Dimensions and Competencies for Supervision and Consultation

Analysis of Collaboration and Consultation

In case study 18: A Resistant Supervisee (Herlihy & Corey, 2006), the doctoral student, functioning as the supervisor for the intern/supervisee needs assistance in contending with the supervisee's escalating resistance. The doctoral student made an effort to seek support from her student supervision group; however, she has not consulted with the faculty member in charge of internships (Herlihy & Corey, 2006). As the doctoral student in this case, I would have consulted my supervisor immediately upon assignment to supervise an intern who was also a friend. If I had not discussed the dual relationship with my supervisor initially, I would have done so when the intern's resistance became apparent. I would also collaborate, as she did, with peers, but the situation should not have continued, and would not have if the doctoral student had immediately consulted with her supervisor.

Had the doctoral student sought supervision after the initial assignment, she would have been advised against supervising her friend. Providing supervisory services within a dual relationship is prohibited by the ethical codes of the American Counseling Association (ACA) (2005) (Standard F.3.d.) as well as the American Mental Health Counselors Association (AMHCA) (2009) (Standard III.5.). Dual relationships between a supervisor and supervisee can degrade the experience of both parties (ACA, 2005). It is unethical in most cases, except when there is a potentially beneficial aspect of such a relationship. In this case, no potential benefit exists.

Ethical Issues in a Past Employment Setting

An ethical issue that occurred during past employment took place in a hospice setting when a nurse was advised a client to limit disclosure to family members. Although in some cases, this might have been appropriate advice, in this circumstance, the client had transient bouts of hypercalcemia which left her confused and forgetful. The situation had been defined in informed consent and was agreed upon that every aspect of the client's treatment and therapy would be shared with the family.

In my position, I had no authority to direct or correct the nurse, although I reminded her of the stipulations in the client's initial agreement. She said I had no right to inform her about her patient and I should mind my own business. Following the protocol for this type of dilemma, I promptly sent an email to my supervisor and copied the attending physician with a brief summary of how the nurse was handling the situation. I also spoke to my supervisor shortly after emailing her and asked how we should handle this problem. She contacted the hospital liaison in charge of nursing staff for the hospice, and the nurse was removed from the case immediately.

Later that evening, I called a peer within the organization who functioned in a similar capacity to mine. I asked her opinion of how she would have handled the situation and how she contended with similar situations. This was helpful, not only to gain her opinion, but to have exposure to other difficult ethical challenges in the hospice environment. Although counselors may be exposed to numerous dilemmas and have seasoned experience in ethical decision making, consultation and collaboration continue to be beneficial, and even crucial, for the most optimal resolution of ethical issues (Remley & Herlihy, 2010). My first action was to contact my supervisor. In this case, I recognized the gravity of the situation and that my supervisor was the person who had the authority to correct the nurse's inappropriate action.

Ethical Decisions and Actions in the Above Dilemma

As an ethical counselor, I would have advocated for the client and would have taken action similar to that of my supervisor. In this situation, and in any agreement covered in informed consent, these boundaries must be respected and facilitated throughout the relationship. Although the nurse believed she was acting in her patient's best interest, from the perspective of her written directives, as well as the informed consent agreement with the client's hospice team, she was not. In a hospice setting, or in any counseling environment, acting within the guidelines of informed consent is critical, especially when clients may not be able to advocate adequately for themselves (ACA, 2005; AMHCA, 2009).

Additionally, now that I am aware of ethical decision-making models, I would have considered one of them in determining my actions in any ethical dilemma. For this example, I might have used Welfel's model since it includes consultation with a supervisor as well as peers prior to and after making the decision. Implementing an ethical decision-making model helps the counselor organize and gather pertinent information as well as rely on a more subjective composite of information. Cottone and Claus (2000) cited Kitchener's seminal work related to counseling "in the absence of clear ethical guidelines, relying on personal value judgments...(is) not adequate" (para.2).

