CBT and Person Centered Therapy for Depression

Case Conceptualization and Treatment Program
Part I: Client Conceptualization
General Background Information of Client
Jake is a 45 year old single white male. He has a degree in engineering but struggles to hold a job for longer than a few months because he is an alcoholic and inevitably shows up for work one morning drunk and is dismissed. He has good people skills and passes interviews easily and well, which is why he has very little problem finding new employment in spite of his employment history. The problem is that he cannot remain sober. He also has an addiction to marijuana. He is tall and well-groomed and in overall good health aside from his addictions with substance abuse. He is also a devout Catholic and feels that his faith is very important to him.
Client’s Presenting Concerns
Jake’s primary issue is combating alcohol addiction. He does not want to stop using marijuana as he feels it helps him with his nerves. He has been using marijuana since he was 16.
Deeper problems are Jake’s issues with responsibility. He talks quite a bit about his faith, about settling down, finding the right woman, and starting a family. However, he also fears that he may have missed the boat on this. He still dreams of being a musician and laments that his authoritarian parents did not encourage him to be an artist but instead pressed him into engineering. He is happy as an engineer and proud of his accomplishments, but at the same time he feels the need to self-medicate quite a bit with alcohol and marijuana. Whenever he gets a new job he always fears that people there are out to sabotage him and he has some paranoia over this.
Jake does recognize a need for change but the change he is proposing is, while not superficial, incomplete. He wants to stop drinking as much as he does—but he is not willing to give up alcohol altogether; nor is he willing to stop using marijuana. It appears that there is some trauma related to his childhood, as he has mentioned that his father abused him physically (not sexually), and when Jake was 20 he did attempt suicide. However, when he drinks through the night he begins to call friends and tell them that he wants to kill himself. One friend has recently tired of this and called the police on Jake. Jake was shocked and instantly showed more self-control. Nothing came of the incident, but it was something of a wake-up call to Jake. He lost his job the next day, as he showed up for work drunk. That also added to the wake-up call.
Behavioral Description
Jake is:
· Outgoing
· Friendly
· Proud of his accomplishments, which he enjoys talking about
· Nervous
· Negative at times without ability to shake negative thoughts/feelings
· Concerned about his alcohol addiction
· Worried about his state in life—single, unmarried, no children
The behaviors that are in need of change are his dependency upon alcohol and his tendency to let negative thoughts and feelings undermine whatever positive direction he is heading in.
Affective Manifestations
Jake reports experiencing:
· Depression
· Anxiety
· Negativity
· Paranoia
· Hurt when people seem out to get him
Unspoken emotions that Jake is not verbalizing and does not seem to be aware of are: anger, neediness, insecurity, fear, sensitivity, egoism.
Needs the client has that are not being met include the need to feel supported emotionally and socially, the need to be fulfilled creatively and work-wise, and the need to love and be loved in return. He is prevented from attaining self-actualization because he feels there are roadblocks that keep cropping up, preventing him from happiness. He recognizes that some of his behaviors are self-destructive but he does not seem to be aware of the extent of the dangers.
Cognitive Patterns
Three irrational beliefs in regard to Self, People, Problems and Life are:
1. Self:
a. believes he is extremely talented;
b. believes he is often slow at his work and that people get frustrated with his pace;
c. believes that people try to hurt him because they are jealous
2. People
a. believes people cannot be trusted
b. believes his friends love him
c. believes he wants to help others and can by talking to them about religion
3. Problems
a. believes his problems are his own fault
b. believes his problems are not his own fault
c. believes the devil is often trying to trip him up
4. Life
a. loves life
b. believes life to be too oppressive and often wants to get away
c. believes life is passing him by because he is unmarried and has nothing on the horizon
Jake’s general thought patterns are scattered, obsessive. Jake is both impulsive and restrained. He will do seem open to doing anything at the slightest suggestion so long as it is not what he would see as sinful—but if there is some hint of danger or impropriety he might refrain, or he might just begin to second-guess the initial impulse and back away from doing anything altogether, retreating into familiar areas in which he is comfortable—being alone, drinking, playing music. However, he is aware that too much of this is bad for him because he begins obsessing over the ones that got away andd so on. When he gets into a negative space in his head it is very difficult for him to move on from this. He will obsess over negative ideas and past injuries that he feels he has suffered unjustly from others.
