Social anxiety is a chronic, debilitating psychological condition. Hermeneutic Single Case Efficacy Design (HSCED) is a legalistic mixed-method case study method for evaluating therapy efficacy in single cases. Using a case of Person-Centred Therapy (PCT) with a client experiencing social anxiety difficulties, we addressed the standard HSCED research questions of pre-post client change, causal role of therapy, and change processes. In addition, we explored adaptations to HSCED for ambiguous outcomes. Based on a rich case record, affirmative and sceptic cases were constructed and adjudicated by three judges.The judges held that the client changed considerably (but not substantially) and that therapy contributed considerably to client change. Change processes central to PCT were held to be active, as were client resources. The new procedures enabled judges to make sense of the ambiguous outcome data and can be further extended and developed. PCT can bring about considerable change in socially anxious clients.
- social anxiety, hermeneutic Single Case Efficacy Design, person-centred therapy
Author: Jane Barry
Michael has made an appointment to see his School Counsellor. He is due to finish school this year and is undecided about what direction he should take once he leaves school. Michael is a high achiever and his parents want him to make the most of his opportunity to enter University and study Law or Medicine. Whilst Michael is interested in Medicine, he feels that his interests at the moment are directed towards working and travelling abroad. He wants to discuss his preferences with the School Counsellor and to talk about the pressure he has been experiencing.
For ease of writing, the Professional Counsellor is abbreviated to “C”.
Essential Case Information
“C” has known Michael for the last 18 months and has developed a rapport with him. Michael and his parents have visited “C” a few times to discuss Michael’s career options and the subjects that would benefit him the most. From these meetings, “C” has ascertained the following information. Michael’s parents would like him to achieve a high OP score and are encouraging him to pursue science and maths subjects to allow him access to University to study Law or Medicine. Michael’s father is a Barrister and would like to see his son follow on in his professional footsteps. Michael’s mother wishes for Michael to have a professional career, but she has also encouraged his interest in arts, history and travel.
Both parents have contributed considerable time and energy into Michael’s education and Michael is very grateful for their support. As he has a very close relationship with his parents, Michael feels a great deal of pressure to follow the goals that they have set for him. Whilst he would like to follow a career in Medicine, he is not sure that he has the life experience to make such an important decision. After the last meeting, Michael confided to “C” that he did not want to go into university straight after school. If he could have his own way, he would prefer to take some time off from study and travel for a while. He has a close group of friends who are interested in welfare work. Together they have plans to travel and work voluntarily. These dreams with his friends seem exciting and challenging to him and would allow him some time to come to a decision about his career.
Michael has talked to his parents about travelling, particularly to his mother. She is understanding of his need to see the world and to experience a different side to life, however she is also concerned that he is still very young and inexperienced. She would prefer to see him enter University first and travel when he gets a little older. Michael’s father is also concerned about Michael’s preferred directions. He fears that if Michael doesn’t undertake University at this age, he may spend his life wandering around the world, without any substantial training to fall back on. Michael’s older sister (Theresa) has dropped out of her studies and has spent the last 5 years travelling. Michael’s father does not want to see his son follow the same direction as his sister. He has offered to finance his son’s further education if he enters university directly after school.
“C” has previously administered a Personality Need Type Profile for Michael, and has found him to have moderate type C/D needs. After some discussion with Michael, “C” believes that he has fairly high need gratification through his school work and home life, however the disagreement with his parents has been causing him some discomfort, particularly because of his security needs.
“C” has decided to use a person-centred approach with Michael. “C” believes that Michael has the resources to come to his own decision about his life. Because of the rapport that already exists between “C” and Michael, “C” suspects that Michael may look to him to acknowledge his right to choose his own path. Because of “C’s” respect for both Michael and his parents, “C” believes that a person centred approach would be of benefit, to ensure that the responsibility for the decision remains with Michael.
When Michael arrives, “C” begins the session by making him comfortable and asking some questions about his sports interests. Both “C” and Michael are interested in touch football, and it is a topic that they have discussed in some detail in the past. As this conversation draws to a close, “C” asks Michael about his reasons for making the appointment.
As Michael explains the difficult decision he has to make, “C” pays close attention to Michael’s body language and his description of feelings. “C” attempts to make Michael feel listened to by making eye contact with him and by sitting forwards, in a more active listening position.