Seeking Consultation and Supervision

In most situations, it is crucial to contact a direct supervisor when a complex ethical dilemma arises. Peer consultation can be as valuable as supervisory consultation in many situations. It is interesting to note that Haag Granello, Kindsvatter, Granello, Underfer-Babalis, & Hartwig Moorhead, (2008) found considerable value in the use of peer consultation to enhance supervisor cognitive development. Additionally these authors believe a correlation may exist between peer support and collaboration and the well-being of counselors. Haag Granello et al. (2008) used a multiple perspective model that they believed broadened the counselor's perspective and enhanced their ability to think critically whether or not they used the specific information at a later time.

Qualifications of Supervisor/Consultant

Supervisors or consultants should have an advanced degree in counselor education, or are doctoral students, as in case study 18 in Herlihy and Corey (2006) and have the experience and expertise to provide scholarly opinions and advice. They should understand the breadth of ethical decision making in a contemporary counseling setting, and have detailed knowledge of ethical codes (Remley & Herlihy, 2010). Additionally, supervisors should have an accurate sense of multicultural and diversity issues as well as experience in resolving ethical issues in various circumstances. As part of informed consent between the supervisee and supervisor, the supervisor must "make students aware of the myriad potential ethical issues facing counselors, including culture and diversity, technology, and boundary issues as contextual factors that affect the resolution of ethical dilemmas" (Herlihy & Corey, 2010, p. 237).

Evaluating My Role as an Ethical Counselor

Working Alliance

Herlihy and Corey (2006) believe "a strong working alliance between supervisor and supervisee is essential for supervisee growth and development" (p. 235). This relationship assists the supervisee as he or she becomes an ethical and competent counselor. As an ethical counselor seeking supervision, I will not hesitate to express my mistakes as well as my fears to my supervisor. In return, I will expect encouragement, constructive and fair criticism, and direction (Corey, 2006). When a supervisor cannot help, he or she will refer me to a professional who has information or experience necessary for my development and growth.

Competence

Prior to engaging in supervising counselors, I will obtain specific training, and as the ACA Code of Ethics (2005) states, before counselors supervise others, they will be trained in appropriate supervisory methods (Standard F.2.a.). Furthermore, I will foster the characteristics and competencies of effective supervisors listed in the Ethical Guidelines for Counseling Supervisors (Association for Counselors Education and Supervision, 1993). As an ethical counselor, I will keep abreast of contemporary research as well as advances in counselor supervision, and understand the need for continuing education. For supervisors and consultants, the ACA (2005) Code of Ethics prohibits falsely representing expertise, experience, and knowledge. When seeking supervision or consultation, I will expect this same level of competence (Remley & Herlihy, 2010).


References

American Counseling Association. (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. (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

Association for Counselor Education and Supervision (ACES). (1993). Ethical guidelines for counseling supervisors [White Paper]. Retrieved from the ACES website: http://files.acesonline.net/doc/ethical_guidelines.htm

Cottone, R. R., & Claus, R. E. (2000). Ethical Decision-Making Models: A Review of the Literature. Journal of Counseling & Development, 275-283.

Haag Granello, D., Kindsvatter, A., Granello, P. F., Underfer-Babalis, J., & Hartwig Moorhead, H. J. (2008, September). Multiple perspectives in supervision: Using a peer consultation model to enhance supervisory development. Counselor Education & Supervision, 48(1), 32–47.

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.

Case # 18

Case # 18 Brief Summary
In case # 18 (Herlihy and Corey, 2006), a doctoral student is supervising the internship of a former friend and colleague. After the first several weeks of the semester, the intern becomes less responsive to her supervisor's requests and feedback. The dual relationship does not seem to be working for the supervisor/supervisee relationship. The supervisor seeks help but has not been able to resolve the issue.

Dual Relationships

The ACA (2005) Standard F.3.d. advises against accepting relatives or friends as supervisees. If the doctoral student had immediately notified her supervisor that she had a relationship with the intern, she could have made other arrangements for the intern and supervised another intern. If she had considered there might be a potential benefit to the dual relationship as stipulated in Standard F.3.e., she should have discussed and documented the rationale for thinking the interaction would work and consulted with her supervisor about the possible conflict (ACA, 2005).

