Use the Case Study Provided as a pdf to answer these 7 questions: These seven

Use the Case Study Provided as a pdf to answer these 7 questions: These seven questions are separate ones so please respond to them separately, using 7 separate sections. (1) As we know, there is no perfect case example. What are strengths and weaknesses of this CBT case example (2 pts) (2) Based on this case example, what are the procedures of doing cognitive-behavioral therapy? (2 pts) (3) What techniques were applied to this case example? How were they applied? (2 pts) (4) Highlight two techniques used in this case example that you consider the most effective. Explain why they were most effective. (2 pts) (5) What critical moments or turning points do you see in the case examples? Explain these moments (2pts). (6) What CBT techniques other than those used in this case example can benefit the client in the case example? Please explain (2pts) (7) What theoretical approaches and techniques we have covered during this semester can be integrated with CBT to help the client in this case example? Clearly explain why they can be integrated? (2 pts)
8Client Presenting with Conduct DisorderMandy Drake and Mike ThomasLearning objectives By the end of this chapter you should be able to:Identify the presentations for conduct disorderDescribe the development of conduct disorder from a cognitive perspectiveDescribe how anger is maintained through maladaptive coping mechanismsOutline the main strategies used in the treatment of anger managementUnderstand the importance of trust and relationship building in the treat-ment of anger management Diagnostic criteriaAnger as a diagnosis is usually not included as a single mental health disor-der as it is within the emotions commonly observed and experienced. Anger itself is usually a normal response to a situation which causes anxiety, stress or frustration and therefore remains an emotion within cultural, social and psychological parameters. The DSM-IV-TR (APA, 2000) and the ICD-10 08-Thomas & Drake-4286-Ch-08.indd 11105/11/2011 12:39:26 PM
COgnITIve BehavIOUr TheraPy Case sTUDIes112(WHO, 2007) classify anger management difficulties under conduct disorders, the former within the criteria 312.81, 312.82 and 312.89 and the latter within F91.0, F91.1 and F91.2. Some of the ICD-10 criteria may be found amongst other symptoms of mental health conditions such as depression, development disorders, psychosis and diurnal mood disorders, and these should be dis-counted as differential diagnoses. The conduct disorder itself is usually sub-categorised as follows: •Conduct disorder confined to the family context (ICD-10 F91.0) wherein the behaviour is almost exclusively with close family members and is confined within the home •Unsocialised conduct disorder (ICD-10 F91.1) which occurs amongst children who persistently display aggression and violence towards other children as well as demonstrating many of the ICD-10 F91 criteria •socialised conduct disorder (ICD-10 F91.2) which may be found more frequently amongst adolescents and, as the name implies, is found in socialised tolerance in gang membership, group delinquency, stealing in company or truancy from school •Oppositional defiant disorder (ICD-10 F91.3), a difficult diagnosis to apply which requires good clinical assessment as it can be seen in young children who are trying out the boundaries of behavioural acceptance by adults and peers. severe mischievousness may not in itself be enough to be given this diagnosis. Other criteria in F91 must also be presented for the diagnosis to be applied.The DSM-IV-TR (APA, 2000) gives three sub-types which are not too dis-similar to the ICD-10 and include Childhood-Onset Type (code 312.8), Adolescent-Onset Type (code 312.82), and Unspecified Onset (code 312.89), and grade the level of the conduct disorder as mild, moderate and severe. The DSM-IV-TR also notes that an individual must have demonstrated at least three of the behaviours during the past 12 months and at least one during the past six months.The ICD-10 (WHO, 2007) criteria code F91 states that conduct disorder is characterised by persistent anti-social or aggressive behaviour which is more severe than mere childishness or adolescent resistance. There may also be higher than normal levels of fighting, bullying, cruelty to animals, or destruction of property, fire-starting, stealing and repeated lying. In young people other anti-social characteristics may include truancy and running away from home.Poor frustration tolerance, temper outbursts, irritability and recklessness are associated features and it is no real surprise to learn that accident rates are higher amongst people with conduct disorder than in those without it. Day and colleagues (2008) also suggest that the homicide rate is higher amongst individuals who have anger management difficulties. In addition, suicide attempts and actual suicide rates, as well as reckless living (levels of smoking, 08-Thomas & Drake-4286-Ch-08.indd 11205/11/2011 12:39:26 PM
