Table of Contents
- Client History
- Issues to Address
- Intervention Strategies
- Theoretical Frameworks for Intervention
- Person Centred Therapy (PCT)
Anxiety is not an unfamiliar experience to most people – one would have had experienced a sense of “nervousness”, usually characterized by worry and increased heartrate, in stressful situations such as a major examination or a job interview. These bouts of anxiety tend to be short-lived in normal people; while those suffering from an anxiety disorder are prolonged and more frequent, not necessarily associated with a stressor, and affect daily activities (Beyondblue Support Service, 2016). Anxiety disorder presents itself in various types, one of which is Social phobia. This disorder is characterized by physical symptoms such as palpitations and stammering, excessive worry of saying or doing the wrong things, and active avoidance of social situations. Possible causes include the individual’s temperament, family history, and environmental influence such as bullying and humilation (Beyondblue Support Services, 2016). The following section examines a specific case of Social phobia.
Andy, 25, is a single male living with his mother and brother. He is currently working at a post office as a mail sorter, and had been there since he quit University. Andy grew up in a typical nuclear family with two siblings – an elder and a younger brother – and regularly felt that he had to compete for his parents’ attention. Much of his childhood was spent in school care as his parents were working full time. Andy reported that he would prefer to be alone during his adolescence and young adulthood. At Grade 8, he was the constant subject of bullying in school and had been disowned by his circle of friends; his brothers exacerbated the situation by criticizing him when Andy wanted to report the incident to his parents. Moreover, Andy constantly felt humiliated in class when he tried to ask questions as his teachers would chastise him.
Issues to Address
Andy reported that he was extremely self-conscious during his time in University when he spoke to strangers, classmates and even friends – so much that he would experience symptoms of panic attacks (difficulty speaking and hearing, perspiration, and hot flashes) when he was around people. He became increasingly uncomfortable in social situations and began to reject invitations to any social activities, as he was “afraid of saying or doing something stupid” (Refer to Case Study 4, p. 12 attached separately). He chose his job at the post office because he does not have to deal with people. However, Andy mentioned that he does not have an issue with authority figures and even welcomes constructive criticism from his supervisor at work. Judging from the symptoms Andy exhibits, it can be diagnosed that he is suffering from Social phobia upon reference to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) by the American Psychiatric Association (2013).
A review of the literature revealed three broad categories of treatment for Social phobia: Psychological, Medical, and Complementary and Lifestyle interventions (Reavley et al., 2013). For the purpose of this paper, only psychological interventions shall be considered. Various treatment procedures have been conducted to tackle the issue of Social phobia, to name a few that had produced desirable results: Attention Training, Behaviour (Exposure) Therapy, Cognitive Behavioural Therapy (CBT), Psychodynamic Therapy, and Person Centred Therapy (PCT) (Donald, Abbott, & Smith, 2014; Reavley et al., 2013; Stephen, Elliott, & Macleod, 2011). This paper will compare and contrast PCT and CBT treatment procedures in relation to the client’s situation, and to decide on the optimum treatment plan.
Theoretical Frameworks for Intervention
Person Centred Therapy (PCT)
PCT is closely associated with Carl Rogers. Being a Humanist, Rogers (1979) believed in the innate motivation of self-actualization that each individual possesses. He believed that people are capable of self-directed growth in a therapy, given the necessary climate for constructive change to occur. Purportedly, the six conditions are: Quality of counselling relationship, the state of the client (proposed to be in the state of incongruence, being vulnerable or anxious), the therapist’s genuineness in the therapeutic relationship (widely known as congruence), unconditional positive regard (non-judgemental and accepting the client as a unique individual), empathy (sensing the client’s world as it were the therapist’s), and the client’s perception of the therapist (Rogers, 1957).
The counselling approach of PCT minimizes questions, focuses mainly on client’s feelings and meaning of what the client mentioned, and constantly identifies strengths of the client to help clients be more optimistic and empowered to move towards a positive change (Australian Institute of Professional Counsellors [AIPC], 2013). Stephen and colleagues (2011) theorized that social anxiety is the result of conditions of worth – an individual’s perception of other’s expectations of what is valued – placed upon the individual by others, and therapists display of congruence, empathy and unconditional positive regard is key to resolving the anxiety. This is consistent with Rogers’ (1957) idea that the inconsistency in an individual’s perception of self leads to a state of tension, known as anxiety; the therapeutic relationship of client and counsellor is paramount for tackling issues.
Drawing from the main ideas and approach of PCT, it is possible that Andy could perceive the counsellor’s display of congruence, empathy, and unconditional positive regard and open up in his discussion of his issues of Social phobia. The counsellor may utilize positive asset search to identify and reflect Andy’s strengths and resources that he can employ to confront his anxiety. The counsellor may, at a later stage, explore Andy’s notion of not fearing authority figures but only in other social situations. This might be the key to allowing Andy to overcome his fear of other social situations as interaction with his superior is essentially a form of social situation. Perhaps a deeper understanding of Andy’s formulation of apprehension towards social situation is required, and by doing so, Andy may feel more empowered to confront his deep seated fears of social situation, resulting in an overall resolution of his anxiety concern.
