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©Routledge/Taylor & Francis 2014
Therapy in Action
Behaviour Therapy
Each chapter of the textbook incorporates a novel case study involving a client presenting with a set
of concerns and a therapist addressing these concerns using the therapy discussed in that particular
chapter. Since each therapy is best suited for certain types of difficulties, each case study is unique
in order to ensure that the examples provided are as clear as possible. This session can be viewed by
watching the associated video content of the therapy session in action and this document is designed
to accompany the observation to support your understanding.
The aim of these case studies is to provide the reader with a real-world example of therapy in
action. Unlike many other fields of psychology, counselling and psychotherapy are not exclusively
academic. In order to fully understand therapeutic approaches and methods, the reader must
appreciate how these concepts can be applied in interactions with clients. The best way to present
these interactions is in the form of case studies and we hope that you are able to use these examples
in order to further your own understanding and practice of counselling and psychotherapy.
The therapy session lasts for one therapy hour (50 minutes) and it is presented as the initial session
in a new therapeutic relationship. Prior to this session, the client will have completed an initial
assessment questionnaire and the therapist will have read this paperwork to ensure familiarity with
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the case (please refer to the assessment form online for more information). Please note that these
videos depict REAL interactions – although the session has been arranged for the purposes of the
video and the sessions will not continue after the recording, the interaction within the session is
genuine. No actors are used in this session. The client was one of the authors and the problem
presented was genuine. The therapist is an experienced practitioner in the field. The only ‘fake’
aspect of this recorded session is that the client did not really seek therapy and this is not really the
first session of a series of therapeutic contacts.
After the conclusion of the therapy session, the therapist is invited to answer a few key questions
about the session. This question and answer session lasts no longer than 10 minutes, thus the video
lasts for an approximate total of one hour.
Therapist Credentials
The therapist in the behaviour therapy session was Keith Mathews. Keith is Senior Psychological
Therapist at the Department of Clinical Psychology, Betsi Cadwalladr University Local Health
Board. Keith works in secondary care community adult mental health services, working with
individuals with complex and enduring psychological difficulties. He is trained in cognitive
behavioural psychotherapy, dialectical behavioural therapy, schema therapy and integrative
psychotherapy. He also supervises practising psychotherapists and trainee clinical psychologists. He
has taught cognitive behavioural therapy process skills on the North Wales Doctoral Programme for
Clinical Psychology and currently teaches schema therapy on the same programme. Additionally,
Keith teaches assessment and formulation skills on the Masters in Therapeutic
Counselling programme at Coleg Llandrillo Cymru. Keith is a Senior Accredited Practitioner with
the British Association for Counselling and Psychotherapy
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Client Presentation
The client in the behaviour therapy session was Fay Short. Fay has an acute fear of heights. She has
recently experienced high levels of stress at her workplace and some associated physical symptoms
(including headaches and backache). However, her primary reason for seeking therapy is a desire to
overcome an intense fear of heights. She has previously experienced person-centred therapy for a
short space of time over ten years ago, but this was unrelated to her current fears. She would like to
overcome these fears during therapy so that they no longer impact on her ability to take part in
activities that involve heights.
Transcript of Session
T denotes therapist, C denotes client.
T: Hi Fay, nice to meet you. As you know, my name’s Keith and I’m a cognitive therapist so just
before we get chatting about the difficulties that have brought you here, I just want to let you know
that today’s meeting is, of course, confidential. The limits to confidentiality are that I will be
keeping some notes just to make sure I’m up to date with what’s going on in the sessions so I can
refer to, as a record of them, but also that if there was any concerns around risk I’d need to have you
to be able to go to appropriate sources whether it’s a GP to talk about concerns, or if there’s risk to
yourself or other people. Is that acceptable?
C: Yes, that makes sense.
T: Okay. My notes are open so if there’s anything you’d like to read in them, and at the end of the
sessions I will destroy them.
C: Okay.
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T: Okay. Now you gave me a bit of information when we talked on the phone the other day about
some of your difficulties, I understand it some concerns you have around being in situations where
there’s sort of height involved.
C: Yes.
T: So what we’re going to do today, I’m going to ask a bit about the problems that you’ve been
facing, how it’s affecting you, the type of difficulties you’ve experienced in relationship to this and
how it’s affecting your life, and then try to get an idea about what’s holding the problem together so
we can start to focus on ways to try and help to overcome this problem.
C: Okay.
T: Okay, before we start is there anything you would like to ask me, is there anything you would
like to know about myself or about the therapy itself?
C: No, I think that’s clear, I think that the confidentiality thing would have been a question but
you’ve kind of covered that.
T: Okay, well if at any point during the sessions that you want to ask me about myself I’m more
than happy to share that with you. Okay. So perhaps we could start by just telling me a little bit
about your problem and how you are affected by that at the moment.
C: Okay, so as I said on the phone it’s a fear a fear of heights, and it’s, on a day-to-day basis it’s not
hugely problematic, I don’t live in a tower block or anything, but basic things like, erm, being able
to go to the top of a ladder to clean windows at the top of my house, or touch up paintwork at the
top of my house is problematic.