Although the doctoral student has sought help from her supervisor, she should revisit the issue with him before the problem escalates. She may need to meet with the intern and express her concerns, re-clarify the boundaries of their relationship, and let her know she will have to "red flag" her if she continues to fail to fulfill the requirements of her internship. The supervisor should review the boundaries of their professional relationship with the intern and her responsibilities in the supervisee relationship.

The ACA (2005) Standard F.4.d. states that supervisors and supervisees have the right to terminate the relationship with adequate notice. Every effort should be made to rectify the situation prior to making this determination, however. The supervisor would refer the intern to another appropriate supervisor. In this case, it would be better to terminate the relationship.

The AMHCA (2009) Standard III.5. advises counselors against engaging in dual/multiple relationships that could cause bias in their judgment. Standard III.10 states the expectations of monitoring the supervisee that includes regular meetings, review of case records, and direct observation of supervisee's clinical work. The supervisee/intern cannot breach her responsibilities in her relationship with her supervisor. Standard III.11. states the stipulations of informed consent. The supervisor should review any breaches agreed upon during their initial meeting when the informed consent was signed.

Best Solution

The best possible solution would be for the doctoral student to realize the gravity of her mistake and let her supervisor know she should no longer engage in supervising the intern with whom she has had a previous friendship. She would need to clarify her position with the supervisee/intern and let her know that they should not continue the dual relationship. The doctoral student's supervisor will find an alternate supervisor for the intern.

One example in which the counselor should seek immediate supervision or consultation is when the counselor realizes he or she has made an error in judgment, action, or decision. Rather than to try to resolve the issue by oneself, using the 'two heads are better than one' theory, the counselor will benefit and probably find easier resolve with the help of a supervisor or consultant. Once an error has been made, resolution often becomes more complex and it is wise to gain the help of a peer or supervisor.

I would also seek consultation if I thought I was ineffective with a particular client. Especially as a new counselor, I would want to make sure I was giving the process enough time without subjecting a client to ineffective therapy.

Ethical Model

For this case, I would use Welfel's' model for ethical decision making (Cottone & Claus, 2000). If I have developed ethical sensitivity, this model seems like a good fit because it includes two steps important in this situation - consulting with the supervisor and peers as well as informing supervisor of the chosen action. I also appreciate the last step of reflecting on the experience.


References

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

Cottone, R. R., & Claus, R. E. (2000). Ethical Decision-Making Models: A Review of the Literature. Journal of Counseling & Development, 275-283.

Herlihy, B., & Corey, G. (2006). ACA Ethical Standards Casebook (Sixth ed.).

Reality and Family Systems Therapy

Key Concepts and Unique Attributes
Whereas reality therapy emphasizes choice and responsibility as a means of self-fulfillment, family systems therapy gives priority to the affect familial affiliations and interactions have on client's direction and choice. Reality therapy is based on the choice theory, which assumes people need satisfying relationships to experience fulfillment. Family systems therapy is founded on the notion that individual's learn to function as part of a system that is the family. Individuals develop a way of being within the family which becomes the way they relate in larger systems or social situations.

Reality therapy rejects the medical model as well as the significance of one's past, although the family systems therapy addresses the foundational experience of the individual's past and present role in the family unit as a significant contribution to present functioning. Reality therapy claims people continue to make choices that satisfy the fundamental needs of "survival, love and belonging, power or achievement, freedom or independence, and fun" (Corey, 2009, p. 317). In essence, family therapy posits people navigate foundational needs by orienting themselves within the family unit. As the individual learns to function within the family, so he or she learns to relate to the rest of the world (Corey, 2009). Neither theory supports the medical model of illness.

Historical/contextual development of the theory

William Glasser rejected his original psychoanalytic training in an effort to find a theory that emphasized personal responsibility. After spending years amending, revising, and developing William Powers' control theory, he established his theory, and called it choice theory. The essence and basic assumption of his theory is the idea that people control their lives by the choices they make.

The family systems approach was born over many years, but especially during the 1950's, 60's and 70's. Adler's seminal contribution to the systems approach inspired further explorations into family therapy theory and practice. Other theorists contributed additional core concepts and slight variations to the theme of the family as a primary systemic contributor to psychological disturbances and the individual's relationship to the world.

