1 CASE OF GWEN New Feature for Gerald Corey's Theory

CASE OF GWEN

New Feature for Gerald Corey’s Theory & Practice of Counseling and Psychotherapy (10

edition)

Gwen is a 56 year old, African American woman presenting with fibromyalgia, difficulty sleeping,

and a history of anxiety and depression. She reports feeling stress and isolation on her job and is having

a difficult time managing her multiple roles. Gwen is oldest of five children, and, after her parents'

divorce, she took on the responsibility of caring for her younger siblings. Gwen’s parents divorced when

she was 10 years old and she recalls being happy for the divorce because they fought constantly. She

remained in contact with her father but after the divorce she remembers her life as ending her childhood.

Gwen has been married to Ron for 31 years and has 2 adult children, Brittany age 29 and Lisa age 26. She

has a bachelor’s degree in accounting and is employed at a large firm as a CPA. She does not have enough

time to spend with friends or to do the things she once enjoyed because of her long work hours. She also

helps her adult children with their bills when needed and is the primary caretaker of her mother, who is

living with her and is in the advanced stages of dementia.

This is her first time in formal counseling. She reports having gone to her pastor when she was

feeling “down” in the past. Gwen also reports a history of sexual molestation by an older cousin but states

she has worked through it. She comes into counseling because she is having difficulty staying focused at

work and is generally feeling sad and overwhelmed. Gwen also reports experiencing a great deal of

anxiety. She states she is not suicidal, but is “sick and tired of feeling sick and tired.” Gwen summarizes

her current situation by saying, “I realized the other day that I am tired of just existing and surviving. I am

tired of half living. I actually want to be happy and I know I have to do something very different in my life.

So here I am." Gwen was referred to the therapist (Dr. Kellie Kirksey) by the pastor of her church.

Despite the many challenges in her life, Gwen says that her faith in God is strong; it is her faith that has

brought her into counseling. Her trust in her pastor gave her the courage to call for an appointment.

Intake Session

During the initial session, Gwen begins the initial intake session ready to unload the burdens of her life.

She has filled out all of the required forms and feels good to have a confidential place to share her

challenges. I notice the tension in her face and body. She states that she has held everything together for

everyone far too long. The first step of our journey is to build a working alliance based on mutual respect

and my being fully present with her and the story she wants to tell. I let her know that this is her time to

use as she pleases, and that it is a safe and confidential space.

Gwen begins by saying she feels a heaviness in her heart, which is associated with all that is

expected of her at work and with her family, what she has not accomplished, and where she is heading. I

acknowledge this heaviness and ask her to start wherever she wants. We begin with a subjective

orientation in which I want to facilitate the unfolding of her story. As she speaks, I listen empathically,

paraphrasing what I hear, and then asking the next appropriate open-ended question. Each of these

questions develops from a careful listening to what she has already said. Her statements inform my

questions, not the other way around.

A number of life concerns bring her into counseling. A few of her concerns relate to her work. She

experiences mounting tension on the job and, when she asserts her opinions, she is labeled as emotional

and angry. The more tension she experiences at work, the less she engages at home. An additional

concern is that her mother is slowly fading into another world due to dementia. Gwen reports feeling

terrible about herself and not even wanting to be around people anymore. Everything irritates her and

she prefers to spend time by herself.

Gwen: I feel like a shell of a person. I am not depressed where I am wanting to kill myself. I

just feel numb. There is no real point to doing this daily routine of waking, suffering

through the day, and going to bed just to get up and do it all over again. My life is like

a flat note with little joy. I don’t go out; I don’t have sex; and I am too tired to do

anything. Nothing I do is good enough. I start projects, and then it’s like they

disappear. Nothing ever gets finished, and then I feel worse about myself.

Sometimes I feel like I want to go into a cave and never come out. I feel like I will

lose everything if I don’t make some changes in my life. Everything looks good on

the outside, but inside of me, I am on edge and need to do something different. My

pastor and mentor tell me I am sabotaging myself. Because I love them, I am

listening for the first time. Usually, I get defensive and withdrawn, but this time, I

want to get better and I am ready to do what it takes. I am done with feeling tired all

the time and hiding from people.

Chapter 7 Client-Centered Therapy with Gwen

Gwen arrives for this session moving quite slowly. She reports having been in pain for the past few

days. I asked her to describe the pain in her body and she explains that “it is a full body achiness. “I can’t

sleep through the night and I feel tired all day long. I try to push through the achiness, but sometimes I

just want to sit down and not get up.” I ask Gwen to tell me more about this and she replies: “I don’t mean

sit down and die, I mean sit down and take a break from life for awhile. I have just been feeling down and

stressed.”

