Case example 1, Part 1

I’m going to give a few case examples over the next while, using the 5 levels already described to help illustrate the practice of Integrative CBT. The examples are, of course, fictionalised composites based on my clinical and supervisory experience.

The first example is "Richard", in his mid-thirties, single, a secondary school science teacher. There are obviously many different things going on in the therapy process, so the following are just some strands picked out from the imagined first few sessions, for illustration purposes. Richard came to therapy because he was feeling very depressed and was losing motivation and enjoyment, even for the job he loved. He had gone to his GP, who had prescribed antidepressant medication, but also suggested he try CBT.

Level 1:

Every client needs to first of all tell their story at their own pace, in their own way, and Richard especially so. He was very self-conscious about doing this, and kept saying how badly he was telling it, and how confusing it must be for me. I assured him it was fine whatever way it came out, that I was getting the information I needed, and that I would ask him anything I needed to know.

Despite this reassurance, Richard continued to be visibly anxious and restless during the first few sessions. In fact, he looked more anxious than depressed.

Level 2:

Richard had some immediate concerns which he was anxious to make decisions about:

Should he take sick leave, as his GP was suggesting?

Should he try the medication, or would this interfere with therapy?

Should he tell his parents about his situation, or would that just worry them?

These are questions which may have deep roots (especially the last one), but which also needed to be dealt with at a practical level for now, in order for the therapy to proceed. However, useful responses to them partly depend on a clear, agreed diagnosis, which may or may not match that made by the GP, who typically only has a few minutes with a patient.

Level 3:

As we discussed Richard’s current concerns in more detail, it emerged that what he felt most low about were his interpersonal difficulties. While he had always felt fine teaching in front of a class (until recently), he had never felt comfortable in the staff room, or going out for a drink after work. He had had some friends during his school days, but had been very socially isolated in college, and had remained so since. He lived alone, and his weekends were very lonely – he usually went to visit his parents, but otherwise had little social contact.

When we looked more closely at Richard’s specific cognitions, emotions and behaviours, it became clear that we were not just talking about shyness or lack of social skills. His anxiety was mainly about his belief that people thought of him as “awkward”, “stupid” and “pathetic”, and he tended to avoid much contact when in the staff room, busying himself with work.

This pattern clearly constitutes Social Anxiety (see last week’s blog), and this was very clear to Richard once he had a chance to read about the typical symptoms. Since research has shown that CBT can be very effective with Social Anxiety, we agreed to work on this over a few weeks and see how we got on.

Level 1:

Richard felt that his problems had been really understood for the first time, which strengthened the therapeutic alliance.

Level 2:

This diagnosis also had implications for Richard’s practical concerns above. First of all, it was becoming less clear that the primary diagnosis was actually depression – his gradual descent into low mood, low motivation and hopelessness might well be fully explained by his years of loneliness without hope of change.

We therefore agreed that he might discuss with his GP leaving the medication until he had tried some CBT – if it became necessary, we could look again at the medication option (which doesn’t necessarily interfere with CBT work, but can facilitate it).

It also seemed that sick leave might just feed his sense of isolation, and that therefore it might be best if we worked first on his dread about going into work.

This meant providing training in some basic anxiety management techniques, and suggesting to Richard that he practice them and see how they worked for him in coping with his daily anxieties.

Level 4:

We also discussed a bit about how these problems might have come about, though I explained that the CT approach would involve working on the current maintaining cycles before we would decide whether we needed to do much work on the underlying core beliefs.

However, we at least mapped out the territory at a basic level, identifying that Richard’s critical father and anxious mother, along with his own innate sensitivity, may well have left him with a fear of judgement by others, as well as a lot of doubt about his own ability to connect. More specifically, his main core beliefs could be along the lines of: “Nothing I do is ever good enough”, “people are critical”, “I’m different” etc.

Level 2:

We decided that the question about sharing his problems with others close to him was an important one, but that perhaps his parents were not the best people to start with. The only other person he felt at all close to was his younger sister, and he decided to share just a little of what was going on for him with her.

Level 5:

Gaining some understanding of Social Anxiety as a common human problem, teasing out some of its roots in his development, trusting some professional helpers and one family member with some of his concerns (none of whom reacted with shock or horror), all helped Richard to begin to humanise his painful experiences somewhat, even before much had been done to substantially change what was quite a deeply ingrained pattern.

Continued next week…