Psychodynamic & Cognitive Behavioural Therapy Methods Applied

COUNSELLING METHODS – CASE STUDY

Psychodynamic & Cognitive Behavioural Therapy Methods

Applied

By Karyn Krawford 09/03

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Introduction

The psychodynamic group consists of four main therapies;

Freud's psychoanalytic approach, Jungian, Adlerian and Object

Relations. The therapist is focused on personality

reconstruction, gaining insight to unconscious motivations and

suppressed materials predominately relating to early

childhood. "The basic psychodynamics of the person are established early in life

during the stages of psychosexual development. The role of subsequent experiences

is determined by the motivational patterns established in early childhood (Mischel,

1971, pg.51).

The cognitive-behavioural group consists of four behavioural

treatment therapies; Behavioural Modification, Cognitive-

Behavioural, Rational Emotive Behavioural and Reality Therapy.

Behavioural therapists are concerned with the belief systems

and thinking process causing the dysfunctional behaviour,

which is treated through client's action. "Cognitive therapies

assume that distortions in a person's thoughts and beliefs (cognition's) can lead to a

number of mental health problems including depression and anxiety" (Robinson,

2000, pg.19).

I have prepared some perspectives of Richard who has been

referred to a psychotherapist after being convicted of drunk

driving. He is 25 yrs old, experiences high anxiety,

depression and has had suicidal thoughts. Additionally he

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cannot establish close relationships to others and is fearful

of certain types of women. He remembers a rough family life

and suffers from low self-esteem, thinking he is better off

dead which is what his mother used to say to him.

By assuming the role of the therapist I apply techniques from

each therapy most helpful to individual issues mentioned in

the case study. I have included points on the therapist's

character, as I believe this would determine the effectiveness

of the outcome, timeframe and application strength of each

technique used. In the conclusion I have put together main

points to explain my reasoning.

Application of Psychoanalysis to Richard

I would help Richard increase his awareness, gain insight to

his behaviours and understand the meaning of his symptoms. "The

term psychodynamic is a general term that encompasses those areas of psychology

which assume that we are driven by the content of our unconscious minds"

(Robinson, 2000, pg.81). This would be done by examining unconscious

processes and decisions made in early childhood to help

Richard see new alternatives and make new choices. "Using

therapeutic methods to bring out unconscious material; childhood experiences are

reconstructed, discussed, interpreted and analysed" (Corey, 2001, pg.87).

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I would encourage Richard to explore and experience his

feelings and memories. "According to psychodynamic theory, the basic

motives persist and press for discharge across diverse settings, but their overt

manifestations or 'symptoms' are transformed defensively. Hence the task is to find

the person's fundamental motives and enduring dynamics behind the defensive

facade and sure distortions of his overt behaviour (Mischel, 1971, pg.169)."

Adlerian Techniques

I would incorporate the Adlerian view of social and goal

orientated therapy. I would help Richard understand that he is

the creator of his own life that has been shaped by childhood

experiences and that his perception in his first 6 years is

influential of his current perception. I would focus on

inferior feelings and constant strive to obtain superiority.

Richard says people always leave him when he most needs them

and that he does not have what it takes to keep a wife.

Analysis: It is clear to me that Richard is feeling inferior

to significant people like his parents, wives and boss, that

he believes he needs these people, that they are better than

him. He displays a need to be superior and meet there

perceived standards causing further feelings of inferiority.

Information on these significant people and memories can be

determined

by using a questionnaire. "After these early recollections are summarised

and interpreted, the therapist aim is to provide a point of departure for the

therapeutic venture. This process is called a 'lifestyle assessment' (Corey, 2001 pg.

115).

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Alderian Therapy includes incorporating social interest,

community feeling and birth order.

To be happy and connect with others we need to feel a

belonging in society. Richard would need to master how to

relate to others, make a contribution, achieve intimacy, have

self-acceptance and develop a spiritual dimension. Encouraging

Richard to identify old patterns and act as if he was a new

person - the person he wants to be, would do this. Corey

(2001) explains the reorientation stage as the final stage in

therapy "This phase focuses on helping people discover new and more functional

alternatives. Clients are encouraged and challenged to develop the courage to take

risks and make changes in their lives" (pg. 124).

