Discussion of Client, Family, and Practice Setting

C.B. is a 35-year-old single mother of two sons aged seven and five. Some years back, she divorced her husband and is raising the children on her own. Things had been progressing well until the COVID-19 Pandemic struck, leading to a collapse in the economy and job loss in many sectors. The hospitality sector where she was working is among the industries that were adversely affected. Unfortunately, she lost her job in a hotel and has been unemployed ever since. She does not want family and friends’ assistance because she believes this will be an enormous burden. Financial constraints have pushed her to the limit and have led to the development of depressive symptoms. Currently, her mental and emotional conditions are in a bad state, and immediate intervention is needed. She lacks self-esteem, is irrational, and does not have the confidence to apply for a job. My task as her therapist is to help her overcome these obstacles and get a job to sustain her family. 

Process Recording Vignette 

Therapist: Good morning C.B., how are you today? 

C.B: I did not wake up so well, but otherwise I am doing great. 

Therapist: I’m sorry to hear that. What is the problem? 

C.B: I feel weak and tired. 

Therapist: Have you seen a doctor? 

C.B: No, I think its not sickness. Its just my emotional state today. 

Therapist: Okay. So, before we start, what do you think made you feel weak and tired today? 

C.B: Well, my youngest son asked me if I was going to work today, because he saw me dressed up. 

Therapist: I see. You should take such things positively. Because his question shows you the need to be motivated and start working again. You should not let him down. 

C.B: I won’t. 

Therapist: Okay, let’s start from where we left. How have you been since we last talked? 

C.B: Not bad. Things have been tough but I am trying my best to overcome the challenges. 

Therapist: What exactly has been tough? 

C.B: I guess waking up every morning and not going to work. Seeing my children there makes me want to cry because they don’t know I can’t provide for them. 

Therapist: Okay. And have you tried going out and getting a job? 

C.B: Yes, I did. As a matter of fact, I met an old school mate from College. We talked for a while and I told her of my situation. 

Therapist: Yes, what did she say? 

C.B: Well, she said there is an opening at her workplace and asked for my C.V. 

Therapist: Did you provide them? 

C.B: (smiles) Of course yes. I can’t let that chance pass me by. 

Therapist: That’s good to hear. It means you are making progress. 

C.B: You should also know that I also applied in three other companies as well. 

Therapist: I can see you are motivated to get a job. 

C.B: I guess so. 

Therapist: And how does this make you feel about yourself? 

C.B: It makes me feel good. For once, I feel like I am a productive person. I think this is a promising start even though I have fears. 

Therapist: Please share them. 

C.B: Sometimes, I think of the disappointment on my face if these jobs do not go through. I don’t want to be a burden to my family and friends. They have done enough for me. 

Therapist: Well, I think you have made major strides in your life. Fears are normal for everyone. It would help if you tried to get rid of these feelings and embrace positivity. I am sure they will give you a call soon. And maybe then, you won’t get time to come see me. 

C.B: (grins) you can be assured I will continue with these sessions until you say we are done. 

Therapist: What about your sleeping patterns. Have they improved? 

C.B: No, I sleep for less hours, but the nightmares have stopped. So whenever I am awake, I watch motivational stories until I fall back asleep. 

Therapist: If you continue with that spirit, you shall overcome this. I believe it’s a temporary situation that will come to pass soon. You are doing well. Just embrace a positive attitude and it will be over soon. 

Assessment Method 

The Cognitive Behavioral Theory (C.BT) serves as a helpful therapy for treating the client based on the highlighted problems. According to Ribeiro (2020) , the main driver for success lies in the way it evaluates the interaction between cognition (thinking), feelings (emotion), and actions (behavior). In our case, negative thoughts caused the patient to experience emotional distress. She suffers from psychological problems and interprets her problems negatively. The sessions aim to help her become aware of these negative interpretations and distorted thinking that affect behavioral patterns. 

I want to help her develop an alternative way of thinking to alleviate her mental and emotional despair. The client’s interaction with the world embodies the psychological representation of an inaccurate and disordered ideology. I established that she has distorted cognitions, as seen from poor sleeping patterns and lack of psychological stability. The objective is to help C.B. discriminate between her thoughts and reality. She must learn to understand that cognition influences feelings that shape personal beliefs. I was proud that I helped identify destructive beliefs and resolve behavioral and emotional problems. Beck & Beck (2011) note that each person holds a unique set of assumptions about themselves and their world that guides them through life and determines their reactions to the situations they encounter. 