To gain a better understanding of how Gwen’s pain has affected her week, I administer a brief

rating scale at the beginning of this session and another instrument at the end of this session. The

Outcome Rating Scale (ORS) is a short questionnaire developed by Scott D. Miller that assesses how well a

person has been doing (individually, interpersonally, socially, and overall wellbeing) during the last

week. I tell Gwen the ORS will give us a quick view into how she sees her current level of functioning and

feeling. The ORS can also help Gwen see which particular areas of her life hold the most stress for her.

She glances over it and sees that marking on the left indicates low-level feelings and marking on the right

of the form indicates high levels. Gwen marks quickly and has indicated that personal well-being and

interpersonal relationships are her most significant areas of challenge.

Gwen: Before I became the caregiver for my mom, I used to get to the gym about 3 days a week. I loved

doing zumba and yoga! It really made a difference in my stress level. Working out just fell by the wayside,

as my life got busier.

Therapist: That must be exhausting; you take care of your mom, husband, grown kids, colleagues, and

everyone else. Yet you are not taking care of yourself.

Gwen: Not at all. I have totally abandoned myself. I am feeling worn down.

Therapist: Tell me more about being worn down.

Gwen: I guess saying I am worn down is a bit extreme (Gwen is smiling). My body is definitely telling me

to slow down and focus on me for a change.

Therapist: What would it look like if you slowed down and focused on yourself?

Gwen: I am not sure. It’s been a while since I actually paid attention to myself. I feel sad saying that out

loud. I know I want to do something different. Even if it’s a small something!

Therapist: You seem determined to make some small change now.

Gwen: Yes, I want to make myself a priority. Like starting to take my breaks at work again and use that

time to take care of me. I used to do some stretching at my desk and walk around the building. It was

actually fun. We would do a pedometer challenge at work…it was good, I don’t know why I let all of that

go. I just started putting everyone and everything in front of me. We even have a lunch time zumba class I

could go to. I forgot how happy doing those little things used to make me.

Therapist: You regret that some of those activities aren’t in your life. What would it look like to make

yourself a priority in some small way?

Gwen: I guess I could find 15 minutes to do something for myself. I could even go get my hair done.

Maybe a break in my regular routine would be helpful. It’s been forever since I treated myself…

Therapist: Before you leave I want to give you the Session Rating Scale (SRS). All you have to do is rate

today’s session based on four items: our relationship, goals and topics, therapeutic approach, and overall

view of our time today. It’s similar to the one you took at the beginning of session.

Gwen takes a moment to fill out the form and passes it back with marks reflecting that she felt heard

and we talked about what she wanted to discuss. She also marked that there was something missing

from session, which gave us an opportunity to identify what might be missing for her. Using the ORS and

the SRS is a good way to get client feedback on her own progress and her perception of the value of the

therapy session. As a therapist, I invite this feedback and see it as a useful way of getting a client’s

perspective. In collaboration with Gwen, I strive to make adjustments in my work with her based on her

feedback. Gwen then says a few words about how she is feeling.

Gwen: I am definitely not as tense as I was when I first came in. I needed to get some things off of my

chest. I would have liked more suggestions from you on what I need to do next. I know you don’t have

the magic answer, but sometimes that’s just what I want.

Therapist: Thanks for your honest feedback. The goal is for you to be the director of this session and of

your life. As you lead the way your own answers will surface to assist you in resolving some of your

challenges. In today’s session you clearly identified areas of stress and then you reconnected with

activities that brought you peace and relaxation in the past. You were able to find your answers within

yourself.

Person-centered therapy is a collaborative journey driven by what the client brings into session.

The therapeutic goal is to assist clients in arriving at their own healthy conclusions and solutions. Thus, I

followed the lead provided by Gwen of what was troubling her and attempted to work within the

framework of what she said she wanted. Each step along the way I show empathy and compassion for her

challenges as she works to rebuild self-trust and reconnect to her own sense of personal power and

value.

Questions for Reflection

 What are your thoughts about soliciting client feedback by using rating scales such as the

ORS and the SRS?

 Gwen is wanting more suggestions from her therapist? If you were her therapist, how

would you intervene with her when she wants more direction from you?