This form of deep exploration of meaning and unconscious feelings may be exclusive to the PCT approach as it requires the counsellor to attempt to fully understand the client’s situation through empathy, and guide the client towards a constructive growth. On hindsight, as PCT tends to be a least directive approach of psychotherapy, the treatment may take a much longer duration to see effect. It may not be advisable to rely solely on PCT if the client is increasingly struggling with his daily activities. Judging from Andy’s symptoms, which seem to be increasingly intense, perhaps a more directive approach may be utilized to reduce the tension he exhibits whenever he is in a social situation.
Cognitive Behavioural Therapy (CBT)
CBT was formulated by Aaron Beck as a psychotherapy for disorders such as depression and anxiety. Beck (1979) built on the idea of Albert Ellis’ Rational-Emotive Therapy and emphasized the role of emotions in his Cognitive theory of anxiety and depression. The way to alleviate emotional distress and relevant symptoms is to focus on the distorted automatic thoughts, dysfunctional attitudes and pessimistic behaviours, and attempt to induce a positive change. Essentially, CBT looks at how an individual interprets a situation and focuses on the relationship between thoughts, emotion, and behaviour (Heslop, 2008). Treatment includes utilizing behavioural techniques, such as roleplay and systematic desensitization, and identifying the inappropriate reactions during the treatment process to enable the client to view the situation more objectively, thereby restructuring the client’s distorted automatic thoughts and feelings (Beck, 1993).
CBT is a two-fold process involving cognition and behaviour. To illustrate, he client may be able to resolve the anxiety of situation outside of therapy through a) the rehearsal effect: Utilizing experience gained from practice to counteract irrational ideas in the phobic situation; and b) behavioural techniques such as desensitization which produces a significant change in the client’s concept of the phobic situation such that the feelings of apprehension are eliminated (Beck, 1993). The directive approach of CBT may be beneficial to resolving Andy’s Social phobia by employing the method of roleplay in the treatment procedure. The counsellor may get Andy to vividly imagine himself in a scenario while talking to a stranger or friend, played by the counsellor. Naturally, this has to be done after the counsellor has secured the minimum therapeutic relationship through rapport building with Andy and to understand what Andy thinks and feels during his bouts of anxiousness in social situation. After the roleplay, the counsellor may point out to Andy his irrational thoughts during the session and seek to restructure these detrimental thoughts and beliefs through repeated exercise of such scenario.
CBT has been found to be highly effective in the treatment of anxiety and can be completed in a relatively short period of time (Reavley et al., 2013). The skills learnt in CBT can be incorporated into daily life to help the client cope better with future situations, even after treatment. However, due to the confrontational approach of CBT, it may induce more stress and anxiety to the client, for example, Andy might experience panic attacks during the roleplaying session and choose not to attend subsequent sessions. Moreover, the focus of CBT is on the present and does not deal with the possible underlying causes of the issue, such as childhood trauma, and external issues such as family problems that might have an impact on the individual (National Health Services [NHS], n.d.).
Strategy for Intervention: Comparison of PCT and CBT
The comparison of both PCT and CBT approaches revealed strengths and limitations that may be complemented by a combination of both theoretical approaches. Considering the strengths of PCT, Andy may be able to feel more in control through having a deeper understanding of his issues. That a long duration is required for a pure PCT therapy is recognizable because a strong therapeutic relationship that requires in-depth understanding of the client can only be achieved over a considerable amount of time. This limitation of PCT can ostensibly be offset by adopting a more directive approach while still maintaining the basics of PCT approach – congruence, empathy, unconditional positive regard, and positive asset search.
While CBT may provide a quick alleviation of symptoms of Andy’s Social phobia and teach him specific skills to combat future symptoms, it might not resolve the root cause of his issue. It is my opinion that due to his traumatic experience of bullying in his childhood, lack of family support, and socially inhibited temperament, Andy might have a yearning for love and belonging from significant people in his life. The CBT approach will not actively identify this aspect of Andy’s situation. With the inclusion of the PCT ideologies, the counsellor may incorporate in the session exploration of Andy’s underlying motivations that affect his thoughts, feelings and actions. Hence, this combined approach ideally leads to an increase in self-awareness and encourage exploration of Andy’s deep-seated motivations, restructure automatic thoughts and beliefs, and obliterate self-defeating behaviours in social situations.
The client, Andy, mentioned the symptoms that he exhibits during social situations, which are symptoms of Social phobia. Causes of his phobic behaviours may be directed towards his traumatic childhood experience, lack of family and social support, and his introverted nature. Theories of PCT and CBT were briefly discussed, followed by an evaluation of their strengths and limitations, and their applicability to Andy’s case. Overall, this paper a combination of PCT and CBT approaches as the most beneficial approach for Andy. This tailored approach of PCT to CBT had been found to produce desirable outcomes (Charlesworth, Sadek, Schepers, & Spector, 2015). Granted, this approach may not prove to be useful upon actual interaction with Andy; this is only an analysis of Andy’s situation and possible intervention strategies planned after the initial session with him. However, by having a concrete framework of strategy moving forward, it provides a clear idea for the counsellor to deal with most aspects of Andy’s case of Social phobia.