Cognitive and Behavioural Psychotherapy for Distressing Thoughts in Work.

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Andrew Lancelot                                                                                                PSM013

'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.  The store management did not apologise or offer Ellen her job back.  Ellen feels that she was treated unjustly and the union did not do everything it could have done.  Ellen has kept a file of letters and press cuttings related to the incident two years ago and the meetings about it since.  

Ellen now works locally for a well-known national supermarket and is happy with her work – she feels that she is good at her work.  Ellen describes, however, that she suffers from stressful “incidents” when “small things” set her off.  She felt that any criticism of her in work would make her feel tense and angry and she would feel like crying.  This resulted in her avoiding talking to people in work for a while and also avoiding going to work related events such as outings or parties.

Both her present managers, work colleagues who know about the incident, family and friends are very supportive.  It was possible for Ellen to confide in them and some work colleagues about the distress she sometimes felt and found that people were very helpful.  Indeed her manager in the supermarket is particularly insightful into the idea about avoiding issues making her worse and suggested she see a “counsellor”.

Assessment

The sessions took place in the local GP surgery – notes were taken and the use of mind-maps proved valuable in recording detailed information without interfering with the therapeutic relationship or the flow of the sessions.  This also helped the production of formulation diagrams.  This technique is described in Williams et al (1997). Assessment sessions consisted of using BASIC-ID as developed by Arnold Lazarus and described by Palmer and Dryden (1994).  It has been developed in more depth by Lazarus (2000) in a paper for the American Psychological Association and also in a chapter of a book in the same year. It is a multi-modal approach to assessing an array of issues, based on the assumption that most psychological problems are multi-faceted and a comprehensive therapy would rely on a careful examination of seven parameters.  Lazarus describes these as being ‘behaviour’, ‘affect’, ‘sensation’, ‘imagery’, ‘cognition’, ‘interpersonal relationships’ and ‘biological processes’ (the final parameter covering medical and biological factors).  

Ellen described how she would avoid social events related to work such as outings and parties if she was recently upset about any comments that she interpreted as being critical of her work practice.  This would happen when anyone made what she termed “throw-away” comments such as “you are up to no good.” and so on.  Ellen also said that she was not able to go in to the store that she was dismissed from in town – something she wished she could do.   Ellen said she would feel angry and frustrated, would blush and not speak to anyone – withdrawing and going very quiet.  This may last for the rest of the shift although she was usually better when she was home and certainly by the next day.  Ellen described her tension at these times as excruciating – if zero was relaxed and 10 was the worst tension it could be - she said she usually scored around an “eight”.

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Ellen also completed the Beck Anxiety Inventory (Beck, 1988) and the Fear Questionnaire (Marks and Matthews, 1979).  She did not show any significant score on the anxiety inventory, scoring just 4 – these symptoms relating to specific incidents in the week.  Ellen said she did not suffer with any tension as a matter of course in everyday life.  Similarly Ellen did not score highly on the Fear Questionnaire either except for the specific situation of being in the store from which she was dismissed.  In this case she scored maximum in terms of avoiding the situation.  She also described ...

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