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Introduction to Theories in Psychotherapy
Introduction to Theories in Psychotherapy
A single woman in modern-day society is often faced with many dilemmas leading to
later psychological dysfunction. This is especially true if the young woman is a lesbian and
devoid of a solid inner foundation and plagued with self-esteem issues. Lesbian women are
human beings like everyone else except for the affixed label defining their sexual orientation.
Society’s desire and need for labels can create much psychological havoc in individuals who
Women who define themselves as lesbians encounter many of the same psychological
issues as everyone else. Depression and anxiety may be more evident within some areas of this
diverse group due to public ridicule, misunderstanding, and scrutiny. When members of a
socially diverse group make the conscious decision to engage in psychotherapy, the therapist
must take into consideration the nature in which the individual fits into the diverse grouping.
Many therapeutic techniques are designed to enhance and bring forth an inner understanding and
confidence which, in turn, provides the client with the ability to accept the self. Psychotherapy
techniques can greatly enrich and change the quality of life experienced by the diversely grouped
client, but a caring and well trained therapist will work diligently to aid the client in reaching the
Dana is a thirty-two year old, single, Caucasian, female who defines herself as a lesbian.
Her parents are deceased, by natural causes, and she has one sibling, a brother, who lives in
another state. She indicates having little if any contact with her brother. Dana has been single for
the past eighteen months since breaking up with her long-time partner due to an incident of
infidelity. Dana reveals that her ex-partner had been involved in an affair outside of their
relationship boundary for several months before discovering the infidelity. Dana has no
children, biologically or through any previous relationships. She works as a cashier for a small
retail business, but she is now on a leave of absence due to the recurring panic attacks.
Dana reports being diagnosed with Bipolar Disorder I over a year ago following a brief
hospitalization for unexplained depression and a sudden burst of energy that could not be
explained. She is currently on a medication regimen of 500mg of Depakote twice a day. She
briefly continued with outpatient Cognitive Behavioral Therapy (CBT) and was released with
only intermittent appointments to see the treating psychiatrist for medication.
Dana enters the therapeutic setting with the chief complaint focusing on recurring panic
attacks. She explains that sometimes the panic attacks will start and seem to dye-down before
resurging and setting off another panic attack. She says the panic attacks seem to come in
waves. The symptoms associated with the panic attacks include numbness in her hands, chest
pains, confusion, sweating, and worrying that she is having a heart attack. After several trips to
the local emergency room to confirm that she was not having a heart attack, the attending
physician diagnosed Dana with having had a panic attack. She was then referred to the mental
health agency for follow-up. The referral was made three months ago.
Dana has taken a voluntary leave of absence from work because she is scared of having
another panic attack at work or while driving. She refers to her home as her “safe haven”. It is
revealed that she is reluctant to leave her home even to check the mail or go to the grocery store
because of the insatiable fear of having another panic attack. The panic attacks are now reported
to be occurring at home and include waking her up from sleep. Dana defines the episodes as
feeling out of control. Further questioning uncovers new “habits” that Dana has now engaged in
as well. Dana exposes that she now feels that she can ward off the panic attacks if keeps every
door and window locked while inside her home. She also tells how repeating the word “Amen”
after saying a prayer will also help to ward off the panic attacks.
Physically, Dana appears to be lacking sleep. Her eyes have darkened circles beneath
them, and they appear to be puffy from either crying or from allergies. All the lab work indicates
that her Depakote level is well within the safe range and that she is continuing to take her
medication. While her facial appearance resembles exhaustion, her body language suggests
otherwise. Her right foot is constantly bouncing, and she continually changes positions in her
seat. Her hands are kept clasped together tightly, and it appears as if she is trying to wring out a
In light of the earlier diagnosis of Bipolar Disorder I
, Dana’s records were sent before
this appointment. Dana was diagnosed with Bipolar Disorder I, 296.4x, with the most recent
episode being manic (American Psychiatric Association, 2000). This diagnosis shows a family
history, in the deceased parents, of clinical depression, alcoholism, and anxiety. No differential
With the presenting symptoms available, it appears that Dana is now experiencing two
associated mental illnesses common in individuals with Bipolar Disorder. The first mental
disorder is Panic Disorder with Agoraphobia. The DSM-IV-TR defines Panic Disorder with
Agoraphobia, 300.21, as a feeling of sudden terror recurring repeatedly without explanation
(American Psychiatric Association, 2000). The agoraphobia occurs when the individual limits or
alters their lifestyle to accommodate the possibility of future panic attacks. The client
experiences panic attacks that are unexplained and unexpected, and the client the condition has
been present for at least thirty days. The client is now using avoidance to prohibit the possibility
The second mental disorder present is Obsessive Compulsive Disorder (OCD). OCD,
300.3, is evident in the client’s need to repeat a specific word several times and keeping all the
doors and windows locked as a means to respond to the obsession (American Psychiatric
Association, 2000). Dana feels that these behaviors will help to ward off future panic attacks.
