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Counsellor and Client Relationship Role Play

Paper Type: Free Essay Subject: Psychology
Wordcount: 4945 words Published: 8th Feb 2020

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This TMA is based on a role play.

Linda is a 27 year old woman who works in a very busy and stressful job as a Health & Safety Officer delivering training and presentations to the company’s employees and management, alongside carrying out risk assessments and fire safety checks. Linda recently moved in with her partner Jim who is a senior manager at the same company where Linda works. They both work long hours. The couple have been in a long-term relationship for 7 years. They have no children, but have talked about one day starting a family in their future. Linda was prompted to come to counselling at the suggestion of her doctor. Linda presented to her GP’s surgery complaining of an itchy rash covering her arms and torso, and of throbbing headaches at night and in the morning, low moods and feeling anxious. Linda said that medical tests showed there was no physical reason for these complaints. Therefore her doctor suggested that she work through with a counsellor the problems she was having in her life to help relieve the symptoms as they may be directly related to stress and tension. Linda was happy to do this as she stated she was very unhappy with how she was feeling and her attitude at this time and would try anything to help herself. She expressed how she had always been a happy, positive person.

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Linda is seeking one to one support as a private client with me using Cognitive Behavioural Therapy Skills. This was Linda’s first session of 10 and was a 45 minute session. This is a counsellor-client relationship. Linda has been having problems in her long-term relationship with partner Jim and stated that they seem to be spending less time together since she moved in with Jim. She explained that when they do get to spend time together they seem to be fighting the whole time. Linda is feeling depressed and upset; she is unable to focus in her job, feels worthless and has fears for the future with her partner Jim as she believes he is going to break up with her.

From my professional point of view and drawing from the work of Beck (1991) looking at the symptoms she’s displaying it would suggest that Linda may be suffering from anxiety. I feel that her feelings and anxieties around the relationship with her partner Jim could be a contributing factor on Linda’s current situation and the way she is feeling at this present time. She has stated that her and partner Jim’s jobs are not only very stressful and very demanding due to working long hours, but also they work at the same company not leaving much down time for them both. This would suggest that the added pressures at work could in some way be a contributing factor on Linda’s home life and we would need to visit this in our sessions together.

My rationale for selecting the below segment of the therapeutic interaction for analysis was to not only to show that by taking the client out of her current situation and putting her in another gave her a fresh pair of eyes, but it gave her the space to look at a situation in a different way. It demonstrates how maladaptive thinking can heighten a situation and lead to more stressful and negative outcomes. By doing this she understood that she could apply this to her own current situation and begin to help reduce her feelings and anxieties about it, by challenging her thinking and coming up with more realistic outcomes. 

In the segment I feel it shows a good use of Ellis (1977) ABC Model and how our thoughts, feelings and beliefs are linked.  It shows empathy and lets the Linda know that she is not alone and that her feelings and behaviours are not uncommon in situations like these. That our thinking can runaway with itself and maladaptive thoughts and behaviours do or can occur, but it is how we deal with those errors in our thinking that is key to how we manage situations and gives us more realistic outcomes. Drawing from the work of Rogers (1980) I feel that this segment demonstrates how using active listening skills and reflecting back to the client enables me to show that not only does it highlight to the client what she is really saying, but gives the client a sense of me  “the counsellor” knowing where she’s coming from. It confirms I understand her; I’m listening to her and again shows’ empathy towards her.

Counsellor:  I can see Linda that talking about this is very difficult and upsetting.  So how about let’s say……Have you ever been getting ready for work and say…. you had a important presentation to do that day, and go to get in your car and it doesn’t start?

Client: Yea!

Evaluation: I see that the session is stuck almost and upsetting. I’m attempting to take her out of her situation and change her focus. Giving her the room to breathe and calm down, but still focusing on a stressful situation, just not the current one.

Counsellor:  And at that point how did you feel?

Client: Um, really mad and really upset.

Counsellor: Do you recall what was going through your mind at that time?

Client:  Yea all sorts. Um, I need my car. I have to get to work. I mustn’t be late.

Thoughts of even getting the sack.

Counsellor:  Okay, and were you able to problem solve and come up with a solution, for your thinking “I need my car to start”, “I have to get to work” “I mustn’t be late” and thoughts of getting the sack.

Evaluation:  I wanted Linda to see the added stress and anxiety she was putting on herself just by her thinking, reflecting back so she knows I’m listening to her and to let her hear what she is saying. 

