Client Assessment and Formulation with Person Centered Approach

The case study of this paper is about Laura, 51yrs old lady, who has faced personal upheaval for which she is experiencing severe trauma. Laura had a head injury 10 years ago that led to her cognitive difficulties charac-terized by executive dysfunction including repetition, impulsiveness, poor planning, and disinhibition.

I completed the assessment for Laura. Based on a structured assessment form provided by the counselling service that lasted 50 minutes. I confirmed confidentiality of the sessions to the client. However, GP inter-vention can be requested with client approval if risk is identified. An agreement and frequently ask questions sheet (FAQs) including all these data is given to the client before the sessions begin.

Three months before the assessment, her husband left the marital home after giving her notice the previous night that he is walking away from her life. Subsequently, her husband has set up home with another woman. The proceedings of divorce are underway. This has impacted Laura very adversely. She felt alone and utterly abandoned leading to her inability to cope and a sense of hopelessness for the future. She recollected about her suicidal thoughts and the way she came close to initiate self-harm on many occasions.

Firstly, the case of Laura has had similarity to FS case as explained by King [1]. Both Laura and FS have had the experience of psychological distress along with trauma and a head injury related executive dysfunction. In the case of FS, the therapy turned out to be problematic as the client experienced his difficulties and trau-ma evoked repeatedly outside of sessions. The client was encouraged in accessing his perseverative difficul-ties and traumatic memories meant the inability of FS in disengaging from these when he is not inside the sessions. Therefore, King argued that there should be caution when therapy is conducted with such clients. Therefore, I decided following Laura in seeing if there is occurrence of similar issues as observed by King, and if possible, how to ameliorate them.

Secondly, Laura presents a platform in observing whether Person Centered Therapy to deal with her traumat-ic stress can be effective. The challenge in this case is whether extreme executive difficulties have the likeli-hood of impairing access to the processes of innate growth posited by the Person-Centered Therapy. At the outset, my prediction of this study has been that this could be an effective approach with a client of this type. I had experienced previously success with another type of neurological impairment client, which was related to myalgic encephalopathy with its interfering with their cognitive processing [2].

Assessment techniques and resources

This work deals with evaluation of efficacy of person centered, interactive therapy for Laura who also has head injury. The approach involves maintenance of respect for the client as implementation of therapeutic conditions was tried upon as advocated by Carl Rogers [3]. There would be openness to the goals and needs of the client who has the will of using approaches and techniques from other therapeutic modalities in the likes of cognitive behavioral therapy [4].

The model used widely, either on the basis of integration or in its own right, is the client centered approach [3]. The clients are allowed, with this model, in exploring their difficulties at their own pace and in their own time. This approach has also shown working well with neurological populations to help them coming in terms with their psychological distress and difficulties. For instance, Ward & Hogan, [2] have found effec-tiveness of this approach in a small trial that involved participants having myalgic encephalitis. These partic-ipants often had been coming in terms with severe personal loss. This has similarity with Laura as she faces neurological symptoms such as mental slowing, fatigue, lacking concentration.

Person Centered Approach offers a non-threatening and emphatic relationship to the client characterized by congruence, empathy, and unconditional positive regard. The involvement of emphatic understanding is with communication with the client that the counselor can understand and grasp in relation to the “frame of refer-ence” or the own perspective of the client. It should also be ensured that a genuine relationship is developed. The counselor must not hold opinions or attitudes about the client which he or she is unaware of and that can be detrimental to the relationship [5]. Finally, the counselor must have an “unconditional positive regard” to the client so as to avoid the communication of any negative attitude for the client. However, it should be not-ed that the counselor does not have to approve all behaviors of the client so long the counselor responds the client in a manner that is respectful and congruent with the therapeutic relationship.

Client in context and contextual information

Laura displayed considerable level of fear of her husband. She also feared physical consequences from her husband despite the fact that there has not been any history of physical abuse. Laura also experienced dis-tressing and recurrent recollection of the night when she got the announcement from her husband of his leav-ing her. This led her with a sense of a foreshortened future. She found it difficult to concentrate that had the lasting of over a month. Moreover, the distress started to impair her ability of functioning on a social level.

The emotional reaction of Laura to the fact that her husband left her was characterized by frequent recalling of the moment when he declared of his leaving. When Laura recollects this incident, she was overcome with intensely felt despair that drove her to tears. Her concerns involve that it would be very difficult for her to survive without her husband and the fact that she was dependent on him for last one decade. She has also given description that as she has been left alone, it would take a lot more time for her in completing a task.

Laura, for past many years has performed the homemaker’s role. From her account, it is clear that her need included considerable support and help from her husband in achieving certain daily tasks. Certain routine tasks like preparing meals for the family needed a lot of concentration and effort and can be taking several hours.