Role of the Therapist

In reality therapy, the therapist's intention is to create a close therapeutic relationship and function as the client's advocate (Corey, 2009). In the role of a teacher, the therapist teaches clients self-evaluation as well as how to evaluate relationships; specifically how well their relationships fulfill their needs and desires. The therapist continues to provide guidance in helping clients determine what they want, and how they intend to fulfill those desires. The therapist challenges clients to explore their behavior and commit to change that will facilitate fulfilling their goals. The therapist always encourages hope and maintains a relationship with the client that they have a sense of camaraderie.

In the family systems approach, the therapist functions as a collaborator, teacher, coach and model supported by respect, caring, empathy and an authentic interest in each family member (Corey, 2009). The therapist helps the family see patterns in the individual relationships and how each member can get stuck in particular roles that become detrimental to the individual and the family as a whole.

Research Support for the Theory
Bitter (1993) believes "human living is always influenced by experiences in families and groups" (p. 1). He found using techniques consistent with family therapy in couples therapy helped clients engage in change rather than remain in established routines that were detrimental to the relationship. Keeling, Dolbin-Macnab, Hudgins, and Ford (2008) found potential for family systems therapy to enhance family health in when families provide care for elder members. Corey (20090 claims family systems therapy is useful in marriage counseling, communication problems within families, during family crises, and creating better individual relationships within the family as well as creating a better holistic family functioning.

Reality Therapy has been used extensively for addiction therapy as well as recovery intervention programs (Corey, 2009). Carbo and Carbo (2010) found reality therapy effective for middle school students with behavioral problems. Furthermore, reality therapy is effective for clients seeking change and for a short-term approach (Corey, 2009). Minatrea and Wesley (2008) found using animal assisted therapy with reality therapy was effective for treating substance addiction.



Bitter, J. R. (1993). Communication styles, personality priorities, and social interest: Strategies for helping couples build a life together. Individual Psychology: Journal of Adlerian Theory, Research & Practice, 49(3-4), 330-350.

Carbo, B. C., & Carbo, T. M. (2010). Reality Therapy: A Group Intervention for Middle School Students With Behavioral Problems. Lecture presented at American Psychological Association 2010 Convention Presentation.

Keeling, M. L., Dolbin-Macnab, M. L., Hudgins, C., & Ford, J. (2008). Caregiving in Family Systems: Exploring the Potential for Systemic Therapies. Journal of Systemic Therapies, 27(3), 45-63. doi: 10.1521/jsyt.2008.27.3.45

Minatrea, N. B., & Wesley, M. C. (2008). Reality therapy goes to the dogs. International Journal of Reality Therapy, 28(1), 69-77.

Counseling Minor Clients - Ethical and Legal Considerations

Four Ethical and Legal Issues Related to Counseling Minors

Confidentiality, counselor competence, reporting abuse and neglect, and informed consent require special consideration when counselors provide services to minors. Although often the guidelines for working with minors may seem ambiguous, or ill-defined, following ethical codes and legal statutes is essential. This may be espcially critical when decision making relies on the counselor's discretion.

Confidentiality

Ethical and Legal Conflicts. In some states, the law requires counselors to maintain confidentiality with clients as young as 12 in the school setting, but in a counseling setting parents usually have a legal right to information regarding their child until the age of 18. Ethical codes advise counselors to maintain confidentiality as specified by federal and state laws, but parental rights are upheld by law in most states. Many times counselors are "caught between allegiance to their minor clients and the legal reality of parental rights" (Herlihy & Corey, 2006, p. 201).

Related Ethical Codes. Standard A.2.a. states all clients have the right for informed consent and the freedom to decide to enter and remain in therapy after understanding their rights and responsibilities as well as the responsibilities of the counselor (ACA, 2005). Furthermore it states in Standard B.1.b., Standard B.1.c., and Standard B.2.d. counselors must respect clients' right to privacy unless they disclose an intention to harm self or others or when the client discloses they have a communicable and life-threatening disease. When counseling minor clients, the Standard B.5.a. states counselors must protect confidentiality according to federal and state laws (ACA, 2005).

