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Applying Theory in Practice

By the term ‘psychotherapy’, it is usually meant forms of therapies for emotional and psychiatric disorders. This form of treatment is based on talking and the relationship with the therapist hence has alternatively been termed as counseling. Therefore, planning counseling for a patient with complex problems is a dilemma. Which would be appropriate, expressive or supportive forms of dynamic psychotherapy, a cognitive-behavioral therapy, or a combination of all elements? The personal choices of the counselors have profound effects on patient outcomes.

It is a frequent situation in actual clinical practice when the therapists are known to deviate from the model they had initially chosen since within counseling, they began to perceive the necessity of a different approach (Olfson et al. , 2002). With improvement in knowledge, the approaches to therapy have shifted into the realm of ego psychology guided by object relations theory, self psychology, and interpersonal and relational models. These models are connected to one another and are applicable to adult functioning. Thus there are multiple psychotherapy models which may lead to better outcomes of counseling.

It has been demonstrated that integrative approaches may be of better therapeutic potentials in many complicated cases. In this case scenario, a demonstration of integrative approach has been made, which has been supported by evidence from literature. Scenario For ethical reasons and for the purpose of confidentiality, the identity of the client will remain undisclosed. The client is a 39-year-old woman of Asian origin. She is married and lives with her husband. They have three children, and the eldest is a daughter of 17 years of age.

She is followed by a 16-year-old brother and a 14-year-old sister. While seen in counseling, the client is well-dressed, apparently overweight. She avoids eye contact, wriggles on her chair, and speaks rapidly. When asked about her problems, she states she is of late feeling very unhappy and anxious. She reports difficulty sleeping with break in the continuum of sleep, and as a result, she wakes up several times in the night. Along with that, she has frequent headaches, feels anxious, and even sometimes feeling dizzy. The client thinks she is depressed.

She has noticed she tends to cry easily over trivial matters. Along with that, she feels down a lot lately. She has noticed that she eats too much lately. Background She was married at the age of 19, and her husband was her first serious boyfriend. She was the eldest of the three children in her paternal family. Her father was somewhat distant, and sometimes, he used to be authoritarian and rigid. Her mother, on the other hand, was always critical about her. When asked specifically about this, the client remembers she would never be able to please her by anything.

As a child, she does not remember having fun and always hoped to please her mother by taking the role of caring her siblings. With this background, her current psychosocial history becomes relevant in that she was a stay-at-home mother caring for her children until they became adolescents. Once they grew up, so that she could leave them at home, she entered the University part-time to complete a teaching degree that she wanted to pursue. She has completed that, and she would now need to find a teaching job to obtain registration.

She is afraid that now her situation will be more complex than before. She is frightened to face the new scenario where she will have to create a balance between her three roles, teacher, mother, and a wife. She is anxious as to how she would be able to cope with the reality when she actually gets a position in teaching. This would mean she will have to move beyond her home into the workforce, and she wonders how her family would cope with this kind of change. She is now trained as a teacher, but she is not sure whether she is on the right path.

She is anxious and afraid that she might fail. Her husband is not very keen on her joining the workforce. He appears to be revisiting her decision to make changes and wants to keep a status quo. She is obviously in a dilemma as to which course to pursue. She does not want and does feel afraid to challenge him too strongly, if she “ends up being alone. ” Due to her recent frequent occurrence of symptoms such as broken sleep and feelings of panic and anxiety, she has consulted a doctor, who found no physical causes pertaining to her symptoms.

Obviously, the problems in this client are depressive and anxiety disorders. As is expected, in this client, these are bound to produce significant and substantial morbidity in this client over a period of time, unless intervened. In order to provide appropriate care, while counseling, it would be pertinent to establish a therapeutic relationship and rapport with the client. Evidence suggests that the quality of the relationship between the psychotherapist and the client that develops in the first interview may have really very important influence in the outcome (Bond and Perry, 2004).