 Can you think of any techniques you might want to use in helping Gwen find an increased

sense of peace and relaxation in her life?

 How does this approach fit with who you are as a person?

Chapter 4 Psychodynamic Therapy with Gwen

Gwen shows up late for her appointment and states she is feeling frustrated with a work project she is

behind on. “I feel like I am on the edge of falling apart, like nothing is going right and everyone is looking at

me like I’m a failure. I am just sad and unable to put the pieces together. I am behind on everything...and I am

scared I will lose it all.”

As a psychodynamic therapist, I believe the genesis of psychological problems are rooted in the

unconscious mind. Issues brought into session often stem from unresolved childhood conflicts and trauma that

have been repressed. When I speak of trauma, I refer to childhood pain and suffering as a child experiences it,

not necessarily an extreme or horrific event. I listen to Gwen with the goal of allowing her to connect to what

lies beneath the surface of her strong emotions. My aim is assisting Gwen to see how her early history has

impacted her current habits, feelings, and behaviors. Once Gwen is able to bring the unconscious material to a

conscious level, she is in a position to work through the material as an adult and have a better understanding of

her triggers and recurrent emotional conflicts that have taken her back to those childhood feelings of inadequacy

and fear. My goal is to assist Gwen in making unconscious material conscious so she can understand the

origins of the behavior, recognize and explore some of these patterns, work through early experiences, release

dysfunctional behaviors, and begin relating to life from a position of greater clarity and strength.

Gwen continues discussing her frustrations with work and begins to cry. I take the opportunity to

facilitate her into a more relaxed state in order for her to bypass the conscious mind and find out what is

happening at an unconscious level. My intervention is not the typical free association of traditional

psychoanalysis, rather it is more of guided association based on familiar emotions. I say to her: “Sit back and

relax for a moment. Go back to one of the very first times in life when you felt this same or similar feeling of

frustration. Let yourself go back in time, back to when you were a little girl and you had the sense that nothing

was going right and that things were falling apart.” I give her prompts such as, “You feel yourself getting

younger and younger. When you are there tell me how old you are, who is there with you, and describe the

situation. I am watching Gwen’s facial expressions. After a few minutes she begins to speak: “I am five years

old and I am sitting at the kitchen table crying. I have on a pink dress and the front of my dress is dirty. My

mother had told me to wait for her in the car. Instead of waiting in the car, I started playing in the back yard and

got dirty. She hit my legs and I just cried and cried. She yelled and told me that I always mess everything up.

All I wanted to do was to play. I never got to play, I just wanted to kick the ball around and have some fun.”

I ask Gwen what that little girl needed in those situations and she replies: “I needed understanding, and

someone to tell me it was going to be okay. I needed love, even though I was not the perfect little girl.” I ask

Gwen to reflect on what decision she made at that time as a little girl. Gwen paused and then replied: “I

decided I had to be perfect in order to be loved.” I ask Gwen to reflect on how often this early decision affects

her life now. She sits quietly for a while and then makes the comment that she often feels like that little girl.

Gwen is surprised by the feelings and insights that have surfaced for her saying: “I had not thought about those

early times in ages. I can’t believe those situations still bother me. I had not realized that.” In that moment

Gwen recognized the power of the unconscious and how bringing the unconscious material to the surface can

serve as a healing force in her life. I tell Gwen that as an adult she is now able to give that little girl part of

herself love, acceptance, and attention.

Gwen tells me that loving the little girl part of her sounds a bit strange but she is open to being a bit

gentler with herself, just as she wanted her parents to be easier on her and just love her as she was. She says, “I

never imagined those spankings and getting yelled at stuck with me all these years. So now I see that

everything seems to be connected and all that I have ever experienced is still impacting me today. Wow! I have

to go home and sit with all of this.” As Gwen leaves my office I tell her to pay attention to her dreams and keep

a dream journal for the next week so that we can continue to explore the unconscious material through the

symbols in her dreams. Gwen smiles and says she had no idea therapy would be like this. I remind her that

psychoanalytically-oriented therapy is a long journey and she is not alone.

As a therapist it is important to be aware of countertransference (the therapist’s unconscious reactions to

the client). As Gwen spoke of getting spanked as a child, I could relate to her pain and felt her sadness. I could

have told countless stories of pain inflicting upon me during my childhood, but it is not my session. However, I

can use my countertransference in a productive way by deepening my therapeutic relationship with Gwen and

showing empathy for the hurt child that she was. My job is to examine what feelings and sensations come up for

me in a session in relation to my client and to challenge myself to seek supervision or peer consultation when

necessary to avoid engaging in behavior that is not therapeutically beneficial.

