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Cognitive and Behavioural Psychotherapy for Distressing Thoughts in Work.

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'Reputation is an idle and most false imposition; oft got without merit, and lost without deserving.' Othello Act 2, Scene 3 Case Study: Cognitive and Behavioural Psychotherapy for Distressing Thoughts in Work Introduction The Community Treatment Service (CTS) in Pwllheli is a team of 5 nurses and a social worker offering intensive support, therapies and can provide out-of-hours support for patients open to Care Managers from the Community Mental Health Team and the North West Wales NHS Trust GP Counselling Service. Her General Practitioner referred Ellen to the GP Counselling Service. A brief telephone call described Ellen as suffering from work related stress and anxiety. The only further information given was her telephone number and address so that an appointment could be made at the local GP Health Centre. This is indicative of the extent of pre-contact information given about patients referred and other information about her is obtained after initial assessment sessions. Ellen is 43 years old and lives in Pwllheli with her husband and daughter. She is currently employed part time by a well-known local supermarket, and also part time by a shoe store in town. Along with seven other people Ellen had been dismissed from her previous job as an assistant in a well-known national store for allegedly stealing sweets. This occurred two years ago and the incident actually made front-page news in the local press. The store management had installed close circuit cameras in the store and had alleged that the members of staff were eating from the "Pic'n'Mix" sweets. Ellen maintained her innocence and had involved her union. After some legal battles she actually received �1000 compensation in an out-of-court settlement providing she did not go to the press with the story. ...read more.


She had already discussed this with her current manager who told her that doing this would "just reinforce her worries and make them worse" and that she was a good worker and wanted her to stay. We did discuss the relationship between her distressing thoughts, resulting physical feelings, behaviour and that avoiding issues would indeed reinforce her thoughts. The use of a small portable whiteboard to provide diagrams of this idea and later for use in describing a formulation proved invaluable in this case. As part of Ellen's assessment she was given her first homework exercise as being to go in to the store in question in another town. Ellen described that her fear was centred on the store in her hometown where this incident occurred, and that this was not a problem in any other store. Ellen said, for example that she had not been to this store at all in any location for the past three years, but was visiting the town of Caernarfon this week. It was decided to confirm this by asking Ellen to go in to the store to see if this was a problem for her. Guided imagery (see Padesky and Greenberger, 1995) was used in this session to practice and predict how she would feel going into the stores in Caernarfon and in Pwllheli. Using self-rating scales again Ellen predicted that there would be no problem at all going in to the store in Caernarfon but felt that going in to the store in Pwllheli would be very stressful. Indeed, Ellen reported back to the next session that there was no problem with going in to the store in Caernarfon at all confirming that her fears and anxiety symptoms seemed to be specific to the store where the incident took place. ...read more.


The Role of Supervision The use of supervision with this case was very important. The justification for adaptation of an existing model by Ellen to fit with her feelings was useful. Pwllheli is also in a rural area, where there is a shortage of supervisors. Whilst it was possible to arrange face-to-face supervision on a monthly basis there was also use of Internet (MSN Messenger) and e-mail supervision. This is something that has been discussed by the professional body BABCP - Lewis (1999). The use of guided imagery/discovery and prediction scores was an aspect of this case that was borne out of supervision sessions. The importance of this is described by Milne (2003) who concluded that supervision in CBT was effective, and that transfer of skills from supervision to therapy sessions was marked. Conclusion This is an example of a case referred by general practitioner with no more information pre-initial meeting than name and address. In many ways this was not a disadvantage and as a practitioner this author feels comfortable with that, given that there is adequate supervision in place and the confidence of the general practitioner in question. Indeed, it could be said that there is something of an advantage with a referral unsullied by previous opinion, which may tempt one into following red herrings. Ellen had not come to the attention of the psychiatric services but left untreated the stress could have continued to build and she could have ended up as such, or perhaps being placed on medication. Instead, Ellen's prognosis is hopeful and she is continuing to do well in treatment. This case also shows the importance of supervision in developing an idiosyncratic formulation, keeping track of time management, keeping the momentum of therapy and using co-workers. Providing it can be justified, collaboration with the patient in this way can lead to adaptation of existing models and finding something unique. ...read more.

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