Separate Pages)

Student Number - 12240294

Presenting the case

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Table 1.1 Demographic details

Table 1.1 - Demographic Details

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3. Rationale for the use of Cognitive Behavioural Therapy

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5. Assessment and Measurement Tools

Table 1.2 Assessment Process

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Discussed scepticism towards Cognitive Behavioural Therapy.

SUDS to be taken from client.

SUDS to be taken from client

SUDS and psychometric assessments to be taken from client.

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Table 1.4 Becks Depression Inventory Results

Graph 1.1 Becks Depression Inventory Results

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Table 1.5 Novaco Anger Scale and Provocation Inventory Classifications

Table 1.6 - NAS-PI Results

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Graph 1.2 SUDS Results

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The initial part of the

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When a project at work

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Fig 1.2 Topographical analysis Anger/Jealousy

When someone told

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Cognition: Structure & Processes

Shout at wife / colleagues

Fig 1.3 Anger Case Formulation

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I dont trust my wife

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7. Problems and Goals

Fig 1:5 9 Box Model Problems and Goals

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What is she doing, Who

To be able to manage feel

Sad, Upset, Angry, Hot,

To be able to manage the

Shout at wife / colleagues,