T: Yes. Uh, huh.
C: Travelling in lifts, if I think about it. I actually had a nightmare just remembering the other day
about being in a lift and it breaking and it plummeting, erm, so those kind of things. Generally I’m
not outside in the open air where there’s a risk of falling all that much, but for those types of
situations I suppose for me the bigger issue is when I travel so my husband and I like to travel a
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little bit and see the world a little bit, and inevitably that means either flying which involves going
up very, very high or when we visit places we always seem to end up in a situation where you need
to go to the top of something like the Eiffel Tower or a pyramid or whatever.
T: Yeah, so it sounds like it’s affecting sort of more day-to-day things like you know, sort of
cleaning your windows, things like that, but also particularly around when you go away you find
yourself in situations where, I guess, you’d rather not be in.
C: Yes.
T: Okay, okay, and it sounds like it’s affecting you in terms of the content of your dreams as well.
C: Yeah, yeah.
T: Okay. So, just to give me a little bit of an idea about when this started to become a problem for
you and your understanding about how it’s developed as a difficulty for you.
C: Okay, well, I’ve always been nervous of heights, so for as long as I can remember I’ve always
been a bit anxious about going up high and, you know, going up ladders or when you have rope
bridges and things like that, those types of things, but it’s never been a very, very strong fear. And
then about three years ago my husband and I went to Cambodia. We were volunteering over there,
but we visited the temples in Angkor Wat, an absolutely amazing place, and most of the temples
you can climb to the top and you get a view of all the surrounding countryside which is amazing.
And the way that you climb them, a lot of them are these stone steps and they were fine, I managed
with those without a problem, but there’s one particular temple and it’s completely, completely
vertical. It’s not completely vertical but it’s practically vertical, and the way you got up it, they’d
kind of bolted this wooden ladder to the side of it, and you essentially just climb this ladder. And it
was very, very, very high and the ladder wasn’t in the best condition. And so, initially my husband
was going up there and I said I’m not going and I sat out, and while I was sitting there I watched
him go up and I saw a man coming down with a baby, was carrying a baby down the ladder and I
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just, I felt so embarrassed that I couldn’t do it, and there was a guy carrying a baby, so I decided
that I was going to do it anyway.
T: Right, yeah.
C: And I climbed up the ladder and I about half way up it really hit me and I started to feel really
dizzy and I started shaking and I couldn’t breathe properly. So really I’m just absolutely terrified,
and by the time I got to the top I was crying and I think I climbed, I crawled over the top of the
ladder and just sat down on the floor and no one could move me at that point.
T: So it sounds like it’s a really distressing experience and it sounds like it was something that was
influenced by you seeing that guy climb down. It sounds like your initial sort of urge was not to go
up.
C: Yes.
T: But there was something about seeing that guy coming down, I’m just wondering, I mean it
sounds sometime ago this but do you have, do you have any recollection about what was going
through your mind when you saw this guy coming down with a baby?
C: Well I was, I was cross anyway that my husband did it and I couldn’t because I kind of feel, it’s
a little bit like anything he can do I can do as well, I mean within reason, you know, if it comes to
bravery that kind of thing, I like to think I would do, I mean not to a ridiculous extent, he could lift
something that I couldn’t lift because he’s a lot stronger than I am and that’s fine, but in terms of
when we went to the Eiffel Tower even though I don’t like heights, we went to the same level and
we always do do those things together, so I was already feeling a little bit disappointed in myself.
T: So, so at the beginning when you saw your husband going up and you’re thinking to yourself I
really prefer not to do this, there was, what were you telling yourself as he was climbing up there?
C: I was telling myself that I really don’t want to do this but I’m actually really disappointed in
myself for doing this, it’s pathetic, it’s stupid. Why can’t I go up? And then this guy is coming
down with a baby and then it’s even more stupid, there’s somebody coming down carrying, not
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even holding on properly can bring a child and, I mean, okay one of my thoughts was that guy’s
really stupid for taking a child up there, but in the main I was thinking it must be safe and I’m just
being a complete coward for refusing to go up there.
T: So on one hand you were sort of saying that guy, it’s not the best idea to do that, but on the other
hand you were sort of making quite a lot of sort of judgements and evaluations about yourself?
C: Yeah, I suppose I was, yes.
T: Okay, so I’m asking you that just to sort of get a sense of what was going on for you as you
anticipated going up this ladder in the temple. And it sounds like as you climbed the ladder there’s
lots going on for you inside yourself, physically you were noticing lots of sensations and just sort of
again I know it’s a long time ago so were there particular things that you would notice about what
was going on in your body that you were paying attention to?