Interpersonal Patterns
Jake interacts well with other people. Jake is very outgoing, friendly, polite and sensitive to the feelings of others. He is hyper-aware of his environment and can switch from displaying extreme caution in his demeanor to be perfectly at his ease and laughing when he feels comfortable with where he is or who he is around.
He is happy to get to know people and he is very open and honest in his talks. He discloses a great deal of information that most people would resist disclosing so openly. He appears to do this without thinking and later, upon reflection, he is more guarded as he senses that he may have revealed too much about himself upfront. He displays some paranoia with regard to what one might do with the information he has disclosed and does not demonstrate ease and comfort until he is reassured that the person to whom he is talking will not share the information with anyone.
He has several friends from church; however, he is aware that given his latest meltdown some of them do not want to talk to him again until he gets help. He has a brother and a sister but both of his parents are deceased and his siblings live in other states. He does not have any very close friends near where he lives and he is constantly having to relocate for work every time he gets a new job. He would like to live closer to church so that he can receive the sacraments more often and more consistently. Church is a strong support for him.
Jake copes with problems by calling others to vent and talk about his problems with others. However, he also drinks excessively and uses marijuana to cope with them as well. His approach overall is haphazard and he needs to be better about identifying problems and triggers and responding to them effectively.
Contributing Factors
Background and environmental factors that have influenced Jake both positively and negatively are his isolation: he lives alone; friends are not nearby; neither are his siblings. He relies on phone conversations and social media to make connections. In one way isolation is good because it gives him time to himself so he can be creative without anyone getting on him about it; in another way, he spends too much time in isolation and ends up giving in to the temptation to abuse alcohol since there is nothing else to do and he feels it helps him to express himself creatively.
The main trauma he experienced as an adolescent was from his father beating him. His father was a very angry man and took it out on Jake whenever Jake would play music in his room or do anything that upset his father. His father beat him several times until Jake finally had enough. Jake wrestled in school and he tackled his father to the floor and then chided him. He left home after that and did not return. Jake stayed with friends through the rest of high school. It was not until years later, just before his father’s death, that he patched things up with his father and forgave him. The trauma of being abused by his father stayed with him and contributed to his desire to use drugs and get away from his problems. Jake used LSD and had a psychotic episode in which he believed the CIA was trying to bomb his car. He also believed devils were trying to take him to Hell and that the only way to get to heaven would be to kill himself while wearing a miraculous medal. Jake spent time in a mental hospital but that was more than two decades ago.
Family issues stem from his mother being very cold and distant towards him. Jake never received any affection from his mother and he received abuse from his father. He was left to support himself emotionally. According to Erikson’s model of psychosocial development, being left alone during formative ages can be damaging to the person’s psychosocial development especially as they are trying to define themselves and establish their role in adolescence (Shriner & Shriner, 2014). Perry andd Szalavitz (2006) conclude as much in their professional experience: children need nurturing from care providers and if they do not receive, it creates a trauma that the child can spend the rest of his life trying to deal with.
Gender issues with Jake are that he is insecure about his masculinity. He does not have an outlet for sexuality since as a devout Catholic he believes it is sinful to have premarital sexual intercourse. Because of his alcoholism, he struggles to stay sober long enough to keep a steady job. Because of job insecurity he feels he is not in a position to pursue a wife as it would mean starting a family.