The skills that are involved include acceptance, empathy, and attending skills. It is important to share identical values between the client and the counselor (Rogers, 1980). Although shared language, culture, and religion have been noted to be important, there was no such barrier noted in this client. As indicated in the scenario section, a systematic interview may help to reach a diagnosis. The client did not have any health problems. Although this history does not suggest the presence of any other psychiatric diagnosis, it is important for the counselors to make a diagnosis.

This needs a diagnostic interview (Bains, 2005). For example, syndromes such as phobias, compulsions, delusions, and hallucinations if recognized may be effectively treated by psychotherapy, whereas unstructured assessment interviews may not be sufficient to diagnose them. This patient had evidently depressive and anxiety disorder which are having substantial impact on the functioning and quality of her life. The National treatment guidelines for these conditions comprise cognitive behavioral therapy and interpersonal psychotherapy.

Although the literature in this area of study is not developed yet, research supports the efficacy of such treatments. In panic disorder, the efficacy of cognitive-behavioral psychotherapy has been strongly supported. While administering psychotherapy, it could be logical that an integrative model be used for the treatment of the anxiety disorder of this patient. It is important to know how this patient developed and maintained her emotional problems.

This client’s problems may be formulated in psychodynamic terms, but the therapy or counseling is expected to yield to the own experiential search and processing of the client, and this according to Rogerian principles must occur within the confines of a safe and nonjudgmental therapeutic relationship (Horvath & Greenberg, 1994). It has been argued that this approach is beneficial in some patients, but in many others, the benefits may be limited. It may be assumed that anxiety somehow becomes conditioned to the phobic concept, and the client ultimately gets habituated to the experience of anxiety through repeated exposures.

There is also an element of imaginal exposure, and this could lead to repeated images of the anxiety state through the experience of extremely painful emotions. This would place the client in a powerless position, either in a state of humiliation or harm. These may be manifestations of long forgotten trauma in the client’s history or these may recapture or contact previously contacted prototypes that used to symbolize the client’s senses of helplessness, powerlessness, or doom that had been originally experienced by the client much earlier in her life (Barlow, 2000).

The client’s history will support this. The confrontation with the situation would lead to very high anxiety. If the client is able to experience the anxiety, the anxiety eventually would lead to a variety of emotions, rage, humiliation, shame, hopelessness/helplessness, and despair. It is through such experiences, the client would come to realize that anxiety may function as a variety of feared emotions, which may be frightening and painful.

Rogerian client-centered approach talks about empathy, genuineness, and unconditional positive regard as the three conditions necessary and sufficient for a therapeutic change. This theoretical framework is considered to be the structural foundation of many counseling scenarios. This approach would definitely recognize that the frightening and painful emotions that a client experiences are the media through which the client ultimately would come to realize that anxiety functions as a signal or an alarm of emotions which have embedded meaning and can be threatening.

When the experience of this meaning and its related explorations are complete, there is high probability that anxiety would disappear. This particular client found her depressive sorrow to be painful as the anxiety associated with it. Her anxiety signaled the depressive sorrow to be surfaced, and this was a feeling for which he had no tolerance. These are clinical observations which may be predicted on the client’s being able to explore the implicit meaning her in-the-moment anxiety and its somatic expressions. Many patients are unable to experience this anxiety directly.

It has also been observed that anxious people tend to shift their attention away from the immediate experience of anxiety to more distant foci from the perceptual point of views leading to a thought on implications of being anxious. This has been referred by some as cogitation since the person may start obsessively think about anxiety, leading to enhancement of the level of anxiety further. In the literature this has been termed as anxiety sensitivity which may ultimately prove to be self-focused attention that may capture the experiential stance that is distant perceptually.

Roger’s approach gives a full acknowledgement to organismic experiencing. According to some authors, it is the most important and fundamental construct in the person-centred approach. From that perspective, the primary intention of the counselor would be to facilitate the client’s being in close proximity to her body. The theory of personality in counseling attempts to find out the basic units of personality and the factors that energize and direct human behavior.