Depending on the birth order and sibling relationships, the

people in a family will experience the same environmental

upbringing but have different psychological situations. "Birth

order and the interpretation of one's position in the family have a great deal to do

with how adults interact in the world"(Corey, 2001, pg 133).

Analysis: Assuming Richard is an only child he may feel a

great need for achievement and drive, which is what he may

have been doing to try to please his parents and wives by

being a perfect husband and son. Only children may not learn

to share or co-operate with other children but will deal well

with adults who could be contributing to the disintegration in

Richard's close relationships. Only children are often

dependant or tied to parents. This would explain Richard's

need to keep a wife as he may be using her as a replacement 5

for his dependency on his mother. The same might apply to his

boss as a replacement to his father dependency. "The only child has

a problem of her own. Although she shares some of the characteristics of the oldest

child (namely, high achievement drive), she may not learn to share or cooperate with

other children" (Corey, 2001, pg. 113).

I would prepare a summary for Richard to read aloud in order

to discuss necessary areas and to judge his reactions.

Analysis: It could be that Richard is engaging in the

following;

• Over generalising by saying 'all people let him down'.

• False or impossible goals by 'being perfect father,

employee and husband'.

• Misperception of life and life's demands by believing 'it

is not possible for him to have a good marriage or good

relationship with other males'.

• Denial of his basic worth that he 'is unlovable,

incompetent and why would other want anymore to do with

him'. "Freud suggested that at any moment in time we are aware of only

some of our thoughts - our conscious thoughts". "According to Freud it is very

difficult, or sometimes impossible to become aware of our unconscious

thoughts (Robinson, 2000, pg.44).

• Faulty values like he 'must be a perfect husband, father

and employee or he will fail in life'.

Corey (2001) explains about summaries and integration. He

explains "it is useful for the counsellor to have the client read the summaries

aloud. In this way the client has the chance to discuss specific topics and to raise

questions. Also the counsellor can learn much about the client from hearing the

client read and observing his or her nonverbal reactions" (pg.122). 6

Anxiety

Anxiety is a danger warning and motivates us to action.

Richard is clearly experiencing a high level of anxiety by his

binges, drinking and other destructive behaviours. "Anxiety is a

state of tension that motivates us to do something". "When the ego cannot control

anxiety by rational and direct methods, it relies on unrealistic ones - namely, ego

defence behaviour (Corey, 2001, pg.70).

Ego Defence Mechanisms

Richard was referred to a therapist by his doctor for a

drinking problem he is not acknowledging. The Ego regulates

and controls personality to suit environmental needs.

Consciousness is controlled and impulses are monitored.

Defence mechanisms operate on unconscious level to help us

cope with anxiety. They either distort or deny reality. "In it's

(the ego) search for food or sexual release, for example, it must locate the

appropriate tension- reducing objects in the environment so that tension reduction

can actual occur" (Mischel, 1971, pg.32).

Analysis: Richard's ego is blocking reality from

consciousness by not accepting he has a problem with drinking

alcohol. "Denial is blocking distorting thoughts and feelings of pain". The result

is painful thoughts and feelings are being excluded from awareness. This is called

Repression. "Repression is one of the most important Freudian processes, and it is

the basis of many other ego defences and of neurotic disorders (Corey, 2001, pg. 71).

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Richard uses the word depressed as a way of justifying his

behaviour and disguising his true desire. This is called

Rationalisation, which is distorted logic reasoning.

"Rationalisation helps justify specific behaviours, and it aids in softening the blow

connected with disappointments" (Corey, 2001, pg.72).

Robinson (2000) explains defence mechanisms; "People use defence

mechanisms in very flexible and creative ways and it is not possible to predict which

defence mechanism will be used by a particular person in a specific situation" (pg.

28).

Projection & Transference

As a therapist I would say very little to enable Richard to

project past characters onto me and his feelings he had

towards these people who have been suppressed. "The main

characteristics of projective techniques are that they are presented as ambiguous

tasks for the subject; the purpose of the test is disguised, and the person is free to

respond as he wishes (Mischel, 1971, pg.96).