ClIenT PresenTIng wITh COnDUCT DIsOrDer113drinking or drug-taking), are higher amongst individuals with conduct disor-ders than the general population.Predisposing and precipitating factorsThere is a lack of clarity regarding causative factors with the general view being that it is a combination of genetics, upbringing (especially early years), environment and socialisation which together appear to cause a lack of anger containment or lower levels of tolerance in situations most people find acceptable.Van Goozen and Fairchild (2006) propose a genetic link, stating that alterations in neurotransmitters may be genetically inherited. Whiting (2008) also notes a genetic tendency by suggesting that low levels of stimulation cause higher than normal arousal responses resulting in extreme behaviours and risk-taking. Another argument put forward is that it may be related to early life exposure to violence or aggression in the home environment (Herrenkohl et al., 2007) which causes psychological trauma and later life aggression. Other early life experiences may also play a part, such as lack of attachment to or from a parent, abuse, neglect and bullying. This is important as verbal IQ levels and overall school performance may have been adversely affected by disruptive behaviour during childhood and adolescence, and the lack of such understanding by edu-cationalists, health and social care staff will have a negative impact on compliance and treatment progression (NICE, 2005a). An important aspect of anger and aggression that may sometimes be missed by professional support is the role that shame plays in the individual’s life. Here anger and aggression can serve the purpose of disassociating the discomfort of shame by transferring the emotions into a more acceptable outlet for the individual.Ford, Byrt and Dooher (2010) suggest that brain trauma, alterations in brain functioning or alcohol and substance-abuse damage, may also increase the potential for aggression, although it is unclear whether this is due to loss of inhibition or frustration.Cultural factors also appear to play a part, with societal and individual responses to ethnicity, cultural groupings, sexual orientation, religion, gender, age or disability all increasing the frustration, anxiety and anger of those who perceive that they are not understood or recognised. In some families there may be an additional tolerance for casual violence that is not accepted by the rest of society, for example where the male is typically seen as the domi-nant figure imposing authority through intimidation and dominance which is then perceived as an attribute for others to imitate. The same can be applied to gang culture with its emphasis on demonstrations of dominance through aggressive or violent acts.08-Thomas & Drake-4286-Ch-08.indd 11305/11/2011 12:39:26 PM
COgnITIve BehavIOUr TheraPy Case sTUDIes114However, all this must be kept in perspective as managing anger through aggression and violence is not a modern social phenomenon. Dolan’s (1994) exploration of domestic violence between the years 1550 and 1770 found many similarities with modern times, particularly the levels of domestic crime recorded and the themes of familial traits, early childhood experiences, trauma and alcohol abuse in the perpetrators. The cognitive view is one where there is a psychological, physical and environmental interaction which precipitates a series of response stages. These stages serve to either contain or release the emotions and thoughts which may be anger, anxiety or frustration (Westbrook et al., 2007). Usually there is a trigger which precipitates a negative automatic thought. This in turn creates emotional responses simultaneously with physiological responses. The individ-ual’s negative thought pattern perceives these somatic and affective changes as appropriate responses which in turn drives the response further and provides a rationale for the reaction and consequences (Kinsella and Garland, 2008). Demographic incidenceConduct disorder is the most prevalent diagnosis of both children and ado-lescents in hospitals and outpatient settings (Whiting, 2008), with estimated lifetime prevalence of approximately 10 per cent (12% amongst boys and 7% amongst girls). The average age of onset is around 11 years. Whilst aggression is more typically found in males, probably due to more social acceptance, it does not mean that females do not also engage in aggressive and violent behaviours. Antai-Otong (2008) noted that women with psychiatric disorders were just as aggressive as men, and whilst pre-hospitalisation behaviour indicated that men were more prone to violent attacks involving weapons, at immediate hospitali-sation women were actually more prone to violence against others. Continuum of severityConduct disorders may occur before pre-school age but symptoms usually appear from middle childhood to early adolescence. Onset is rare after the age of 16 years and some individuals with milder symptoms go on to have adequate social and personal adjustments in adult life, although the earlier the onset the poorer the outcome in adult life (DSM-IV-TR; APA, 2000). Poor anger management, as noted above leads to a poorer quality of life with a higher incidence of broken relationships, accidents, homicides, suicide attempts and entry into the criminal justice system08-Thomas & Drake-4286-Ch-08.indd 11405/11/2011 12:39:26 PM