C: Yes, most definitely because that was the really scary thing for me. It wasn’t, it wasn’t so much
heights, it was the fact that I couldn’t control it, so I was physically shaking and just felt really
really weak and kind of, you know, I’ve only ever fainted once in my life, but you know that feeling
where the world starts to kind of recede a little bit and you feel like you might just pass out, and
then just not being able to stop crying and that was a really scary place
T: So really really distressed, but also just for me to make sure that I’m picking up the right things
which seem to be influential in that experience, erm, you were noticing sensations and sort of
sensations you associate with fainting ...
C: Yes.
T: ... and I’m just wondering when you noticed those sensations was there any sort of thoughts
about what might happen or what would happen to you?
C: Well, I mean, given that there was no safety net or harness or anything like that, the only thing
that I could think kind of over and over again, I suppose I had two thoughts and one of them was
'This is utterly ridiculous that you are getting this wound up about something that really is quite
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simple, you’re just walking up a ladder, it’s not scary at all' and on the other hand I was thinking
'Oh my gosh, if I do actually black out I’m going to fall backwards and I’m going to probably, at
least seriously hurt myself if not kill myself'.
T: And at that point when you sort of had these two this is okay, one 'This is okay, it’s just climbing
a ladder' and the other though was 'Gee I could black out and fall backwards' imagining you think
you could hurt yourself badly ...
C: 'I’m probably going to die' is probably the thought that was going through my mind.
T: So it was really quite an intense thought.
C: Yes.
T: And can I just ask you, what we do in cognitive therapy will often ask people to rate the strength
of ideas so, you know, as that thought was running through your mind, say 10 was that it was really
believable that you really thought that was going to happen, and 0 being you didn’t really believe
that, how would you rate that from 0 to 10?
C: I would say 10, I firmly believed that I was gonna ... okay, maybe a 9 I think. I suppose if it was
a 10 I’d have probably just clung to it and refused to move, and the fact was I did keep moving ...
T: Right.
C: ... apparently the tour guide afterwards mentioned that apparently there has been a case where
they had to get out air rescue to remove someone from the top of this temple because they couldn’t
get back down again, they panicked.
T: They just froze.
C: And that didn’t happen, thank goodness, so ...
T: So, it didn’t, but to all intent and purposes you really believed that something really bad was
about to happen?
C: Yes.
T: Okay, so, and you got to the top.
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C: Yes.
T: And what happened then when you got to the top? You kind of, in a sense, disproved you were
going to fall, but was that any consolation?
C: No. No I was convinced I was going to fall going back down. I think going up something is, in a
weird way, better than going down because you’re not, you’re not looking where you’re going and
so I ended up going down backwards because then I wasn’t having to look at the drop. So when
you’re going up something you’re looking upwards and therefore you’re not thinking about the drop
behind you. Whereas coming down usually you’re more forwards, and some people were coming
down forwards, so when I say ladder it’s a complete ladder, it sticks out and it is possible to go
down forwards but it’s practically ladderish, and I didn’t, I went down backwards and clung on to it.
T: So, okay, so when you clung on to it that’s what you were doing holding on really tight. So how
did that go as you were coming down the ladder?
C: Very, very slowly.
T: Right.
C: The other people coming down, because there’s only one ladder, the other people were actually
climbing off the ladder and climbing on the rocks to get round me because it took such a long time
for me to get back to the ground.
T: So it sounds like you’ve got this really vivid image of what was happening, and the image that
you have is of you holding on really tight, taking your time I would imagine.
C: Yes.
T: And people almost climbing around you ...
C: And me swearing at them, in my head, not out loud (laughs) ... that could’ve been awkward.
T: Okay. So what was, what was running through your mind as you saw these people climbing
around you?
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C: I think I was just really, really embarrassed. Embarrassed that I was panicking this much and
really scared that I couldn’t control it, so I was just thinking that, that it’s stupid, that I should be
able to control this and that I’m not going to fall, I’m holding on, I’m perfectly capable of walking
and that’s all I’m really doing so it’s stupid for me to feel this anxious, and yet at the same time also
thinking 'Oh my gosh, if I let go for a second, that’s it, I’m going to fall'.
T: So the holding on wasn’t based on that thought 'If I let go, if I don’t hold on really tight
something really bad is going to happen to me'. It sounds like there was another train of thought
which was saying 'I’m really making a bit of a show of myself here and people are sort of really
noticing me' so feeling kind of embarrassed, yeah, okay, and uncomfortable about the situation you
found yourself in, and the other thought was along the lines of 'this is something I can do', am I right
thinking that?
C: Yeah, but in thinking 'this is something I can do' it wasn’t a positive thing, it was a 'you’re being
an idiot for not being able to do this'.
T: Right.
C: So it was a very kind of ...
T: Okay, so that’s clarified that, it was a really quite a judgemental thought.
C: Yeah.
T: Okay. So, and what happened after this ... you clearly got down ...
C: (laughs) I’m not still up there.
T: You’re not still up there ...
C: I’m very glad ...
T: So that’s good to know, and what happened after that? What sense did you make of what
happened to you?
C: Erm, the thing that really struck me was that I couldn’t control physically how I reacted.
T: Okay.