Laura’s executive functioning report was found in her medical record. There was administrating of two standard tasks from the version 3 of Wechsler Adult Intelligence Scale [6]. These are the digit span and block design tasks. The scaled scores have been four and seven respectively, which is suggestive of the scores being 63 and 70 respectively in the full-scale IQ. Contrastingly, on the vocabulary subtest, her scaled score has been 16. This suggests she had 134 overall full-scale IQ. This indicates that current level of executive func-tioning of Laura has been very low in comparison to a level of high pre-morbid ability.

Formulations

Laura suffered a head injury ten years ago. This led to her inability of pursuing her normal occupation and the experiences of certain difficulties in daily tasks to run her home. Her perception about herself was that she has become totally dependent on her husband. Her husband has taken responsibility for all complex affairs of the household.

Seemingly, a pattern was developing over the years where Laura’s perception about herself has been her de-pendence on her husband. She started to look at herself in way where she does not have the capability of any independent existence without the support of her husband. This culminated into a behavior where Laura found herself helpless on her own and therefore her views were self-perpetuated of her dependence on her husband. The relationship of Laura with her husband, in many respects, cannot be called as ideal, although she has been emotionally highly dependent on her husband. Therefore, the self structure of Laura came to be dominated by her thoughts of dependence on her husband along with her inability of copying or carrying out complex tasks without his help [7].

Treatment plan

The treatment plan for Laura has been formulated into two parts. Firstly, a Person Centered relationship will be given to her so as to enabling her to process her emotional reaction as her husband has left her. This would be allowing her to experience fully her feelings within the safety that the relationship provides her.

Secondly, it can be expected that her feelings’ intensity would subside over time and she would develop the ability of exploring other aspects of her feelings apart from her sense of overwhelming despair and loss. It can also be anticipated that with the unfolding of the sessions, it would be possible for Laura moving on to consider more practical ways of coping with her everyday challenges. Alongside this, the sessions will also help her in making use of both her loved ones and other community resources with the ability of moving forward towards an independent and a new existence.

These twin aims are expressible as two intervening goals, according to pluralistic framework. The first goal is not feeling emotionally overwhelmed because of the departure of her husband. The treatment of this goal is with Person Centered therapy. The second goal is working on some specific home management tasks in enabling Laura to be as independent as possible to carry out the task. The addressing of this goal is by the use of rehabilitation oriented, action focused and psycho-educational interventions.

Informed judgments

In the case of Laura, the question remains whether she dwells repetitively on her predicament’s negative as-pects and the ability of coping. I have taken the decision of recording and transcribing all our sessions, fol-lowed by the rating of the negative and positive coping statements that have had the occurrence and the in-stances of suicidal ideation. This would indicate whether the in-session behavior of Laura has seen augmen-tation of these dimensions. This would also have the repetition later as the therapy progresses to find if the proportions of the negative and positive coping statements have undergone any change.

These transcripts have allowed me in discussing the process of therapy and in ensuring the faithfulness of the sessions to the Rogerian Person-Centered way of working. As it has been mentioned before, the Person-Centered Therapy was chosen as the approach in dealing with Laura’s emotional difficulties. I have also in-tended in addressing Laura’s other concerns that involves practical issues of day to day life with the use of principles of rehabilitation in an integrative way.

Pluralistic approach

The approach of pluralistic has been a framework allowing the integrating of different theoretical approaches with the process of collaborating with the client. Cooper & McLeod [4] described the process of assessment of client and derive a set of goals agreed upon. These goals are the means to achieve them and the reviewing with the client throughout the therapy process.

The pluralistic framework allowed integration of Person- Centered Therapy with rehabilitation oriented, more action focused and psycho-educational interventions. The last component comprised of intervention in rela-tion to problem solving in helping Laura recognizing and dealing with and overcoming difficulties to remem-ber.

Monitoring of therapy and usage of feedback information

The scheduling of the supervision sessions has been on a weekly basis. The structuring of the supervision sessions in considering progress on work has been with the client and through exploration of any concerns or difficulties. The therapist would be noting the brief summaries that discussed issues and the points that are related to the future sessions are immediately recorded at the end of every session.

Critical exploration

Laura’s therapy was open ended and she had 43 sessions in total. The 43 sessions had frequency of once a week throughout the year.

Session 1-43: Works with Emotional Trauma and Phase it in Practical Difficulties

Emotional trauma

After the assessment initially, the counselor and Laura agreed that her most important goal initially was pro-cessing and coming to terms with trauma that has happened because of her divorce. The traditional Person-Centered approach was taken in helping Laura dealing with her trauma [8]. The counselor reflected carefully the narrative of Laura while facilitating her experience that had association with her mental states. The first eight weeks of therapy was dominated by this approach.