ClIenT PresenTIng wITh COnDUCT DIsOrDer115 Case study rationaleBen is a 16-year-old male referred to the day care unit of the local Child and Adolescent Mental Health Service (CAMHS) from the Primary Care Mental Health Team (PCMHT). This referral means that Ben will move into special-ist mental health services and his care will consequently be at step 4 of the Stepped Care model. However, the care Ben receives involves CBT interven-tions occurring at the immediate level of negative automatic thoughts, thus the case demonstrates how low-intensity interventions, typically seen at lower levels of the care pathway, can also be applied within the specialist services. ClientBen is 16 years old and has been referred to the unit following an altercation with the educational psychologist, where Ben swore and became aggressive during an assessment session. He had been absent from school on numerous occasions during the last year and when he did attend he was accused of bul-lying and threatening other pupils. He was consequently due to be suspended but the school disciplinary panel recommended he be seen by the educational psychologist first. Ben had been increasingly violent towards his mother and his sister during the previous three months and he was a well-known member of a local gang of youths. This gang were suspected of vandalising property, threatening older residents and attacking other young people late at night, but as no one had come forward to verify this no proof had been established by the police. Ben’s provisional diagnosis by the psychologist was socialised conduct disorder at moderate level (DSM-IV-TR; APA, 2000).assessment sessions 1–5Initial assessment indicated that Ben lived with his mother and sister although his father visited the home occasionally. Ben’s mother had stated that these visits were often a trigger for Ben’s aggression as his father would come around asking for money or alcohol. After his father had left Ben would be extremely angry, and over the last few months he had become violent towards his mother and his sister after such visits.Ben had been an ‘average’ pupil throughout his school years and, according to his mother, had deteriorated educationally only in the last year, since he started 08-Thomas & Drake-4286-Ch-08.indd 11505/11/2011 12:39:26 PM
COgnITIve BehavIOUr TheraPy Case sTUDIes116to ‘hang out with the wrong crowd’. His school teachers found him surly and uncommunicative and were frequently catching him bullying other pupils for money or snacks, which had led to a recommendation that he be excluded. Ben had subsequently been referred to the educational psychologist to whom he was threatening and aggressive, resulting in the psychologist referring him to the PCMHT, who in turn had referred him to CAMHS due to his age.In the first sessions Ben revealed that he mistrusted and disliked authority figures but in the main he frequently fidgeted, looked at the floor and avoided any communication. If he did reply it was with guttural utterances or mono-syllables. He slouched and exhaled heavily throughout the first three sessions and often refused to reply to any questions put to him. He was clean, well groomed and always attended on time, but he refused to complete any assess-ment scales for anxiety or depression, although he presented no observable signs of either. In view of Ben’s reluctance to engage with the therapeutic process, and concerns that he might not continue to attend the sessions, socialisation to the CBT model was paramount. At this stage the intention was to assist Ben to understand his current difficulties and their impact on his life, as well as to introduce the principles of CBT. The approach adopted was to explain the five aspects of your life experience model (Padesky and Mooney, 1990) using the example of when Ben became aggressive with the psychologist (Figure 8.1). Ben showed an interest in how situations influenced his thoughts. He could see the negative nature of his thinking and how this then activated physical and emotional responses, which in turn influenced his reactions and behaviour. This encouraged Ben to participate a little more in the assessment process. It was found that he responded well to Socratic questioning, which is a method commonly used in CBT to gather information from specific and recent exam-ples of the problem in question. An example of this is shown below:ENVIRONMENT ThoughtsPhysical Reactions Moods BehavioursFigure 8.1 Five aspects of your life experience © 1986, Center for Cognitive Therapy08-Thomas & Drake-4286-Ch-08.indd 11605/11/2011 12:39:26 PM
