A Cognitive Behavioral Approach

A Cognitive Behavioral Approach for Aaron

The cognitive-behavioral approach has strengths and limitations specific to the needs of the client. According to Corey (2009), REBT and cognitive behavioral therapy assume clients can change irrational thinking, and that they have an overall prevailing goal toward well-being and communication with fellows and loved ones, as well as a desire for growth and self-actualization.



Strengths of this Approach

Using the cognitive behavioral approach for Aaron has several benefits, the first of which is for the immediate relief of some of his symptoms. As Matthew Geyer (Laureate Education, Inc., 2006) remarked, rather than using the depth of investigation more common in psychoanalysis, cognitive behavioral therapy contends with the more external symptoms with less of an exploration into his past and the depths of his psyche. It seems essential to help Aaron integrate his thoughts about his health and performance with his capacity to care for himself in a way that is conducive to his health, rather than a detriment.

Corey (2009) claims REBT focuses on the client's ability to integrate the capacity to think, feel, and behave. Cognitive behavioral therapy has been effective in a wide range of applications that include skills training. Perhaps incorporating this aspect of cognitive behavioral therapy would appeal to Aaron's desire to focus on his athletic abilities and simultaneously relieve the obsessions associated with his training regimen and his other compulsive behaviors. Research suggests cognitive behavioral therapy is usually therapeutically effective for obsessive compulsive disorder as well as for eating disorders (Butler, Chapman, Forman & Beck, 2006).

Some research has found a cultural context for obsessive behavior (Okasha et al, 1994). For this reason, I would want to involve his parents to some extent, at least to determine their values and how, and for what Aaron has been rewarded throughout his life. As stated by Geyer (Laureate Education, Inc., 2006), having Aaron's parents as allies during this process may be critical.

It will be important to take into account Aaron's developmental stage. Teens can have issues about self identification. I would want to be sensitive to Aaron's idea that his performance as an athlete may be a significant part of how he sees himself. I would want to strengthen his sense of self-esteem and self-efficacy, helping him perceive himself as multi-dimensional, not just as an athlete, but as a young man with considerable options for a positive future.

Additionally, I like the idea of helping Aaron develop a new set of coping skills (Corey, 2009). Although he may not initially concede to the idea of his use of compulsive behavior to cope with his underlying insecurity or other inadequacy or inefficiency issues, but as he begins to reorient himself to rational thought, he will most likely need new coping skills to replace his maladapted ones. One last thought about using a cognitive behavioral approach with Aaron is the flexibility of the approach. Enlisting the help of Aaron's parents should be helpful in creating a bargain or a contractual agreement with Aaron; as Aaron continues to create healthy and rational habits, he will be allowed to continue his involvement with athletics. If he does not, he will be forced to forfeit his involvement in sporting events and training.

Limitations of the Approach

Although cognitive behavioral therapy may be effective in ameliorating some of Aaron's symptoms, it is not devised to delve deeply into why Aaron uses the compulsive behavior (Laureate Education, Inc., 2006). Additionally, if Aaron does not see a benefit to a particular change or a goal of therapy, he may not have the motivation to make the necessary changes. One idea would be to approach it from a health perspective. If he understands that osteopenia will eventually eliminate him from athletics in general, that may affect his motivation.

Corey (2009) describes the importance of understanding the client's world prior to trying to change it. If Aaron has reservations about change as defined by the therapist, he will not maintain the motivation necessary for significant change (Corey, 2009; Laureate Education, Inc., 2006). It will be important for Aaron to understand the difference between his perceptions and those of the therapist, and that the new perceptions will serve him better than his current approach to his health and well-being. Furthermore, Corey (2009) states the cognitive-behavioral approach minimizes emotions and does not explore underlying issues. It does not focus on the past or the client's history which may contribute to a significant degree, the reasons for the client's behavior. It will be important to keep these limitations in mind when working with Aaron.


References

Butler, A., Chapman, J., Forman, E., & Beck, A. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17-31. doi: 10.1016/j.cpr.2005.07.003

Corey, G. (2009). Theory and practice of counseling and psychotherapy (8th ed.). Belmont, CA: Thompson Brooks/Cole.