Client: Um, no…..Yea, well I guess I was just so upset and panicking that my car wasn’t starting and I needed it. I was unable to think about anything else.

Counsellor:  Yea I hear what you’re saying there, this is a totally normal reaction Linda, as our minds can start running off when we’re facing a stressful situation. Sometimes we make things harder on ourselves by thinking irrational thoughts and thinking the worst……

Evaluation:  This shows empathy by letting Linda know that she is not the only one that experiences this and it’s a normal automatic reaction.

Counsellor:  So, Linda in CBT we use a range of skills and tools and one of these is called the ABC model.  (A) is the activating event, which in that scenario would be the car not starting. (C) is the consequence that comes from (B) your beliefs………. that you could get the sack, that you needed the car to start. So do you think that it was the fact that the car didn’t start? Or, what you were telling yourself about the car not starting which caused you to feel upset?

Client: Um, I guess it would be what I was telling myself.

Counsellor:  And that was?

Client: That I needed to have the car to start to get to work.

Counsellor:  in this scenario do you feel you might’ve been able to think differently, maybe something more realistic that would cause you to feel less upset and panicky?

Evaluation: I’m introducing the ABC model and working through it, getting the client to revisit the scenario and letting her come up with more realistic thinking, reinforcing that by taking a breath she can think more clearly and reduce maladaptive thoughts and come up with more positive solution.  

Client: I guess if I wasn’t so focused on you know, my shit car, I could think about “Ok my car won’t start, now what am I going to do?”  I know call Dad, or just figured out another way to get to work; like order a taxi.

Counsellor:  Great! Do you see the way you’ve just given yourself options, instead of closing down and getting more stressed and anxious……

Client:  Ah Right!

Counsellor:  And you were able to get through the problem okay. Right!  So in that situation, you can see that it’s actually your beliefs and errors in your thinking that’s causing you to feel more upset.  And not because the car didn’t start (the activating event), and how the three are all linked; your thoughts, feelings and behaviour…….. Does that make sense?

Client: Yea, Yes I see what you’re saying…yeah

Evaluation: Again I am stating that by taking a moment to look at the situation gives options. This reinforced the links between thoughts, feelings and beliefs. I’m confirming that Linda understands and gets it, the model and the links.

Counsellor: Can you see how this could help, how you’re feeling about your current situation?…………

Linda’s initial assessment showed that she was having awful low moods, feeling stressed, anxious and has fears about her future and would benefit from seeing a CBT counsellor to work through these problems she’s experiencing.

Beck (1970) suggests cognitive behavioural therapy CBT can be used to treat individuals with a wide variety of psychological problems. CBT is founded on the concept that how we predict (our thoughts), how we tend to feel (the emotion) and the way we tend to act (our behaviour) are interlinked. Specifically, our thoughts confirm our feelings and our behaviour. Therefore, negative and unrealistic thoughts will cause us distress and end in issues (Beck, Emery and Greenburg 2005). Once an individual suffers with psychological distress, the approach within which they interpret things become disordered, that consequently has a negative impact on the actions they take. CBT aims to assist individuals to become conscious of when they build negative interpretations, and of behavioural patterns that reinforce the distorted thinking. Cognitive Behavioural Therapy helps individuals to develop other ways of thinking and behaving that aim to reduce their psychological distress.