The counselor will inform the parents and legal guardians about confidentiality as it applies to the minor's counseling sessions and work toward establishing a collaborative relationship with the parents (ACA, 2005, Standard B.5.b). When information must be released, the parent must be notified. Additionally, the minor should receive an explanation suitable for their developmental ability to understand why their confidentiality is being breached (ACA, 2005, Standard B.5.c.).

Resolving the Conflict. In many cases of counseling in private practice, the parents must understand confidentiality as it applies to their child in therapy (Remley & Herlihy, 2010). Difficulties may arise when children (especially adolescents) disclose information to the counselor that they do not want disclosed to the parents. When the child is in apparent danger, or may be exposed to foreseeable harm, it is necessary to inform the parents, however, the counselor can use discretion when disclosing other information to the parents. Resolving this conflict may include encouraging the child to disclose the information to the parents with the counselor's help. If the child refuses to disclose the information to the child and the counselor deems it necessary, the counselor should fully explain to the child why the information must be conveyed to the parents (Remley & Herlihy, 2010).

Counselor Competence

Ethical and Legal Conflicts. The law has no prescription for specific competence when counseling minors. However, the ACA (2005) describes the boundaries of competence for mental health counselors as practicing in situations based on "education, training, supervised experience, state and national professional credentials, and appropriate professional experience" (p. 9). When the counselor enters into a new area or specialty, and when developing new skills, counselors must make every effort to protect their clients from harm. This is especially true with children as a population already considered vulnerable (Remley & Herlihy, 2010). According to Lawrence & Kurpius, (2000) some psychological disorders are specific to children and applying the rules of adult psychopathology to them is incompetent and inappropriate.

Related Ethical Codes. ACA (2005) Standard C.2.a. states that counselors should understand and practice within the boundaries of their knowledge and experience and should not hold themselves out to providing services of which they are not appropriately trained. For the best possible outcome, counselors who work with children should be trained and experienced in providing services to minors. The ACA (2005) Code of Ethics Preamble states that "members are dedicated to the enhancement of human development throughout the life span" (p. 3 as cited by Lawrence & Kurpius, 2000).

Resolving the Conflict. Counselors should realize that effectiveness in adult counseling does not always transfer to working with children (Lawrence & Kurpius, 2000). The ACA (2005) directs counselors to consult with other professionals when confronting ambiguous situations with minors or when their experience is lacking (Standard C.2.e.). Additionally, counselors must continue to monitor their effectiveness and take reasonable steps to make any appropriate improvements (Standard C.2.d.). Counselors should understand theories of child development as well as gender role development. As with counseling any population, counselors must refrain from imposing their beliefs and values on their minor clients (Standard A.4.b.).

Reporting Abuse and Neglect

Ethical and Legal Conflicts. "Failure to report child abuse...constitutes one of the most common breaches of the law and ethical standards" (Lawrence & Kurpius, 2000). Reporting such abuse upsets the therapeutic process as well as the client/counselor relationship and can "disrupt and irrevocably destabilize the family in which the abuse occurs" (Lawrence & Kurpius, 2000, para. 41). Although reporting child abuse is difficult and may result in additional trauma for the child, the family, and the counselor, it is imperative to report such abuse. In most states, laws exist for the immediate notification of suspected child abuse and neglect and must be upheld by anyone responsible for the care and treatment of minors (Herlihy & Corey, 2006).

Related Ethical Codes. The ACA (2005) Standard B.2.a. requires a breach of confidentiality when the counselor believes such disclosure will protect the client from serious and foreseeable harm. In the case of reporting child abuse, federal and state laws require such reporting by mental health counselors and other health professionals.

Resolving the Conflict. Child abuse and neglect must always be reported to the proper authorities. In cases of suspected abuse, the counselor must be certain to gather adequate evidence and information prior to filing a report (Girgus, 2010). When making a determination to report abuse or neglect, the counselor should keep in mind the importance of advocating for what he or she thinks is best for the minor (Diaz et al., (2004). Lawrence and Kurpius (2000) note counselors may have to make ethical decisions that can put them in an ambiguous situation with the law and even with clients. Reporting child abuse and neglect will have significant consequences for the counselor, the child, and the family. Herlihy and Corey (2006) recommend consulting with other professionals as well as obtaining legal advice in any situation that may have future legal or ethical repercussions, or when the counselor has little or no experience with such reporting.