Laureate Education, Inc. (Producer). (2006). Case study: a CBT/behavioral therapy perspective In Counseling and Psychotherapy theories [Streaming Video]. Baltimore: Author.

Okasha A, Saad A, Khalil A. H., El Dawla A.S., Yehia N. (1994). Phenomenology of obsessive-compulsive disorder: a transcultural study. Comprehensive Psychiatry 35, 191–197.

Vulnerable Populations: Terminally Ill Clients and the Elderly

Terminally Ill Clients

Terminally ill clients face extraordinarily challenging issues and decisions that, under the best of circumstances, can be stressful.  They also have to make difficult medical decisions.  Many are in pain or affected in various ways by chemical therapies and pain medications.  Some clients wish to explore the option of  ending their lives, others are angry and afraid (Duba & Magenta, 2008).  Regardless of their personal experience of coping with terminal illness, these individuals are more vulnerable to hardship and trauma than other client populations.  Most of these individuals do not want to deal with death or the idea of assisted suicide in secret, and need someone to talk to (Lowe, 1997), but family members may not be willing to discuss assisted suicide.  The hospice movement continues to play a significant role at this stage of life and offers this population necessary support, although too little is known about how individuals come to grips with this stage of life (Neimeyer, Courier, Coleman, Tomer, & Samuel, 2011).  This further perpetuates their vulnerability.  

Standard A.9.a. of the American Counseling Association's (ACA) (2005) Code of Ethics provides guidelines for end-of-life care for terminally ill clients that counselors should help these clients receive high quality care that fills their needs, supports and encourages their self-determination, and enables their ability for informed decision making in their care.   Standard A.9.b. (ACA, 2005) states that when these clients seek to explore their options for suicide, counselors must be aware of related issues and refer them for the most appropriate help. 

 

Standard A.9.c. (ACA, 2005) discusses confidentiality as it applies to terminally ill patients who discuss suicide.  The counselor has the option to decide whether to breach confidentiality.  This decision, however, must be made according to the individual's circumstances as well as the law. 

The Elderly

A second vulnerable population is the elderly.  According to Remley and Herlihy (2010), this population continues to grow in this country along with the underrecognized problem of mistreatment of these individuals.  Especially in those people over the age of 75, health issues that compromise their ability to remain autonomous are far more common.  When cognition and normal functioning decline with age, individuals are rendered dependent on family members or an institution for their care.  Not only can this provoke esteem issues, but Remley and Herlihy (2010) claim found estimates that 10 million or more elder adults suffer some form of maltreatment each year.  Even when these elders are being fairly and well-treated, they may still have issues of being dependent on others, fears, or other concerns that are consistent with this age and developmental group.  Although these clients may not be facing end-of-life care issues, they must still be given the right to the autonomy and respect given to all clients.

As long as a client is mentally competent and continues to make self-decisions the counselor must respect their dignity and promote their welfare as stated in Standard A.1.a. (ACA, 2005).  The client continues to have the right to informed consent (Standard A.2.a.) and confidentiality and its limitations (Standard A.2.b.).  Standard A.2.c. charges counselors with being competent and sensitive to the developmental circumstance of the client.  This is significant for elders who may have declined cognitively and physically.  Any information given by the counselor should be understandable and clear.  Certainly, at this stage of life, it remains important for counselors to refrain from imposing their personal values, attitudes, and beliefs onto their clients (Standard A.4.b.).

When any client's legal status changes, it would be important to revisit all the initial considerations of beginning counseling such as informed consent and any confidentiality issues that coincide with the new or changing rights of the individual.  

American Counseling Association (ACA). (2005). 2005 ACA code of ethics [White Paper]. Retrieved from the ACA website: http://www.counseling.org/Files/FD.ashx?guid=ab7c1272-71c4-46cf-848c-f98489937dda

Duba, J. D., & Magenta, M. (2008, October). End-of-life decision making: A preliminary outline for preparing counselors to work with terminally ill individuals. The Family Journal, 16(4), 384-390.

Lowe, A. D. (1997). Facing the final exit. American Bar Association Journal, 83(9), 48-52.