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After going through the contract and the counselling process with Linda, I asked “what problem would you like to focus on today?” When Linda started to tell me, she became very distressed and broke down. I give her a tissue and offered her a glass of water.  At this point it was clear to me that I had to try and change Linda’s focus; therefore, I felt that the use of an analogy would be beneficial for Linda. Blenkiron (2005) posits that using an analogy with clients can somewhat reduce stress levels and give the client a different way of looking at situations as they feel less attached to it. By doing this I was able to introduce the ABC Model. The model was created by Albert Ellis in 1957 and was initially called the ABC Technique of Irrational Beliefs. It is now a major aid in cognitive behavioural therapy and widely utilised (Ellis & Dryden, 2007). Ellis believes that it is not the activating event (A) that causes negative emotional and behavioural consequences (C), but rather that a person interprets these events unrealistically and therefore has an irrational belief system (B) that helps cause the consequences (C). Using the ABC model was very effective as I was able to explain to the client in a non-complicated way, and she was able to understand it and follow it. When we examined her responses Linda was able to identify errors in her thinking and the maladaptive thoughts which were causing negative consequences.  Additionally, she was also able to come up with more realistic and rational solutions to the scenario which in-turn gave a lesser feeling of stress. Following on with the session we then set Linda homework, an “action plan”, as many clients take exception to the word homework and think of it as something they would have done at school. The action plan is a key part and not optional. Evidence shown by Conklin & Strunk (2015) suggests that clients who engage in homework have better outcomes than clients who do not. Hawton, Salkovskis, Kirk and Clark (1989) postulate that setting mutually agreed homework can help to reinforce what has been learnt throughout the session and can demonstrate the client’s commitment to meeting their goals. The homework / action plan we set in Linda’s session was the Daily Record of Dysfunctional Thoughts (DRDT). Beck, Rush, Shaw and Emery (1979) postulated that by using behavioural skills like the DRDT we can access our automatic thinking and train ourselves to identify our automatic thoughts, identify the effect these are having on our feelings and evaluate cause and effect in this process. The DRDT requires clients to record when something happens in the client’s life; an activating event which causes a negative or puzzled emotion. They are then required to state what was happening at the time of the event and their associated thoughts and images. Following from this, they rate how strongly they agree with the thoughts out of 10 before being required to come up with alternative explanations and score them out of 10. The client is asked to bring in their DRDT on the next session so that we can go through it together. This is not to show that the client’s underlying beliefs are either irrational or wrong, but rather Beck (1991) proposes that it’s to explore inferences particularly those that have arisen when emotions are strong, as he believes that these could be responsible for the client’s emotional distress (Beck et al, 1979). Looking at DRDT I will be analysing it for evidence of Beck’s (1988) 11 common cognitive errors.

After setting the homework I started to end the session by asking Linda for feedback. According to Janse, D Jong, Van Dijk, Hutschemaekers and Verbraak (2017) using feedback can significantly reduce the number of CBT sessions required and therefore can improve the efficiency of CBT. To do this, I firstly congratulated her for coming in, sharing with me the problems she’s having and the progress she had made already within her first session. Then I asked her questions to gain feedback from her; how did she think the session went? Did she feel she got something out of the session that was beneficial? Did she feel happier about coming to counselling and less apprehensive, now that she knows what it entails? I asked if maybe it’s less scary than she might have first thought? And does she feel okay?  I asked Linda if there was anything that’s bothering her, that maybe she thinks I didn’t understand? Is there anything she would like to see changed in future sessions? After gaining the feedback all that was left was to thank Linda again for coming in and congratulate her for the progress she made in the session. I then gave Linda the time, place and date for the next session, and expressed that I’m looking forward to seeing her next week and to keep up the good work by using her action plan/DRDT.

In the following section I will critically evaluate my overall application of CBT skills and the model I used in Linda’s first session by identifying and discussing the strengths and weaknesses of my approach.

From my first interaction with Linda I felt it was a good idea to build a good counsellor-client relationship. Different theorists use the terms “therapeutic relationship” and “alliance” interchangeably. Bordin (1979) differentiates between the therapeutic relationship from the therapeutic alliance by describing the alliance as being a relationship inside which both the therapist (the change agent) and the service user (person who seeks change) are at the core of change and must work conjointly in therapy. Every therapist and service user has valuable contributions to make to therapy, and conjointly the relationship may well be a partnership throughout, that each therapist and service user work on to realize the client’s goals. Bordin (1979) dispels the false belief of the therapist being viewed as a “magician” and advocates for the employment of the therapeutic alliance.

Correspondingly, many authors believe Hobson (1985) who states that the therapeutic relationship is what is crucial in any therapy. Yalom and Leszcz (2005) uphold that the connection is integral for any therapy to be effective and vital for service users. The therapeutic relationship between client and counsellor accounts for 30% of positive outcomes in therapy, as discovered by Lambert (1992). Duncan (2002) tells how therapists place such a great deal of stress on tools and technique, whereas the perception of how the service user views the therapeutic relationship is what is crucial to positive outcomes in therapy.

