Assignment 4- Overview of work with client

PREENGAGEMENT:

           In attempt to encourage Bill to be more involved with his house mates and be more socially involved at home, I instructed Bill last week to come up with an activity that the whole group could be involved in, and further instructed him that it should be in addition to baking that day.  The reason I chose this was because Bill has been withdrawing himself from all group activities in his home, and furthermore spending that time secluded in his room.  In assessing what method I could apply to him in order to get him to be more involved in group activities, I thought that by putting him in charge of the activity, not only might he be excited about it, he would have a very difficult time finding a reason not to participate.  

          I explained to Bill that I wanted to do something different when I visit him this week, and because he was showing such emotional growth over the last few weeks, I wanted him to pick the event that we would all do together.  To my surprise, he seemed pleased and excited that I have put him in charge of this task, throwing ideas out right from the start.  I told him to think about it a little longer and let me know when I see him on Thursday. 

          Upon my arrival this week, he was slightly agitated from his car ride home because he thought that his house mates were talking about him during the ride home.  During this visit I will attempt to follow the ABC cognitive behavioral model for identifying distorted thoughts and see if he will realize where his misconceptions are when interpreting stimuli.

NARRATIVE:

Bill: I know that J and P were talking about me on the ride home. And Mary (the house manager) didn’t even say hello to me when I walked in.

SW: What makes you think that they were talking about you on the ride home?

Bill: I just know they were.

SW: Okay, how about we ask them together if they were talking about you? I will go with you and help you if you get stuck.

Bill: Okay.

WE WENT TOGETHER TO ASK THOSE THAT BILL THOUGHT WERE CONSPIRING AGAINST HIM WHETHER THEY HAD IN FACT BEEN TALKING ABOUT HIM IN THE CAR.  BOTH RESPONDED SEPARATELY THAT THEY WERE NOT TALKING ABOUT HIM IN THE VAN.

Bill: I don’t believe them.

SW: Have they ever lied to you before?

Bill: Well, P has never lied to me, but J has!

SW: So if P has never lied to you, why do you think he is lying now? Did he say something or do something that makes you think he is a liar?

Bill: No….

SW: So, let’s review something for a second.  You said you heard them whispering in the van.  Correct?

Bill: Yes.

SW: So from that you thought that they were talking about you, correct?

Bill: Yes.

SW: And that made you upset?

Bill: Yes, I know they were, you are just trying to stick up for them.

SW: First, I am not sticking up for anyone nor am I on anyone’s side.  I don’t take sides. Can you think of some other things they could have been talking about that they needed to whisper?

Bill: No.

SW: They both just told you that they were talking about someone else, and it was not you.  Do you think it is possible that you misunderstood what they were doing and got upset for no reason?

Bill: I guess so, I don’t know. It doesn’t matter anymore, let’s do our project.

SW: Are you putting words in their mouths because that's what you think they said?

Bill: Well...I don't think so, maybe.

SW: Remember how sometimes you think you know what everyone is saying?  And we discussed before how you have this habit, even if they tell you otherwise?

Bill: Yes, I remember.  But I am very sensitive...

SW: It's okay to be sensitive.  But please try and remember that you have this habit, and just because you think they feel that way doesn't mean they do.  We just asked both of them if they like you, or if they were talking about you, and they both said they like you very much and were not talking about you.  Do you think that everyone is lying to you?
Bill: No.
SW: Then i think we should believe them this time.  What do you think?
Bill: Okay, can we make the birthday cards now? I really want to make them.  I don't want to talk about this anymore.
SW: Yes, of course.

IMPRESSIONS:

Bill was able to refocus his attention to making a birthday card for one of the residents in the nursing home we visited a few days prior.  He was able to admit to me that there was a possibility he was wrong, but he so strongly believed that he wasn't.  There really is no way for me to prove whether his roommates were talking about him, or how distorted his reactions actually were based on the event, because I was not there.   Despite these feelings, we were able to complete the activity he put together for the group.  The activity turned out to be very successful.  Bill was the one who invited everyone to join us, with my prompting, and was able to enjoy the rest of the time we spent together.  Everyone shared and talked nicely as we played.

At the end of our time together, I complimented him on a job well done in regards to planning an activity for the house.  In addition, I also praised him for his efforts in thinking positive and turning the situation around so that he could enjoy the activity instead of probing at the fact that he thought he was the target of the van’s conversation.  This supported my theory on how much he has grown emotionally since the beginning of our time together.

PLANS FOR THE FUTURE:

I plan on asking Bill to chose and activity for the house because I believe this will make it harder for him to stay in his room and not participate during the activity.  If he chooses it, it most likely is something that he wants to do. 

I also plan on continuing my praise of his noticed efforts to turn around his mood, as I think this will positively reinforce his behavior.  It seems as though he is not able to fully understand my attempt to point out a distorted thought, but the fact that he acknowledges the possibility that there are other sides to the story is a big accomplishment on his part.  I will not give up the attempts to show him other options despite his lack of understanding, as he is making great progress regardless.

Assignment 3

There is one specific intervention that I am continuously exploring with Bill throughout our time together which is known as cognitive behavioral therapy.  The goal throughout the cognitive-behavioral therapeutic process is to help Bill become more aware of his thought distortions which are directly related to some of his psychological distress.  One objective is to allocate where and what are the causes of the behaviors present and address triggers or patterns as a result of the distorted thoughts.  The client and therapist are encouraged to work together in order to compare these thoughts to those of reality and societal norms, functions and expectations (Mulhauser, An Introduction to Cognitive Therapy and Approach).  