Questions for Reflection

 What interventions did the therapist make to help Gwen begin to see how her early

experiences have an impact on her present behavior?

 What therapeutic value do you see in facilitating Gwen’s exploration of early childhood

pain?

 If you were counseling Gwen, what potential countertransference issues might surface for

you?

Chapter 9 Behavior Therapy with Gwen

Behavior therapy focuses on what clients are doing in their life and how it may be impacting their

current level of functioning. In Gwen’s daily life, she has a tendency to move towards getting everything done

without enlisting the support of others. She identified increasing her ability to communicate with others and

asking for support as one of her treatment goals. Her homework was to practice asking for help on projects both

at work and at home. In our last session we spent time engaging in behavioral rehearsal. She practiced

conversations where she would ask someone for support. It was difficult for Gwen and although she was

hesitant, she was willing to try on the new behaviors. Gwen was late for our next session, and she showed up

looking tired and defeated:

Gwen: Sorry I am late, I began leaving work early to take my mother to the doctor and the

appointment ran longer than I expected.

Therapist: That’s fine. I am pleased you were able to make it. Last week, you talked about feeling

disconnected from your husband. We agreed that asking for assistance and sharing with

him your daily life could possibly have a positive impact on your communication.

Therapist: How has attempting this gone?

Gwen: I expressed to colleagues that I needed help when completing some tasks at work, but I

fell back into the same pattern of silence when at home.

Therapist: Tell me more about falling back into the same pattern of silence.

Gwen: I wanted to ask Ron to help with my mom but ultimately I feel like she is my mom and

my responsibility. He sees what I am doing and could offer to pitch in.

Therapist: It seemed like you felt eager to express your need for support to Ron but something

stopped you. What do you think caused you to stop? [Introducing the Behavior technique

of A-B-C Model]

Gwen: I hate to ask – It is my responsibility. I think I am the only one who can do it. I would feel

like a burden on Ron if I asked for help.

Therapist: It must be an overwhelming amount of pressure to be solely responsible for so much.

Gwen: Yes, it is hard to make sense of it all.

Therapist: Let me see if I understand. It sounds as if with Ron, your thought is that taking care of

your mom is your sole responsibility [Antecedent], you do not want to feel like a burden

so you stop yourself from asking for support [Behavior].

Gwen: Yes, when I get home I want to talk, but I do not want to become a burden on someone I

love. So, I just withdraw myself [Consequence].

Assessment is a large part of behavioral therapy and reviewing homework assignments helps us to see if our

approach is effective. I want to support Gwen in trying on new behaviors and give her positive reinforcement

with encouraging words.

The next session.

Gwen came into this session and expressed that although she was aware of her pattern happening, she was

still not able to express her feelings to her husband. So, I decide to introduce Gwen to the concept of

mindfulness in order to bring her out of her cycle of automatic behaviors that have kept her in a pattern of stress

and feeling overwhelmed. Mindfulness helps to quiet the constant chatter of the mind. It helps to increase

present-moment awareness and aids in the relaxation response. I want to give Gwen some simple tools for use

and practice at home. She is so accustomed to the pattern of doing everything in a frenzie and has difficulty

being in the present moment. Gwen could profit from slowing down and engaging in self-care activities.

Mindfulness practice can bring increased peace and calm into her life.

I invite Gwen to be still for a few moments to engage in a few mindfulness practices, which have

become a part of behavior therapy in recent years. As Gwen is sitting quietly, she is finally slowing down long

enough to notice how she is feeling in her body.

Therapist: Gwen please bring your awareness to the top of your head and slowly begin to scan your

entire body for any sensations of tension or tightness. What are you noticing?

Gwen: I am aware of tightness in my chest. It feels like a ball of stress.

Therapist: Focus all of your attention on the sensation in your chest. As you consciously tell

yourself to relax, simply notice the sensations without judging them. How are you

feeling?

Gwen: It’s a little strange, but I feel more at ease than when I first walked in the door.

I encourage Gwen to practice paying attention to her behaviors and to consider using a mindfulness

practice as a way of refocusing on what she wants to bring into her life. Before she leaves session I ask her what

goal she wants to work on for the next session. Gwen says she will work on the communication with her

husband and see what it feels like to ask to be supported. It is my hope that her mindfulness practice will lead to

an overall reduction in stress and increased presence and connection in her life.