Cultural issues involved with Jake are his Catholicism. He has strong religious beliefs that have motivated him to action throughout his life, in both positive and negative ways. He feels that he is assured of Heaven after this world if he remains truthful to the teachings of the Catholic Church and this gives him comfort, confidence and solace in the face of affliction. At the same time, he appears to box himself into a narrow way of thinking and a negative one when it comes to dealing with his issues. Instead of taking ownership of his drinking, he tends to lay blame for difficulties on devils or on Masons (he refers to them a lot) who are out to destroy the Church. Curiously, Jake does not seem to be bothered by what drunkenness might be doing to his chances of getting to Heaven, even though he is very wary of engaging in sinful activity for that reason. This might be one avenue to pursue with Jake.
Jake has several strengths: he is out-going, trusting, friendly, open and honest, and willing to listen. He also has several deficiencies: although he considers some things, he does not consider them very deeply before moving on to an old grievance; he his open and honest in his conversation with others—and yet he is not very open and honest with himself or he would see that much of his problem is rooted in his own vanity and pride. He is interested in becoming a better person; yet he already believes he is a great person because of what he has accomplished. He is interested in being sober and wants to enjoy sobriety for the sake of attaining stability and getting to a point where he can possibly start a family; yet he enjoys being under the influence because he feels it enhances his creative spirit. He has contradictions throughout his character that indicate he is being pulled in two directions at once.
Jake has a great deal of awareness of his own cognition, affect, behavior and problems; yet at the same time he will deny this awareness if his vanity and pride rear up. He is almost of a split mind in that he can see himself clearly when he is adopting a spirit of humility and truthfulness—but this clarity goes away as soon as he returns to his old grievances and begins focusing on the negative thoughts and feelings, how he has been wronged in life, how his parents neglected and abused him, how certain friends have used him in the past, how women have mistreated him, and how coworkers have been jealous of his good looks and talents and have secretly plotted to sabotage him. When he gets in that line of thinking, he loses all perspective of his problems and his own role in creating them for himself. At the same time, he is aware of the trauma he endured as a child and he is quite open about it and how it has impacted him. He is willing to face all of that and to reconcile with his past. The problem is keeping him focused on that positive goal and moving in the right direction.
Part II: Treatment Plan
Goals of Treatment
1. Help the client to deal positively with his alcohol addiction so that he can commit to a life of sobriety.
2. Help the client to address his childhood trauma so that he can deal positively with the injuries he still bears and move forward in forgiveness.
3. Help the client to identify the negative triggers that pull him back from a positive frame of mind, undercutting his efforts to achieve his own personal goals—such as job security, finding a life partner, and settling down.
What is necessary to help Jake is a sense of how to assist him with each of these three goals. The first deals with conquering an addiction, which is a bad habit that has been formed over numerous years, that has weakened the will and captivated the intellect. Alcohol is his first choice whenever boredom or some impulse distracts him from his higher purpose. Breaking that habit requires focus, attention, and a serious game plan. It can be accomplished but not without the help and assistance of a support network (Best et al., 2016). Currently, it is unknown whether Jake’s support network is suitable for this purpose. For a strong support network, one needs reliable friends who are going to be there when he needs assistance. Some investigation is needed in this area to see if anyone in Jake’s support network can be relied upon to serve that role.
Jake is also carrying around with him some trauma from childhood. This trauma needs to be addressed so that Jake can put it behind him. Currently, he is aware of what happened and he acknowledges it, but he has not processed it in a truly healthy way or else he would be able to put it behind him or use it for a positive purpose in his life. Instead, he uses it as a crutch to justify his weaknesses: he has been wronged in his childhood and so therefore any indulgence that he engages in now is all right. That reasoning is poisonous to his well-being and needs to be reversed.
Jake is also susceptible to negative triggers that pull him into an obsessive, depressed state. He exhibits some signs of bi-polar disorder but barring a clinical diagnosis it may be said that he experiences fits of euphoria and intermittent despair, made worse by alcohol usage. Jake needs to be brought to a position where he can not only identify the triggers that lead him to a negative frame of mind but where he can also identify positive thoughts and actions he can turn to in order to overcome the negative triggers and counter them in a positive and healthy way.
