Assessment and Report Writing in Counselling

Table of Contents

Client Report.

References.

Client Report

CLIENT NAME: Edward Crane

AGE: 42

REPORT AUTHOR:

DATE OF REPORT:

(any other relevant statements i.e. confidentiality, consent etc)

Consent has been obtained for conducting therapy session with the client.

The current report has been developed and formatted based on the Zuckerman text reading (Zuckerman, 2019).

Referral reasons: The current client’s has gone through assessments such as Beck Depression Inventory and Beck Hopelessness Scale. These suggest that Edward has Major depression (American Psychiatric Association, 2013). It is the reason due to which Edward has been referred by his family physician to the therapist. Apart from that, as reported by the client, his wife suggested him to visit the therapist as he seemed depressed.

Background information and history:

The client has gone through an assessment of his problems, his family his thinking and others through using a questionnaire. The client is married and has two children. He is the sole earner of the family and he is departmental supervisor for the regional office of a large international insurance company. As per the information shared by the client, the behaviour of the client is dependent, identified to be sharing too much information at one place, confused with different thoughts and associated feelings. He shares that he feels abandoned and the time he is going through is the time of crisis. Additionally, as per the client the reason behind he is feeling sad, angry and abandoned is due to his wife who started going to school which she had not done before.

Factors that played a role in counselling process:

  • Personal

As per the views of Burgess et al., (2017), personal factors that generally play important role in counselling process include Attitudes, motivations, family status, gender, special vulnerabilities, circumstances and others. In the current context it has been identified that the client’s personal factors that were playing an important role in his or her counselling is his attitudes towards the situation he was experience. On the other hand, it has been identified from that session that the client had special vulnerabilities rooted in the protective behaviour of his parents and near relatives towards the client, for instance, at an early age, the client was not allowed to do certain tasks such as travelling and was always taken care of. As per the client, this has started making feeling him incompetence. This thought is another personal factor that has played important role in the current therapy scenario.

  • Social

The major social factor that has been identified to play an important role in the context of the current client is cultures, customers and religions and values. It has been identified from the sessions that the client was thinking that his wife is supposed to take care of him, the home and the children which has been observed to direct the thoughts and feelings of the client to a specific direction (Catarino et al., 2018). It is required to communicate with the client more in order to identify the reason of this stream of thoughts which is playing an important role with cognition of the client.

Summary of counselling intervention used:

Initially, the therapy has started with an agreement with the client (consent) that there will be 10 sessions working through which the issues can be taken to solution. In the first part of the therapeutic process, the initial interview and assessments have been done based which it has been identified that the client is suffering from major depression (Janse et al., 2017). In the initial conversation with the therapist, the client seemed to share high amount of information which has been predicted by the therapist that it will lead the client feeling guilty and foolish for sharing this much of information. Therefore, it has been decided to make a clinical choice. It has been chosen by the therapist to stay connected with the thoughts and feelings of the client. The initial part was focused on obtaining data and to create a ground for indentifying problems and strategies. The initial part has also included a goal setting attempt. The client has been discussed about handling the feelings such as down and depressed. Another goal was to work on developing skills for adapting with broad range of problems (central issue). In this session, the changing style of communication to make it more non-threatening is required to be noticed.

During this session a problem list has been delivered and secured the agreement of the client to the therapy. After the session, ideas about cognitive therapy and the schedule of sessions has been discussed. After session two it has been identified that the BDI score has increased to 24 which has been due to sensitisation by the external and internal experiences. Here, problem definition and recollection has been performed so that client can get aware about the process he might go through. During the third session a change in circumstance has been identified and the therapist gone through the same. The technique is used to focus on the thoughts and feelings of the client. In the third session the client has been encouraged to focus on his feelings rather than on what his situation (Uchendu & Blake, 2017).