Questions for Reflection

 What could be the consequence(s) if Gwen does not change her behavior?

 What kind of homework might you suggest to Gwen?

 What kind of mindfulness practices would you like to incorporate into your daily life?

Chapter 10 Cognitive Behavioral Therapy

Gwen comes in, takes a seat and begins telling me about the upcoming office retreat that she has to attend.

Gwen has gotten into a pattern of isolating herself and using excuses not to socialize with others due to her

anxiety, and she is approaching the retreat with negative expectations.

Gwen: I am dreading spending 8 hours out in the country with a bunch of people I don’t really

care to spent time with in the office! I know it’s going to be horrible!

Therapist: I tell Gwen to stop for a moment and pay attention to her thoughts around being with her

colleagues. What evidence do you have to support your prediction about attending the

retreat? [Sensing a cognitive distortion]

Gwen: I never interact with my co-workers and I can’t imagine that the retreat will be

interesting. I feel anxious when I am around my co-workers. I do not feel that I am a part

of their group. I feel judged and scrutinized by them.

As a cognitive behavior therapist, my role is to serve as an educator for Gwen. I collaborate with Gwen

and want to teach her that it is her faulty assumptions or cognitive distortions that fuel her anxiety. She can

learn to replace the detrimental ways of thinking and actually change her emotions and responses to

circumstances in her life. Teaching Gwen to monitor, challenge, and reframe her thoughts will allow her to be

her own therapist who is more self-aware and able to actively dispute faulty beliefs. I want Gwen to see that

she is functioning based on her old irrational thoughts about her ability to be with her colleagues and these

thoughts have caused the anxiety. “Awfulizing” the upcoming social event triggers her desire to isolate.

Therapist: Consider reworking or restructuring your old way of thinking about the retreat so that

you can practice dismantling your cognitive distortions. Instead of telling yourself that

you will have a horrible time at the retreat, what might be a logical truth about going to

the event? Imagine a picture in a frame. At this time you have an old dusty frame on the

picture of the retreat and how you fit in at work. What would happen if you put a new

frame on the picture? Creating new ways of thinking about a situation is like putting a

new frame on your thoughts. How can you reframe your thoughts about going to the

retreat and interacting with your co-workers in general?

Gwen: Well, I don’t have to say it will be horrible. I guess that thought does not help me to feel

good about going. I truthfully don’t know how it will go at all. Maybe I can tell myself

to show up without judgment for a change and just see what happens. I get caught up in

negative thinking sometimes, which doesn’t help.

Therapist: When you hear negative words in your mind or coming out of your mouth allow yourself

to cancel those thoughts. Then begin to dispute the statement and replace it with

something that has its base in logic and supports how you want to feel and think about

yourself. Tell me some of the cognitive distortions that keep you stuck in anxiety or

negative feelings.

Gwen: Well, I sometimes think I never do anything right and things won’t get any better for

me.

Therapist: What kind of new statement might you tell yourself?

Gwen: (Thinks for a time…) “I have done many good things in my life and because I am

human I can make mistakes. I don’t have to be perfect.”

Therapist: Connecting how you are thinking, feeling, and behaving is a new practice for you

which will need to be reinforced with practice at work and at home.

Therapist: What can you do differently in the work place to foster relationships with your

coworkers that might serve to reduce your anxiety in the office?

Gwen: Wow, homework! I guess I can take the initiative and actually say hello to my co-

workers instead of walking through the office ignoring them. I can try to take note of

times when people in the office are actually kind to me. I really do want to create

positive relationships in the office and not feel like an outsider. I am beginning to

realize that there is really no evidence to support my faulty beliefs that I am being

judged and scrutinized by my co-workers.

I give Gwen a journal to record her homework experiments and how doing a new behavior impacts her

anxiety level. I encourage her to stay aware of the automatic thoughts that occur to her so she can become more

adept at catching and disputing them. In our next session, we will go over her homework and evaluate the

response it has had on her level of anxiety in the workplace.

Questions for Reflection

 What role (if any) does Gwen play in her experiences of isolation?

 How does the therapist intervene with Gwen to assist her in looking for evidence for her

negative thinking?

 What is one additional CBT technique that you can think of using if you were counseling

Gwen?