Approaches to be Utilized
The counseling theories that would be best suited to the needs of Jake can be found in the humanistic, cognitive and behavioral theoretical approaches; humanistic because this approach posits that people have within themselves all the resources needed for overcoming any difficulties: it is an empowering theoretical approach and one that could be of use to a person so hampered and impaired in his own will power, as is often the case with people suffering from addiction. They can be supported with the affirmation that they are strong enough to set themselves on the right path; they can be bolstered and reassured with the humanistic approach, as it is one that sees the counselor in the position of helpmate and friend rather than as director. The counselor helps the client to find within himself those resources previously untapped. The counselor helps the client to see that they have been there all along, lying dormant, like oil beneath the ground, waiting to be discovered. It can be a great joy to the client to believe it so. This is the reason the humanistic approach suits the case of Jake. Rogers’ person-centered theory is a good way to approach Jake’s situation, using humanistic counseling. Rogers (1951) argued that “the best vantage point for understanding behavior is from the internal frame of reference of the individual” (p. 495). This certainly applies to Jake and it is that internal frame of reference that he will likely be happy to apply to his own situation since he enjoys self-reflection and thinking about his own situation in life. Rogers (1951) believed that “psychological maladjustment…[occurs when a person is] denying awareness of significant sensory and visceral experiences” (p. 495). For Jake, he seems to be denying some aspects of his own experience, and it is important for him to become aware of these so that he can be more present in the moment and make the necessary adjustments that need to be made.
The cognitive theoretical approach also applies. This approach applies well with Jake because part of his problem is that his view of himself does not align quite with the reality of who he is. Yes, he may be a talented engineer—but he has a drinking problem that prevents his talent from becoming fully obvious or of even any real utility to an employer. Until he sees the reality of himself, his condition will not improve. Cognitive counseling theory can be of great use in helping a client to get his thinking in sync with the reality of his situation.
The same can be said of behavioral theoretical approach. Behavioral theory posits that people tend to conduct themselves in problematic ways when they are in an environment that enables them or gives them the opportunity to do so. Controlling one’s environment can be a good way to begin to apply the behavioral approach to counseling. In Jake’s case, this would imply helping him to see how to adjust his lifestyle and living situation so that he is less likely to abuse alcohol.
The cognitive and behavioral approaches can be combined in cognitive behavioral therapy (CBT). CBT is a good type of therapy for helping a client to identify the reality of his situation and the triggers in his own person and environment that lead him on to problematic thinking and behavior. It then helps the client to see what steps might be taken to adjust for these problem areas or triggers. Taking these steps or engaging in more positive thinking can be strong ways to help the client address the issues without having to get into a psychoanalytical frame of mind. Trauma-informed therapy can be useful here as well, as it helps the client to cope with the trauma of the past and see how it affects emotions and outlook and behavior. It can be a good focal-point for navigating the personal experiences, wants and needs that Jake has.
I would recommend individual therapy for Jake as he is sensitive and has a lot to unpack. It would be good for him to do so in a safe environment where he feels he is trusted to share and he feels he can trust the therapist. In a group setting he may become paranoid, as often happens when he is in a group and does not know who he can trust. Family therapy would not work in this case either, as his parents are dead and his siblings live far away.
I would use encouragement and empowerment to help Jake, first, by adopting the humanistic approach, as this is an approach that lets the client know that everything he needs to solve his problems can be found within him. It lets him know that he has the tools and resources and all he has to do is summon them. Looking at his life from his own perspective can be a good place to start, but his faith is also strong and it would also help if he was encouraged to use his faith as a foundation for getting in touch with the person he wants to be. This aligns with the person-centered approach used by Rogers and the key is to help Jake to know himself more fully.
Jake can be guided to know himself more fully and more realistically with some help, but he should never be directed. Rather the counselor should help him to probe by asking questions that get Jake to think and reflect without feeling that he is being pushed. This can be a time-consuming process but it is important that Jake feel that he is in charge and that he is directing the sessions because he has to take ownership of the changes and he has to begin to hold himself accountable. CBT is therefore helpful in the sense that it puts the client in charge of identifying and implementing the positive solutions to negative triggers. Trauma-informed therapy will also help Jake to process his childhood trauma and give him the sense that he can overcome the negativity simply by accepting and forgiving.
