1 TMA (CASE STUDY)

INTRODUCTION: REFERRAL FROM DOCTOR AKHTAR (GENERAL PRACTIONER) REGARDING HIS PATIENT ; OSMAN VIKRAM, AGED 30, DIAGNOSED WITH SEVERE REACTIVE DEPRESSION AND ANXIETY. REFERRAL TO CBT COUNSELLOR, MR ADAM RUSSELL (NHS CBT COUNSELLOR ) AT GLASGOW STOBHILL HOSPITAL. MR RUSSELL HAS TO DETERMINE IF THIS IS AN APPROPRIATE REFERRAL FOR CBT. MR RUSSELL SEEKS AND CONSULTS WITH DOCTOR AKHTAR TO GAIN INFORMATION, PERTAINING TO ELEMENTS OF OSMAN'S CASE. TO DEDUCE A FORMULATION , ORIGINS,PRECIPITANTS AND PROBLEMS. DETAILS OF OSMAN'S PERSONAL AND FAMILY HISTORY. GATHERING THIS DATA, MR RUSSELL DECIDES THAT OSMAN'S QUALITY OF LIFE AND HIS EMOTIONAL WELL BEING COULD BENEFIT FROM CBT. MR RUSSELL ASKS FOR OSMAN'S CONSENT TO SEND HIM A COLLECTIVE QUESTIONAIRE TO COMPLETE AND RETURN. ( COLLECTIVE, SYMPTON CHECK LIST, BDI (BECK-1979), FSI (DAVIDSON, THOMAS & MARTINEZ-2006), ASKING DETAILS OF TRAUMA, FAMILY & SOCIAL BACK GROUND.ALSO INCLUDED A TREATMENT & EVALUATION AGREEMENT, OUTLINING CONFIDENTIALITY , THE THERAPISTS QUALIFICATIONS AND ALL INFORMATION REQUIRED FOR OSMAN'S INFORMED CONSENT. MR RUSSELL PREPARES TO OFFER OSMAN AN INITIAL INTERVIEW, ENSURING IT IS IN PLEASANT/PRIVATE SURROUNDINGS, TWO COMFORTABLE CHAIRS FACING EACH OTHER. MR RUSSELL DRESSES IN A CASUAL FASHION, PREPARING TO USE POSITIVE BODY LANGUAGE, EMPATHY AND CONGRUENCE. THE FOREMOST AIMS IN THE FIRST INTERVIEW TO ESTABLISH A COLLABORATIVE AGREEMENT OF POSSIBLE TREATMENT, INITIAL DIAGNOSTIC HYPOTHESES TO DEVELOP A WORKING PARTNERSHIP. WHEN OSMAN ARRIVES MR RUSSELL GREETS HIM IN A WARM/REASSURING MANNER.

MR RUSSELL STATES OSMAN SHOULD CALL HIM ADAM AND ASKS IF THEY CAN SPEND THE FIRST 10 MINUTES, TO REVIEW THE QUESTIONAIRE. THE DATA REVEALS OSMAN IS A BRIGHT STUDENT AT GLASGOW UNIVERSITY, STUDYING ORGANIC CHEMISTERY, HE HAD MET AND FELL IN LOVE WITH A FELLOW STUDENT, ALICIA, AGED 25. OSMAN'S FAMILY ARE DEVOUT MUSLIMS AND DO NOT APPROVE OF OSMAN'S RELATIONSHIP WITH ALICIA. AS THEY HAD AN ARRANGED MARRIAGED IN MIND, OSMAN IS SEVERELY DEPRESSED AND AGITATED AS THE DEGREE OF HIS FAMILY'S HOSTILITY IMPLIED THREATS TOWARD OSMAN AND ALICIA FROM HIS FATHER AND 2 ELDER BROTHERS. OSMAN HAS DIFFICULTY COPING, FEELING SCARED, FATIGUED AND STRESSED., 2 OSMAN ALSO EXPRESSED SUICIDAL THOUGHTS, TAKING TO DRINKING FEELING SOMETHING TERRIBLE WAS GOING TO HAPPEN TO ALICIA AND HIM. AS ADAM MOVED ON TO THE INTERVIEW, HE FOUND OSMAN , BRIGHT, VERY AGITATED AND NERVOUS. ADAM RELATES HOW HE IS A CBT COUSELLOR, HOW HE WILL EXPLAIN THE CBT/ABC METHOD, REASSURING OSMAN THERE IS NO COMMITMENT AT THIS STAGE. ADAM EXPLAINS GENTLY HIS 'EXPERTISE' AND HOW HE IS QUALIFIED TO PRACTICE CBT. REASSURING OSMAN BY CONVEYING POSTIVE REGARD, BODY LANGUAGE AND A 'LISTENING' EAR. OSMAN STARTS TO OPEN UP AND RELAYS HIS PREDICAMENT, HIS FAMILY'S DECLARATION THAT OSMAN HAS BROUGHT DISGRACE ON THE FAMILY'S HONOUR, BY BEING ' INVOLVED WITH ALICIA. HOW THE COMMUNITY WILL 'JUDGE' THEM AND THE GREAT SHAME THEY WILL ENDURE. ADAM HAS TO PREPARE OSMAN FOR THE GUIDED/AGREED PATH IN THE CBT JOURNEY, HE CONVEYS TO OSMAN IT MAY BE A DIFFICULT,

