Emmy is a trainee counsellor completing placement at a community centre. Her supervisor, Claire invites her to observe an intake session with new client, David.

 Below is a summary of the information provided by David in the first session. 

David is 42 years old, works as a court recorder at the County Court. He wants to be a novelist, has done lots of writing courses, but has never published. David has been living with his partner Julie (40yo) for four years, a high level Victorian public servant who earns more than David. Neither David nor Julie have children. David has had one previous live-in relationship which ended when she left him after four years because “she said it wasn’t going anywhere”. He had other brief relationships when he was younger, which usually were ended by the other person. David reports dissatisfaction with Julie, “the spark’s gone / she’s really critical of me / doesn’t appreciate me”. He says Julie complains about him not planning anything, never following through with stuff – “you never have big plans for the future, I feel like our life’s going nowhere”. David is noticing female colleagues, is uncomfortable about this. He worries that he’s noticing them and maybe he’s being obvious: but he’s sure none of them would ever be interested in him. David was diagnosed with type two diabetes six months ago. He feels frustrated and discouraged by increased health needs such as insulin, feels “old”. He’s now eating well with support of dietician and Julie who does most of the cooking. David reports poor sleep and poor concentration. He loses focus at work easily (a big problem for his role in the Court). From David’s perspective, his physical health is OK – he’s very inactive – walks when he needs to but doesn’t do much else. No pets in the household. David has a small but close friendship network – mainly couples who are friends of Julie’s. David likes reading, dislikes sport. He says he has no addictions but relies on wine “to help calm me down at night” – this began as a glass or two at night, now it’s not unusual for David to drink a whole bottle. David says his father “was a big drinker, mum always complained about him.” David is the youngest of two boys by two years. David’s father left when he was 18 months old. They never had any relationship. David doesn’t know where he is now and has no curiosity about him. David’s mother re-partnered when David was 4 years old. David liked his stepfather. He left when David was 9 years old, with no contact afterwards. David’s brother Andrew was very good academically & at sport, David’s mother compared David to him critically very frequently, verbally abusive to him. David’s brother now lives interstate, is a construction project manager, married with 3 children. He has no real contact with David and not much with their mother. David speaks on the phone with his mother twice a week and sees her once a fortnight. She continues to criticise him while idolising his brother. It appears to David, that his mother lives for her yearly visit to his brother & the children in Queensland. David stays in contact with his mother “because she’s got nobody else”. When David was diagnosed with diabetes, his mother said “well you never were any good at sport, not like Andrew. You’re so lazy, no wonder you’ve got diabetes.” When David was 22 years old, he was in a motor vehicle accident (MVA) – his friend, Brad was driving. David and his other friend argued who would get the front passenger seat, David won, laughing at his mate as he complained about it. The car was the smashed with some force at an intersection by a semi-trailer. David’s friend in the back seat was killed. David and Brad (the driver) survived with minor injuries. David describes himself as “always been anxious, always felt like this as long as I can remember”. He says he became far more anxious about things since the accident. David has never learned to drive and says he likes relying on public transport. David reports that he values his job because it’s quiet, controlled and he’s not likely to be startled at it. Julie is very worried about David, and organised counselling for David. David has been feeling “pretty low” and finding it hard to do much for the past six months. He often has a sense of unease in his gut, talks about feeling “empty”. David is highly anxious in different situations: e.g. when talking with female colleagues, contemplating what to wear of a morning, what to have for lunch, whether to meet up with work colleagues for a drink after work. David is aware of the racing of his heart when he wakes up in morning. At different points during the day, he notices the beating of his heart in the absence of physical exertion or any specific trigger. Apparently insignificant decisions, such as whether to go to the supermarket or not, can cause him almost to freeze. David says “it’s really stupid – I just can’t make the decision, and I know that’s really dumb”. He says “I’m never sure what people think about me – even if they say they like me, I don’t really believe them. I’ve never fitted in. Just the other day I was going to have lunch with a workmate, then he cancelled on me – I thought “oh, I knew that would happen”, it happens to me a fair bit”. From Emmy’s perspective, David presents as reliable, diligent and compliant. He also seems honest, forthcoming and engaged in therapy despite some initial ambivalence. David has high “pressure of speech”, finds it difficult to finish sentences because he wants to describe other relevant factors. He references this and says Julie gets annoyed as he “never gets to the point”. At the conclusion of the intake session, Claire says “for your learning, I’d like you to have a go at completing a case conceptualisation for David using our Five Ps Template”. Emmy’s completed case conceptualisation is overleaf.

Emmy’s completed case conceptualisation: 

Presenting Issues 

• Poor sleep 
• David has been feeling “pretty low” and finding it hard to do much for the past six months. He often has a sense of unease in his gut, talks about feeling “empty”. 
• David is highly anxious in different situations: e.g. when talking with female colleagues, contemplating what to wear of a morning, what to have for lunch, whether to meet up w work colleagues for a drink after work. Wakes up in morning, heart starts racing. Really notices the exertion of his heart in the absence of physical exertion or any specific trigger. Apparently insignificant decisions can cause him almost to freeze – whether to go to the supermarket or not. 
• He says, “it’s really stupid – I just can’t make the decision, and I know that’s really dumb”. 
• He says “I’m never sure what people think about me – even if they say they like me, I don’t really believe them. I’ve never fitted in. Just the other day I was going to have lunch with a workmate, then he cancelled on me – I thought “oh, I knew that would happen”, it happens to me a fair bit”.

Counsellor Reflections :Strong negative self-talk which David doesn’t notice as a problem in itself

Predisposing Factors 

• Father left when David was 18mo, never any relationship since. 
• When David was 22yo was in a motor vehicle accident (MVA) – he & two friends driving, David argued with his mate about who’d get the front passenger seat, David won, laughing at his mate complaining about it, they were then T-boned at an intersection by a semitrailer, David’s friend in back seat was killed, David & the driver survived with minor injuries.

Counsellor Reflections : Is this connected with David never getting a driver’s licence?

Precipitating Factors 

• David diagnosed with type two diabetes six months ago. Frustrated and discouraged by increased health needs such as insulin, feels “old”.

Counsellor Reflections : none

Perpetuating Factors 

• David’s tendency to self-criticise

Counsellor Reflections : This self-talk is powerfully negative

Protective Factors 

• Now eating well with support of dietician and Julie who does most of the cooking.
•  Likes reading. 
• Julie is very worried about David, and organised counselling for him 
• Reliable – diligent. Honest, forthcoming, engaged in therapy despite some initial ambivalence. 
• Likes his job because it’s quiet, controlled, he’s not likely to be startled at it

Counsellor Reflections : Work helps David participate in society. 

Is David engaged in counselling for David?

Emmy and Claire discuss the formulation completed by Emmy. Claire and Emmy review the following CBT intervention plan.

1. Please review the CBT Treatment plan and answer the following questions:

a. What are the strengths of the above CBT Treatment Plan in terms of how this would be helpful for David’s outcome? Justify your answer

b. What are the limitations of the above CBT Treatment Plan with regards to David’s problems? For instance, what do you see as the gaps and what implications might these gaps have in terms of providing the most effective treatment for David? Justify your answer.