Richard says he has had three marriages which all ended with

his wives leaving him. I would help Richard explore the

relationship connection to how he felt about his mother dying

and leaving him and how that may relate to his current wives

leaving him. Fordham (1995), describes transference

recognition " ... if he could define what was taking place (in the client/therapist

relationship) this could be used as a basis for making interpretation of the patient's

material (pg. 128).

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Analysis: Richard made a decision in early childhood years

that all women will leave him resulting in feelings of

abandonment. He possibly acted out of unconscious decisions to

behave in a way to prove his theory true.

Object Relations

The word object refers to the significant other person, which

is applied to a feeling or drive. This serves to satisfy a

need rather than an individual. "Specifically people search for

relationships that match the patterns established by their earlier experiences. People

who are either overly dependent or overly detached, for example, can be repeating

patterns of relating they established with their mother when they were toddlers

(Corey, 2001, pg.83).

It is possible from this perspective that Richard did not

complete the separation phase from his mother, which is when

the infant does not see a separate self in the first 3-4 weeks

but as one whole merged with his mother.

People can be diagnosed, from this perspective, as either

narcissist or borderline personality disorders, depending on

which stage of the separation process they ended in.

Analysis: Richard displays much self-destructive behaviour

like drinking and binging. He displays anger at others

unjustifiably, is unstable with relationships and work, is

possibly irritable, has mood shifts affecting others, is

disillusioned by his life situation, lacks true identification

by seeing himself as hopeless, has poor impulse control by

attacking others, lack of understanding others and cannot

tolerate anxiety by using drinking to try to control it.

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Fordham (1995) explains "Identification leads to the formation of a secondary

character, the individual identifying with his best developed function to such an

extent that he alienates himself very largely or even entirely from his original

character with the result that his true individuality falls into the unconscious (pg.

63)”. He elaborates further that when a person sees an

alternative the morbid id is no longer unconsciously

supporting "It now has a disassociate effect, splitting the individual into two

mutually estranged personalities" (pg. 63).

The above behaviours and that fact that Richard has

experienced traumatic crises in early years and his mother has

withdrawn emotional support by dying, are all major symptoms

of borderline disorder. "Borderline and narcissist disorders seem to be

rooted in traumas and developmental disturbances during the

separation/individuation phase. However, the full manifestations of the personality

and behavioural symptoms tend to develop in early adulthood" (Corey, 2001, pg.85).

The three phases of treating this disorder is applied to

Richard using the following;

1. Richard's past memories and feelings about his mother

dying and his father abandoning him would be explored in what

would be a safe and warm environment. Freud explains how

childhood memories can be recovered through visual images,

dreams and removing distortion and displacement forces "In my

opinion we take infantile amnesia - the loss, that is, of the memories of the first years

of our life - much too easily; and we fail to look upon it as a strange riddle" (Freud,

1966, pg.86).

2. Relativeness of past would be linked to present awareness

of wives and boss abandoning him. Awareness of Richard now

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abandoning his family. Richard would acknowledge his painful

feelings and memories and those disassociated. We would

explore his perception change of how he saw himself, how he

saw his father and mother in the past and how he sees himself

and these people now. "When they lose (through death, rejection or

abandonment) such external objects, whom they have relied upon for ongoing

supplies of approval, love or admiration, they have lost an integral part of

themselves" (Mann, 1994, pg.46).

Richard would acquire new feelings and behaviours through this

awareness and acknowledgement. He would assume responsibility

for his current situation and actions through recognition of

emotional growth and past upbringing.

3. Richard would be given homework and encouraged to take

action by teaching him the meaning of these process so he

gains insight and understand and to maximise change from old

behaviours to new behaviours. This would lead Richard to

feelings of empowerment through achieving this.

Interpretation

I would listen for gaps and inconsistencies in Richard's

stories and make interpretations of his feelings toward them.

Some of Freud's theories include watching for mispronounced

words, forgotten names and slips of the tongue "Rather than relying

on peoples reports about themselves as accurate self-representations, he interpreted

verbalisations and overt behaviour as highly indirect, disguised, symbolic

representations of unconscious underlying forces" (Mischel, 1971, pg.30).

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Richard felt abandoned and unloved when his father left him.

Richard says he feels angry towards his boss firing him. There

may be a connection with the two relationships but

inconsistency in the way Richard feels which needs to be

explored.