DISTRESSING PROCESS, BUT THAT ADAM IS A 'MIRROR' TO OSMAN'S INFERENCES, THOUGHTS AND EMOTIONS. TO USE 'OPEN QUESTIONING' TO PROBE AND DELVE INTO OSMAN'S DYSFUNSTIONAL THOUGHTS AND THE PARTICULAR ONES THAT LEAD TO OSMAN'S SPECIFIC EMOTIONAL/BEHAVIOURAL PROBLEMS ? ADHERING TO THE TIME TABLE OF THE SESSIONS (1 HOUR) HOW DRDT'S WILL BE USED, AGREED HOME WORK. SO ADAM KNOWS EXACTLY WHAT PATH THE SESSIONS WILL TAKE TO BENEFIT AND EVENTUALLY EMPOWER OSMAN. THE FACTUAL DATA IS ESSENTIAL BUT NOT AS VITAL OR EQUAL TO THE UNDERSTANDING/EMPATHY WITH OSMAN. ADAM HAS TO ADHERE TO THE 'CBT TOOL BOX' AT HIS DISPOSAL, THEORY AND CONCEPTUALIZATION, HE NEEDS TO KNOW HOW TO GO BEYOND MERE DIAGNOSIS TO ARRIVE AT AN UNDERSTANDING WITHIN THE CBT METHOD OF WHY OSMAN HAS HIS DEFINED PROBLEMS. ADAM HAS TO GATHER MORE DATA ON OSMAN'S THOUGHTS AND EMOTIONS. ADAM POSTULATES THE ACTIVATING EVENT IS HIS FAMILYS HOSTILITY CONCERNING HIS RELATIONSHIP WITH ALICIA, THE COGNITIVE MODEL (BECK) SITUATIONS/EVENTS-EMOTIONS/BEHAVIOURS-PHYSIOLOGICAL RESPONSES. INTERMEDIATE BELIEF-CORE BELIEF. CONSEQUENCES; LOSE OF FAMILY, IMPLIED VIOLENCE IF OSMAN DEFIES THEM. OR GOING ALONG WITH THE ARRANGED MARRIAGE AND LOSING ALICIA WHO HE LOVES. ADAM WILL USE GHERKINS MODEL TO REVIEW THE TENSIONS/STRESSORS AFFECTING OSMAN (SELF), FAMILY/COMMUNITY (SOCIETY) GOD (ALLAH & OSMAN'S PERSONAL FAITH.) OSMAN HAS TO TAKE AN ACTIVE ROLE IN HIS TREATMENT , HE WILL BE TAUGHT TO BE PREPARED TO QUESTION HIS THOUGHTS/EMOTIONS DURING THIS STRESSFUL, DIFFICULT TIME. CBT AIMS TO WORK ON A 'DEEPER' LEVEL THROUGH THE EXAMINATION 3 AND ANALYSIS OF NEGATIVE THOUGHTS AND EMOTIONAL EXPERIENCES. ADAM AND OSMAN , BOTH COME TO THE CONCLUSION THAT OSMAN HAS

CERTAIN SCHEMATA'S. (BECK,PEARSON 1994). THESE INFERENCES ARE THE UNDER PINNING COGNITIVE FOCUSES THAT BUILD OSMAN'S EXPERIENCES. IN THE FORM AS ' IF/OR/THEN' BIAS OR DISTORTION IN THINKING. THEY ARE THE CORNER STONE OF NEGATIVE AUTOMATIC THOUGHTS/EMOTIONS. WHEN ADAM CAN GENTLY GUIDE OSMAN THROUGH THE CBT/ABC JOURNEY THEY CAN BE IDENTIFIED , THEIR VALIDITY (PROS AND CONS) WITH THE RELEVANT EVIDENCE. AFTER AN AGREED PERIOD AND THE EMPOWERMENT OF OSMAN CAN BE ACHIEVED. AS CBT IS A SKILLS BASED , COGNITIVE THERAPY , OSMAN WILL LEARN SELF MONITORING AND BE SHOWN AND TAUGHT THE CBT SKILLS TO ADDRESS AND DEAL WITH HIS DEPRESSION AND ANXIETY. ADAM WOULD ALSO PROBE AND EXAMINE UNDER LYING ANGER/RAGE ISSUES THAT FUEL OSMAN'S COGNITIVE ERRORS. PERHAPS USING ROLE PLAY TO UNDERSTAND HIS FAMILY'S MOTIVES , THE FUNCTIONS AND EMOTIVE INFERENCES THAT ARE HAVING SUCH AN ACUTE AFFECT ON HIM. THUS TAKING OSMAN TOWARD A BEGINNING,MIDDLE AND REALISTIC/POSITIVE CONCLUSION. THIS IS THE CBT/ABC MODEL, AS ADAM AS THE COUNSELLOR PLACES HIMSELF IN OSMAN'S EMOTIONAL 'SKIN' PLACING HIM AT THE CENTRE OF OSMAN'S IDENTITY, AS THIS IS DELICATE AND ESSENTIAL TO EMPOWER THE CONGRUENCE AND EMPATHIC ABILITY TO 'LISTEN' TO REACH UNCONDITIONAL ACCEPTANCE REVIEWING THE 'ROGERIAN' INNOVATION AND POSITIVE REGARD. WORKING IN A FACILATING ATMOSPHERE AND ONGOING COGNITIVE EDUCATION. THE EXAMINATION AND REVIEW OF OSMAN'S DRDT'S AND HOME WORK BRINGS TO THE SURFACE THE EXPECTED OBEDIENCE, NOT QUESTIONING THE WISHES AND ORDERS OF HIS FAMILY, WITH IN AN AUTHORITARIAN CONTEXT. SON'S ARE EXPECTED TO OBEY AND NOT QUESTION THE FAMILY. IT IS NOT A RELIGIOUS IMPERATIVE BUT A CULTURAL ONE. THE 'STRUGGLE' BETWEEN PARENTAL LOVE/LOYALTY AND THE LOVE