ClIenT PresenTIng wITh COnDUCT DIsOrDer117Therapist (T): Tell me about the last time your father visited you.Ben (B): I dunno … it was last week … (Shrugs.)T: What happened?B: Same old same old …T: I don’t know what normally occurs, would you mind letting me try and see it from your point of view?B: He knocked on the door as usual, shouting, drunk as always. Mum opened the door and he started on her. It drives me mad that she lets him treat her like that …T: What did you do?B: What do you mean what did I do! I went out didn’t I, pushed him away, threatened him … threatened to flatten him.T: Was this all on the doorstep?B: Always is. We won’t let him in the house. But he just stands there shouting the odds. I have to go out but mum locks the door and … I can’t get to him. (Leans forward and stares at floor.)T: Does he stay out there for long?B: F****** ages man, makes me want to kill him …T: So how do you calm down?B: (No answer for several minutes.)T: Ok Ben, you don’t have to say anything. Let’s talk about the physical effects of anger. (Therapist leads the session into psycho-educational material.)It took several assessment sessions for Ben to feel comfortable enough to speak more openly and it was only in session 4 that enough information had been gathered to devise a conceptual presentation of his main present-ing problems. The first phase of the formulation highlights the triggers and immediate presenting problems, whilst the second phase highlights the rein-forcers for the original responses. These are shown in Figure 8.2, and are based on the work of Zarb (1992). Ben did not initially accept the conceptual presentation, particularly any suggestion that he was anxious, but he did accept that his aim was to push people away and that he mistrusted authority figures. It took another session, however, before Ben was willing to discuss tasks outside the sessions.Treatment sessions 1–3The cognitive approach to interventions tends to follow the work of Novaco (1979, 2000) who in turn based his work on Meichenbaum’s Stress Inoculation Training (1975). The model takes three stages of therapeutic input: a pre-paratory stage which helps the client to identify patterns of anger, triggers 08-Thomas & Drake-4286-Ch-08.indd 11705/11/2011 12:39:26 PM
COgnITIve BehavIOUr TheraPy Case sTUDIes118and negative automatic thoughts (NATs) associated with the anger; a skills acquisition stage which supports the client in learning new techniques to both recognise provocation and lower the level of arousal; and an application stage wherein the client practises hypothetical situations, applies new skills and then reviews the outcome in order to learn different adaptations to anger. Novaco stressed that the approach is self-directional and the therapist role is to continue the engagement with the process as the attrition rate in anger management treatment is commonly high.Preparatory stageThis stage had already commenced during assessment through the sociali-sation and Socratic dialogue, and to develop this further homework was introduced. The use of language was particularly sensitive as Ben prepared to complete exercises outside the sessions. Words such as ‘homework’, widely used in CBT interventions could not be ascribed to Ben’s work as he may have felt disempowered and they would possibly remind him that he was back at school. Session 6 reviewed the parameters of the therapeutic process Initial presenting problems Presenting problemDuration/frequencyRelated cognitionAggressive and threatening towards his immediate familyAggressive towards those viewed as authority figuresAnimosity and aggression towards fatherLast three months/after father has visited the houseLast year/almost dailyLast few years/continuous feelingMother and sister are weak. They don’t know how to stand up for the family or to the fatherMistrusts and is suspicious of authority. Views them as interfering and unhelpfulHe is a bully and takes things the family need. Dominates and frightens his motherFigure 8.2 Main presenting problems (after Zarb, 1992)Reinforcement contingencies of presenting problems Target behavioursNATs/emotionsDesired consequencesShouts and threatens mother and sisterThreaten others, particularly authority figuresShout and become violent towards fatherThey are too weak to help me, I need to stand up for myself. (Frustration and anger)They interfere and don’t understand what’s going on. (Frustration and anger)He is a bully and hurts me and the family. (Anxiety and anger)Mother and sister leave me aloneThey leave me aloneFor the father to disappear from my life and leave the family alone08-Thomas & Drake-4286-Ch-08.indd 11805/11/2011 12:39:26 PM