It also looks into the mechanism of development of personality and how the personality becomes dysfunctional. These elements pertain ultimately to structure, motivation, growth, psychopathology, and changes related to personality. While talking about experiencing of a client, it includes all sensory experiences both symbolized and unsymbolized at respectively conscious and unconscious levels. Thus it becomes necessary to treat both surface symptoms her anxiety and the underlying conflicts and beliefs that may potentially drive the state of disorder.

Thus an initial symptom focused management strategy with a subsequent intent to help patients explore, allow, and process the painful emotions which may drive the emotional state. In any etiological model, there may be factors involved in any condition which are common in psychodynamic, cognitive-behavioral, experiential-existential, and biomedical models for the anxiety and depressive state. The common factors may serve as the constructs that may form the foundation of an integrating etiological model. Anxiety provoking disorders may be based in troubled self-perception and experiencing.

Every such disorder is based on troubled self-perception and related experiences with a sense of danger or imminent catastrophe. Like any other patient, the client in this scenario also has specific unconscious catastrophes that she dreads, which are attended by unacceptable painful emotions. If this is called self-endangerment, at the level of the conscious, this would be characterized by a sense of lacking safety, feeling powerless, and losing control. This would involve both immediate anxiety and cogitation about its implications on self.

Therefore, there is a shift of attention automatically, and the individual thus fails to discover the preconscious meaning of this state of mood. Implicitly, the client anticipates a confrontation with a severely painful view of self, which when exposed may lead to pain. This leads to a chronic struggle with an individual subjective experience. These can basically be organized painful experiences related to self or replication of memories related to such. These painful views about self may also be specific memories of previous experiences as in this client.

The client, however, is afraid of both the meanings of the views of self and also the accompanying emotions such a humiliation, rage, and despair. These self views may be predominantly unconscious but would definitely influence the actions, feelings, and decisions of the clients (Ingram, 1990). The external and internal factors that provoke anxiety are known to develop through certain life experiences and fears associated with these. These internal factors may as well stem from the painful memories beyond the conscious awareness. These relate to both physical and psychological survival.

Physical fears are expressed in the form of physical symptoms, but psychological fears are those of being unlovable, beings abandoned, unworthy, unacceptable, isolated, rejected, weak, dominated, pathetic, humiliated, or controlled. All these may culminate into a dread with a sense of impending loss and destruction of the meaning of life. The goal of psychotherapy is to build trust on the client’s own life; acceptance of the personal responsibility for own thoughts, feelings, or actions; and acceptance of the inevitability of loss of loved ones, relationships, careers, or physical capabilities (Elliott, Greenberg & Lietaer, 2003).

The model which is being discussed here attempts to synthesize elements from psychodynamic, cognitive-behavioral, and experiential therapies. In this model, the ultimate or intermediary treatment goals are defined. The core intermediary goal would be the resolution or reduction of symptoms of anxiety disorder with the ultimate goal being healing of the self that generated the symptoms of anxiety or depression.

The other subsidiary goals of the counseling may be enhancement of self-efficacy of the client, enhancement of tolerance of individual emotional experiences, particularly negative effects, identification and modification of various affective and cognitive defenses that the individual erects against the emotional experience. All of these may help restructuring of the client’s toxic views of self leading to increment of the client’s ability to engage in authentic relationships. These are built of the premise that increased ability to tolerate painful affects would result from reduction of anxiety.

This can be, in therapy, achieved only through a focus on the client’s direct and in-the-moment painful experiences. In this way a sense of control over the symptoms will be accomplished, following which the client could be invited to explore the determinants of her symptoms. As has been mentioned earlier, the beginning would be difficult in the form of building a therapeutic relationship because of the self-protecting interpersonal styles of these patients (Beitman, 1992). As is evident in her life history, there are stories of betrayal, empathic failures, mistreatment, and difficulties with attachment.