FOR ALICIA CAUSED EXTREME DISTRESS AND EMOTIONAL TURMOIL FOR OSMAN THE BUILD UP OF FEAR/ANGER TOWARD HIS FATHER AND BROTHERS. INFERENCES THAT PLACED OSMAN IN A TEARING/IMPOSSIBLE DILEMMA. THE STRONG CONTENT OF CONFLICTING EMOTIONS/NEGATIVE THOUGHTS. TO CRITICALLY EVALUATE THE CBT SKILLS, THE TRANSFERENCE AND SOCRATIC QUESTIONING TO ENABLE THE UNCONSCIOUS TRANSFER OF REPRESSED, THOUGHTS/EMOTIONS, THE THERAPIST IS AN ' EMOTIONAL' DETECTIVE TO PROMPT AND ASK THE 'RIGHT' QUESTIONS TO UNLOCK THE CORE BELIEFS. 4 SO THAT THE CLIENT IS EMPOWERED AND BECOMES THEIR OWN COUSELLOR. WORKING THROUGH THE MAZE OF THEIR CONFLICTED EXPERIENCE AND TO ENABLE A RESOLUTION AS TO HOW THESE 'THOUGHTS/NEGATIVE EMOTIONS IMPACT ON THEIR LIFE. THE JOB OF THE COUNSELLOR IS TO BE PRECISE, EMPATHIC, GENTLE AND ENGAGE IN AN AGREED EDUCATIONAL, ACTIVE ROLE THAT GUIDES AND ENCOURAGES THE CLIENT. CBT NEEDS TO FOCUS ON THE 'NOW' THROUGH AN EXPLORATION OF THE CLIENTS EMOTIONS/THOUGHTS, BELIEFS, ATTITUDE AND RESULTANT BEHAVIOUR. THE CLIENT IS SHOWN AND TAUGHT VIA CBT TO THINK IN A MORE CONSTRUCTIVE, REALISTIC WAY TO CHANGE THE NEGATIVE 'THINKING' WITH PRACTICAL AND POSITIVE APPROACHES TO LIFES PROBLEMS. CBT IS AFTER ALL A PURELY JOINT/AGREED VENTURE TO ASSIST AND EMPOWER THE CLIENT. AARON BECK THE 'FATHER' OF CBT CONCLUDED THROUGH HIS CLINICAL, PRACTICE THAT PEOPLE WITH DEPRESSION/ANXIETY WERE PRONE TO EXHIBIT RECURRANT LIFE INFERENCES/HISTORY OF LOSS, ANGER, RESENTMENT AND A VARIANT OF NEGATIVE THOUGHTS/EMOTIONS. LEADING INTO UNHELPFUL ACTIONS i.e. OVER-GENERALISATION, ETC, VICIOUS CIRCLES OF MALADAPTIVE ATTITUDES/THOUGHTS AND EMOTIONS. SPECIFIC, GENTLE QUESTIONING TO AID THE CLIENT TO EXAMINE AND REACH A POSITIVE RATIONALE TO CHALLENGE NEGATIVE/THOUGHTS

AND EMOTIONS. WILLIS & SANDERS,TRANSFORMING THE IMAGE,1997, CITE DISTRACTION AS VERY AFFECTIVE TO AID CLIENTS WITH DEPRESSION/ANXIETY, HELPING THEM TO NOT FOCUS ON NEGATIVE THOUGHTS BY DOING A PRACTICAL TASK , PROBLEM SOLVING CAN ENCOURAGE CLIENTS TO ACHIEVE A MORE POSITIVE/REALISTIC CONCLUSION TO DEPRESSION/ ANXIETY VIA SETTING TASKS AND GOALS, THIS CAN BE AN ESSENTIAL PART OF THE CBT 'MACHINE'. THE CLIENTS NEW WAY OF RESPONSIVE/POSITIVE THINKING TO VIEW THEIR REALITY. CAUSING THE NEGATIVE THOUGHTS/EMOTIONS AND MALADAPTIVE BEHAVIOUR TO DIMINISH AND FADE THROUGH THE ONGOING CBT METHOD. D.G. MYERS 2004, EXPLORING PSYCHOLOGY STATES THAT ALL THERAPY APPEARS TO OFFER CLIENTS A POSSIBLE EXPLANATION OF THEIR PROBLEMS AND THE REALISTIC WAYS OF VIEWING THEIR INTERNAL/.EXTERNAL WORLD. THE COUNSELLOR ARMED WITH SENSITIVITY/CARING/POSITIVE REGARD USING HOPE, TRUST,COMPASSION AND THE ABILITY TO DON THE CLIENTS 'EMOTIONAL' SUIT , WHILE EXTENDING THEIR OWN SENSE OF SELF. THE NATURE AND GIFT TO EMPOWER THE CLIENT IS VITAL IN CBT. , SCHEDULING ACTIVITES, SELF MONITORING ENSURES AND PROMOTES ONGOING HOME WORK, EVEN WHEN THE CLIENT IS RELUCTANT OR AVOIDS AGREED DRDTS OR HOMEWORK. 5 THE COUNSELLOR GUIDES THE CLIENT TOWARD A 'FEEL GOOD' FACTOR IN ACHIEVABLE TASKS. THE CLIENT/COUNSELLOR WORK TOGETHER TO RESOLVE ANY 'STUMBLING BLOCKS' IN THE ONGOING SESSIONS. THERE CAN BE NO LACK OF CLARITY FROM THE COUNSELLOR IN EXPLAINING, SOLVING,AIDING AND GUIDING THE CLIENT. THE COUNSELLOR HAS TO ASSUME RESPONSIBILITY AND ADJUST TREATMENT-,

