Counseling Paper: Client Overview And Case Conceptualization
This case conceptualization will focus on a young, male violin student named Paul who recently began study at a prestigious conservatory in New England. The client presents problems relating to anxiety for which he has been referred to counseling. The purpose of the paper is to analyze the client and his presenting problem through the lenses of multiple theoretical approaches. Paul will be described using the ADDRESSING model of client diversity. I will use the same model to describe myself as it relates to my role as the counselor. Paul’s treatment will be discussed using Adlerian therapy, person-centered therapy, and cognitive behavior therapy approaches. Finally, goals for treatment will be summarized and attention will be called to particular elements of diversity that may be relevant.
Paul Drucker is an 18-year-old male who identifies as “White” and heterosexual. Paul has been referred to counseling by the college health center after a recent incident where Paul fainted from exhaustion. Paul is a first-year student at a very prestigious conservatory in Boston, Massachusetts. An accomplished violinist, Paul has come to the conservatory from his home in Waverly, Iowa. Paul has been playing violin since he was five and has taken piano lessons as long as he can remember. Music has been a major motivator for Paul, and he has found a lot of success. He performs often at church and in his community and was selected for Iowa All-State Orchestra for four consecutive years. Paul did well in school, specifically in math classes, but music was the focus of his high school career. Music also was a way for Paul, the youngest of two brothers, to separate himself from his athletically gifted older brother. Paul notes how it “makes [his] parents proud” to see how much he has accomplished as a musician. They told him, if he kept practicing, he could be the concertmaster of the New York Symphony someday.
Paul comes from a very successful family in Waverly, Iowa. His mother is a partner at a law firm and his father is high level executive at GNB Bank. Paul’s parents met while attending the University of Iowa where his father was earning his MBA and his mother was earning her JD. Paul’s paternal grandparents also have substantial landholdings in northern Iowa where they operate a farm. Paul has benefited from his family’s wealth. From a young age, his parents were able to encourage his musical passions by paying for private lessons and sending him to summer music programs. Paul’s violin and bow, valued at $16,000, were a graduation present from his family. Additionally, Paul has been able to travel extensively. Many of the family’s summers and vacations are spent with Paul’s mother’s parents in their native Greece. Paul’s mother moved to the United States for college in the 1980s and has remained there since. His mother’s first language is Modern Greek, and she has taught both of her sons to speak it fluently.
Paul was raised with exposure to both his mother’s Eastern Orthodox Catholic faith and his father’s Jewish traditions. Although he was baptized in the Eastern Orthodox church, Paul says he draws from both faiths when considering “spiritual matters”. During his intake interview, Paul indicates he has a relatively good bill of health, with only a diagnosis of asthma noted. Paul is skeptical about counseling, stating that his mother has said that only “sick people” need to see a therapist.
At college, Paul has had to deal with not excelling for the first time in his musical career. Although back home in Iowa he was constantly receiving praise for his abilities, he now finds himself the weakest player in his violin studio and sitting last chair in his section during orchestra. In order to “catch up” to his peers, Paul has been skipping meals and forgoing sleep in order to practice. He is worried that he is “incompetent” and a poor violinist who must improve. Although he is able to focus when playing, the rest of the day he notices he feels very “weak” and occasionally sees his hands trembling. During this period of time, Paul has lost weight and reports constantly “feeling tense” and worrying about his abilities.
I am a natural born citizen of the United States born in New Castle, Pennsylvania in 1991 and raised in Phoenix, Arizona before moving back to my home state. As a child I was diagnosed with Tourette’s Syndrome and have been actively treated for it with medication since third grade. My family primarily is of European (English, German, and Italian) descent and I would identify myself as White. While my family raised me as a Protestant, specifically a member of the Pentecostal Church, I left the denomination during college. I spent a few years trying to find a church that resonated with me and eventually began attending Catholic services. By chance, I got a job teaching part-time at a Catholic high school while I was attending graduate school, and the experience strengthened my connection with the denomination. This year I was officially Confirmed and baptized into the Catholic Church and joined a parish in Huntingdon, Pennsylvania.
My faith has played a large part in my life, specifically as it intersects with my sexual identity. I identify as a homosexual male and a member of the LGBTQ+ community. A lot of my college years were spent trying to reconcile my sexual identity with my faith identity. The college I attended for my undergraduate degree was not particularly conservative, but it was a college affiliated with the Presbyterian Church. The struggle to reconcile these parts of my own identity spurred my research interest in LGBTQ+ students at Christian colleges.