Thus it becomes very important to negotiate the trust. The attempt at repair of self begins through buildup of trust on the therapist and self. Usually by the third or the fourth session, the client may be ready to begin the phase II targeted to alleviation of symptoms with the primary focus being on achievement of control over the symptoms. Cognitive-behavioral interventions are in the ascendency during this phase. Thus, relaxation strategies and cognitive restructuring of thoughts surrounding these stimuli may be the areas of interventions in this phase of treatment.

The therapeutic alliance must be monitored in this phase of intervention. When some control has been achieved of the symptoms, in some patients, the therapy stays complete. In some patients, however, it becomes necessary to explore the roots of these symptoms. This needs a shift of therapeutic focus and technique with the goal to elicit the tacit self, the feared emotions, and the causes for all of them. Wolfe focusing technique leading to imaginal exposure may be suitable for such purpose.

In this technique, the client is first instructed to relax and to engage in diaphragmatic breathing for 2 minutes (Barlow & Wolfe, 1981). While inducing, the patient is told to allow her to be open to thoughts and feelings during the exercise. Subsequently, the patient is instructed to focus on the anxiety provoking thoughts. Conclusion There is a range of approaches for effective and compassionate patient care, and applying these approaches, schools of thoughts, and theories in psychotherapy practice can be sometimes extremely painstaking even for the most experienced and seasoned practitioner.

In the actual setting of clinical practice, there is, however, the need for a synthetic approach to psychotherapy which can integrate all theories toward the direction of patient care. It is however easy to talk about any integrative approach, but conceptualization of the same in the clinical setting, in a given case scenario is usually abstract, and no single framework is available that can incorporate all methodological approaches. The main approaches in the field of psychotherapy include psychodynamic, behavioral, cognitive, humanistic, multicultural, and systemic.

It is to be acknowledged that there has historically been rivalry among theoretical orientations, where clinicians used to use in practice their own personal theoretical frameworks. This would invariably lead to a blinding attitude to any other alternative conceptualization that could lead to potentially superior interventions in psychotherapy. As has been evidenced in this assignment, a synthetic approach involving different theoretical methods may be better while counseling for some specific conditions. Reference List Bains, J. , (2005).

Race, culture and psychiatry: a history of transcultural psychiatry. History of Psychiatry; 16: 139 – 154. Barlow, D. H. , & Wolfe, B. E. (1981). Behavioral approaches to anxiety disorders: Report on NIMH-SUNY, Albany Research Conference. Journal of Consulting and Clinical Psychology, 49, 191–215. Barlow, D. H. (2000). Unraveling the mysteries of anxiety and its disorders from the perspective of emotion theory. American Pychologist, 55, 1247– 1263. Horvath, A. O. , & Greenberg, L. S. (1994). The working alliance: Theory, research, & Practice.

New York: Wiley. Beitman, B. D. (1992). Integration through fundamental similarities and useful differences. In J. C. Norcross, & M. R. Goldfried (Eds. ), Handbook of psychotherapy integration (pp. 202–230). New York: Oxford University Press. Bond, M. and Perry, JC. , (2004). Long-Term Changes in Defense Styles With Psychodynamic Psychotherapy for Depressive, Anxiety, and Personality Disorders. Am J Psychiatry; 161: 1665 – 1671. Elliott, R. , Greenberg, L. S. , & Lietaer, G. (2003).

Research on experiential psychotherapies, In M. Lambert (Ed. ), Bergin & Garfield’s handbook of psychotherapy and behavior change (pp. 493–539) (5th ed. ). New York: Wiley. Ingram, R. E. (1990). Self-focused attention in clinical disorders: Review and a conceptual model. Psychological Bulletin, 107, 156–176. Olfson, M. , Marcus, SC. , Druss, B. , and Pincus, HA. , (2002). National Trends in the Use of Outpatient Psychotherapy. Am J Psychiatry; 159: 1914 – 1920. Rogers, CR (1980). Client-centered psychotherapy. In HI Kaplan, BJ Sadock, and AM Freedman, Comprehensive Textbook in Psychiatry (2153-2168). Baltimore: Williams and Wilkins

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