In this session, a problem solving approach has been taken by using three column technique generally used in cognitive therapy. In this session, the client has been introduced with the process of separating the situation from the feelings and feelings from his thoughts. The client learns how to differentiate between the real world and his own feelings. The client’s thought was being abandoned. In this session, he has been guided to challenge his thinking, focusing on the problem developing strategy, maintaining focus. A principle of cognitive therapy is seeking and evaluating data, though the subjective experience is stronger and is difficult to modify. In session four, the BDI score was increased to 28, however, he was given with home work for performing the planned tasks without assistance of his wife or any other person. From the session five, the client has been found to show improvement as he successfully spent his weekend without depending on other individual and he reported that the client did not have any issues with his wife as he had before.

In this session, the client has demonstrated lesser dependence on any other person for spending his time with. Next three sessions, Edward has been encouraged to collect, examine and challenge automatic thoughts regarding his job and his wife. However, in session nine a significant decline in the BDI score has been observed, which was an objective indicator of improvement of the client. In this session, the client has admitted that his relationship with his wife got better during the past three sessions. This might be indicated to better emotional regulation which was achieved as Edward learnt to separate thoughts and feelings from the situation he experiences. In this session client has informed that he was feeling more independent and relieved. However, it has been decided at the end of the session that next session will be devoted to work on anger (Goodyer et al., 2017).

In session thirteen, the client has shown significant change in his thought process mastering the skills for separating thoughts, feelings and identified himself as a “needy” person and shared that he feels anger when the go through the thought that he needs assistance from someone and seeks to be surrounded (Olthuis et al., 2016). The improvement after long three sessions where he supposed to identify and work on the automatic thoughts he demonstrated that the automatic reaction attached to his thoughts was anger. The focus has been shifted to the central issue of client’s thought that “I am not competent enough” and he has been suggested differentiate between what he likes to happen and what is his needs. After 15th session, it has been identified that the client has more improvement in his thoughts that he learnt to accept things, now is feeling better and less worried with his work life.

The cumulative impact of the session improved client’s skills to separate his thoughts and feelings from the situation he is experiencing. The client learnt to accept the circumstances, feeling more independent and worthy. Apart from that the client has accepted that he learned about evidences and how those can be used. Most importantly, the client has informed that he learnt how not to upset himself.

Recommendations on Efficiency of Cognitive-Behavioural Therapy

It can be recommended to scheduling the follow up sessions until the client develop and master skills for manage his emotion and deal with them independently.

It is also suggested to focus on the cultural factors which might be an important factor to influence the thoughts and feelings of the client.

References for Efficiency of Cognitive-Behavioural Therapy

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Pub Inc Etc etc

Burgess, E., Hassmén, P., Welvaert, M., & Pumpa, K. L. (2017). Behavioural treatment strategies improve adherence to lifestyle intervention programmes in adults with obesity: a systematic review and meta‐analysis. Clinical obesity7(2), 105-114.

Catarino, A., Bateup, S., Tablan, V., Innes, K., Freer, S., Richards, A., ... & Blackwell, A. D. (2018). Demographic and clinical predictors of response to internet-enabled cognitive–behavioural therapy for depression and anxiety. BJPsych open4(5), 411-418.

Goodyer, I. M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., Hill, J., ... & Senior, R. (2017). Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial. The Lancet Psychiatry4(2), 109-119.

Janse, P. D., De Jong, K., Van Dijk, M. K., Hutschemaekers, G. J., & Verbraak, M. J. (2017). Improving the efficiency of cognitive-behavioural therapy by using formal client feedback. Psychotherapy Research27(5), 525-538.

Olthuis, J. V., Watt, M. C., Bailey, K., Hayden, J. A., & Stewart, S. H. (2016). Therapist‐supported Internet cognitive behavioural therapy for anxiety disorders in adults. Cochrane Database of Systematic Reviews, (3).

Uchendu, C., & Blake, H. (2017). Effectiveness of cognitive–behavioural therapy on glycaemic control and psychological outcomes in adults with diabetes mellitus: a systematic review and meta‐analysis of randomized controlled trials. Diabetic Medicine34(3), 328-339.

Zuckerman, E. L. (2019). Clinician's thesaurus: The guide to conducting interviews and writing psychological reports. Guilford Publications.

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