Analysis: Richard possibly repressed feelings of anger towards

his father in earlier years and is projecting them onto his

boss. Richard is using anger to cover feelings of hurt and

abandonment towards his boss but which may not be acceptable

to his ego. Corey (2001) explains that in Freud's Phallic

stage theory "basic conflict centres on unconscious incestuous desires that a

child develops for parent of opposite sex and that, because of their threatening

nature, are repressed" (pg. 75).

Termination

Richard's sessions would be terminated when we both agreed

certain conflicts and issues are resolved. Richard would be

able to see how past history, particularly relationships in

this case are relative to the present, have developed

emotional awareness, has an understanding of his effect on the

environment and the environment on him and is less defensive.

Alderian Therapy recognises the importance of taking

responsibility and making choices. Corey (2001) says "human

behaviour is not determined solely by heredity and environment. Instead, we have

the capacity to interpret, influence and create events" (pg. 109). The therapist

themselves plays a major part in how long and how far the

therapy sessions go. "No analysis can take a patient further than he has

gone himself" (Fordham, 1995, pg.127). 12

Application of Cognitive Behaviour Therapy to Richard

Firstly, I would help Richard acquire a more realistic outlook

of life and how his faulty cognitive processes have led to

destructive behaviours in daily living. "To a large degree cognitive

behaviour therapy is based on the assumption that a reorganisation of one's self-

statements will result in a corresponding re-organisation of one's behaviour" (Corey,

2001, pg.297). The main focus is on setting goals and solving

problems rather than past occurrences by asking Richard to

identify his problems and then assist him with formulating

goals. I would help him view his problems from a more

realistic perspective that will increase his chances of

finding solutions to future problems. "Insight alone does not typically

lead to personality change, but it can help clients see how they have continuing to

sabotage themselves and what they can do to change (Corey, 2001, pg. 303)”.

Richard would be educated on the process of cognitive therapy

and how he could become his own therapist. Corey (2001)

explains how behaviour therapies are seen as an 'educational

process' because clients are given tools to learn how to

replace faulty thought processes with new ones. "They learn how to

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replace such ineffective ways of thinking with effective and rational cognitions, and

as a result they change their emotional reactions to situations" (pg.298).

Treatment of Depression

Richard has possibly turned angry feelings towards his

parent's inward after he was abandoned at an early age and is

focused on negative and unrealistic interpretation of events.

Corey (2001) explains Beck's theory on depression in three

components; a negative view, experiences are interpreted

negatively and accommodation of a negative future outlook.

"Beck (1987) writes about the 'cognitive triad' as a pattern that triggers depression"

(pg.315). From this perspective I have assessed Richard as

follows;

1. Richard displays a very negative view of himself as

hopeless and a failure. He has most likely blamed setbacks

and personal inadequacies without considering circumstantial

explanations such as having to rebuild his life after

dissolved marriages.

2. Richard is selecting negative facts to focus on and

conclude his negative perception. "Selective Abstraction consists of

forming conclusions based on an isolated detail of an event". "The assumption is

that the events that matter are those dealing with failure and deprivation" (Corey,

2001, pg.311).

3. Richard has a gloomy vision and future projections. He

may expect his future difficulties to continue causing failure

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into the future. It is likely Richard has screened out

successes that do not match his negative outlook.

Using this perspective, the techniques and methods I would use

are;

i) Bringing the tasks and activities Richard is good at and

positive strengths to his attention.

ii) Questioning Richard's activity level, as most depressed

people are inactive, withdrawn and tired. They believe

they will fail at anything they try. "Therapy procedures

include setting up an activity schedule with graded tasks to be completed"

(Corey, 2001, pg.316).

iii) Encouraging Richard to try some small activity first

which would bring him success because doing something is

better than doing nothing. "Some of the behavioural symptoms of

depression are inactivity, withdrawal and avoidance" (Corey, 2001, pg.316).

iv) Asking Richard to identify and provide reasons for self-

critical behaviour and then discuss how his language

could be changed. Corey (2001) explains REBT (Rational

Emotive Behaviour Therapy); "Clients who use language patterns that

reflect helplessness and self-condemnation can learn to employ new self-

statements" (pg.306).

v) Make use of role-plays and humour. "Clients can rehearse certain

behaviours to bring out what they feel in a situation". " .... counsellors employ

humour to counterattack the overserious side of individuals and assist them

in disputing their 'masturbatory' philosophy of life" (Corey, 2001, pg.306).