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C: And that was, that really, really frightened me because I’ve always kind of prided myself on, I’ve
always thought that in a bad situation I’d be able to talk myself round, so I’ve always thought, you
know, I might be frightened but I would be able to logic my way out of it and I’d be able to talk
myself round but the reality was I couldn’t, I was just so frightened that physically I just had a
really bad reaction.
T: Now I know this is some time ago and retrospective estimates are quite difficult to keep, one of
the things we will be doing is asking you to keep a record of these types of thoughts like you notice
in these situations. But in terms of that sort of, the thoughts that you have, and it sounds like you
have quite a lot of different thoughts you are having, which was the thought that really upset you the
most as you were, sort of, thinking about what had happened?
C: I think the fact that I couldn’t control it was probably the thing, I think if I was gonna, after the
fact obviously there isn’t the thought 'I’m going to die' because I’m no longer in that situation so
that becomes negligible but the thought that firstly 'I can’t control this', erm, secondly 'if this
happens again, again I’m not going to be able to control this' and thirdly 'oh my gosh, how
embarrassing, everybody thought I was stupid'.
T: Okay, so it sounds like there’s a few thoughts, there’s thoughts in the situation itself which is
'something really bad’s going to happen to me, I could kill myself'. Alongside that there was this
real sort of self-consciousness about how other people might see you; the thought that seemed, in
that situation at least, to be really sort of difficult for you was about being in control ...
C: Yes.
T: ... being able to control yourself. Because it sounds like, you know, you’ve always been able to,
sort of, deal with these feelings okay.
C: Yeah.
T: Okay. So, after that event, how were things for you after that event in Cambodia?
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C: Well, they were actually worse, so prior to that we’d been up several temples, and I’d been okay,
none of them were as high as that, and I’d managed. After that it just, even a slight height and I
would feel really, really anxious and just quite panicky. Even if it was like a ridiculously small
height it just, even climbing a very small ladder and then having to hop across something I just
would feel really, really anxious about it.
T: Okay, and again so when you were noticing feeling anxious what was, what sort of thoughts
were going through your mind, what were you making of that?
C: I think I was mainly embarrassed, embarrassed that I was getting this wound up again and this, I
could kind of excuse the previous one because it was very high and it was dangerous, but then it
was small heights and I was getting, I was starting to shake and feeling my breathing going and so I
was just really embarrassed and telling myself it was stupid.
T: Okay. So it sounds like again there’s lots of sort of evaluations about yourself in relationship to
those situations that you’ve been finding kind of scary, but then there’s quite, sort of, negative
judgements about yourself I guess?
C: Yes, yeah.
T: And was there anything that you’d sort of come across that you’d sort of thought could help with
these thoughts and feelings that you were having when you were in those situations, did you come
across any solutions or anything that you thought would help around that?
C: No, I suppose avoiding going up there, going on anything high. Usually if my husband’s with me
then that makes things a little bit easier.
T: So having your husband in close proximity to you.
C: Yeah, so that makes things easier, and not having other people there helps, so if I’m on my own
then I can kind of do it in my own time, and so the less people the better really, because I’m not
really thinking about other people watching me
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T: So let me just sort of sum this up then, Fay. So, following that experience in Angkor Wat there’s
been a set of sort of thoughts that you had at that experience, but it sounds like after that it
continued, you’re really sort of watchful about those feelings, how you might feel in situations and
quite aware of how you might appear. And since then it sounds like you’ve found, erm, ways to try
and minimise those concerns and those worries that you have, and one of those is by keeping your
husband, your husband’s name is?
C: Colin.
T: Colin, okay. So by having Colin close, and by staying away from other people in those situations,
that is something that you found brings your anxiety and discomfort down?
C: Yes, I think so.
T: Okay. I’m just sort of thinking, from those events back in Cambodia, can you just give me a
sense about now how it affects you and have any of those sort of thoughts have they occurred since
that time?
C: Erm, well, on a kind of ... so there’s been a couple of times, so last Christmas we went to
Australia and there were three notable occasions. One of them, we went into the water, in quite deep
sea water, and I’m not a swimmer and I’ve never really liked the water. I sound like I’m riddled
with phobias, I’m not terrified of water and I can swim, I’m just not a strong swimmer and so it
would be silly to go into dangerous water, but on this occasion I realised in the water, we were
swimming with dolphins and we got into the water, and it was just seeing the drop underneath me
and the same sort of thoughts were coming then, and my real fear was that I was just going to go
into panic and was just going to start splashing about and panicking and not being able to swim, and
that would be very embarrassing.
T: Yes, and I was going to ask you then, what was the meaning that had for you at the time. Can
you picture yourself there in the water; can you imagine yourself being there? What was running
through your mind at the time, about what people would notice, what would happen?
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C: I think what I was thinking was that if I panic one of two things would happen, I’d either drown,
which is awful because obviously drowning and dying isn’t great ...
T: Not good for your health.