ClIenT PresenTIng wITh COnDUCT DIsOrDer119including restating issues of confidentiality and trust, stressing that Ben could lead the speed and level of the sessions and that therapy would attempt to go at his pace. The principles of CBT were again outlined with a specific focus on the need to identify negative automatic thoughts (NATs) and their trig-gers. For this purpose Ben agreed to keep an anger diary, completing columns 1 and 2 only at this stage (see Figure 8.3). Also as homework, Ben was asked to look for any patterns within the diary and he identified that it was when he was criticised or controlled that he became angry, as well as when he had any contact with his father. Furthermore, he could see that it was when he had been drinking alcohol that his anger increased and that his typical NATs tended to be that his mother was weak, his friend disrespected him and that his father deserved everything he got.In preparation for the next stage of therapy Ben was asked to continue with his anger diary but to go on to complete all columns (Figure 8.3).sessions 4–7Skills acquisition stageThe aim of this phase is for Ben to learn new ways of managing his anger by challenging his negative thinking, lowering his physical arousal and changing his behaviour. SituationImmediate feelings and thoughts (0/10)ImmediatebehaviourSix hours after the situation (0/10)After a night’s sleep (0/10)Mother nags me for staying out late with friends drinkingFeel angry and tense/she is weak and irritating 8/10Shout and threaten her until she leaves me aloneStill angry with her/want to leave home, it’s a dump here 6/10Less angry/she’s alright if she leaves me alone 2/10Friend C disses me saying am disabled cos not in schoolVery angry/he is wrong to diss me in front of others/wrong to diss me anyway! 9/10Walked away to stop myself hitting himMad as anything/C will have to be hurt for what he said. He can’t get away with it 8/10Angry/C will get it very soon. He is gonna get hurt bad 8/10Dad came round again, drunk. I pushed mum out of the way and threatened him ’til he left. He says he’ll come back with his mates. Some chance.Angry/could kill him. He’s a bad man that deserves everything he gonna get 9/10Shouted and threatened him until dad leftNot as angry/Thinking how I can get him to stay away. Maybe visit his house? 6/10Not bothered/he is an irritant, not worth bothering about 2/10Figure 8.3 Ben’s anger diary08-Thomas & Drake-4286-Ch-08.indd 11905/11/2011 12:39:26 PM
COgnITIve BehavIOUr TheraPy Case sTUDIes120Therapy began with thought challenging, the NATs identified in the pre-paratory phase being the focus of this, starting with ‘My mother is weak.’ This commenced with an examination of the evidence for this thought and Ben responded by recalling that his mother nags him a lot and that she appears to be afraid of his father, whom she’s never prevented from bothering them. Ben was prompted to consider why his mother behaved as she did, with the exam-ple of her nagging him after he’s been out being used to focus the discussion. Whilst initially Ben was unable to see beyond this being a sign of weakness, he eventually started to consider the possibility that it might be because she was worried about him and that her reaction, rather than being an attempt to control, might in fact be an attempt to care.An impromptu conversation with his mother also served to challenge Ben’s belief about her weakness when between sessions he had talked to her about her behaviour towards his father. He was surprised when she disclosed that she was not afraid of his father but in fact felt pity for him ‘having to come round and beg from us’ and that she did not need Ben to fight for her. It was more difficult to challenge the thoughts Ben held regarding his friend disrespecting him, as discussion identified increasing evidence for this thought but little evidence against. The conclusion reached was that it was a realistic thought and that his friend was not displaying friendship towards him.Perhaps the most difficult thought to challenge was that his father deserved ‘everything he gets’, primarily because Ben became very angry at attempts to discuss this and he could not therefore articulate the meaning of ‘everything he gets’. It did, however, become apparent that this NAT was supported by an underlying dysfunctional assumption that Ben should be responsible for pro-tecting his family, although this had already been weakened by having earlier challenged the thought about his mother’s weakness. Following the thought-challenging exercises Ben was supported to develop more balanced alternative thinking. It became apparent that Ben had con-tinued to dwell on his father’s behaviour, as despite remaining angry towards him Ben was adjusting his negative thoughts away from his father deserving ‘everything he gets’ to thinking that his father did not deserve anything from him as he ‘was not worth it’ (Figure 8.4).It was during this phase that Ben appeared to be more accepting of therapy, which was demonstrated through his commitment to his diary. Completion Angry thoughtBalanced thoughtMy mother is weakMy friend disrespects meMy dad deserves everything he getsMy mother is stronger than I thinkMy friend is not my friend My dad deserves nothing from me – he’s not worth it.Figure 8.4 Balanced thought chart08-Thomas & Drake-4286-Ch-08.indd 12005/11/2011 12:39:26 PM