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vi) Asking Richard to prioritise a list of things to do so he

can begin accomplishing them. He can manage activities by

crossing off completed tasks and breaking them down into

units. This procedure will ensure Richard is not

exaggerating external demands, problems and pressures.

Corey (2001) explains how clients can magnify the

importance of their difficulties, "through rational exploration,

clients are able to regain a perspective on defining and accomplishing tasks"

(pg.317).

Cognitive Behaviour Modification

Richard displays impulsive binge behaviour, inappropriate

anger and has extreme mood swings. The process and techniques

I would use for this condition are;

1. Advising Richard he is contributing to his depression

by negative self- talk and imagery. "When they begin

therapy, their internal dialogue is characterised by negative self

statements and imagery" (Corey, 2001, pg.319).

2. Explaining to Richard he is not a victim of negative

thoughts or feelings. Discuss how he can become aware

of this through observing his actions, ways of reacting

to others, physiology, ability to listen to himself and

how he responds to others.

3. Helping Richard change his internal dialogue by new

self-statements and by keeping a diary of his thoughts,

feelings and behaviours that we would subsequently

evaluate together at sessions.

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4. Teaching Richard how to gather information on his

fears, what situations are particularly stressful and

then rehearse the new set of self-statements.

5. Evaluate preparation for stressful situations, ways of

handling a situation and perceiving it as a challenge,

how to cope with overwhelming feelings by doing

something useful to change them and giving him credit.

6. Teaching Richard relaxation techniques and help him set

a routine. Relaxation training according to Jarvis,

Tebbut & Mattick (1995), involves teaching procedures

of progressive muscle relaxation, meditative relaxation

and isometric relaxation. "In order to relax, your client needs to

learn to identify both the triggers that increase tension and the areas of

his body where the tension occurs". "Have your client consider which day-

to-day events cause increased tension" (pg. 112).

7. Homework assignments would be set to apply the above

techniques. Richard will be asked to write down these

assignments and the outcomes, which will be carefully

checked at each meeting. If he did not follow through

with them, we would collaboratively consider failure

reasons. This method covers three phases in this

therapy which are; self-observation, starting a new

dialogue and learning new skills. Meichenbaum

(1977) proposes that behaviour change occurs through a

sequence of mediating processes involving the

interaction of inner speech, cognitive structures and

behaviours and their resultant outcomes.

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Belief Systems & ABC Theory

Richard is currently experiencing feelings of anger towards a

former boss who fired him when he most needs financial

support. Questions I would use to help Richard examine what

might be a faulty belief system are;

1. Why he thought his boss fired him

2. How he categorises 'important men' and how they 'all' let

him down. Does he believe certain men who are considered

'important' be financially and emotionally supportive at

'all' times.

3. What specific ways have they let him down and why does he

perceive it an inconvenience. (Is there a more convenient

time people could let him down in future)?

4. Is it possible some bosses are different and there are

better jobs.

5. If things do not to the way he planned this time, is it

so bad or shocking? Would things always go 'so' badly in

future?

6. What is a 'good' wife and is necessary for him to do to

maintain a marriage or relationship. This area needs to

be elaborated further to find out why Richard believes he

'needs' to have a wife.

We would need to discuss how and what behaviours have

contributed to negative outcomes with others and what areas we

could work on changing to prevent further relationship

breakdown.

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Alcohol is clearly a major behavioural problem. Richard could

be engaging in negative self-talk automatically. "The thoughts that

lead to bad feelings or urges to drink or use of drugs often happen so quickly that

your client may be unaware of them occurring" (Jarvice, Tebbutt & Mattick, 1995,

pg.99).

According to Jarvice, Tebbutt & Mattick (1995), one way

Richard could become aware of his negative thinking is by

filling out a thought monitoring wheel describing the

situation, feelings, automatic thoughts that precede feelings,

then the positive challenge to counteract the negative

thoughts, outcome thoughts and feelings. An example is

provided in their theory on Cognitive Restructuring.