The kind of therapeutic relationship that would be best for this client would be one of mutual trust, respect and care. That would help Jake substantially as it would give him the real support he needs to begin to build out his own working plan for tackling his issues. Because of his temperament, which is not choleric and is very sensitive, it is important that he not feel pushed or pulled in any one way. The decisions have to be made by him.
What is necessary for Jake to undergo therapeutic change is the realization that he is not who he thinks he is and that his ideal self can be attained but it would mean making serious changes to his life. He knows what goals he wants to pursue but he has deep insecurities that stem from his trauma and from years of substance abuse that prevent him from making those changes. Jake needs to realize this and find the will power to make those changes. He needs to build out a solid support system so that he is making these changes knowing that he has friends who have his back no matter what. He is too isolated as is and there is no one really in his corner. That needs to change and he needs to find a proper support system, perhaps through church.
Specific Techniques
Techniques that can be implemented using person-centered therapy include congruence, unconditional positive regard, nondirectiveness and reflection of feelings. Using the CBT method, one technique that could be used is guided discovery. While this may seemingly clash with nondirectiveness, it can actually complement nondirectiveness at times.
First, and most important for person-centered therapy, is congruence. This is a technique by which the therapist’s tone, words and body language are aligned. It is important that the client gets a consistent, coherent signal and message from the therapist. Congruence helps to build trust. It lets the client see that the therapist is whole and centered and is not saying one thing with his words and saying another thing with his body language. If there is no congruence demonstrated the client is going to think that there is something wrong with his own person that he is not connecting well with the counselor. The connection is vital and Jake needs it, so congruence has to be shown throughout.
Second, unconditional positive regard allows the client to feel accepted, respected and cared for, and that is important for Jake because he has felt neglected and abused in his life and now he is isolated. He needs to know his therapist is in his corner and is not going to judge him. This is something that the counselor must show for Jake especially since he is coming from a place of disconnectedness. He has to feel that he is not being judged.
Third is nondirectiveness and this is simply the technique of letting the client steer the therapy session. The therapist does not give advice or plan activities. However, I think that this can work some of the time and that other times it is necessary for guided discovery to take place, which is why that technique is also recommended here. Nondirectiveness can empower the client, and it is important that Jake feel empowered so that he can explore who he is—but it is also important that the counselor help steer Jake to the reality. The reality is not always going to be readily seen by the client when nondirectiveness is the only therapeutic technique used. It is helpful for exploring, but Jake will need some guidance. That is why guided discovery is also needed.
Guided discovery through asking the miracle question is a good way to get Jake thinking about how he might change. The miracle question is common in CBT and poses a situation in which all the client’s problems have been miraculously solved—what would he do? How would he act? It is meant to get the person thinking in a more positive manner.
Reflection of feelings would return us to the humanistic approach and it could also be used in trauma-informed therapy. It is a way for the therapist to let the client know that what he has shared is being heard by the therapist. That is important so that the person does not just feel like he is talking to the wall. He has to know that he is heard, which helps with validation and processing.
References
Best, D., Beckwith, M., Haslam, C., Alexander Haslam, S., Jetten, J., Mawson, E., & Lubman, D. I. (2016). Overcoming alcohol and other drug addiction as a process of social identity transition: The social identity model of recovery (SIMOR). Addiction Research & Theory, 24(2), 111-123.
Perry, B. D., & Szalavitz, M. (2006). The boy who was raised as a dog: And other stories from a child psychiatrist's notebook – What traumatized children can teach us about loss, love, and healing. New York, NY: Basic Books.
Rogers, C. (1951). Client-Centered Therapy. MA: Riverside Press.
Shriner, B & M. Shriner. (2014). Essentials of Lifespan Development: A Topical Perspective. Bridgepoint Education: San Diego, CA.