ClIenT PresenTIng wITh COnDUCT DIsOrDer121of the additional columns enabled Ben to identify an important pattern, which was that his level of arousal could dissipate over a 24-hour period in the majority of situations (Figure 8.3). This was particularly important as Ben had rejected the reading materials on physical relaxation techniques (such as breathing exercises, mindfulness methods and daily physical activities), report-ing that they were unhelpful.Ben was by now developing good awareness that his own thinking about a situation differed from that of others, but he still felt that his resulting behav-iour was acceptable. His diary inserts revealed that Ben’s main method of dealing with his angry thoughts was through shouting and threatening, and whilst he initially insisted that he was happy with this response further discus-sion began to change this. When questioned about the consequences of his behaviour Ben reluctantly admitted that it had no real long-term benefits as not only was the conflict not resolved but he knew that it was in fact wors-ening his relationship with others. Ben was therefore prompted to compile a list of alternative behaviours (see Figure 8.5) with a view to applying these in practice, in the form of behavioural experiments.sessions 8–11Application phaseThe aim of this phase is for Ben to apply and review alternative strategies to manage his anger.Ben identified his mother’s nagging as the area he would like to address first and so the initial focus was on exploring different situations in which his mother nagged him, with alternative behaviours being discussed. After exploring these hypothetical situations Ben agreed to apply alternative thinking and behaviours when his mother nagged him and to record the incidences for discussion in subsequent therapy sessions. The results of these behavioural experiments can be seen in Figure 8.6. Whilst it was clear that Ben was able to apply the new strategies in anger-provoking situations it was also clear that alcohol influenced Ben to return to his old unhelpful responses. Walk away from situationGo out for a walkReduce alcohol intakeUse the balanced thinking chartSleep on itFigure 8.5 alternative behaviours08-Thomas & Drake-4286-Ch-08.indd 12105/11/2011 12:39:27 PM
COgnITIve BehavIOUr TheraPy Case sTUDIes122Following the success of the behavioural experiments Ben agreed that he would continue to apply his new anger management techniques in all situ-ations as they arose and that he would again record these for therapeutic discussion. The excerpts indicated that Ben showed a lack of improvement regarding his alcohol consumption, but in other areas he continued to make progress, particularly in his relationship with his mother and sister. He was beginning to feel in control of situations and relationships and becoming more flexible in his responses; for example he was making efforts to come home earlier in the evenings and also to make time to eat with the family at least twice weekly. Ben had also been on a shopping trip with them although he did say that he would not be repeating that exercise as it bored him. Regarding the friend who repeatedly disrespected him, Ben was slowly distancing himself, his diary showing that his new perception was allowing him to break away from the friendship. As a result Ben reported spending time with friends who preferred to stay indoors ‘listening to music and things’ rather than walk the streets as the nights grew cooler.In relation to his father, Ben would still retreat into mumbling and would avoid eye contact if session time focused on this and his thought diary indicated that there was little progress. Therapy therefore concentrated on continuing the hypothetical exercises around this relationship, and despite his reluctance Ben went on to apply them in his dealings with his father. This proved successful, the strategies of most benefit being to instigate balanced thinking or walking away.Treatment evaluation sessionsIn the penultimate session Ben appeared with heavy bruising of the face and hands and disclosed that his old gang friends had taken against his decision to SituationInitial thoughts and feelingsBehaviourWhat happened afterMum nagging because I was late home and missed teaAt it again! Feel tenseApplied balance, thought ‘it’s only because she cares’. Went to my room for 30 minutes to calm downWent downstairs and watched television with mum. No falling outMum going on at me for not cleaning my roomStop nagging! IrritatedWent out for a walkSpoke to mum, said I’d clean the room next day and she said ok. No falling outCame home drunk, mum shouted at me (again!)Stop talking to me, stop shouting, and leave me alone!Shouted at her and stormed off to bedNext morning felt bad, let her down. Mum ignored meFigure 8.6 anger diary records of behavioural experiments08-Thomas & Drake-4286-Ch-08.indd 12205/11/2011 12:39:27 PM