C: Definitely not ... or, or I will start ridiculously thrashing about and making a complete scene and
somebody is going to have to rescue me and drag me out of the water.
T: Okay.
C: And everybody is just going to think that I’m an idiot.
T: So there’s two things that you really feared at that point, one is that you could die, okay and as
you say that’s real grounds for feeling really scared when you believe that’s going to happen, and
the other thing was actually you’re going to really stand out and you’re going to make a bit of an
idiot out of yourself and everyone will notice and pay attention to you. Okay, and what actually did
happen?
C: Er, in that particular situation the pod of dolphins came by and the second you see a dolphin
within arms reach you just, everything else just went completely out of my head and I calmed right
down, er, so I think it was a very, I think if I’d just been in water it might have been a very different
situation but it was a complete distraction, there was no way I was going to be thinking about
anything other than the fact there was this amazing creature next to me.
T: So it really sounds like when you became distracted and you started to focus your attention away
from these thoughts, actually your feelings changed quite dramatically and your anxiety levels came
down.
C: Yeah.
T: Your physical discomfort came down as well?
C: Yes.
T: Yeah, and it sounds like you started to attend and focus your attention on actually what sounds
like a fantastic experience. Erm, have you noticed anything similar, you know, in other situations
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because the themes that we seem to be talking about here is (a) is that something really bad can
happen to you in these situations which seems to have a real effect upon, physically how you feel
and emotionally how you feel and it sounds like it influences your behaviour, so for instance it
sounds like you hold on really tight or you get close to your husband, yeah? And the other one that
seems to happen is that you actually really start to be aware of other people and how you’re going to
appear towards other people, and it sounds like then, you know, you feel really uncomfortable,
really anxious. Physically I imagine you feel pretty uncomfortable too?
C: Yes.
T: What I wasn’t sure about, what is it that you do at times when you’re just aware of people and
that they might notice you. What do you do to try and manage that?
C: You mean if I’m not high, if it’s not a feeling of heights situation, so just in everyday life?
T: Well it could be either, I’m just sort of thinking in relationship to these situations, the problem
seems to be in high situations or like in the sea when you’re aware of the translucent sea and you
can see the sea floor and it’s, you become very aware of other people around you. And is there
anything that you do in that type of situation to try and manage it, or to stop it from happening,
these things such as people might start to notice you getting upset or distressed?
C: Other than avoid the situation, or try to, try to not look like I’m distressed and I think that’s what
really scared me in Cambodia because I couldn’t stop myself. So normally I would put on a brave
face and pretend I’m fine, and for the people around me, I mean usually my husband knows because
he knows me and so he will be, he will know if I’m really anxious, but to anybody else I wouldn’t
appear it, but that’s part of my job, I’m a lecturer and I don’t think there’s a lecturer alive who can
honestly say that they don't feel a little bit nervous before they get in front of 300 students and give
a lecture.
T: Yes, it’s normal to feel uncomfortable when you’re in a social situation when you are the focus
of attention ...
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C: But normally in those situations I’ve put myself there and you just take a deep breath and get on
with it, it’s fine.
T: Sure. So it sounds like it’s quite different from your day job when you actually are on show, to
situations like this, and I wonder what you’d, how you’d account for the difference between those
two different scenarios because they sound ... they have similarities but there’s quite a different
viewpoint you hold about them.
C: I guess there’s two things, one of them is I have control in one situation and I don’t have control
in the other. I have control over what I do if I’m lecturing, or in any of those situations whereas if
I’m, if I’m trying to climb something and if I’m shaking I don’t have control over that and if I’m
crying I don’t have control over that. And the other thing is competency, when I’m lecturing I know
I’m competent at what I’m doing, I’m not doing something that I think I’m at risk of failing. If I’m
trying to swim I’m at risk of looking stupid or drowning or if I’m trying to climb something I’m at
risk of panicking or crying or doing it badly.
T: Okay, so can I just reflect that back to you. So when you’re in a situation such as lecturing you
feel competent and in control and you feel confident and you are able to portray that so of 'I’m in
control, I’m capable'. It’s that situations when you feel you’re not in control and you don’t feel
competent and you’re judging yourself in some way in a negative way in terms of your
performance, that’s when you start to feel really uncomfortable and what this also seems to be
associated is that’s prompted by a fearful situation like being in a high place.
C: Yes.
T: Is that a fair summary?
C: Yeah, I think so.
T: Okay. Now, I’m just sort of thinking now in terms of helping to help you understand the process
of cognitive therapy, now I’ve been asking you lots of questions about your thoughts, and you
might be thinking why he isn’t asking me when actually the fear I have is heights, but it seems that
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actually the judgements that you make seems to be a key factor in this, about yourself in terms of
yourself in relationship to others, but also about what might happen to you as well. Now in
cognitive therapy what we’ll be looking at is these relationships between situations such as being in
these high places, and the sort of evaluations about yourself about what might happen in the future
and how other people might perceive you. They’re called triads. And what we look at in cognitive
therapy is to help you to sort of recognise how those sort of thoughts you might have about yourself
in these types of situations, how they influence your responses in terms of your emotional
responses, your behavioural responses, and what you might do to prevent some of those predictions
that you make.