By letting Linda know that what she was going through was real it demonstrated congruence within the relationship. This is in agreement with Rogers (1980) who emphasized the importance of conveying respect to the client. Similarly, Ellis (1977) warns that clients can feel manipulated if they sense that the counsellor is making valued judgments on them. Taking both of these points into consideration I ensured I gave the client the space to show her emotions and tell her story to the best of her abilities via actively listening to her with an accepting ear, displaying genuine empathy with unconditional positive regard (Rogers,1977). Tursi and Cochran (2006) emphasized the significance of empathy; being warm, accepting and genuine is a key contributor to the success in the outcomes of CBT.  I feel in doing all these things and being a certain way with my client; like my body language being open, accepting and making good eye contact, goes a long way in establishing a good if not great relationship between client and counsellor. Research has measured the relationship between therapist’s nonverbal behaviours and variables thought to be related to successful therapy. For instance, increased therapist eye contact with a client has been found to be related to more positive perceptions of the therapist in terms of rapport, respect, empathy, and genuineness (Darrow & Johnson 2009).

In addition to ensuring a good rapport, I used the concept of agenda setting. This is where the counsellor and client sits down and sets out collaboratively an agenda for the counselling session. We looked at the presenting issues that Linda was having to enable her to then prioritise which of the issues she would like to work on within the session. Setting an agenda helps us both to be on the same page every time we meet and helps with focusing on setting goals during every session (Ramsay & Rostain, 2015).

An equally significant aspect of my approach and application of CBT during Linda’s session was how the interaction reflected the Triadic structure of CBT as postulated by Goffman (1986); Vanderstraeten (2001). This structure highlights the interactions which occur within all human encounters. During my session with Linda I applied this structure by beginning with an introduction to the session and myself as a counsellor. Following on from this involved a time of working together towards her goals and exploring her maladaptive thoughts. Finally, the third element of the triadic structure was the closing of the session which involved setting homework and gaining feedback from Linda.

Taking from my learning, I used Ellis’ ABC model with Linda as research has shown that clients who suffer from stress and depression could benefit from the model. This is done by demonstrating to the client that they may have errors in their thinking and have maladaptive thoughts which impact on their lives in a negative way. I noticed that Linda was using a lot of I must, I need, I have to statements. Ellis believes statements like these are linked with problematic thinking, maladaptive thoughts and behaviours, which can lead to emotional problems as they are extreme, rigid demanding and inflexible. (Ellis, Adrams & Adrams, 2009). Therefore, this would lead me to consider that Linda has errors in her thinking and is having maladaptive thoughts, which is leaving her feeling stressed and feeling depressed. Ellis had a distinctive way of pointing out the irrational thinking these words imply. He referred to our insisting that things be what we want them to be instead of what they are as musterbating and shoulding. When his patients would demand that something must or should happen in a certain way, Ellis would tell them that they were musterbating or shoulding on themselves. These particular plays on words help to emphasize the negative and self-destructive aspects of irrational thinking. When we musterbate and should on ourselves, we spend all of our time focusing on the negative events and we do not spend time to figure out what we can or cannot do about these negative events (cited in Primavera & Pascale, 2015).

One of the Strengths of using the ABC model by Ellis (1977) with Linda was that I found it easy to explain the model and principles to her. For that reason she was able to follow the model effortlessly and she made the connection between her thoughts, feelings and behaviours, and how they affect each other. I feel this is key factor to be able to challenge the errors in her thinking and for making positive progress. Furthermore, I used the DRDT (Daily Record Dysfunctional Thoughts) as Linda’s homework as this not only cements in the links between our thoughts, feelings and behaviours and the effect this has on the outcomes of her life but it also gives a platform for her on daily basis to challenge the errors in her thinking (Beck et al, 1979). Another salient aspect is that also it shows how committed the client is to changing their lives and the counselling process. Given the advantages of using a DRDT, by setting this homework for Linda it will enable her to challenge her dysfunctional thinking and is therefore a strength of the approach I have taken in the session. 

It is important to note however, that with this particular client I would have to say I was pretty lucky in the sense of Linda’s willingness and ability to embrace CBT counselling as she said she would do anything to help herself and she was told that counselling could help with the problems she’s having. Therefore, there was no resistance from Linda she is open to change and trying new ways in helping herself. This meant I was able to get straight on and start working alongside her to explore the problematic issues she is having in her life and guide her in working towards change. Another salient observation of the therapeutic interaction was that I might have inadvertently, at times, steered the conversation. Therefore in future sessions I will be more self-aware and make sure that the client comes up with their own outcomes.

In conclusion, I have based my counselling practice on the theories and models which were developed and expanded by Albert Ellis and Aaron Beck, and from my further reading. I feel that the CBT model that I applied was appropriate for the problem that Linda presented with and that my approach was both professional and facilitated a good client-counsellor relationship.

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