More than one client 

Patients like C.B. make assumptions that shape their worldviews and actions based on encountered situations. They react in inappropriate manners that prejudice their chances of success and happiness. The setting and treatment model for more than one patient will be the same because they share the same conditions. My client is assuming that she is a failure and is not loved by the people she knows. She is the kind of person who seeks approval from those around her and feels rejected if she encounters a major setback. Therefore, her interaction is affected by this assumption and, as such, has left her in a dissatisfied state. C.B. has an incompetent attitude and feels she has no control over her happiness and her children’s. The loss of employment has dramatically affected her cognitive ability by taking away her self-esteem. C.B. is clouded by the notion that all human problems must have a perfect solution, and if it is not found, disaster strikes. She has forcefully held on to this thinking mode and employed emotive techniques to deal with the situation. 

From my assessment, I realized that depression-prone individuals like C.B. tend to develop negative self-schemas. Her beliefs and expectations are pessimistic and have been acquired as a result of a traumatic event. Such patients are prone to making logical errors because they selectively focus on specific aspects of the event while equally ignoring relevant information ( Wenzel, 2017 ). For instance, C.B. concentrates on her lack of job and ability to provide for her children. These thoughts are automatic and occur spontaneously, thus bringing uncertainty to the future of her family. There is the possibility of losing her house and children to foster care if she fails to secure employment soon. These fears have interfered with normal cognitive processing and impaired her perception, making her obsessed with negative thoughts. 

Session Analysis and Conformity to Selected Approach 

During the session, I worked with the patient to break down her problems into separate components; feelings, thoughts, and actions. Together, we analyzed the areas that need to be addressed and determined their effect on her life and family. One of the things I found useful was helping her understand the extent of the damage she is during to herself. Ribeiro (2020) notes that as a therapist, one should strive to make the patient see the implications and consequences of her thoughts and actions. Progress can only be made if they acknowledge their shortcomings to achieve a change in destructive behavior. We sought to practice the proposed changes after each session in her daily life. Moreover, discussions are always made on the next session to see what she was able to accomplish. The aim is to stop C.B. from having a negative attitude in life, even after her treatment works. The focus of the approach is on the patient and their ability to bring positive change into their lives. 

Limits of the Model 

One of the limits of the approach is that it only addresses the patient’s current problems and focuses on a specific issue (unemployment). Consequently, I am not able to address the potential underlying causes of her mental condition. For example, I may change her thoughts and behavior, but wider problems in her family and childhood will still not be solved. Wenzel (2017) notes that these factors have a significant impact on her health and well-being. The method, therefore, treats the symptoms by making psychoanalytic assumptions. If early events are indeed the source of her present difficulties, then another distressing incident in the future may bring back the same mental condition. 

Treatment Relationship 

The relationship between a therapist and a patient is vital for treatment success to be achieved ( Wenzel, 2017 ). We had a healthy relationship with the patient founded on care, respect, and an emotional bond of trust. There was an established agreement on the therapy’s objectives and collaborative effort to achieve the treatment goals. The client was free to share negative emotional responses freely because she trusted me to help her deal with these situations. We had a shared sense of ownership in the project and, as such, trusted that each side was working equally hard to contribute to the therapy’s success. We collaborated on tough decisions, but I always let her make the final choice at the end once we weighed the possible options and outcomes in each scenario. As a therapist, I understood that every close relationship has challenges and misunderstandings and, as such, was patient and calm with C.B., avoiding judgments. I believe the success of our connection was based on how we dealt with difficulties whenever they emerged. Whenever she was faced with a situation she felt she could not overcome, like interacting with people and getting the strength to find a new job, I was there to handle the difficulties and negative feelings. The main secret to achieving progress is the connection we have with each other and our openness level. She is not afraid to mention the setbacks and distress symptoms she is experiencing because she has faith in me as her physician. 

Interaction and Influence of Social Identities 

C.B.’s underlying social identity is her social-economic status because she lost her job and cannot provide for her family. The outburst of the COVID-19 Pandemic is to blame for this loss and has drastically reduced the country’s available job opportunities. As a parent, she has lost hope and despaired because her two sons depend on her. Not only does she lack self-esteem, but she also has negative thoughts that may lead her to make irrational decisions. Therefore, making progress is challenging because she lacks the drive, confidence, and motivation to apply for another job. 

The other social contrast that had a significant influence on the treatment is her sexual orientation. As a female victim of unemployment, she is vulnerable because many employers may prefer employing males in such a crisis. Existing stereotypes are still prevalent in the employment sector, and as such, this affects her position as a single, unemployed mother. She feels helpless and believes herself to be a burden on loved ones. If she does not get a job, she will fail as a mother and as a parent. These facts have confused her cognitive thinking ability and reduced her sleeping hours. 