C: Okay.
T: Okay, with a view that actually thoughts I guess are a hypothesis based on the best available
evidence that we have available at the time. Yes?
C: Right.
T: And I guess what you might be able to say after the event is 'actually, well I can see that quite
differently at the time'. So we need to become aware of our thinking. What we do in cognitive
therapy is to help people start to notice their thoughts and how their thoughts, they tend to sort of be
judgemental, or they might tend to may be what’s called overgeneralised, they can start to become
problematic for the person. Okay. So what we’re helping to do is help people to start to notice their
thinking patterns, so then people start to become more aware of them, with a view to help them to
start to create a, if you like, evidence for and against them so that people can come out with more
balanced thoughts.
C: Right.
T: Okay. Does that make sense?
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C: It does, so it’s about, it’s about having a more logical thought processes and balancing the
evidence that’s available so that you can make a judgement based on evidence rather than based on
bias or something.
T: And what we’re looking for is balanced thoughts, rather than negative or positive thoughts,
because sometimes positive thoughts are irrational thoughts, you know, I guess if we were to have a
party in the middle of the A55 and had a positive thought about a juggernaut coming towards us that
might not be a very helpful thought ...
C: No.
T: So what we’re looking for is a balanced thought which takes into account both sets of evidence,
you know, both in the sense of, you know, when I’m on a ladder it’s scary and it’s fearful but that is
set against the others, that actually when I’m on a ladder generally I tend to do well and I’ve got
experience and I know that I can usually manage these situations. So taking those into account
you’d arrive at a more balanced thought. Does that make sense?
C: Yeah.
T: Yeah, okay. But sometimes what also people do is what you’ve mentioned, is staying away from
situations because you anticipate that actually that is going to be something scary and difficult. So
also what we need to do is help you to sort of think about situations that you’re staying away from
because that also prevents you from finding out whether you’re able to manage those situations or
not, and also because avoidance tends to be a way of maintaining difficulties in the long term.
Okay. Now what I wanted to ask you about is actually had you considered what the goals were for
this treatment for yourself?
C: Well, I can, a long-term goal, this summer I’m hoping to go to Snowdonia, I have a friend
coming over from Australia to stay with us, and we’d like to go walking, and I feel very anxious
about the idea of going up mountains. Obviously walking, and hills and things seem fine, but the
idea that it might be kind of rocky, unstable terrain and then there might be a sheer drop and I might
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have to walk along the edge of that drop. So I guess a goal for me in the long term being able to do
that without, because loads of people do that so I guess looking, thinking about balance, that’s
sensible to be able to do that. I’m not suggesting going rock climbing because I don’t think that’s
something that I would want to do but, to just to be able to do that without feeling terrified.
T: So something that you aspire to do this year with your friend coming over from Australia is to be
able to go for a walk, and be able to sort of do that with a degree of calmness.
C: Yeah.
T: Yeah, okay. When you think about that now, what thoughts does that bring to mind, what sort of
ideas does it generate?
C: Erm, I can imagine getting half way up, with the aim being to get to the very top and having to
cross an area that has a sheer drop and just not being able to do it.
T: Right.
C: And the thought of my friend being there and me not being able to breathe and shaking and just
having to turn back, I just think that he would think that I’m just really stupid, and that’s just a
really ridiculous thing to happen.
T: Right, so again there’s quite a lot of predictions which sound quite similar to the ones you’ve told
me about just now, that actually there’s two parts, there’s (a) that you would lose control and (b)
that actually people with you would then judge you, and the consequences of that I guess. Okay, is
that a fair summary?
C: Yes, I think so, yeah.
T: Yeah, okay. So in terms of the actual problem, how frequently are you getting these difficulties,
what sort of problems are they bringing to your day-to-day life?
C: In general they’re not a huge day-to-day thing as I’m not often up high, but for really practical
things, just really simple things like being able to go up a ladder at home to be able to change a light
bulb, or clean the upstairs windows, those kinds of things I just, I won’t do those things.
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T: So in terms of the longer term goal like maybe going for a walk in the mountains when friends
are around and so forth, but I’m just wondering, is being able to do some of these sort of things that
you’re currently staying from, is that something else as well?
C: I think so, yeah, being able to do it comfortably so, I think that I would if, if I didn’t have
somebody else to do it I probably would do it. I wouldn’t allow my windows to get dirty, but I think
being able to do it without the, the big build-up and the fear that comes with it would be a good
goal.
T: Okay. So now I’m just thinking in terms of the sort of problems that were identified to you in
this chat we’ve had so far, then there’s definitely clear fears of certain situations. Alongside those
sort of situational fears, which I guess are called phobias, there’s also the thinking we’ve identified
in relationship to judgements about yourself coming to some sort of sticky end, in which you are
going to come to some harm, serious harm. There’s the thoughts about how you might be perceived
by others and what you try to do to prevent that from happening, and it feels like you’ve also
developed a set of behaviours to try and prevent those things from happening, okay. That seems to
me, from what you’ve told me, as being the presenting difficulties. Is there any problems that I
haven’t touched on which you feel are, which would help me understand what the overall problems
are?