In regard to working as a counselor to Paul, there are some important strengths I would like to highlight. The first is my ample experience working with college students, particularly first year students. Outside of counseling work, I have spent a total of three years as a residential life professional working directly with college students. I have a strong understanding of college student development and have hands on experience engaging with first year students who are struggling with transitions to higher education.
Another strength is my background in the arts. My undergraduate degree was in music education, and I spent five years teaching music after graduation. Even after leaving teaching, I have stayed active as a musician. Paul is also an artist and considers music to be an integral part of his life and identity. My background could give me some insight into Paul as a fellow artist and offer a bridge to engage him. Our shared experience in the arts could even be a tool in the therapeutic process.
Finally, consider that Paul, on top of his transition to college and a more competitive group of peers, is also dealing with moving from rural Iowa to a major city. Paul understandably might feel alone and nervous. I have had the experience of moving across the country on multiple occasions and previously lived in Iowa (very near to where Paul is from). My experiences moving across the country and my knowledge of his home could be a way to connect with Paul through appropriate self-disclosure and be a way to convey empathy.
In counseling Paul, I will be using cognitive behavior therapy (CBT) as a foundational approach to his treatment. More specifically, Rational emotive behavior therapy (REBT) will be utilized. The use of REBT is dictated by the nature of Paul’s presenting problem. Paul’s distress is rooted in a belief that he needs to be the best and perform at a certain level to maintain self-worth. When Paul feels he is not living up to these standards, he experiences dysfunctional emotions. Cognitive behavior therapy would be a useful foundational approach for Paul because it focuses on changing dysfunctional emotions and cognitions into functional ones (Stefan, Cristea, Tatar & David, 2019). CBT is also an approach that plays to my strengths as a counselor and my background as an educator. My experience as a teacher could be valuable utilizing CBT, particularly in REBT where “the therapist functions as a teacher and the client as a student” (Corey, 2017, p. 441).
One of the advantages of an integrative approach to therapy is to be able to engage clients in regard to feelings, cognitive patterns, and behavior (Corey, 2017). In Paul’s case, the CBT approach will be integrated with person-centered therapy. In person-centered therapy, the client “experiences feelings that were previously denied to awareness” (Corey, 2017, p. 432). Considering the relationship between the therapist and client, person-centered therapy melds well with REBT. Both REBT and person-centered therapy require that clinicians “strive to unconditionally accept all clients and to teach them to unconditionally accept others and themselves” (Corey, 2017, p. 275).
The final counseling theory to be integrated into Paul’s therapy will be Adlerian therapy. Adlerian therapy will be useful in Paul’s case because it will offer a way to conceptualize his distress and goals. Adler’s concept of striving for perfection describes an individual’s desire to move toward their perceived perfection (Corey, 2017). Paul’s musical aspirations can be explored by considering how they might indicate a fictional finalism or “an imagined life goal that guides a person’s behavior” (Corey, 2017, p. 100). Adler’s theory may also be helpful in understanding how Paul’s family might affect his drive for success.
To conceptualize Paul’s case, I am first going to begin by using Adlerian theories to try to better understand what has led up to Paul’s destressed episode. Adlerian therapy gives consideration to birth order and the different experiences siblings can share in the same household (Corey, 2017). Paul is the second of two children. Paul’s older brother has had success as an athlete where Paul has not, but Paul has found his own success as a musician. Adler describes the second child of two as being in competition with the older sibling at all times and trying “to surpass the older brother” (Corey, 2017, p. 103). Paul’s experience is in line with what Adler describes for the second child saying, “If one is talented in a given area, the other strives for recognition by developing other abilities” (Corey, 2017, p. 104). Although Paul could not compete with his brother as an athlete, he found he can win parental attention and praise as a musician.
Paul has found a lot of success in music, and that success has earned him praise from his parents. This praise has influenced the life goals that drive his behavior. Paul’s fictional finalism contains the highest level of success as a musician (becoming concertmaster of the New York Symphony). Paul also comes from a wealthy, high SES family, so there may be expectations of living up to his parents’ level of success. Paul keeps moving toward this guiding self-ideal even if the behaviors are negative. Paul’s final goal is subjective, so he has the power to define it and choose how he will behave to accomplish it (Corey, 2017).
A person-centered therapeutic approach can be used with Paul in order to establish an effective working counseling relationship and create the conditions necessary for change. Carl Rogers, in discussing the therapeutic relationship, identified six core conditions necessary for therapeutic personality change (Corey, 2017; Tursi & Cochran, 2006). One core condition includes unconditional positive regard for the client, which is in line with Albert Ellis’s belief that a clinician should avoid making value judgements while utilizing CBT (Tursi & Cochran, 2006).