Informed Consent

Ethical and Legal Conflicts. Lawrence and Kurpius (2000) point out informed consent is a contractual agreement between the client and the counselor for the initiation of therapy and falls under the jurisdiction of contract law. In most cases, however, when providing services to minors, the contract is between the parents and the counselor. This may present a conflict for the counselor, especially if the minor child is old enough to want to be involved and directive in the counseling process. Adolescents can consent to their own care when they are pregnant, married, emancipated, or when they are parenting (Diaz et al., 2004). Related Ethical Codes. The ACA (2005) Standard A.2.d. states when counseling minors, counselors must obtain informed consent from the parents or legal guardian (or other appropriate third party) prior to initiating therapy with a minor client. Counselors should include the minor in the agreement to initiating therapy, and include them, as appropriate, in decision making (Lawrence & Kurpius, 2000). Lawrence and Kurpius (2000) recommend making sure the minor client understands the implications and repercussions of therapy and obtaining their consent as well. Furthermore, they recommend using language understandable to the child's particular developmental ability.

Resolving the Conflict. Obtaining parental informed consent prior to initiating therapy is essential and a legal and ethical requirement. Lawrence and Kurpius (2000) note that in most cases, keeping the minor informed and integrated into decision making is helpful to the therapeutic relationship, although this does not waive parental consent or other parental rights.

References

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

Diaz, A., Neal, W. P., Nucci, A. T., Ludmer, P., Bitterman, J., & Edwards, S. (2004, May). Legal and ethical issues facing adolescent health care professionals. Mount Sinai Journal of Medicine, 71(3), 181-185.

Girgus, J. (2010). Barriers preventing the reporting of child abuse and neglect: A comparison of school social workers in public and private settings (Unpublished doctoral dissertation). Walden University.

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

Lawrence, G., & Kurpius, S. E. R. (2000). Legal and ethical issues involved when counseling minors in nonschool settings. Journal of Counseling & Development, 78(2), 130–136.

McCurdy, K. G., & Murray, K. C. (2003, October). Confidentiality issues when minor children disclose family secrets in family counseling. The Family Journal, 11(4), 393–398.

Miller, C. P., & Forrest, A. W. (2009, April). Ethics of family narrative therapy. The Family Journal, 17(2), 156–159.

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

Evaluating Client Profile 2: A Cognitive Approach

Using the Cognitive Approach with Aaron, Client Profile 2

Strengths

The cognitive approach has benefits for Aaron that include the immediate relief of some of his symptoms (Laureate Education, Inc., 2006). Cognitive therapy has been effective for adolescents in applications that include skills training and obsessive compulsive disorder as well as for eating disorders (Butler, Chapman, Forman & Beck, 2006; Lewin et al., 2005; Storch et al., 2010). This approach will teach Aaron cognitive skills with which he can challenge his faulty and irrational beliefs that contribute to his unhealthy behaviors. Cognitive therapy supports a flexible therapeutic process, which can be tailored to Aaron's needs (Corey, 2006).

Limitations

Cognitive approaches do not ordinarily focus on clients' past emotional experiences, although painful ones that intrude into clients' present functioning must be recognized in the therapeutic process before they can proceed toward re-orienting themselves to more effective ways of thinking. This approach is not designed for deep, reflective self-awareness and understanding, and it tends to minimize emotions (Laureate Education, Inc., 2006). Aaron seems heavily invested in the use of ritualistic behavior that may represent an acute underlying emotional condition. His therapist will reevaluate Aaron's progress on an ongoing basis.