'CUTTING THE CLOTH' AS REQUIRED. SCHEDULED ACTIVITIES CAN BE VIEWED AS BEING ASSOCIATED WITH PLEASURE OR GOOD MOOD,IN SELF MONITORING,THOSE THAT APPEAR DIFFICULT AND NEED GENTLE REVISION, THOSE THAT OFFER AND DELIVER NEW INSIGHTS INTO THE CLIENTS PROBLEM AND AID ONGOING PROGRESS. OBSTACLES ARE REVIEWED, DISCUSSED AND AN AGREED AGENDA IS WORKED ON. THE COUNSELLOR COULD CONSIDER USING AND APPLYING AGREED GRADED TASKS MAKING IT EASIER TO MOVE ON, EASING THE CLIENT TOWARD MORE COMPLEX HOME WORK. 'SUCCESS THERAPY' IN A WAY, ENSURING A GENTLE CONTINUATION OF THE CBT METHOD. DRDTS CAN ILLUSTRATE AND PIN POINT THE CLIENTS 'FEELING/THOUGHTS' NOTING THE TIMES AND FEELINGS , MOODS BE THEY MALADAPTIVE, UPSETTING,BLEAK AND IRRATIONAL. THE COUNSELLOR QUERIES THESE PROCESS RATIONAL/POSITIVE OUT COMES TO AID AND EMPOWER THE CLIENT. PRECISE , DELICATE QUESTIONING TO RESOLVE THE INITIAL CONCERNS, TO LOCATE 'KEY' MEANINGS TO ARRIVE AT THE CORRECT CORE BELIEFS. THE DRDT WILL BE 'WORKED ON' USED INDEPENDENTLY BY THE CLIENT. AS THERAPY PROGRESSES IN AGREEMENT WITH THE COUNSELLOR, THE CLIENT CAN RETAIN THE ABILITY TO EXAMINE AND QUESTION THEIR OWN MALADAPTIVE THOUGHTS AND FEELINGS, THE VITAL QUESTIONS ARE: WHAT IS THE EVIDENCE FOR AND AGAINST THE BELIEF ? WHAT ARE THE POSSIBLE INTEREPRETATIONS OF THE EVENT/SITUATION ? WHAT ARE THE GENUINE, REAL IMPLICATIONS, IF THE BELIEF IS ACCURATE ? THESE CAN BE MODIFIED TO SUIT THE CLIENT NEEDS. (COGNITIVETHERAPY & RESEARCH, M.E. ADDISON , N. JACOBSON ,1996) STATED A 12 WEEK COURSE OF CBT WITH BEHAVIOURAL METHODS, ACHIEVED RESULTS SIMILAR TO THOSE IN AN OTHER 12 WEEK COURSE, THAT USED CBT METHODS IN ADDITION TO PURELY BEHAVIOURAL ONES. WHERE THESE METHODS HAD PREVIOUSLY BEEN THOUGHT OF AS SUPPLEMENTARY IN CBT , THERE USE AND APPLICATION CAN BE VERY USEFUL IN TREATMENT. DRDTS/SELF MONITORING CAN SHOW A 'RECORD' OF RELEVANT BAD