A specific core condition is that “the communication to the client of the therapist’s empathetic understanding and unconditional positive regard is to a minimal degree achieved” (Corey, 2017, p. 173). Communicating this empathy and establishing a positive and trusting relationship will be especially important because of Paul’s stigmatized view of therapy. Paul states that his mother has a negative view of therapy, which may be influenced by her upbringing. Paul’s mother was raised in Greece and he has a lot of contact with his Greek relatives. Counseling is a relatively new field in Greece, where culture has been traditionally focused on the collective versus the individualistic (Malikiosi-Loizos & Ivey, 2012). The field is growing and progressing, but it has not been officially recognized in Greece even though “psychology and counseling have their roots in Greek philosophy and traditions” (Malikiosi-Loizos & Ivey, 2012, p. 115).
Paul also grew up in a rural region of the country. Rural communities tend to exhibit a stigma against mental health counseling for fear of a lack of privacy, so building trust with the client is important to avoid early termination (Cohn & Hastings, 2013). Considering Paul’s outlook and background, taking active steps to establish a trusting counseling relationship will be vitally important. If Paul is reluctant to engage in the therapeutic process and share or express his feelings, one option that might interest him, given his background as an artist, may be expressive arts therapy. Expressive arts therapy is a person-centered approach that suggests that creative expression can “lead us into the unconscious, thereby enabling us to express previously unknown facets of ourselves and bring to light new information and awareness” (Corey, 2017, p. 181). If Paul is unable to find a way to express how he is feeling in counseling, artistic express may be a way to help him uncover those emotions.
Cognitive behavior therapy will be used as the foundational theory for Paul’s treatment. Paul’s distress is likely connected to a form of performance anxiety. Performance anxiety is common among musician, even at high levels of performance, where either the performance or (as in Paul’s case) future performance causes distress that is not reasonable considering the circumstances of the performance, the musician’s skill, or the amount of preparation the musician has had (Diaz, 2018). While there is room for Paul to improve as a violinist, he was undoubtedly one of the top violinists in his state and in the country to have gained admission to the conservatory. Paul has unhelpful thoughts about himself and performance that are causing him to undertake dysfunctional behaviors, such as skipping meals, and causing him anxiety. REBT has been shown to be effective for addressing anxiety in college students (Rothman, 2004).
The A-B-C framework (identifying an activating event, client beliefs, consequence, disputing, and new effective philosophy) is a key part of REBT (Corey, 2017). In Paul’s case, the activating event would be placing last in orchestra and realizing he is the weakest player in his studio. The client belief would be that he should be one of the best violinists and needs to be in order to be fulfilled. The emotional and behavioral consequences are anxiety over his performance level and sacrificing health (skipping meals and sleep) in order to practice. The next step, disputing irrational beliefs, is a common part of REBT where Paul will be instructed to ask himself questions to dispute his negative beliefs (Corey, 2017). Paul will learn how to dispute his negative beliefs. Evidence can be presented, such as his admission to a prestigious studio and his all-state selections, that he is not a terrible violinist. He will also be challenged to dispute the idea that he must be the best violinist. An important part of REBT will be psychoeducational methods (which can increase Paul’s cooperation as he will understand the therapeutic process and be more trusting of it) and changing Paul’s language from absolutes, such as must, into preferences (Corey, 2017). Through the REBT process, Paul’s unhelpful beliefs will be replaced with new effective philosophies that can be maintained through homework between sessions (Corey, 2017).
The primary goals of Paul’s treatment will be to reduce his anxiety related to his performance level and to improve his physical health by getting him to stop skipping meals and sleep in order to practice. Combating anxiety will be done by both person-centered and CBT approaches, and REBT will be used to correct the unhelpful behaviors. An A-B-C framework will be used to change Paul’s faulty beliefs about what must happen into healthier beliefs in order to reduce unhealthy behavioral consequences.
It will be important to keep the negative stigma about counseling that Paul has inherited from both his family and his rural community. Paul’s mother is from Greece where the field of counseling is not as developed, so Paul and his family’s opinions of counseling could be stigmatized by that. Paul is also from a high SES family, which may have impacted how he views the importance of success. While unhelpful thought patterns should be addressed, special care must be taken to respect the worldview that Paul has regarding success and not impose the counselor’s own values regarding the matter on to Paul.