C: No I think, I think that seems to be all of it, the not being in control is a big thing and the other
people thinking that I’m, that that’s ridiculous and thinking that I’m stupid for not being in control
is a big thing. And, yeah I think that you’ve kind of covered that.
T: So if we were to sort of prioritise them as you like our problem list and we focus on those, we
will need to prioritise which you’d like to look at first so we can work on ones which are key for
you to overcome.
C: Okay.
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T: Now what I’m also mindful of is about you know people come to therapy but often they don’t
often know the ins and outs of what the therapy is about so would it be helpful if I was to just sort of
go over what you’d expect from therapy?
C: Yes. That would be good.
T: Okay, cognitive therapy tends to be a short-term therapy, that’s why we sort of need to think
about what your goals are, and also to actually identify clear problems, so that we can link the goals
to the problem, so that we’re helping you to work towards something that you want to change. Now,
cognitive therapy is very much an interactive therapy, it’s not something I do to you, it’s, it’s a
collaborative based approach, and the idea of cognitive therapy, it’s a bit like the analogy that’s
often used is, you know, with a runner they might have a coach, but the coach doesn’t do the
running. The coach helps them to identify problems in sort of their behaviour because the goal is to
run an effective race. But sometimes actually running that race is hindered by certain things that we
might do. So my role as a therapist is really to act as a coach to help to identify areas in relationship
to these problems that we can fine tune and make changes in so that you can actually run this race
more effectively. Okay, does that make sense?
C: Yeah, that makes a lot of sense.
T: And part of that, is actually it’s really important that you can give feedback to me and that we
can generate ideas to help you to overcome this so I can come up with ideas, but you can come up
with ideas, with a view to helping you to check out your thinking.
C: Right.
T: Yeah, in terms of some of the ideas you have, some of the thoughts that you might have about
these particular situations that you fear, that you’ve learnt to fear. But also to help you test those
thoughts out, so we’ll be doing things like asking you to keep thought records and diaries, noticing
the type of thinking that happens when you’re introduced to these situations, and noticing how you
respond as a consequence of those thoughts. Does that make sense?
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C: Yes. When you say 'to test the thoughts out' what do you mean by that?
T: Well for instance what can sometimes be very helpful is that when people you know might have
sort of a judgement about sort of this might happen for instance you know 'I’m going to make a fool
out of myself', 'I might get really noticed' then actually what we encourage people to do is to think
of that like a hypothesis you know so it’s like 'I worry that if I do this I’m going to get noticed'
rather than 'if I do this I will be noticed', so to tell the difference between like a worry and actually
an event.
C: Right.
T: So it’s to help to test the thoughts out, to gather evidence for the thought, if it’s accurate or not.
And if it’s not accurate, what might be a more accurate thought so we can update our thinking of it
really, yeah. Does that make sense?
C: Yeah, yes it does.
T: Okay, is there anything that we’ve talked about so far that you’re not sure about?
C: No, no I think, I think I’ve followed pretty much everything that you’ve said.
T: So part of what we’ll do is about introducing you to situations that you fear, helping you to keep
a record of your thinking, helping to help you to develop skills in testing out your thoughts and
replacing those thoughts with more sort of balanced thoughts if you like, with a view that ultimately
that the role is that you become your own coach ...
C: Right.
T: ... so that I become redundant. The whole idea is that you sack me in the end.
C: Right.
T: But with the skills to be able to do this yourself. So that’s why cognitive therapy is short term,
fairly short term, and what we’re talking about short term is about up to ten sessions.
C: Right.
T: Okay, is that within what you’d expected?
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C: Yes, I think so, yeah.
T: Okay. Now the sessions are usually once a week and usually last for 50 minutes, and we meet
here and we use the sessions to refocus our attention to understand the problem, to develop an
understanding of the problem which is called formulation and then we use that like a psychological
map of the problem, so we use that to inform how we go about the treatment. So the first few
sessions will be gathering information, so keeping diaries, keeping sort of observational records of
your thoughts and how you responded to your thoughts, and then once we’ve got a really good idea
about what’s going on, to help you to try and test out some of those thoughts. So you can update
your beliefs about what might happen to you either in relationship to what might happen in the
future, how people might view you, and also to help you to be a bit more sort of kind towards
yourself in terms of the judgements that you make as well because it sounds like you can be quite
harsh on yourself at times. Does that make sense?
C: Yes, yeah, so it would be keeping diaries of the things I think about and then bringing them to
this session so that we can talk about that and identify problems and those thoughts and then maybe
testing out thoughts to see if they are actually true or not.