OR GOOD EVENTS THAT CAN BE DISCUSSED IN THE ONGOING CBT SESSIONS. THE COUNSELLOR CAN PROBE AND ASK THE CLIENT TO RECALL THEIR THOUGHTS AND FEELINGS AT A PARTICULAR TIME. SINCE MEMORY IT'S SELF CAN BE SELECTIVE , THE CLIENT MAY OMIT DETAILS, WHERE AS THE DRDT IS AFFECTIVE AND CAN BE PRECISE. 6 AN ACCOMPANYING APPROACH INVOLVES THE COUNSELLOR LEARNING THE CLIENT TO REVIEW AND RECOGNIZE WHEN THEIR 'THINKING'. RUMINATIONS GO INTO PATTERNS OF COGNITIVE ERRORS. WHERE 'EXAGGERATION', 'LABELLING' AND OTHER BIASED THOUGHTS CAN OCCUR, THE CLIENT CAN USED THE 3 'QUESTIONS (WHAT IS THE EVIDENCE ETC) TO REFRAME AND EXAMINE EXTREME INFERENCES. BEING ABLE TO ANALYSE THEM TO VIEW THEM IN A MORE REALISTIC, POSITIVE WAY. THE DRDT SHOWS , DATE, SITUATION, EMOTION, AUTOMATIC THOUGHTS, ALTERNATIVE RESPONSES AND OUTCOME. THE DATA THE COUNSELLOR REQUIRES TO FOLLOW THROUGH THE AGREED SESSIONS/AGENDA OF CBT TREATMENT. APPLICATION OF CORE CBT SKILLS AS FORMULATED BY AARON BECK, AMERICAN PSYCHIATRIST,PROFFESSOR EMERITUS AT PENNSYLVIA UNIVERSITY DEVELOPED CBT DURING THE 1960'S. HIS BOOK, 'THE CURRENT STATE OF COGNITIVE THERAPY, A 40 YEAR RETROSPECTIVE, 2005. ALSO ALBERT ELLIS'S RBT WORK & CARL ROGER'S UNCONDITIONAL POSITIVE REGARD WORK SHOWS THE DEPTH AND DEGREE OF WORK THAT THEY CREATED, BUILDING THE 'BRICKS AND MORTAR' OF CBT, THERE IS NO DOUBT OF THE GENUINE CREDIT AND ACKNOWLEDGEMENT THAT A THEY ACHIEVED. WITH OUT THEIR CREATIVE , INCISIVE WORK CBT WOULD NOT STAND OUT AS IT DOES TODAY AS A RELIANT AND TESTED PROCEDURE OF COGNITIVE THERAPY. THE COUNSELLOR HAS THIS WORK TO DELVE INTO TO USE AND GUIDE THE CLIENT THROUGH, A GENTLE, AGREED COURSE OF CBT. CLINICAL, DIRECT RESEARCH OF THE CLIENTS THOUGHTS/FEELINGS, BEING ABLE TO 'SEE' AND 'FEEL' AS THE CLIENT DOES IN AN EMPATHIC SENSE ENABLES THE COUNSELLOR TO DIRECT AND ASSIST THE CLIENT IN THE CBT/ABC METHOD.

A BECK CREATED THE RAW TOOLS FOR COUNSELLORS, OTHERS HAVE ENHANCED AND MOVED THE PROCESS FURTHER, NO DOUBT IN THE FUTURE CBT WILL CONTINUE TO EVOLVE AND ADAPT AS AN 'ORGANIC' THERAPY TRIED AND TESTED PROCEDURES THAT THE COUNSELLOR CAN USE, A SPECTRUM OF TREATMENT FROM DRDTS TO ROLE PLAYING. THE COUSELLOR USES DEFINING,DESCRIBING, EVALUATING, LOGICAL AND THOROUGH TECHNIQUES I.E SOCRATIC QUESTIONING TO PROBE THE CLIENTS INTERNAL WORLD, THE 'MINE SHAFT' OF THEIR NATS AND RESULTANT BEHAVIOUR, BE IT DEPRESSION, LOW SELF ESTEEM, ANXIETY ETC. (COGNITIVE BEHAVIOURAL COUNSELLING IN ACTION, 2011) CREATES A STEP BY STEP FRAMEWORK FOR THE COUNSELLOR TO USE AND PLAN CBT TREATMENT FOR THE CLIENT. LISTING THE COUNSELLORS TASKS ON THE CLIENT/COUNSELLOR AGREED CBT SESSIONS. EFFECTIVE TRAINING IS ONLY ONE PART OF THIS PROCESS AS A BECK REITERATED THE COUNSELLOR HAS TO DEVELOP 'POSITIVE REGARD' TOWARD THE CLIENT. THE CLIENT HAS TO BE ABLE TO PUT THEIR TRUST AND VULNERBILITY IN THE COUNSELLORS 'HANDS'. 7 THIS CANNOT BE UNDERSTATED OR MISCONSTRUED BY THE COUNSELLOR AS IT COULD RESULT IN TAKING THE CLIENT OFF ON AN OBLIQUE PATH FROM THE PROPER COURSE OF CBT. THIS TAKES US BACK TO ADAM AND OSMAN'S CBT SESSIONS, THEIR ACTUAL DIALOGUE. INTO SESSION 2 OF OSMAN'S CBT, ADAM USES 'REFLECTION OF FEELING' TO DETERMINE THE THOUGHTS/FEELINGS , IMPULSES BEING EXPRESSED. ADAM:' HOW ARE YOU TODAY ?' OSMAN :' NOT TO GOOD ADAM!' ADAM WAITS UNTIL OSMAN IS COMFORTABLELY SEATED AND OFFERS HIM TEA OR COFFEE. OSMAN DECLINES, GLANCING NERVOUSLY AROUND THE ROOM. ADAM:' LAST TIME, OSMAN WE DISCUSSED THE ISSUES ,RELATING TO YOUR FAMILY, DO YOU FEEL ABLE TO DISCUSS THIS FURTHER AND IN