Neimeyer, R. A., Courier, J. M., Coleman, R., Tomer, A., & Samuel, E. (2011). Confronting suffering and death at the end of life: The impact of religiousity, psychosocial factors, and life regret among hospice patients. Death Studies, 35, 777-800. doi: 10.1080/07481187.2011.583200

Herlihy, B., & Corey, G. (2006). ACA Ethical Standards Casebook (Sixth ed.). Alexandria, VA, USA: American Counseling Association.

Remley, T. P., Jr., & Herlihy, B. (2010). Ethical, legal, and professional issues in counseling (3rd ed.). Upper Saddle River, NJ: Merrill/Pearson Education.

Comparison and Contrast of Behavioral and Cognitive Theories

Key concepts/unique attributes

Both B. F. Skinner and Albert Bandura believed behavior is the result of what is learned from experience (Corey, 2009). Whereas Skinner believed environmental influences control people, Bandura believed people are goal-oriented and have specific intentions and purposes.  He believed the basis for learning is observing others.  Traditional behavioral theory is based on the concepts of classical and operant conditioning and that learning produces behavior (Corey, 2009).  Inappropriate or abnormal behavior results when learning is based on maladapted learning, or learning as a result of maladaptive reactions. 

Cognitive theory (CT) claims faulty and maladaptive thinking causes psychological disturbances (Corey, 2009).  If the thinking can be corrected, so can the resultant disturbance.  Cognitive processes determine how people emotionally experience and react to their environment.  Ward (2011) wrote that Ellis believed individuals "have a tendency towards becoming aware of (their) irrationality and working steadily towards rationality" (p. 106).  In cognitive therapy, clients learn new and more effective ways of thinking (Corey, 2009). 

Cognitive theory takes into consideration the client's early childhood history but believes behaviors continue to be reinforced throughout the lifespan because of patterned thought processes.  In therapy, clients explore maladaptive thoughts and learn to replace them with new rational and appropriate thinking (Corey, 2009).  The primary difference between these two theories is the emphasis on overt behavior in behavioral theory and in cognitive theory, the focus is on cognition or individual thought processes (Corey, 2009).  

Historical/contextual development of the theory

Two influential contributors to behavioral theory were B.F. Skinner and Albert Bandura.   Skinner based his experiments on rats and pigeons from which he theorized humans behave according to reinforcement by their environment.  He referred to this concept as operant conditioning (Olson & Hergenhahn, 2009).  In essence, Skinner believed "we are what we have been reinforced for being" (Olson & Hergenhahn, 2009, p. 76).  It may be interesting for students to note the context within which Skinner was raised.  Siegel (1996) claims Skinner describes it as confining, puritanical, and an incredibly restrictive environment.  One wonders how this environment might have laid a psychological foundation for Skinner's development of radical behaviorism. 

Playing a different role than Skinner in behaviorism's development, Albert Bandura explored his social learning theory, later called social cognitive theory (Corey, 2009).  His theory was, perhaps, the beginning of a bridge between behaviorism and cognitive-behavioral theory (Corey, 2009).  He thought Skinner's theories were too simplistic although he also believed many of the psychological constructs of previous psychological thought were far too laid back, and were neither problem-solving nor action-oriented (Bandura, 2001).   

As explained in Corey (2009) more contemporary forms of behavioral therapy broadened and became more closely aligned with cognitive behavioral therapy.  Albert Ellis played a distinct role in developing cognitive therapy for his clients.  His original training was in traditional psychoanalysis but he found helping clients to change their thinking increased their overall progress.  He developed rational emotive behavior therapy (REBT) based on the idea that "people contribute to their own psychological problems, as well as to specific symptoms, by the way they interpret events and situations" (Corey, 2009, p. 275).  He believed integrating therapy toward the interactions of cognitions, emotions, and behaviors was the most beneficial approach to psychological problems.     
 

Role of the therapist

In Ellis's REBT,  the role of the therapist is somewhat like that of a teacher, challenging clients' irrational beliefs, shows them how they perpetuate their problems by illogical and unrealistic thinking, and teaching them how to change the way they think (Corey, 2009).  Additionally, the therapist helps clients develop a "rational philosophy of life" (Corey, 2009, p. 280).  Developing such a philosophy is a tool that clients continue to use to prevent a return to irrational thinking. 