T: That’s spot on, yeah that’s great. Now what I’ve got with me, is because I knew that you had
some difficulties with situations which are often termed phobias, I’ve brought some information for
you to take away to read to give you an idea about how phobias develop and how they are
maintained, but also some information about cognitive therapy so you can sort of gen up on it so
you can become more aware of it and ultimately to become skilled at applying this to yourself. How
does that sound?
C: That sounds good, yeah, it’ll be good to learn a little bit more about it.
T: Yeah, okay. We’ve got about two or three minutes left, is there anything you’d like to tell me
about the problem that we haven’t covered so far? Is there anything that we haven’t touched on?
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C: Erm, no I think, I think it’s been really helpful to kind of think about those thoughts that I’ve had
and it’s, I’ve never really thought about it in those terms before, so it’s been really interesting to
think about it in terms of the lack of control and other people's reactions to that, and what I think
about the lack of control and other people's reactions to that, so I think that’s been really interesting
but we’ve covered pretty much everything now.
T: Okay. Well how about if we actually set a time maybe next week when we can get together to
talk about it in a bit more detail?
C: That sounds good.
T: Okay.
Analysis of Session
The therapy session can be sectioned as follows.
Introduction
Introduction outlining basic contractual details, especially the limits of confidentiality
Focus specifically on the problem presented by the client and an outline of the intended
coverage in the session (map of the session)
Invitation to ask questions
Story
Client is invited to explain how the problem began, how the problem has developed over
time, and how the problem impacts on current life
Focus on thoughts experienced during experiences of the problem, including rating the
strength of the cognition
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Goals
Cognitive therapy is explained in terms of how thoughts can influence our feelings and
behaviours
Explained how thoughts can be tested for validity to reduce problem cognitions
Identified a specific goal for therapy in the near future
Ending
Outlined the expected duration and content of future sessions (map of the sessions)
Explained that homework will be set each session, such as experiments to test validity of
thought processes and diaries to record thoughts
Set readings as an initial homework
Reflection on how the session was experienced by the client
Invitation to return for future sessions
Key questions to consider in relation to this therapy session
How could the nature of this client be understood from the cognitive perspective?
What does the client appear to think about herself?
What does the client appear to think about the world?
What does the client appear to think about the future?
Does the client hold a positive or negative view of herself, the world and the future?
Does the client hold thoughts based on available evidence?
Is there any indication of any cognitive distortions?
How do the thoughts held by the client impact on her feelings and behaviours?
What is the nature of the therapeutic relationship in this cognitive therapy session?
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Is the therapist honest and open?
Does the therapist have a good rapport with the client?
Does the therapist challenge any cognition held by the client?
Are there any positive or negative effects of challenges to the cognition held by the
client?
Does the therapist suggest any experiments to test cognitions?
Which cognitive techniques are demonstrated in this therapy session?
Which Socratic questions does the therapist use?
How does the client respond to Socratic questions?
How does the therapist encourage the client to identify cognitive distortions?
How does the therapist encourage the client to defend the cognitive distortions?
Does the therapist test any cognition for validity and what is the outcome of this test?
Personal experience of the client
I felt a little bit anxious about this session because it was my first experience of cognitive therapy as
a client (and I was a little worried about being filmed disclosing potentially personal information!).
However, my fears began to reduce as soon as I started talking to Keith. We established a good
rapport and I felt comfortable sharing my experiences with him. He seemed to be genuinely
interested in my story, and this was contrary to my expectations (I had previously experienced
person-centred therapy and I thought that cognitive therapy might be less relationship focused and
more business-like).
I shared my story with Keith at the start of the session and I quickly forgot about the camera. I
found his questions both engaging and frustrating at times – I often wanted to talk about how
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something ‘felt’ but he kept drawing me back to my thought processes. Although this was initially
rather challenging, I did begin to see the value of this focus as he started to explain the way that my
thoughts can impact on my feelings. His explanations in the later part of the session were
particularly helpful and I think that I gained a good understanding of how my thoughts are helping
to maintain my problem.
During this session, I realised several things for the first time. In particular, I realised that one of my
primary concerns about heights relates directly to my own self-confidence. I have a firm belief
about myself – I will look stupid if I panic – and this thought leads me to evaluate myself in a
negative way. This means that I feel a strong need to constantly maintain control over myself and
the wider world, and I recognised that this is both irrational and impossible. This increased
understanding of my own fears has helped me to understand my anxiety a little better, and I now
realise that it is only by facing this fear that I might be able to ‘prove’ to myself that it is not always
‘stupid’ to lose control. Alongside my low self-confidence and need for control, I also realised that I
hold a more legitimate fear of falling. This seemed very sensible to me at the start of the session
(and I guess that I believed that this was why my phobia was justified). However, during the
session, it became clear to me that my fear is far more exaggerated than is reasonable in the
circumstances.
At the end of the session, I had a clear understanding about cognitive therapy and a road plan for the
future sessions. I was confident about my ability to tackle my concerns and I actually felt quite
eager to get started on some of the readings suggested in the session.
Fay Short
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