MORE DEPTH ?'. OSMAN:' I HATE MY F##KING FAMILY !' ADAM:' I REALIZE THIS IS DISTRESSING, I UNDERSTAND THE DEPTH OF YOUR FEELING, DO YOU WANT TO TAKE A SHORT BREAK ?' OSMAN: 'NO, ADAM I'M SORRY, THIS IS EATING ME UP, MY FAMILY, THAT'S A JOKE !' 'THEY WANT ME DEAD, IF I DEFY THEM ?' ADAM USES OPEN INVITATION, GUESTURING TO OSMAN TO GENTLY INVITE HIM TO CONTINUE . ADAM: ' NO SORRYS NEEDED, THIS 'S CLEARLY DISTRESSING FOR YOU, IS IT OKAY TO DISCUSS THIS FURTHER ?' ADAM USES OPEN BODY LANGUAGE, MAKING EYE CONTACT WITH OSMAN, TO ENCOURAGE OSMAN TO OPEN UP , SETTING THE OPPORTUNITY FOR OSMAN TO VENT THESE VOLATILE NEGATIVE THOUGHTS AND FEELINGS. OSMAN:' YES ADAM, I NEED TO GET THIS OUT OF MY SYSTEM , TALKING HELPS ME'. 'MY DAD SAYS I BRING SHAME AND DISHONOUR ON MY FAMILY!' 'HE CALLED ALICIA A WHORE!'. ADAM: ' THIS MAKES YOU ANGRY AND DISTRESSED ? ' ' CAN YOU TELL ME , PLEASE TAKE YOUR TIME, HOW THIS AFFECTING YOU AND HOW YOU FEEL ?' . OSMAN : ' THE DUTIFUL SON BULL S##T ! ' THEY'RE SO BACKWARD AND SPITEFUL, NO CONCERN OR THOUGHT OF WHAT I WANT ? ' ADAM: ' ALL THIS IS VERY RAW AND EMOTIONS APPEAR VERY HIGH ?' ' IS THAT HOW IT SEEMS TO YOU ? '. OSMAN : ' I NEARLY HIT MY DAD FOR CALLING ALICIA A WHORE ! '. ' I AM BEGINNING TO HATE THEM ! ' ' HOW CAN THAT BE , WHY ARE THEY DOING THIS ? '. ADAM MENTALLY NOTES THAT THERE ARE POSSIBLE FURTHER UNDERLYING INFERENCES/ISSUES THAT NEED TO BE ADDRESSED, INRELATION TO THE ACUTE TENSION ( ACTIVATING EVENT ,OSMAN'S RELATIONSHIP WITH ALICIA, PLUS HIS FAMILY DYNAMIC). THE BEHAVIOURAL FALL OUT (B) ' DO AS WE SAY, WE WILL DISOWN YOU, THREATS. THE FEARFUL POSSIBLE CONSEQUENCES OF DEFYING HIS FAMILY AND OR LOSING ALICIA, THE WOMAN HE LOVES.

8 ADAM : ' YOUR FAMILY SEEM TO BE GIVING YOU A VERY LIMITED CHOICE ? ' OSMAN : ' IT IS THEIR WAY OR NO WAY, I'M A COMPLETE WRECK, I CAN'T CONCENTRATE ON MY STUDIES , I'M READY TO QUIT UNIVERSITY ' . ADAM : ' I UNDERSTAND THE DEPTH AND AFFECT OF YOUR FEELINGS, THESE ARE VERY ACUTE COMPLEX ISSUES, WHICH WE WILL WORK ON TOGETHER ' . ADAM NOTES THE POSSIBLE APPLICATION OF GHERKINS MODEL RELATING TO OSMAN.(SELF) , GOD ,( OSMAN'S FAITH ), FAMILY ( SOCIETY/COMMUNITY ). THE TENSIONS BETWEEN THESE ISSUE THAT ARE STRESSING OSMAN. ADAM RESOLVES TO TEST OSMAN'S GENUINE COMMITMENT TO CARRY OUT RAW AND LIKELY DISTRESSING DRDT/HOMEWORK. ENSURING THE DRDTS ARE FORMULATED, DISCUSSED OPENLY AND AGREED. OSMAN : ' WHAT DO I DO LOSE MY FAMILY OR THE GIRL I LOVE ? ' . ADAM : ' YOUR FAMILY'S STANCE IS VERY DISTRESSING TO YOU, YOUR DAD'S AND BROTHERS HOSTILITY, IS THIS THE MAIN PROBLEM , DO YOU THINK ? '. OSMAN: ' YES AND NO ? , IT IS SO SENSELESS, ALICIA IS TERRIFIED OF MY FAMILY ! ' . ADAM USES A GENTLE REASSURING VOICE TONE : THIS CAUSES YOU PAIN, HINDERS YOUR POTENTIAL HAPPINESS, IS THAT RIGHT ? ' . OSMAN : ' DAMN RIGHT, MY DAD AND BROTHERS ARE DEVILS , I WILL NOT LOSE ALICIA ! '. ADAM HAS PREVIOUSLY APPLIED THE DOWNWARD ARROW TECHNIQUE AND THE DYSFUNCTIONAL ATTITUDE SCALE TO OSMAN'S CASE, NOTING THE VERY HIGH LEVELS OF OSMAN'S DEPRESSION AND ANXIETY. ADAM HAS PLANNED AND CONSTRUCTED THE PATH TO GUIDE OSMAN INTO THE JOINT ' WORKING TOGETHER ' OF CBT/ABC METHODOLOGY. ADAM WILL INTRODUCE CAREFUL AND PRECISE SOCRATIC