Chapter 6 Existential Therapy with Gwen

In working with Gwen from an existential approach my goal is to be a witness to her subjective

experiences in the world. Existential therapy assists clients in exploring powerful life themes as they are

dealing with them presently. It is important for me to hear and understand the serious concerns that

Gwen brings to this session. Gwen walks into my office and I observe her rounded shoulders and can feel

the heaviness of her emotions.

Therapist: Tell me what you are experiencing. [Phenomenological Inquiry]

Gwen: I feel overwhelmed, shut down, sad, lifeless, and exhausted.

Therapist: It sounds like the feelings you just described are similar to your description upon

entering counseling – numbness, feeling like your life is a flat note with little joy.

Gwen: Yes! I am tired of the violence. I am tired of young black men that look like my son

losing their lives. This has got to stop, something has to change in our country and I

don’t mean on the surface. Something has really got to change.”

Therapist: I can hear the pain, fear, and sadness in your voice as you speak about your son. (I

want Gwen to know I hear the pain and fear she holds for her son’s life)

Gwen: I can’t even sleep at night. I am trying not to watch the news because young people

dying feels like an everyday occurrence. It’s not fair. Life cut short by ignorance and

misunderstandings. When I haven’t heard from my children in a while I get a hole in

the pit of my stomach and I am just sick thinking I will lose my child.

I am focused on being present for Gwen as she grapples with the challenging existential themes in

her life, such as a search for meaning, accepting anxiety as a condition of living, and the awareness of

death. I listen to Gwen discuss personal stories of racism and injustice and how it feels like a fog that is

always there but no one can do anything about it. Her sense of helplessness is real. My job is to assist her

in seeing that she has options in how she confronts experiences of injustice and unfairness as they occur

in her life. As Gwen explores and expresses her anxieties and fear around injustice, death, and loss of

loved ones, she will begin to realize she ultimately has the power and freedom to create meaning from

the circumstances that arise in her life. Even those events and experiences that bring her pain can assist

her in taking more control of her circumstances and living in a more vital manner.

Gwen: Worrying keeps me up much of the night. I end up feeling scared and depressed and then I

get into this whole spiral where everything feels wrong. Life is so fragile and can be cut

short in a blink.

Therapist: It seems as though you have come to the realization that we are finite and that time is

limited – and that’s frightening and anxiety producing.

Gwen: I feel helpless. I fear for my son’s life and feel like there is nothing I can do to protect him.

Therapist: With these intense feelings of helplessness, fear, and anxiety – how do you even get

through your day?

Gwen: I have been through a lot and I have survived. Even though I have my fears, I surprise

myself and I bounce back eventually. At the end of the day, it’s my faith and the knowledge

that I am making a difference in the world by passing my faith on to my children that helps

me move forward.

As an existential practitioner, I want to share with Gwen that anxiety is a natural part of life and

that death awareness is a powerful force that can actually assist us in living a fuller existence. In our

awareness of our own mortality we can decide to take charge of our life and make choices that enhance

our existence. Gwen can begin to see that her experience of anxiety may be a key to informing her of

exactly how she might begin to do things differently in her life.

As our session comes to a close I tell Gwen that a main contribution of existential therapy is

becoming more deeply aware of who you are as a person and what gives your life meaning. I remind her

of the powerful themes that surfaced in her session, primarily her ability to identify as a strong, spiritual,

resilient woman. I support her decision to journal more of her thoughts and feelings about what gives

meaning and joy to her life and how she can make a difference in these challenging times.

Questions for Reflection

 What existential questions is Gwen facing in her life?

 How would you experience being in the room with Gwen during this session? What may

surface for you as you sit with her?

 How can the awareness of the fragility of life be a catalyst for making decisions about how

to live more fully?

Chapter 15: An Integrative Perspective with Gwen

There are multiple pathways to health and well-being and the integrative approach offers clients ways of

benefiting from a variety of counseling theories and holistic practices. The integrative approach embraces an

attitude that affirms the intrinsic value of each individual. It is a unifying approach that attends to the person at

the affective, behavioral, cognitive, and physiological levels of functioning. As an integrative therapist and a

woman of color, I am willing to share my experiences with Gwen when it is therapeutically appropriate. I want

Gwen to know that I respect her life experiences, struggles, strengths, unique qualities, and personal reality. I

see Gwen as an intelligent African American woman with great depth and wisdom. Utilizing an integrative

approach with Gwen allows me to take into account the many views of the change process that are available to

assist her at this time in her life.