Through research and readings, I have come to the conclusion that my attempt to change Bill's behavior will be unsuccessful unless I target the source of his distorted thoughts, as they are directly and consciously preventing him from exploring his social interactive possibilities. For example, during Bill's most recent hospitalization into a psychiatric ward, I along with many other staff members strongly encouraged Bill to attend group therapy sessions and activities.  We were aware that this would be unlikely, but are also aware that our encouragement is mandatory and crucial for his social explorations.  To our delight, Bill accepted our advice and attended a session where he met a nice woman who he fell in love with.  Bear in mind, that this behavior is one of his many frequent distorted thoughts, where he falls in love and later gets hurt by someone who is unavailable, but he fails to recognize this and believes that these women have feelings for him as well.  Soon after, the woman explained that she was married and stormed away by one of his brave propositions to express his want to become more intimate with her.  Bill immediately retracted and apologized but not before becoming emotionally and physically upset where it resulted in him returning to his room and refusing to return to any additional sessions at the treatment center.  When I asked him about this instance he explained that he had decided it would be better for him to stay in his room for ever so that he could prevent himself from getting hurt in the future.  


I have been exploring with the framework of cognitive therapy as it directly encourages the therapist to address the stimulus, thought, and emotion in the client.  This is also known as Ellis' ABC model where A is the event, B is the thought or belief about the event that occurred, and C is the feelings or emotions that result in the interpretation of the event and following belief (Mulhauser, 2010, An Introduction to Cognitive Therapy and Approach).  When applying this model to a person with a disability such as schizophrenia, and interpreting the client's distorted thoughts from the ABC perspective, delusions are B’s. "That is, they represent the erroneous belief about the antecedent event, and they may or may not be followed by an inappropriate emotional or behavioral consequence" (Malouf, 1996, Review of Cognitive Behavioral Therapy).   During my sessions with Bill, I have sat with him along with a piece of paper in front of us, where we attempt to identify the event that triggered his response.  I then ask Bill to explain as best as he can how that made him feel and how he responded.  We then return back to the segment where he is interpreting what happened and I put forth some scenarios and other possibilities that can contribute or be an underlying factor in the event.  Typically at this point, we discuss reality and what really happened, as many of his distorted thoughts are a result of his past experience and mental illness.  We explore additional options as to why this person could have reacted in that manner, which usually broadens his perspective on the event and elicits a different response as a result of having better understood the situation.  An example of this is when Bill and I are volunteering at a local nursing home where we visit with the residents and hand out books and magazines for entertainment.  Bill is a very friendly person who is always reaching out for someone to shake his hand or offer some physical comfort through a pat on the back, etc.  In the first months of our volunteer work, Bill would reach out his hand in an attempt to shake the other person's hand.  Some kindly accept as many are uncomfortable and reject this gesture.  Bill automatically reacts and withdraws himself saying that they hurt his feelings because they do not like him and do not want to shake his hand.  This leads to him refusing to continue and express his will to terminate future visits at this nursing home.  At this point I intervene asking him to share his feelings with me.  After he has vented I propose to revisit the thought as to why they did not shake his hand.  We explore possibilities such that maybe the person is religious and does not touch another person other than her spouse (since it is a Jewish nursing home), or the person is simply shy and uncomfortable in touching another person.  Some simply do not hear him when he greets them and are unaware that he even attempted to shake their hand.  After this, most of the time Bill can calm down knowing it was not a personal attack against him, but rather a private reason that may or may not involve him.  


There is significant evidence as to the positive effects this treatment can have upon a person who is capable of understanding and who possesses the will to accept treatment and ultimately a change. "Psychological treatment appears an effective procedure for reducing the impact of stressful psychotic experiences, improving patients’ social functioning and reducing family stress, in conjunction with psychopharmacological treatment" (Fernandez, O., Giraldez, S., (1999) Integrated Psychological Treatment in Schizophrenic Patients). The Brenner group conducted a study that tested the effect of integrated psychological theory (IPT), which is considered an offset of cognitive behavioral therapy, and reviewed the data to determine whether it impacted a patient's cognitive capacity and social perception.  The data showed that by adding cognitive and social therapy in addition to medication, known as pharmacotherapy, there are significant results in terms of improvement in cognitive abilities and growth as well as the ability to recognize and expand their cognitive patterns to avoid distorted thoughts.  "By connecting specific cognitive and social training subprograms to the cognitive and social deficits manifested by persons with schizophrenia, Brenner's group has provided hypothesis driven methods for the field and has brought new enthusiasm to practitioners and researchers alike who know that pharmacotherapy alone is inadequate to meet the comprehensive needs of individuals with schizophrenia"(Liberman and Green, 1992, Whither cognitive behavioral therapy for schizophrenia). 

Fernandez, O., Giraldez, S., (1999) Integrated Psychological Treatment in Schizophrenic Patients. Psychology in Spain. Vol. 3. No 1, 25-35

Liberman, R., Green, M. (1992). Whither Cognitive-Behavioral Therapy for Schizophrenia. VOL 18, NO. 1


Malouf, J. (1996). Review of "Cognitive-behavioral therapy for bipolar disorder" and" Cognitive therapy for delusions, voices, and paranoia". Psychotherapy: Theory, Research, Practice, Training, 33(4), 636-637. 


Mulhauser, G. (2010). An introduction to cognitive therapy and cognitive behavioral approaches. http://counsellingresource.com/types/cognitive-therapy/index.htmll. Accessed March 3, 2011.