In Beck's cognitive therapy (CT), the therapist uses a more collaborative relationship with the client than in REBT, but similarly identifies inaccurate and inappropriate thoughts and beliefs and teaches clients new ways of thinking as well as tools, models, and skills that continue to help them become more rational and accurate in their thinking.  Beck's CT emphasizes the client-therapist relationship more than does REBT.  Beck believed the quality of the relationship was central to successful therapy and that "effective therapists are able to combine empathy and sensitivity, along with technical confidence" (Corey, 2009, p. 291).

 In behavioral therapy, the client-therapist relationship is central to the therapist's ability to correctly implement behavioral techniques.  Functioning as guides and teachers, they "tend to be active and directive and to function as consultants and problem solvers" (Corey, 2009, p. 239).  The behavioral therapist continually assesses the client and strategizes and sets goals in agreement with the client.  The therapist and the client collaboratively evaluate the client's progress.

Research support for the theory

Skinner’s studies of operant behaviors have became the most useful in the field of learning and cognition (Corey, 2009).  Studies have shown that behavior can be conditioned by reinforcements, positively, which increases the probability of the behavior happening again, or negatively, which decreases the probability the behavior will happen again (Olson & Hergenhahn, 2009). Skinner’s theories still remain in wide use, helping users understand and control behaviors in psychological disciplines as well as in issues ranging from advertising to parenting (Olson & Hergenhahn, 2009).  Corey (2009) claims the research of Kazdin (2001) and Spiegler & Guevremont (2003) showed behavioral therapy is generally as effective as alternative therapies, sometimes more effective. 

REBT continues to be useful in therapeutic application in teaching and is effective in increasing student achievement (Warren, 2010).  When comparing REBT and CT, Szentagotai, David, Lupu, and Cosman (2008a) found both had lasting effects that remained effective after discontinuing therapy for patients with major depressive disorder.  Furthermore, at a six month follow-up those effects were better than pharmacotherapy (Szentagotai, David, Lupu, & Cosman, 2008b).  Ward (2011) makes note that the "human capacity of awareness serves as the cornerstone for controlling our responses to external events and limiting or eliminating irrational beliefs and behaviors" (p. 106). 

Bandura's principles regarding self-efficacy have been shown effective in counseling breast cancer patients (Lev & Owen, 2000).  Grusec (1992) believes his theory provides a definitive parameter for future research, and "the theory's potential for developmental psychology has yet to be fully realized" (p. 785). 

 Bandura, A. (2002). Social learning theory. Englewood Cliffs, N. J.: Prentice-Hall.

Grusec, J. E. (1992). Social learning theory and developmental psychology: The legacies of Robert Sears and Albert Bandura. Developmental Psychology, 28(5), 776-786. doi: 10.1037//0012-1649.28.5.776

Lev, E. L., & Owen, S. V. (2000). Counseling Women With Breast Cancer Using Principles Developed by Albert Bandura. Perspectives in Psychiatric Care, 36(4), 131-137. doi: 10.1111/j.1744-6163.2000.tb00601.x

Olson, M. H., & Hergenhahn, B. R. (2009). An introduction to theories of learning (8th ed.). Upper Saddle River, NJ: Pearson/Prentice Hall.

Siegel, P. F. (1996). The meaning of behaviorism for B. F. Skinner. Psychoanalytic Psychology, 13(3), 343-365. doi: 10.1037//0736-9735.13.3.343

Szentagotai, A., David, D., Lupu, V., & Cosman, D. (2008a). Rational emotive behavior therapy versus cognitive therapy versus pharmacotherapy in the treatment of major depressive disorder: Mechanisms of change analysis. Psychotherapy: Theory, Research, Practice, Training, 45(4), 523-538. doi: 10.1037/a0014332

David, D., Szentagotai, A., Lupu, V., & Cosman, D. (2008b). Rational emotive behavior therapy, cognitive therapy, and medication in the treatment of major depressive disorder: A randomized clinical trial, posttreatment outcomes, and six-month follow-up. Journal of Clinical Psychology, 64(6), 728-746. doi: 10.1002/jclp.20487

Ward, J. J. (2011). ‘‘Oh, the Humanity!’’ Kurt Vonnegut and rational emotive behavior therapy’s existential rejoinder to the irrationality of the human condition. The Humanistic Psychologist, 39, 105-120. doi: 10.1080/08873267.2011.540151

Warren, J. M. (2010). The impact of rational emotive behavior therapy on teacher efficacy and student achievement. Journal of School Counseling, 8(11), 1-28.