I began establishing a therapeutic alliance with Gwen by drawing heavily from a client-centered

orientation. It is important for me to extend unconditional positive regard in the midst of acknowledging

the suffering and anxiety she is experiencing in her day-to-day life. I want Gwen to know that she is the

expert on her life and she is ultimately in charge of our work together. I let her know that I will introduce

ideas and techniques and she can feel free to say what does not work for her in our sessions.

When Gwen and I began our therapeutic journey together I was very interested in learning about

her family history. Gwen was encouraged to create a genogram that depicted 3 generations and indicated

educational levels, health issues, relationship patterns, and religious orientation. This approach was

borrowed from family therapy and assisted us in seeing family patterns that have given her strength and

support (her spirituality), as well as patterns that have caused challenges for her (taking on family

members problems). Through exploring family history Gwen begins to slowly recognize she has taken on

characteristics that don’t necessarily belong to her. Generational transmission or passing down traits,

habits, and values from one generation to the next has predisposed Gwen to being a martyr like many of

her female relatives. She is even able to explore some of the old automatic negative thoughts that were

passed on from other generations that keep her in a state of overwhelm. One of Gwen’s faulty beliefs is

that “If I don’t do it, no one else will.” This particular cognitive distortion keeps her is a spiral of doing

everything without reaching out to others for assistance or support. Her belief that no one else can assist

her has caused fatigue and frustration. Through cognitive behavior therapy Gwen becomes more aware

of the thoughts she is thinking and how they impact how she feels about herself.

In our early sessions, Gwen would engage in automatic negative thinking or all-or-nothing

thinking and make statements such as: “I am never going to feel healthy again.” “My children never want

to spend time with me.” “I will always feel isolated.” Examining Gwen’s cognitive distortions and assisting

her in noticing and challenging them helped her to become increasingly more aware of how these

thought patterns cause her distress. I introduced Gwen to a simple 5-minute meditation practice aimed at

both calming her mind of anxious thoughts and increasing her ability to focus. I suggested to Gwen that

during these brief meditations session, she could notice her thoughts, without judgment. This simple

mindfulness practice is likely to have a cumulative impact on her ability to relax and gain more inner

resilience. After continued practice, she will most likely increase her ability to discover that she is not

simply her thoughts, that she can be the observer of those thoughts, and that she can let them flow by

rather than having her thoughts control her behavior and mood.

In my initial interview with Gwen, I let her know that I am not a purist in my approach to therapy

and that I would be drawing from different counseling theories to create a treatment approach that was

tailored to her needs. I typically begin and end a session with a brief assessment that provides feedback

from my clients that can result in making adjustments to the treatment process. I depend on regular

feedback from clients as a way to make the process truly collaborative and to ensure their therapeutic

needs are being met. I make no assumptions and ask Gwen if she is willing to work with what naturally

arises as the therapy progresses. If she does not give an affirmative answer, then our direction of therapy

needs to be modified. As an integrative therapist, my techniques are aimed at meeting the goals of the

client. This statement seems to increase Gwen’s comfort level in trying new ways of being in a session.

It has been a meaningful experience to watch Gwen experiment with different ways of being in her

life. As we have progressed in our therapeutic relationship she has had the opportunity to experience a

variety of techniques—ranging from exercise to yoga—that have assisted her in decreasing her

symptoms of depression and anxiety. Gwen has been able to reflect on what is working best for her and

what techniques she can take back into her daily life for enhanced health and wellness. These activities

increase mindfulness and present moment awareness. They can be considered a cousin to the new wave

in behavioral therapy. The movement practices also help in healthy emotional expression. Gwen began to

see that she has resources and tools that she can use in moments of stress in her daily life. My goal is to

give Gwen multiple tools to heal on the levels of mind, body, and spirit.

As her therapist, I am not connected to working with her from any one particular theoretical

framework. Rather, I am sensitive to Gwen’s personal goals from the moment she walks into my office

and I remain open to the possibilities that lie ahead of us until the very end. My first question for Gwen is

always: “How would you like to best use the time we have together?” My job is be fully present so that I

can effectively integrate therapeutic approaches that will assist Gwen on her journey of transformation as

she returns to a state of optimal functioning and balance.

Questions for Reflection

 What ideas and techniques shared in this piece belong to which theoretical approach?

 How comfortable are you with doing non-traditional therapeutic techniques?

 Based on who you are, what theories seem to be the most natural for you to utilize from an

integrative theoretical approach with Gwen?