Cultural/Gender/Age Issues

Aaron is a 17-year-old athlete of Syrian American descent and his religion is Judeism. The therapist will explore the affect of these cultural aspects as well as those of his parents and the foundational beliefs and the values with which he was raised. Considering Aaron's age and developmental stage is crucial because adolescents are typically contending with the unique consequences of self-identification. The therapist will consider Aaron's social culture of male athletes from whom he may have learned inappropriate measures of success for boys. He will explore Aaron's perspective of therapy as it relates to how his male/athlete culture might perceive it. If this causes conflict, especially with Aaron's motivation, it must be addressed.

Ethical or Legal Issues to Address

Although it is not apparent that Aaron's anxiety is contributing to suicidal ideology or his intent to hurt another person, but this must be addressed in the initial stages of therapy. As a minor, both Aaron and his parents will need to sign informed consent agreements with special attention to the amount of parental involvement versus privacy in Aaron's therapy (Remley & Herlihy, 2001).

Overall Therapeutic Goal

Cognitive therapy focuses on the idea individual's perceptions, not situations, cause maladaptive thoughts (Corey, 2009). This approach is designed to help clients become aware of how they think and develop more appropriate ways of thinking. Because many clients neither question nor identify their internal dialogs, creating an awareness is a crucial first step in changing irrational thinking (Laureate Education, Inc., 2006). One of the key components of Aaron's cognitive therapy will help him integrate rational thinking into his daily life. As Aaron becomes more aware of his perceptions, he will begin to have some control over his automatic thoughts which will, in turn affect the way he responds to them.

The Therapeutic Process

The Beginning

Aaron will benefit from a client-centered approach to help him perceive the therapist as a collaborator in his goal to regain and his health and athletic abilities. Initially, the therapist will want to explore several aspects of Aaron's history as well as his motivation for therapy because this will directly affect how he progresses (Laureate Education, Inc., 2006). Another important issue is Aaron's drug use. The therapist will want to identify any substance abuse or dependence. Collaborating on this issue with other health professionals may be helpful if the therapist is inexperienced (Laureate Education, Inc., 2006).

Goals of Therapy

The goals of Aaron's therapy will be a collaborative effort between him and his therapist. After developing Aaron's awareness of his irrational internal dialog, his therapy will include the use of cognitive tools, which will help him integrate rational and healthy perspectives into his current way of thinking (Corey, 2009). Aaron's therapist may enlist his parents' help to keep Aaron focused and progressing between therapeutic sessions. Ultimately, this approach will help Aaron develop rational thought processes, especially those related to his health, weight, and athletic performance. As Aaron practices more accurate perceptions, he will decrease his automatic responses and his ritualistic behavior (Lewin et al., 2005) .

Specific Strategies and Techniques

The therapist will use Socratic and self-talk discussions as well as debate Aaron's beliefs and values. The therapist will teach Aaron how to argue with his internal dialog and engage him in role playing. Homework will support Aaron in an ongoing therapeutic process outside of the therapy session (Corey, 2009). Cognitive restructuring will help Aaron reorganize and rebuild new ways of thinking. For example, rather than thinking he needs to lose ten pounds, he can realign his focus on creating more muscle to promote his athletic abilities. Restructuring thoughts and self-talk helps clients begin to perceive themselves and their lives more accurately.



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.

Lewin, A. B., Storch, E. A., Merlo, L. J., Adkins, J. W., Murphy, T., & Geffken, G. A. (2005). Intensive Cognitive Behavioral Therapy for Pediatric Obsessive Compulsive Disorder: A Treatment Protocol for Mental Health Providers. Psychological Services, 2(2), 91-104. doi: 10.1037/1541-1559.2.2.91

Remley, T. P., & Herlihy, B. (2001). Professional practice in a multicultural society. In Ethical, legal, and professional issues in counseling. Upper Saddle River, NJ: Merrill Prentice Hall.

Storch, E., Lehmkuhl, H., Ricketts, E., Geffken, G., Marien, W., & Murphy, T. (2010). An Open Trial of Intensive Family Based Cognitive-Behavioral Therapy in Youth With Obsessive- Compulsive Disorder Who Are Medication Partial Responders or Nonresponders. Journal of Clinical Child & Adolescent Psychology, 39(2), 260-268. doi: 10.1080/15374410903532676