The statements of Laura in the early phase had the tendency of revolving around the initial trauma created by the separation, her enormous loss as perceived by her, and her fear related to what will happen to her in the future. For instance, when she had the initial shock that her husband announced that he will leave her, she said:

The first time I had panic attacks is when my husband told me this. It was terrible; he came after seeing his new lady that literally shattered me. In the morning, I was crying, but was trying to control the noise as he was sleeping and could have disturbed him.

And also:

My mind was full of fear as to how I will cope with the situation. Nay, I would not be able to cope. I knew that. I was even contemplating committing suicide but just in the nick of time he came to my room. The cli-ent’s narrative, by the fifth session, started to change. The therapist found that Laura’s emotional trauma has started to lose its raw edge as if she has started accepting and acknowledging these feelings. Laura heard her story’s other aspects being reflected back, which brought other feelings to the fore. Laura started to re-evaluate the relationship that she has gone through with her husband over the years and started to feel angry at some of ways her husband treated her [9].

These signs of her movement had been giving reassurances to the counselor, since it was suggestive that Laura would not experience the negative trauma outside the sessions. Moreover, Laura has been accessing processes of growth and going beyond blaming herself. For instance, she said: It was a life when I never had to go out. I would stay back home and do the household work. I felt I am Cinderella. It was by husband who would go out and brought things for me, whatever I wanted and the best that I wanted.

When her past relationship is reviewed and with the acknowledgement of the anger she felt now, Laura had been able to question a number of assumptions accepted by her over the years. She had the realization that there are a number of notions being planted by her husband by not giving her the opportunities in relearning certain previous skills of her. For instance, she said:

(My husband) told me that I can never have friends. I believed that when he told, but now I am seeing that there are many people who looks out for me and try to help me – amazing.

Unable dealing with housework

Following therapy for eight weeks, other issues started emerging in the narrative that have been worked with and taken up with the usage of other strategies by the counselor in collaboration with the client. The key is-sue, in particular, that have come up several times has been Laura’s inability of dealing with the household paperwork.

For instance, she said:It was half past eight when I found that I have to pick up two papers……it was terrible and was not at all feeling like doing it……still I did……and all the papers that I sorted the whole day……was behind me………I could not take any more. She referred here how the whole day was spent by her trying to sort out paperwork and realizing that in the end what she had done is laying behind her in a big trail.

Memory prompts

Laura was late frequently for sessions because of her difficulties with memory. This prompted a cell phone text system through SMS initiated in the 18th session reminding just ahead of each session each week. Thus, the number of sessions that she missed was reduced as compared to the sessions in the past.

Executive difficulties

During the therapy, it was evident that the executive difficulties of Laura impacted on the therapeutic dia-logue. The statements of Laura were significantly longer compared to what is experienced typically. Howev-er, her statements have a lot of repetition within specific utterances and within a session across the utteranc-es.

Assessment of progress within the process of therapy

I tried to make an objective assessment after the end of every 2 months in relation to whether progress has been made by Laura. I have also been concerned of whether the additional therapy would be undermining the potential of Laura in perseverating on her difficulties and expressing the negative perceptions about her abil-ity to cope. To be specific, as a baseline, I have recorded and transcribed sessions 1-5 with the counting of various verbal behaviors. To be specific negative and positive coping statements and idea of suicidal tenden-cy is notable. The positive coping statements expressed by Laura have shown some glimpses of positive out-look on her current situation. For instance, Laura has said: “but now I am seeing that there are many people who look out for me and try to help me – amazing”.

Contrastingly, she expressed negative coping statements of having negative outlook or not having the ability of doing things. For instance, “It was half past eight when I found that I have to pick up two papers……it was terrible and was not at all feeling like doing it……still I did……and all the papers that I sorted the whole day…… was behind me………I could not take any more.”, or “My mind was full of fear as to how I will cope with the situation”.

Laura, at the end of the therapy, have shown significant gains in positive coping statements in each session and decrease in the negative coping statements and reduction of statements showing suicidal tendency in each session. The therapeutic intervention outcome after the end of the therapy showed positive changes overtime. The changes that have been observed were the reflection of the fact that Laura experienced greater magnitude of wellbeing, was expressing lesser tendency towards self-harming impulses, having a feeling of greater ability for functioning, and was overwhelmed at a lesser degree by her problems [10]. Laura’s case has been the illustration of how a client having executive difficulties can be making use of fairly nondirective therapeutic strategy and being able to adjust and cope with emotional trauma. At the end of the therapy, Laura apparently was less emotionally distressed and more confident. Behaviorally, also, she was being able to cope much better with daily activities in the absence of her husband.

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