ClIenT PresenTIng wITh COnDUCT DIsOrDer123be with other friends, resulting in the gang, led by his friend C, beating him. Ben in turn had contacted several older friends and they had fought C’s gang leaving them ‘hurt badly’. The session therefore focused on Ben’s rationale for his behaviour and reactions which he insisted were not related to NATs but which came instead from a requirement for him to assert himself in his neigh-bourhood and with his peers. ‘You’ve gotta see my view … can’t let them push me around. This needed sorting and it been coming a while anyhow.’This was a difficult session as Ben’s behaviour impinged on the therapist’s own personal sense of responsibility, ethics and a perception that violence is not the answer to such disputes. These views were shared with Ben who responded by stating that such morals were ‘ok where you come from but in my patch you would die’.The final session was also sensitive as Ben had to relinquish his sense of trust and support provided by therapy and to generalise these approaches towards others. Ben suggested that it was not appropriate for him to return to school but that he would consider the remainder of the year completing a work-placement curriculum and this was to be explored with his headteacher.The evaluation of the problem presentation originally conceptualised showed that Ben had not been aggressive towards his sister or his mother for two months and was in fact beginning to enjoy their company. He had also relinquished all contact with some of his previous friends. His father still came round to the house but Ben and his mother had agreed that Ben would leave by the back door and would have no interaction with his father. He now felt that his mother could manage the situation and he did not feel the need to intervene.Ben agreed he had developed a stronger sense of his own anger, the pat-terns that it tended to follow and the triggers that would instigate these strong emotions. He stated that he now had a wider skills set to lower his arousal when he was provoked. Although acknowledging that his alcohol consump-tion was a contributory factor for his anger he showed no inclination to change this aspect of his life.Ben was gaining more success in managing his physiological anger arousal, mainly by walking away or sleeping on issues but he continued to resist exer-cises such as breathing and relaxation, stating they were ‘useless’ and in fact made him tenser. Nevertheless, he found the cognitive and behavioural ele-ments of therapy useful as he developed new adaptation techniques.Discharge strategiesBen was discharged back to the care of his GP who was invited to make a re-referral for top-up sessions should Ben deteriorate within the next year. Beyond this timeframe consideration should be given to the most appropriate 08-Thomas & Drake-4286-Ch-08.indd 12305/11/2011 12:39:27 PM
COgnITIve BehavIOUr TheraPy Case sTUDIes124service for Ben which could be the CAMHS Team or the PCMHT. In either case, further low-intensity sessions would be relevant and these could be offered outside of specialist mental health services at steps 2 or 3. Ben was also informed that he could refer himself to either service.Critique of case studyThis case study highlights the time it takes to build up a therapeutic relation-ship with a client who has conduct disorder and is mistrustful of others. In such a situation much of the early sessions which would normally be taken up with homework tasks (after assessments) had to be suspended and the number of sessions increased. Equally Ben’s reluctance to participate in the assessment exercises meant that therapy had to rely on the Socratic method to gain infor-mation and at times extra data had to be acquired from his mother. It might have been more appropriate for Ben and his mother to have been seen within a family therapy setting using systemic approaches, but his initial animosity towards her meant this was impractical in this case. The language used in therapy was also important; the use of wrong termi-nology or words that would have negative connotations for Ben had to be avoided and this was particularly true in the issue of self-study and out of ses-sion exercises. Language and its use in psycho-educational approaches requires an understanding of the verbal and cognitive abilities of the client in order to balance the information, giving material at the right level for the client. In Ben’s case several sessions were spent in reviewing and repeating exercises to support his understanding and this inevitably hindered other activities.Ben also refused to participate in exercises that would have a beneficial effect on his physical reactions to anger, which again perhaps slowed down progress but is a realistic portrayal, and it may be that in time Ben would resort to breathing and relaxation exercises through being referred to a therapist specialising in mindfulness techniques when he is ready to do so.Problems arising in therapyOne of the main issues in therapy is trust and the establishment of a relation-ship that has objectives and goals. Ben had a history of poor relationships with those he saw as authority figures and it was realistic to expect a period of adjustment to occur before Ben would begin to engage with therapy itself. It would be simpler to label Ben with an intractable conduct disorder but many individuals with the right support at the right time can lead adequate 08-Thomas & Drake-4286-Ch-08.indd 12405/11/2011 12:39:27 PM