“As you know, Mum and Dad are really keen for me to go to University next year, but I really don’t like the idea. I’m not looking forward to more years of study yet,” Michael explained. “I’m getting to the point where I don’t want to do any more study after this year, I’d rather hang out with Paul and Mica. Their parents don’t put the same pressures on them to study and they don’t mind if they travel after leaving school. Compared to them, I feel like I’m wrapped up in cotton wool.”
“C” paraphrased Michael’s comments, focussing on his feelings, “so your feeling that you haven’t got as much freedom as your friends do.” “Well, yeah,” replied Michael, “I’ve always gone along with what Mum and Dad wanted, and so I’ve never had any reason to really disagree with them, and I’ve always kinda wanted what they wanted anyway. But now I don’t. Sure it will be great to go to University one day, it’s not like I’m going to be like my sister and never come home, but Dad is really paranoid about it.”
“C” responded, “It sounds like you’ve got some plans of your own, that are different to your sister’s and your fathers, is that right?”
“Definitely,” Michael said with emphasis. “Definitely,” “C” replied, “you said that with a lot of conviction!” “Yeah,” Michael replied, “you know, I’ve got some really good ideas of where I want to go and what I could do with my life.” “That’s great,” responded “C”, “I’d really like to hear about them.”
As Michael describes his plans for the future, “C” listened carefully and felt proud of the goals Michael was setting himself. “C” appreciated the strength of character that Michael demonstrated, for someone of such a young age. “C” felt that Michael had both the conviction and determination to create meaningful goals for himself and to carry them through.
Michael felt excited and elated to talk about his plans so candidly with someone. He felt that “C” had a deep appreciation of his needs, which inspired confidence in himself and the goals that he dreamed about. Michael was surprised and heartened by the depth of his convictions and the strength of his belief in his goals. Having someone listen to him so intently made him feel special and worthwhile. He genuinely felt that his world was an exciting and challenging place to be.
“C” expressed some of his thoughts to Michael, so as to further convey his genuine concern for Michael. “You certainly seem to have some very clear goals for yourself. From what I know of you, you’re a very determined young man and you’ve achieved very well at the subjects that you’ve taken on. I am sure that you can achieve all of your goals if you keep your determination. It takes a lot of maturity, and a certain type of person to be able to identify your goals so clearly. I can imagine that it must be frustrating to experience some obstacles to reaching your dreams.”
“Yes…I’m not sure what to do about that,” replied Michael. “I know that my parents mean well and are worried for me, but, I think that I want them to support me in other ways now.” “How is their support of value to you,” inquired “C”.
“Probably more valuable than what I realise! You know, they’ve done a lot for me. I’ve always been into a lot of things and they seemed to have sensed that and tried to give me lots of opportunities. In some ways we’re a well suited family, you know? They want a son who achieves well, and I just want to achieve. Up until this point, we’ve mostly agreed about what I achieve at. My sister is different though, she is happier to just accept life as it comes along and she never used to like Dad pressuring her to do stuff. They used to argue a lot and sometimes I think she saw going overseas as a way to escape and be herself.”
“Dad was pretty upset when she went, I think he took it personally. I know he would just go crazy if he thought that I was going to do the same thing. I just wonder if I can ever get him to see that the decisions Theresa made and the ones I want to make have got nothing to do with him. I really don’t want him to think that I’m ungrateful or doing it to spite him.”
“C” reflected, “it sounds like your pretty grateful to your father and that you respect him. It also sounds like you are trying to find some ways to tell him about your plans, whilst still respecting him.”
“Yeah, though I’m still afraid that he won’t agree to my plans,” replied Michael.
“C” responded, focussing on his feelings, “can you tell me more about your fears?” “Well,” Michael replied, “I don’t know, I guess I fear that he’ll back off and not offer me any more chances to go to University.”
“How would you feel if that happened,” inquired “C”. “Really let down, and angry too. I mean, he’s got to let me make my own life now. I’m not just a kid any more,” Michael responded, frowning.
“C” reflected Michael’s meaning back to him. “You’re feeling angry about your lack of freedom and you want your father not to treat you like a kid any more. You want to go to University some day, but you’d like to have a break from study and travel with your friends. You’re afraid that your father will not accept your decisions and you will lose respect for each other. Does this sound right to you?”
Yeah, Michael sighed, “so what am I supposed to do? Why won’t Dad give me some credit for my own sense? Does he think that I’m going to be a kid for the rest of my life? I deserve to make my own plans,” complained Michael.