Methods would be determined by considering environmental

conditions and significant others. Corey (2001) explains ABC

theory of personality as A (the fact), B (person's belief) and

C (consequential reaction). "A does not cause C. Instead, B, which is the

persons belief about A, largely causes C, the emotional reaction" (pg. 300).

Richard would be capable of applying all his new skills and

behaviours in everyday life. Corey (2001) explains

Meichenbaum's evaluation; “Successful therapy involves clients being able to

develop their own voices, take pride in what they have accomplished and take

ownership of the changes they are bringing about" (pg.323).

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Conclusion

Psychoanalysis is a wide, in-depth area to discuss that I feel

restricted in covering all areas that could be applied to

Richard. Most of my ideas have come from Freudian but have

also incorporated Jung's view. I like the idea of 'luxury'

therapy as classical psychoanalysis is considered. Mischel

(1971) explains psychodynamic theory applications; "an exciting

feature of Freudian psychology was that it promised a methodology for at last

studying personality in proper depth and for treating complex human problems with

the sophistication they deserved" (pg. 168).

The obvious constraints and negative points one needs to

consider are the timeframe and expense involved. I think one

would also need to consider the therapists themselves as the

relationship is crucial to the effectiveness of the therapy.

For example in some psychoanalytic therapies a person is not

permitted to practice psychoanalysis unless there is

significant evidence of personal self-development. I think

Freud's theory was restricted by his environment, his own

self- analysis, women viewed as inferior and his own sexual

drives. Alderian therapy is more realistic and easier to

relate to in my opinion, I therefore select this as the

preferred therapy. Alderian therapy is easy to relate to and

more realistic in my opinion and consequently my first choice.

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It doesn't leave out the importance of the past yet

consistently incorporates work on the present.

Cognitive behaviour therapy is useful restricted to treating

certain cases in my opinion. One advantage is the therapist

themselves is not so important as a psychoanalyst is for

example, which means almost anyone can be taught the theory

and techniques. I think it would be most suitable for short-

term behaviour changes and best advantage is the examination

of belief systems. According to Corey (2001) REBT is known as

a brief therapy and can be learned in as little as one

session. There are effectiveness and methods have a scientific

formula to refer to. books, tapes and additional reinforcement

materials available to assist with backup. In Richard's case

I do not believe Behavioural therapy would be suitable as

Richard has some aspects of his past which I believe he needs

to examine and work through for a total change of character.

If Richard were treated only using behavioural techniques, the

trauma he has experienced in his past would most likely

surface again in the future. "Social behaviour theories contend that a

person is what he does". " ... there is no personality change apart from behaviour

change" (Mischel, 1971, pg.2S7).

Scientifically psychoanalysis theories cannot be measured or

tested except through self-analysis. Behavioural therapies

have the advantage that the effectiveness and methods have a

scientific formula to refer to. Considering humans are

capable of examining themselves from outside their bodies, it

is clear we are more than living cells and bone. Sometimes the

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most important things, like air that cannot be seen or

scientifically examined, are forgotten.

My knowledge is restricted to a small area of therapies

available to be able to predict exactly what is best for

Richard, however Alderian therapy is my choice for treating

Richard because it integrates past exploration and present

behaviours and I believe the therapist themselves would

determine the effectiveness of any therapy.

References:

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Corey, G. (2001) - 6th Edition. Theory & Practice of

Counselling & Psychotherapy. Brooks/Cole, CA.

Jarvis, T.J., Tebbutt, J. & Mattick, R.P. (1995) Treatment

approaches for alcohol and drug dependance - an introductory

guide. John Wiley & Sons Ltd, England.

Mischel, W. (1971) Stanford University - 2nd Edition.

Introduction to Personality. Holt, Rinehort & Winston. USA.

Fordham, M. (1995), Freud, Jung, Klein - the fenceless field,

essays on psychoanalysis and analytical psychology. Routledge.

London.

Sigmund Freud (translated by Tysan, A.), (1996), The

Psychopathology of everyday life. Penguin Books. London.

DiCenso, J.J. (1999), The Other Freud - religion, culture and

psychoanalysis. Routledge. London.

Mann, S. (1994), Psychoanalysis and society, an introduction.

University of NSW Press. Sydney.

Robinson, D. (2000), 101 Key Ideas, Psychology, teach

yourself. Hodder Headline Pic., London.

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