Case Studies

A Marriage and Family Counselor Learns a Secret

Brief Summary

During a conjoint counseling session with the primary client, the wife, and her husband, the counselor recommends individual sessions.  During the session with the husband, he reveals his affair of 8 months, but declines the opportunity to involve his wife in the issue and suggests the counselor not bring up the issue to his wife.  He asks the counselor for further individual sessions (Herlihy & Corey, 2006).

Confidentiality

One of the issues considered in this case is confidentiality.  Unfortunately, the counselor did not address confidentiality issues that pertain to sharing information between husband and wife prior to his session (Section A.2.a.), so the counselor is not at liberty to discuss the husband's secret with the wife.  According to the ACA Code of Ethics (ACA), (2005) section A.2.a. on informed consent, clients need to receive information related to confidentiality, and other rights and responsibilities of the client/counselor relationship.  Section B.4.a. (ACA, 2005) clarifies the importance of explaining confidentiality prior to beginning therapy.  Section B.4.b. (ACA, 2005) clearly states the counselor must define and discuss confidentiality issues with the primary client as well as others who will be involved in the therapy. Counselors should discuss limitations of confidentiality as well, and obtain agreement in writing (ACA, 2005).

Depth and Breadth of the Dilemma

The husband, wife, and counselor are all involved in this dilemma.  The husband has the right to confidentiality with his session with the counselor.  The wife is involved, even without knowing, because her husband's secret information may be affecting her directly.  Her psychosomatic responses in the situation may be a direct result of her sensing the husband's incongruous behavior and disloyalty. 

The counselor is involved in the dilemma as well.  She must keep the secret from her original client, a secret that may be an important piece of information to her understanding her illness.  If the counselor continues to provide services to the couple, it may be difficult for her to remain neutral to both clients.  If she agrees to marriage counseling, it will be difficult for her to be effective without revealing an (apparently) key component of the wife's difficulties.   Although it is disturbing the counselor did not receive informed consent or review her responsibilities to the husband prior to his session, ordinarily the counselor would still have to keep his secret from the wife. 

Additional Ethical Codes

The American Mental Health Counselors Association (AMHCA), 2010 states in Section A.2.a that confidentiality is a right given to all clients involved in mental health counseling with the counselor.  Section A.2.l, states when counseling families (together or individually,) each member has equal rights to confidentiality "within legal limits" (AMHCA, 2010, p. 3).

Furthermore, the AMHCA (2010) states in Section A.2.n. counselors may breach confidentiality if the client is engaging in behavior that could be harmful to a third party.  This may provide the counselor with a valid reason to tell the wife, although it should be taken under careful consideration.

Regarding informed consent prior to entering into a relationship with a client, Section B.2.a states the counselor must provide information related to issues of confidentiality as well as other aspects of counseling (AMHCA, 2010).  The counselor failed to provide adequate information regarding confidentiality and its limitations prior to counseling the husband.  Section B.3.a. states when counseling a husband and wife, each party must understand the relationship they have with each other.  Furthermore, this section clarifies this understanding should take place prior to beginning counseling. 

Section B.3.c. requires that if counselors believe they cannot objectively counsel the parties in a family or group situation, they must "appropriately clarify, adjust, or withdraw from roles" (AMHCA, 2010, p. 5).

Potential Actions

Although I realize everyone makes mistakes, informed consent and explaining confidentiality to clients is critical.  I would encourage the husband to tell the wife about his affair.  If he refused the opportunity, I would discontinue counseling for both parties, but would make every effort to help them find other separate counselors.  I would use the Hill, Glaser, and Harden's (1996) Model primarily because I have become most familiar with it, but also because I continue to appreciate the integration of intuitive factors when making ethical decisions.  

This would be the best solution if I were the counselor in the above case.  I would not be able to maintain neutrality because in general, I find the type of behavior he is engaging in despicable.  I would like to continue to counsel the wife, but it may be too difficult to keep information from her that seems so important in her recovery. 