QUESTIONING HE HAS TO GUIDE OSMAN , INFORMING AND TEACHING PROBLEM SOLVING SKILLS, SCHEDULING ACTIVITIES, REVIEWING POSSIBLE SET BACKS AND FAILURES, AVOIDANCE IN COMPLETING DRDTS/HOME WORK THE AGREED INTRODUCTION OF GRADED TASKS , STRAIGHT FORWARD AND UNCOMPLICATED TO PROMOTE MORE CHALLENGING, EFFECTIVE GUIDED CBT. MOVE FORWARD TO SESSION SIX OF OSMAN'S TREATMENT. ADAM : ' YOU STATE IN YOUR RECENT DRDTS , YOU'VE HAD SUICIDAL THOUGHTS, THESE ARE OVERWHELMING , YOU HAVE N'T CONSIDERED OR PLANNED ANYTHING ? OSMAN : ' BLEAK DARK THOUGHTS, SCARING ME, YES I'VE FELT LIKE THAT, BUT I'VE NEVER PLANNED IT '. 9 ADAM ' YOU HAVE A LOT TO LIVE FOR , ALICIA , LOSING YOU WOULD CAUSE HER GREAT DISTRESS AND PAIN '.

OSMAN : ' I'D NEVER DO THAT TO ALICIA SHE IS EVERYTHING TO ME ' . ADAM HAS PLANNED WITH OSMAN A 20 SESSION CBT , TO EMPOWER OSMAN THROUGH THE USE DRDT/HOMEWORK TASKS, CBT IS NOT SIMPLY A 'TALK' THERAPY, ADAM AND OSMAN MUST BE DILIGENT IN THEIR ONGOING GUIDED CBT SESSIONS. STICKING TO AGREED TIME LIMITS OF SESSIONS BUT OPENLY AND ACTIVELY REVIEWING NEGATIVE INFERENCES AND BIAS EVALUATIONS. THE FOLLOW UP SESSIONS WILL EMPOWER OSMAN TOWARD A REALISTIC AND POSITIVE OUTCOME. THE COUNSELLORS 'SELF AWARE ' OPEN REGARD TOWARDS THE CLIENT, THE HIGH STANDARD OF THE APPLICATION OF CBT/ABC METHODS, CAREFUL, GENTLE, PRECISE AND EXPLORING OPEN QUESTIONING. FLEXIBLE , ADAPTIVE AND ENCOURAGING METHODOLOGY OF THE CBT/ABC SESSIONS/TREATMENT.

THE VITAL THING IS SHOW THE CLIENT, THE COUNSELLOR IS ABSOLUTELY IN ACCORD AND HAS POSITIVE REGARD FOR THE CLIENTS EMOTIONAL/THOUGHTS PROBLEMS. ALSO THE CBT TERMINOLOGY IS PLAINLY TOLD AND EXPRESSED IN AN EASY UNDERSTANDABLE WAY TO THE CLIENT. THE COUNSELLOR DOES NOT WANT THE CLIENT TO FEEL 'THIS IS TO MUCH' TO COMPLICATED TO TAKE IN. THE ABC MODEL , ADVERSE SITUATIONS/EVENTS, BELIEFS AND AUTOMATIC FEELINGS/THOUGHTS, CONSEQUENCES, THE RESULTANT OUT COME OF BEHAVIOURS , FUELED BY HIGH EMOTIONS AND FEELINGS. THE COGNITIVE ABC, OUR THOUGHTS ARE REACTIONS TO ADVERSE OR POSITIVE EVENTS, THE CLIENT CAN PUT TO MUCH EMPHASIS ON EVENTS, THAT CAN LEAVE THEM FEELING HOPELESS AND HELPLESS. THE COUNSELLOR HAS TO BE ABLE TO CHALLENGE THE CLIENTS BIAS EMOTIONAL/FEELINGS IN A WAY THE CLIENT 'CAN SEE' WHERE THE PROCESS IS GOING AND WHY. ARBITARY INFERENCES, THE TENDENCY TO ARRIVE AT A NEGATIVE JUDGEMENT. SELECTIVE THINKING, WHAT THE CLIENT THINKS THEY SHOULD HAVE DONE, INSTEAD OF WHAT THE CLIENT ACTUALLY DID ? OVERGENERALIZATIONS, MAKING JUDGEMENTS BASISED ON A SINGLE EVENT. 'BLACK & WHITE ' THINKING, SEEING EVERYTHING IN ABSOLUTES, EVERYTHING IS RIGID AND FIXED. MAGNIFYING /MINIMIZING, BLOWING EVERYTHING OUT OF CONTEXT, THE 'STORM IN A TEA CUP' OR IGNORING AN IMPORTANT EVENT, BY DOWN PLAYING IT'S GENUINE RELEVENCE. THE CLIENT IS SHOWN THE EFFECT OF NEGATIVE AUTOMATIC THOUGHTS, 'SWIMMING IN THE CURRENTS OF THEIR MIND'. TO DEAL WITH THEM IN A COGNITIVE WAY, EMPOWERED TO BE THEIR OWN COUNSELLOR.

