To solidify our learning and get an idea of how it is practically applied, it would be useful to take our knowledge of the three theories we have studied so far and apply it to a range of presenting problems. As I mentioned the last time we used these case studies (22nd November, when we were applying SMART goals to them), because the subjects are not people sitting in front of us that we can interact with, ask questions to and get answers from, it can be hard to really fully understand the situation, because we don’t know the full details of any of them. I do feel however, that now we have knowledge of some theories, applying them to the case studies does explain a few things that previously seemed mysterious and unknowable. I will explain further as I go through each case study.
Case Study 1 – Tom
Tom’s father (Des) died from a heart attack five months ago. Tom is 25 years old and has been estranged from his father for over five years.
His father’s death has had an unexpected impact on Tom, who finds himself exhibiting very intimidating and aggressive behaviour towards his colleagues and friends. Tom had always been very secretive and introverted so this is significantly out of character for him. He assumed that this behaviour is in some way connected to his father’s death but is not sure how to stop it.
Tom has not shed a tear over his father’s death and is mostly concerned for his mother and her grief. Tom’s father was a very intimidating man who ruled the house through a fear campaign. Despite this, Tom’s mother stayed by his side until the end.
Although Tom has not spoken with his father for over five years he has had moderate contact with his mother. Tom is by nature an emotionally withdrawn man, who has difficulty expressing his emotions – a consequence he has surmised form a childhood of not letting his father see that he’s hurt him or give him the satisfaction of seeing him cry.
In applying the Person-centred theory to this presenting problem, helping Tom examine his relationship with his father immediately sprung into my mind. This, I feel, is inextricably linked to him being a “withdrawn man, who has difficulty expressing his emotions”, and he is correct in his summation. He has experienced great incongruence throughout his life because he behaved in a way to please his father by withholding his emotions – clearly he believed that his father was his locus of evaluation. If his father was happy, or at least didn’t have to deal with his sons emotions, then Tom was a good and acceptable person. Because of this, he has no experience of how to handle these tough emotions, and he expresses them in a destructive manner.
A Psychotherapeutic approach would definitely revolve around exploring Tom’s childhood, especially with respect to the Oedipus complex. Upon his father’s death, Tom has seemingly developed the ego defence of introjection; he has almost become his father by acting in an intimidating and aggressive way. Maybe this could be explored with some transference – if the counsellor could present as Tom’s father, maybe he could have one more chat with “him”. This could represent him resolving the Oedipus complex – with Tom finally using the ego defence identification – to copy his father’s masculine behaviours, and become his own man.
Applying the CBT model to this case study reveals the following: The situation here is that Tom’s father has died. I would guess that that makes Tom feel sad he is gone, and maybe angry that they were estranged for the past five years. Sadness leads to listlessness, and the anger he feels would explain his aggressive behaviour – the physical sensations of anger building up in the body need to be released somehow. In this case, Tom is releasing them with anger towards those around him. Treating his loved ones this way could also make him feel guilty, as I don’t think he necessarily wants to hurt them. If they purposefully spend less time around him because of this, then that could make him feel they don’t love him, and make reinforce his feelings of not being wanted. If Tom were to see a CBT counsellor, then the sessions would concentrate on the here-and-now problem of Tom handling his grief by learning to process his emotions in a healthy way.
In this particular case, I think Psychodynamic theory would be the best way to help Tom. Exploring his childhood and his relationship with his father would hopefully resolve some of the issues that he has clearly held on to for a very long time, and is now unconsciously repeating. I do think that he feels a deep shame because he never saw his father for the five years before he died – it is often better to heal the wounds caused when families drift apart in person, but often it cannot be helped. It may well help him grieve for his father as well; I do feel like he needs to have a good cry. Better to let the anger, grief, shame, guilt and sadness out that way than through aggressive, intimidating behaviour.
Case Study 2 – John
John was devastated when he arrived at the hospital and was told it was too late to see his wife, Gayle. None of the resuscitation attempts had worked. John felt it was all his fault; he could have prevented this if only he had spent more time at home with his family rather than working all the time; he could have noticed the warning signs earlier and taken her to the doctor. He had worked so hard to give Gayle and Ryan (their only child) the lifestyles they deserved. Now he was left with no wife and a son he hardly knows. He feels extremely isolated and doesn’t know what to say to Ryan as he doesn’t want to make the situation worse. The last thing John wants is for his son to see him vulnerable.
John went to church occasionally when Gayle managed to convince him. He felt that his wife being taken away was a higher power trying to teach him a lesson about life.
John does not have many friends outside of his workplace and even those are more like associates. Gayle was his best friend.
I think that in applying the Person-centred approach to this case study, it highlights John’s need to be heard in this tough time. It’s always hard with grief. John and Gayle’s relationship has been dissolved because she died. John focused on his work to provide for his family, which seems admirable, but it’s only when he looks back does he realise that it was a mistake. Because Gayle is no longer there for John to explore these things with, he has to do it on his own. Or he would, if counselling did not exist. I think John would really appreciate the simple action of being heard. The counsellor’s unconditional positive regard would further reinforce his belief that he was doing what he thought was the right thing, and to not mope around for the rest of his life thinking about what could have been.
When it comes to a psychodynamic approach, I feel like this presenting problem would revolve around looking into John’s relationship with his own father and then comparing and contrasting it to his relationship with his own son, Ryan. I feel that it could also be useful to look at his parent’s relationship, and see if any patterns of relating that were present there are mirrored in his relationship with his wife in any way. Patterns do tend to repeat, and if John had always rationalised that he was doing the man’s job of providing for his family, that could well be what his father before him did. It would be interesting to see where free-association led in this case in relation to John feeling like it was a “higher power” trying to teach him a lesson about life.