The other social identity that influenced the outcome of the therapy session is religion. Tan (2013) notes that a person’s faith greatly impacts how they deal with and react to traumatic events. Hope is an embodiment of a person’s strength to attain their goals. It reflects their confidence and ability to rise to greatness, even in times of distress. Consequently, this means people who have lost hope have a lost cause. The interaction established that religion plays a critical role in socio-economic perceptions and judgments. Faith determines how individuals and societies perceive poverty and, as such, is a helpful factor in treatment therapies. Research has shown that religious hope positively impacts various areas of human well-being and is related to psychological, physical, and emotional satisfaction ( Tan, 2013 ). It gives a person a purpose in life and lowers their risk of making irrational decisions. I aim to instill a sense of religious coping in the client as a positive response to distress by drawing from encouraging religious writings. By doing this, she will improve her overall well-being and pursue personal growth amidst life stressors. 

Religion is an institutionalized system that shapes the ideologies of beliefs and how they interact in society ( Tan, 2013 ). Depression and anxiety can be reduced by making the patient understand there is a supreme being watching over her. Her body and mind are connected and, as such, will react well to the thought of positivity when faced with an incomprehensible uncertainty. C.B. can be encouraged to get solace from fellow believers, thus adding security despite her economic insecurity and making sense of what is happening in her life. 

I should do a better job showing her the significance of challenges and hardships and why hope is important at this stage in her life. Religion can be a driver of optimism that provides great strength to overcome inequities. C.B. should understand that religion has doctrines and laws that govern her actions. These rules advocate for a righteous life that cautions against sinful behavior and despair in times of need. She should rely on religion as a driver to get a new job, deal with her issues and take care of her children without any worry or concern. At this point, inspiring stories from the Holy Book will help her deal with the issue positively. 

For instance, when there was a time when the Israelites were facing cruel and brutal oppression by the Assyrian empire ( Tan, 2013 ). Nahum’s prophecy, however, gave the people hope that they would soon be freed from slavery and return to their promised land. The verse shows that amid struggle and oppression, God is our source of strength. We are covered by His grace and goodness independent of our circumstances, and though we may not feel his blessings directly, he has great things planned ( Tan, 2013 ). Therefore, the LORD is a good refuge in times of trouble and cares for those who trust in him. 

Impact of Genuineness, Empathy, and Respect 

In counseling, therapists must be sensitive to their client’s feelings, thoughts, and experiences during interactive sessions (Etherington & Bridges, 2011). They should consciously put themselves in the shoes or minds of the subject to understand their emotional state. C.B. experienced emotional distress and confusion. I strived to provide a non-judgmental and empathetic environment where I could listen carefully without preconceptions. Doing this made her feel held, supported, understood, and respected. I achieved success because I possess alert attentiveness to body language, facial expressions, gestures, silences, and intuition. I was also cautious not to become sympathetic to the client as this would cloud my judgment to offer professional services. Sympathy generates a pitiful view, whereas empathy empowers individuals by showing them they are not alone and have the support to overcome life challenges. My voice also reflected professional feelings towards the client, thus shaping the outcome of the treatment. 

According to Beck & Beck (2011) , psychologists and counselors are responsible for upholding high standards of respect for their clients. They must do so with the full awareness of personal and cultural differences. Regardless of who a patient is and their behavior, a therapist is obliged to offer the deserved professional assistance and treatment as a person of value and worth ( Wenzel, 2017 ). I believe that there is good in each of us, and for this potential to resurface, people need to feel valued and appreciated. My role, in this case, was to assist the client feel good about herself by raising her esteem and increasing their sense of worth. I accepted C.B. for the person she is, and over time, her values have positively evolved to that of an optimistic and responsible individual. Wenzel (2017) notes that language is an essential element of showing respect during counseling. A major part of my success was based on my exemplary communication skills and caution of the language I used and its aptness in the client’s context. 

Counselors are expected to uphold a set of attitudes and behaviors that portrays them as transparent and people of integrity ( Hofmann & Asmundson, 2017 ). I was a genuine therapist who understood what it means to be sincere and moral quality to offer advice with openness. The client appreciated the fact that I strived to be myself throughout the session. I was very comfortable with all our interactions and did not try to adapt or change roles to be acceptable to the client. I was without façade and was self-aware of the impact this would have on trust. Consequently, C.B. communicated her feelings appropriately because I established a genuine therapeutic relationship from the start. 

Ethical and Social Justice Issues 

Autonomy 

Autonomy is also a key ethical issue affecting the treatment process. It stresses the principle of independence and encourages counselors to allow the patient freedom of choice to make their own decisions ( Wenzel, 2017 ). The facilitator’s responsibility is to guide their actions and ensure choices are rational and guided by acceptable values. Consequently, if C.B.’s mental condition does not allow her to make competent choices, I will not allow her to take actions that will harm her. Regarding this, I should not decide to help her get a job because this would deter dependency and infringe her rights to pursue this on her own. 