10 THE CLIENT CAN MAKE REALISTIC, POSITIVE DECISIONS, RATHER THAN PREVIOUS PESSIMISTIC , HOPELESS THOUGHTS/FEELINGS. THE CLIENT HAS POWER OVER THEIR SELF/REALITY, GUIDED TO UNDERSTAND AND HAVE GREATER SELF ESTEEM AND PRESENCE. COGNITIVE THERAPY IS AN ONGOING AND EFFECTIVE METHOD OF THINKING, PLACING THE CLIENTS ESSENTIAL IDENTITY IN A COPING SHIELD AGAINST NEGATIVE EVENTS THAT NORMALLY PRODUCE TERRIBLE AND DIBILITATING RESULTS FOR THE CLIENT. ADAM HAS GUIDED OSMAN INTO THE CBC/ABC MODEL, UNDERTAKING SESSIONS OF JOINT AGREEMENT OF TREATMENT, ENSURING OSMAN IS READY AND WILL BENEFIT FROM COGNITIVE THERAPY, AARON BECK SHOWED A DEPRESSED CLIENT HAVE A REOCCURRING NEGATIVE INCLINATION IN THEIR THINKING AND FEELINGS. HOW THE CLIENT VIEWS AND JUDGES EVENTS/EMOTIONS THAT CONTINUE TO FUEL THE DEPRESSION. ADAM HAS TO GUIDE AND TEACH OSMAN TO VIEW EVENTS IN A MORE REALISTIC POSITIVE LIGHT, TO DECIDE AND EXAMINE HIS THOUGHTS , TUNING IN TO THE ACTUAL EVENTS AND NOT THE POSSIBLE INFERENCES AND EVALUATIONS. 'MY FAMILY WANT ME TO GO THROUGH AN ARRANGED MARRIAGE' 'I LOVE ALICIA AND WANT TO MARRY HER', I MAY HAVE TO LOSE MY FAMILY, AS THEY ARE PLACING ME IN AN IMPOSSIBLE POSITION ?' 'IT IS MY LIFE AND HAPPINESS, I WILL NOT BE BULLIED OR THREATENED '. OSMAN WILL DEVELOP ALTERNATIVE REALISTIC, POSITIVE OUT COMES,

' ALICIA AND MY STUDIES ARE THE UTMOST FACTOR IN MY LIFE, MY FAMILY, WHO I LOVE DEARLY HAVE TO RESPECT AND LET ME DECIDE MY OWN FATE' . I CAN CALMLY AND RATIONALLY DEAL WITH ALL THIS ,MY FAMILY ARE BEING MISLEAD BY A CULTURAL BIAS , THINKING THE COMMUNITY WILL SHOW SHAME AND ACUTE DISAPPROVAL IF I MARRY ALICIA, NO MATTER WHAT THEY SAY I AM DECIDING WHO I MARRY, THE CHOICE AND HOW I LIVE. ADAM HAS EMPOWERED OSMAN TO BECOME HIS OWN COUSELLOR BUT REINFORCES THE CHOICE OF FURTHER CBT IF REQUIRED, CBT AIMS TO DEAL WITH THE NEGATIVE INFERENCES AND EVENTS, TO BOLSTER AND RESTORE OSMAN'S SELF ESTEEM AND MAKE HIM COMFORTABLE WITH WHO HE IS AND WHAT HE FEELS. IN A SIMILAR CBT/INTERACTION ADAM COULD LOOK MORE CLOSELY AT BODY LANGUAGE, LOOK AT CONDITIONAL BELIEFS/MODIFYING BELIEFS ? TRY ROLE/BEHAVIORAL SESSIONS TO GUIDE AND DIRECT THE CLIENT IN DEPTH, ACT OUT ALTERNATIVE SCENARIO'S FOR THE CLIENT TO CONSIDER. SEEK MORE EVIDENCE TO EVALUE HOW OFTEN AND HOW BOTHERED THE CLIENT IS BY DYSFUNCTIONAL THOUGHTS LEADING TO NEGATIVE BEHAVIOUR . SEEK ALTERNATIVE EXPLANATIONS , LOOK AT EMOTIONAL INTERACTION BETWEEN CLIENT AND FAMILY/ENVIROMENT. THE IMPACT ON THE CLIENT ? CBT LEARNS CLIENTS TO MODIDFY AND CHANGE UNHEALTHY BEHAVIOUR , THE COUNSELLOR EMPOWERS AND WORKS IN AGREED PARTNERSHIP WITH THE CLIENT. SORTING THROUGH AND READJUSTING THE CLIENTS THOUGHTS/BEHAVIOUR THAT IS CAUSING THEM DISTRESS, REVIEW WORK AND LEAD TOWARD A POSITIVE /REALISTIC OUTCOME.

11

REFERENCES/FURTHER READING.

A.T. BECK, COGNITIVE THERAPY AND EMOTIONAL DISORDERS,1976. J. BECK COGNITIVE THERAPY, BASICS AND BEYOND 1995. R. BAKER, UNDERSTANDING PANIC ATTACKS, 2003. E. RAFAELI,D. BERNSTEIN & J. YOUNG, SCHEMATA THERAPY, 2011. J.A. CULLY & A.L. TETEN, A THERAPISTS GUIDE TO BRIEF COGNITIVE BEHAVIOURAL/THERAPY.2008 D.H.ROTH, LEDLEY,B.P.MARX, R.HEIMBERG, MAKING COGNITIVE,BEHAVIOURAL THERAPY WORK,2005. K.S.DOBSON. K.D. CRAIG. ADVANCES IN COGNITIVE/BEHAVIOURAL/THERAPY.

WEBSITES www.babcp.com www.congnitive-behavior-therapy.org www.bacp.org.uk www.nacbt.org/historyofcbt.htm www.feelinggood.com www.cbtcounselling.co.uk/ www.livinglifetothefull.com http://www.depressiontoolkit.org/treatmentoptions/Psychotherapy/