I think the key in approaching this with CBT in mind would be to make sure John isn’t ruminating on the situation too much. I do feel like that instead of sitting at home all day going over everything in his head, action needs to be taken in this case. I think a homework assignment of doing some kind of father and son activity with Ryan would pay off immensely. It would help their relationship as well as help John realise there is more to life than work. This is similar to my suggestion when we were applying SMART goals to these case studies.
I think that a Person-centred counsellor would help John the most in this case study. He would benefit from being truly listened to. It would also help him to investigate the feelings he had around whether what he was doing was “the right thing”. We all think we’re doing “the right thing” in life, and at times we can even rationalise “the right thing” as something that is not morally right or even legal. John could also examine his ideas around whether Ryan, his son, should or should not see him as vulnerable. Maybe what Ryan needs now is to know that his Dad is just like him: a human, after all.
Case Study 3 – Jared and the Benton Family
Jared Benton is a 15 year old boy who has reluctantly agreed with his parents’ request to come to counselling because of his aggressive behaviour at home and at school. Jared’s Dad, Andrew, and stepmother, Melissa, are worried because his recent conduct at school has led to him being permanently excluded. Jared now goes out during the day and argues with his Dad and stepmother if they ask where he is going. He returns in the evening and spends time on his computer. If he is disturbed, he becomes very hostile and swears and shouts at Andrew and Melissa. Andrew feels that Jared has no respect for Melissa at all and is aware that Jared is less aggressive when he is home, although Jared still has frequent outbursts.
Melissa feels she has no control over Jared and is worried about being home alone with him as when he gets mad at her, he has started to lash out and throw things. Jared concludes that some of the aggression builds because his stepmother is constantly nagging at him to get off the computer and this puts him off his game.
The situation escalated at home a couple of weeks ago when Jared became so frustrated by his stepmother affecting his concentration on his computer game that he threw the console and broke it, amongst other things in his room. Jared was upset by this afterwards as he felt he had no control over his aggression and frustration and has broken valuable belongings that he saved for by working part time with his Dad over the school holidays.
Jared does not want to go back to school as he gets too annoyed at the teachers telling him what to do all the time.
Andrew and Melissa mention that he was never an aggressive child and only started being hostile a few years ago. They are extremely concerned about Jared’s future.
I think Jared would really appreciate the Person-centred approach, as I do not feel that his Dad, Andrew, or his stepmother, Melissa, listen to him. Jared could be suffering from any number of personal problems; he could be having issues with his friends and not want to go to school and see them, he could be being bullied and finds solace in videogames, or he could have been struggling with a certain subject at school. It seems that no-one has ever really asked Jared what the problem was, even though it has clearly been going on for some time, and has escalated. Being listened to in a safe environment and with unconditional positive regard would do him wonders.
Although saying that, maybe Jared does not know what the problem is, as it is buried in his unconscious. The fact he has a stepmother denotes that his birth mother and father are no longer together – for some kids this could be a devastating life event. Psychodynamic counselling could explore this. Jared’s id is clearly in control – seeking pleasure whatever the cost, even if it means breaking treasured belongings. Also, this is an interesting variation on the Oedipus complex – Jared may be acting out this way unconsciously in trying to remove his father from the picture, but because his stepmother is not his real mother, he may not be attracted to her, in which case the prize he is trying to win isn’t actually one he desires.
CBT focuses on the here-and-now rather than what may have happened to Jared and his family in the past, and I think getting those outbursts under control would be beneficial for everyone involved. Teaching Jared about how his thoughts, behaviours, emotions and physical sensations are all linked and can feed negative spirals would be a positive step towards changing his destructive and impulsive thought patterns. I think Jared may also be suffering from depression, as evidenced by him wanting to escape into his videogames, and I believe that some CBT techniques may help him with this as well. CBT wouldn’t change the past, no therapy would, but it would help the present be more bearable for both Jared and his family.
If I had to choose the theory that I feel would work best for Jared, I would have to say Person-centred. It seems to me that Jared does not like authority figures, so if a Person-centred counsellor could display unconditional positive regard, show genuine empathy and congruence towards him and truly listen to what he says, and encounter him as an equal, rather than a superior, I think he would open up. In fact, he may get even more from therapy when he realises that he is the authority on his own life, in that he knows himself better than anyone else does, and that he is totally in control of the direction Person-centred counselling would take.
Going through these case studies has made me notice a few things about the strengths and weaknesses of each of the theories we’ve learned about. A Person-centred counsellor can deal with most problems that are presented, as the theory is based around the client and their needs. Psychodynamic theory looks into the past at things like a client’s childhood dynamics and early memories, and how they shaped the client to be what they are in the present. CBT focuses on here-and-now problems and treats skewed thought processes like phobias and anxiety. Some may lend themselves to particular issues more than others but in general, all three theories are effective at treating a wide range of presenting problems.
For example, a common theme throughout all the case studies was that a person cannot change their past, but they can change their perception of it. They can reframe the events of the past to better understand themselves and work towards not letting those events define them as people. Rather, they become their own true self, and all three theories can provide this conclusion. Person-centred does this when the counsellor demonstrates congruence for the client to experience, which allows the client to come to terms with and be at peace with events of the past. Of course, it is obvious that Psychodynamic theory has this attribute at its core, a key aspect of it being based around unknown mechanisms formed in the past. And even CBT can help a client reframe their past, by using evidence-based exercises and cognitive restructuring, which is replacing negative thoughts with positive ones.