ClIenT PresenTIng wITh COnDUCT DIsOrDer125lives after therapy. Trust is entwined with confidentiality, and again therapeu-tic interaction in cases of conduct disorder takes time as the client begins to realise that confidentiality within sessions is maintained and actively demon-strated by the therapist. Equally at time of discharge the issue of trust remains important. The indi-vidual with conduct disorder who has developed trust in the therapy and the therapist now has to carry on with less support and rely on learning and the acquired skills and adaptation abilities to continue the work therapy had only started. This can be difficult, for, as mentioned earlier, the attrition rate for anger management from referral to treatment end is high anyway and learning to generalise trust and coping skills outside of the sessions is therefore an integral aspect of therapy. That is why the discharge phase stresses the opportunity for the client to informally refer themselves to therapy again; it does not provide maintenance therapy support or even a dependency relationship but provides the basis for the client to feel secure that they can access support if required.The issue of language is important. Ben needed to be treated as a young adult; in fact many issues in his life would test the abilities of many adults and he had to understand that he led the pace of therapy and the level that it could be taken to. In this case the work was around NATs and adaptations to trig-gers and reactions when angry, but his relationship with his father may have a direct bearing on dysfunctional underlying assumptions or even schema level functions. Yet Ben’s immediate problems were of a priority when he first came to therapy and in relation to NATs immediate interventions were appropriate, whilst his youth and the duration and length of therapy pre-vented further work in this area of underlying assumptions at core level. This could be an area that could be explored further if Ben wished to return to therapy. Language therefore had to be targeted at his maturity level, his intel-lectual abilities and his perceptions of adult interaction, and much time was spent in sessions in this area because they impacted on trust and confidence building in the therapeutic process itself.Finally there is the issue of the client’s behaviour outside therapy, which may contrast strongly with the therapist’s view of the world. In this case study Ben engaged in a form of gang dispute which may be accepted in his peer group and he therefore had a rationale for responding in a way that was at odds with the view of violence held by the therapist. Yet it could be argued that Ben was not reacting to NATs in that situation but was responding in a way that was considered the norm amongst his peers. This makes therapy hard as the therapist must judge several things: whether the reaction was a NATs response to triggers; whether therapy itself provided a justification for the actions; and whether therapy can continue from the therapist’s perception rather than the client’s. Trust, after all, works both ways. In this case therapy did continue 08-Thomas & Drake-4286-Ch-08.indd 12505/11/2011 12:39:27 PM
COgnITIve BehavIOUr TheraPy Case sTUDIes126Suggested activity:Think about …because the therapist took the view that Ben was approaching the issues in a way that the therapist might not but the approach fitted Ben’s perception of his world, albeit one which did not fit into the world view of the therapist. 1. On what criteria did Ben meet the diagnosis for moderate conduct disorder?2. how was his anger pattern maintained?3. The socratic methods were important in this case study; how would you encourage the client to gather assessment data with you? 4. what would you have done differently to encourage the client to engage in new physiological adaptations to anger?5. what are the issues around therapeutic trust and boundaries when treating anger management techniques?• Try and recall when you were last angry; can you identify the anger adapta-tion model at work? • Keep your own thought diary for a week and measure your responses to specific situations – immediately, six hours later and the next day. This will help you understand the immediacy of certain thoughts and feelings and how many clients require some time to be free of strong emotions, especially anger.• It takes a lot of nerve to engage in therapy. Practise different approaches to making therapy more acceptable, adapting these depending on the client and their presenting problems. 08-Thomas & Drake-4286-Ch-08.indd 12605/11/2011 12:39:27 PM