“C” nodded and responded, “they’re all important questions Michael, what do you think some of the answers might be?” “I don’t know,” replied Michael, “I thought that you could help me out there.” “Hmm,” said “C”, “that’s a tough one. I can see why you’re having such difficulty in making a decision. On the one hand, you’ve got some very exciting plans of your own that you want to fulfil. On the other hand, your trying to consider the plans that your parents are offering you, to get a tertiary education. I’m also wondering how you’ll make a decision.”
“Ultimately, I’d like to do both,” said Michael. “C” nodded and remained silent for a period. Michael also sat silently, thinking to himself. After a period, Michael replied, “I think I need to think about it some more. I need to talk to my parents some more too. I’ve been a bit afraid to talk about it directly, in case they definitely say ‘no’. I was thinking that I have to put in my selection for university soon, so perhaps I could apply for Medicine, but then defer for a year. It might be easier for Dad to accept, if I did this. What do you think about that?”
“C” replied, “discussing some of your options with your parents is a good idea. Perhaps you might think about how you would approach them. How might you feel if they still did not accept your proposals?”
“I’d feel let down and angry. I think I’d want to leave home if that happened. I wouldn’t want to make a scene, but I do want to live my own life. I think that I would have to leave.”
“C” replied, “that is a serious move, leaving home. Your goals must be very important to you indeed.”
“They are!” Michael exclaimed.
“C” probed further into Michael’s feelings about the choices he wanted to make. In particular he asked Michael about approaching his parents to discuss his goals. “C” focussed in on what Michael would say to his parents to let them know the seriousness of his intentions. “C” also asked Michael to consider how his parents might react to his news. From this, Michael developed some strategies for himself to use when telling his parents of his intentions.
In summary, “C” expressed his appreciation of Michael’s world and experiences. “C” validated Michael’s feelings and goals and complemented Michael on his mature strategies to explain his goals to his parents. Michael’s decisions included setting a time with his parents to discuss his goals, to suit everyone. He thought that they might go out for dinner one evening, to mark it as an important event. Michael would ask his parents to think about their goals for him and discuss these over dinner. In this way Michael would be allowing for his parents to contribute to his plans and hopefully influence them to listen to and respect his own ideas.
As a finishing point “C” asked Michael how he had felt about the session in general. Michael had appreciated the opportunity to talk about his issues and goals so completely to someone. He said he felt clearer about the direction he wanted to take in his life and was beginning to consider how to explain his goals to his parents. He thought that “C” had really appreciated him for who he was and it made him feel more mature in himself. He had hoped that “C” would have offered him some more direct advice about what to do, but understood that it was his own responsibility to decide.
End of Session
Some points to consider with Person Centred Therapy are as follows:
This therapy focuses on the quality of the client / counsellor relationship. It assumes that clients are basically trustworthy and have the inner resources to find solutions to their own problems. It is a less directive therapy on the counsellor’s behalf, meaning that clients are free to set their own goals and create the conditions that will allow themselves to explore their needs and behaviours.
Therapists themselves contribute to the client’s growth by providing a warm, positive, trusting, and open relationship with the client. The three important qualities the counsellor should possess are congruence (genuineness), unconditional positive regard (acceptance and caring) and accurate empathetic understanding (ability to deeply grasp the world of another person).
There are no fixed techniques that apply to Person Centred Therapy, rather there are a set of principles for counsellors to be guided by. Some of these are as follows:
- The client is experiencing a discrepancy between the way they perceive themselves, the ideal picture of themselves and the reality of their situation. They may feel helpless and unable to make a decision, or direct their own life.
- Whilst the client may look to the counsellor for direction, the emphasis will be upon the client to take responsibility for their own decisions and to learn to use the therapeutic relationship to increase their self-understanding.
- The therapist should attempt to understand the client’s world through listening, empathising, respecting and accepting them; and in doing so, the counsellor will be integrating themself into the relationship with the client.
- The therapist should try to experience genuine care and acceptance of their client, otherwise, the client may feel that the counsellor is feigning interest and will not fully disclose their feelings.
- As clients experience the therapist listening to them and accepting them, they learn how to accept themselves. As they find the counsellor caring for them, they start to experience themselves as worthwhile and valuable. When they experience realness from the counsellor, the client is encouraged to shed their pretences with themselves and others.