Confidentiality 

One of the main ethical issues implicated in the case is client confidentiality. According to Wenzel (2017) , this rule requires psychiatrists, therapists, and psychologists to protect their clients’ private information by not revealing its contents. In this scenario, I was responsible for maintaining the required standard of professionalism. When the client shared their struggle of finding a job, I felt remorseful because I have links and connections to potential employers in the corporate world. Therefore, I was torn between letting her find a job for herself or helping her get one faster. A therapist’s default position is to maintain confidentiality at all times, even when they are technically allowed to share this information ( Epston, Stillman & Erbes, 2012 ). It is, therefore, the cornerstone of effective treatment. If I were to help her find a job, I would be forced to share some information regarding her personal and contact information. In the process, I may share her problems and the fact that she is my patient, losing my credibility as a professional therapist. 

Interpersonal relationships 

Relationships also affect the therapeutic case provided. From an emotional perspective, I felt bad for my client because she was going through a very rough patch which I could help remedy. As a mother of two, I felt as if the world was unfair to her and, as such, needed to intervene and bring an end to her distress. I have had similar challenges in the past and have seen the damage such a traumatic event can have on people. Families have been broken, and people have died because of depression issues, and as such, sometimes these emotions are evoked when she reveals what she is going through. Ethically, I am obliged to keep my personal life and feelings separate from my profession. In this instance, it is very difficult because I relate to the patient’s misery and struggle. As a therapist, I must not let these events affect my ability to offer effective counsel to the client. I always find a way to work through the issue at hand when faced with these moments. If I cannot ethically separate personal problems from my professional life, I will be forced to take leave or transfer the client to another counselor. My judgments should not be clouded or impaired by feelings of empathy towards the client. The ultimate goal is to find a permanent solution to their problem and prevent it from happening again should the client face a challenge of the same magnitude in the future. 

Effectiveness 

There was a greater sense of mutuality in the interaction because I understood that psychotherapy is a two-way relationship. Therefore, both parties are equal partners in the treatment process. During the sessions, I made this stance apparent by disclosing my feelings when appropriate and asking inviting feedback from the client about the therapy’s progress. I did not approach the session by acting as the director or facilitator but by committing to being her partner. It helped me build a stronger relationship and foster collaboration with the patient to actualize therapy objectives. I was able to establish the direction of the process through positive interactions. 

I can evaluate progress by measuring the patient’s response to my advice and treatment strategy. In this session, I realized that she adhered to my instruction to make positive adjustments. For example, I had previously advised her to start interacting with people and apply for jobs. In one of her responses, she says that her job search is promising because she ran into an old friend who promised to help her secure employment over the past two weeks. She also attended two interviews she had applied for and, as such, was optimistic she would receive a call from either establishment offering her a job. These provide a great account and measure of the progress I was able to make as a therapist. 

Moreover, the C.B. I knew at the start of the treatment would not have accepted cash from other people, let alone friends, because she did not want to burden others. I was impressed by her positive thinking and reception of the donation, which helped sort bills for the month. At some point in the discussion, she lighted up and expressed the hope of getting back on her feet and fending for her children once more. Finally, C.B. started to realize that she had the strength and courage to determinedly search for an opportunity to make ends meet. I achieved this because I related to and understood her personality traits, motivations, quirks, and conflicts. Ribeiro (2020) notes that patients either act out or resist suggestions for unknown reasons if treatment is not taking the right direction. 

References 

Etherington, K., & Bridges, N. (2011). Narrative case study research: On endings and six 

session reviews. Counseling and Psychotherapy Research, 11 (1), 11–22. 

Epston, D., Stillman, J. R., & Erbes, C. R. (2012). Speaking two languages: A conversation 

between narrative therapy and scientific practices. Journal of Systemic Therapies, 31 (1), 

74–88. 

Hofmann, S. G., & Asmundson, G. J. (Eds.). (2017).  The science of cognitive behavioral therapy . Academic Press. 

Wenzel, A. (2017).  Innovations in cognitive behavioral therapy: strategic interventions for creative practice . Taylor & Francis. 

Beck, J. S., & Beck, A. T. (2011). Cognitive behavior therapy.  New York: Basics and beyond. Guilford Publication . 

Ribeiro, M. D. (Ed.). (2020).  Examining Social Identities and Diversity Issues in Group Therapy: Knocking at the Boundaries . Routledge. 

Tan, S. Y. (2013). Addressing religion and spirituality from a cognitive-behavioral perspective.