The best solution would be for the husband to tell his wife about his affair.  Although I don't believe she would be amenable to him continuing the relationship (as he would like), it might offer the couple the opportunity to heal their relationship, or separate and as amicably as possible, find a way to work together for the sake of the children.

 

A Question of Boundaries

Brief Summary

A counselor agrees to counsel a good friend's son who is also the counselor's son's good friend.  The situation creates an uncomfortable situation between the counselor and her friend (the boy's mother).  Additionally, the counselor has created a dual relationship between herself and her client.  She is functioning as his counselor as well as being the mother of his best friend (Herlihy & Corey, 2006).

Dual Relationships

The counselor has entered into a dual relationship with her client.  She believes, at least initially that the benefit for her client outweighs the harm in counseling her good friend's son.  One of the potential difficulties is putting the client in the position (as an adolescent) to relate to the counselor in both roles.  This could be potentially harmful if he changes the way he relates to the counselor in their sessions because of the role she plays with him when he is at her house with her son.  Furthermore, the counselor claims her perspective of the client has changed because of his personal relationship with him.

Ethical Codes

As stated in the text (Herlihy & Corey, 2006), the ACA (2005) Ethical code of Ethics Section A.5.c. states dual relationships should not be entered into except when there is potential benefit to the client as stated in A.5.d.  Now that the counselor is providing services to her friend's son, she must promote the welfare of her client (Section A.l.a) which may prove difficult in light of her close relationship with the client's mother.  Although the situation does not seem to have hurt the client, it has become increasingly difficult in the counselor's relationship to the client's mother as well as in the relationship with the client as his friend's mother. 

  

There is a good chance that, eventually the dual relationship will cause a more significant dilemma, if not for the counselor, for the teen client.  Section A.4.a and A.4.b claim counselors must avoid harming their clients as well as minimize unavoidable harm, and counselors must be "aware of their own values, attitudes, beliefs, and behaviors, and avoid imposing" on clients (ACA, 2005).  This may become increasingly difficult with the influence of the mother's friendship.

Section 1.A.3.a. states counselors should "make every effort to avoid dual/multiple relationships with clients that could impair professional judgment or increase the risk of harm" (AMHCA, 2010, p. 3).  Furthermore, 1.A.3.b. states when a counselor is making a decision to enter into a dual relationship the counselor should seek consultation as well as using a reasonable decision-making model prior to making the decision.  Section 1.A.3.c. determines when these relationships cannot be avoided counselors should "take appropriate professional precautions such as informed consent, consultation, supervision and documentation to ensure that judgment is not impaired and no exploitation has occurred" (AMHCA, 2010, p. 3).

Potential Actions

If the counselor had consulted with an experienced peer, the recommendation would have been to help the mother and child secure services elsewhere, even with the hardship of distance.  The close friendship of the two mothers as well as the one between the boys should have been a red flag of warning for entering into this relationship.  I would use the Forester-Miller and Davis (1996) Model because it's straightforward and after identifying the problem, applies the ACA Code of Ethics.  After reviewing the ACA and the AMHCA ethical codes, it would be a difficult decision because it would disappoint the mother who was also a good friend, but I believe this would have been the best decision. 

American Counseling Association (ACA). (2005). 2005 ACA code of ethics [White Paper].  Retrieved from the ACA website:  http://www.counseling.org/Files/FD.ashx?guid=ab7c1272-71c4-46cf-848c- f98489937dda

American Mental Health Counselors Association (AMHCA). (2010). 2010 AMHCA code  of ethics [White Paper]. Retrieved from the AMHCA website:  https://www.amhca.org/assets/news/AMHCA_Code_of_Ethics_2010_w_pagination.pdf

Forester-Miller, H., & Davis, T. (1996). A practitioner's guide to ethical decision making [On-line]. Available: http://www.counseling.org/ resources/pracguide.htm

Herlihy, B., & Corey, G. (2006). ACA ethical standards casebook (6th ed.). Alexandria, VA:  American Counseling Association.

Hill, M., Glaser, K., & Harden, J. (1995). Chapter 2: A feminist model for ethical decision making. (1995). In E. J. Rave & C. C. Larsen (Eds.), Ethical decision making in therapy: Feminist perspectives (pp. 18-37). New York: Guilford Press.