The DSM-IV-TR by American Psychiatric Association (2000) specifies the following:
A person with obsessive-compulsive disorder has either obsessions, or
compulsions, or both. The obsessions and/or compulsions are strong enough to
cause significant distress in their employment, schoolwork, or personal and social
relationships. This includes: anankastic neurosis, obsessional neurosis, and
obsessive-compulsive neurosis….The person feels the need to repeat physical
behaviors (checking the stove to be sure it is off, hand washing) or mental
behaviors (counting things, silently repeating words). These behaviors occur as a
response to an obsession or in accordance with strictly applied rules. The aim of
these behaviors is to reduce or eliminate distress or prevent something that is
OCD is often a comorbid condition appearing in conjunction with Bipolar Disorders and Panic
One of the most important acts that a therapist must conduct, when seeing a client for the
first time, involves the explanation of informed consent. A therapist must explain to the client
the following key items: a) the benefits of psychotherapy, b) the risks associated with
psychotherapy, c) alternative treatments, d) cost, e) confidentiality, f) mandated reporting, and g)
termination of services (Corey, 2009). The explanation of informed consent is a legal
requirement of all treating therapists, clinicians, and psychiatrists. Most items are very simply
explicated with the exception of the issue of confidentiality. Clients should be made aware of
the fact that anything and everything said during to contextual confines of the therapy session is
considered private and privileged information; however, in the instance of suicidal or homicidal
statements or ideations, the therapist is mandated to report the information to the proper
There are several psychotherapies that stand to benefit Dana as she faces various, but
similar, psychological problems. Cognitive Behavioral Therapy (CBT) is a form of
psychotherapy used to aid the client in realizing the garbled thoughts and perceptions causing
psychological anguish (Pomerantz, 2008). In humans, thoughts predetermine the actions and
feelings that follow. Aaron Beck studied and researched the correlation between thought and
emotions before giving rise to the cognitive behavioral technique (Corey, 2009). In more
scientific terms, a stimulus creates a thought which then produces an emotion. In some
individuals, the scientific equation works differently causing psychological angst and upset. An
example of the alternative pattern is evident in the following example. Dana has experienced
repeated panic attacks causing her to go to the emergency room for fear of having a heart attack.
The attending physician informed her of the panic disorder and referred her to an agency for
mental health services. Dana has perceived the information provided from the doctor to mean
that she is crazy. Her misconstrued thoughts has caused her more emotional grief as she has
continued to experience more panic attacks in the months that have followed. If she had
surmised what the doctor said to mean that the physical condition, the panic attacks, were not of
a biological origin but rather of a psychological origin, then she could have sought the services
from the mental health organization sooner and already be on the road to recovery. This
therapeutic technique would serve as beneficial in treating the disorders of panic disorder, OCD,
and various aspects of Bipolar Disorder.
The second psychotherapy technique chosen is the Client-Centered Therapy (CCT)
developed by renowned psychologist Carl Rogers (Pomerantz, 2008). The CCT technique
regards each client as being in possession of the necessary tools to aid in their own recovery.
This technique uses the therapist as a guide for the client to discover the hidden answers to many
problems and issues plaguing or disrupting their life. CCT focuses on three guidelines that must
be adhered to by the therapist. These factors are an unconditional positive regard, empathetic
listening and understanding, and congruence (Corey, 2009). When implementing unconditional
positive regard, the therapist allows the client free will to survey every thought and feeling
without the fear of rejection. This may prove tricky in some instances in lieu of mandated
reporting issues within the regulated informed consent. Second, therapists should exercise
empathetic listening and understanding. This is accomplished with reflective listening. It is a
form of communication used to relay to the speaker that he is being understood. Third,
congruence is expressed in the client speaking as a real person. The therapist should refrain from
using words or phrases that cannot be intellectually understood by the client, and the therapist
should develop a personable rapport with the client to ensure a level of comfort in which the
client can effectively communicate and convey their feelings. This therapy is especially helpful
for clients with low self-esteem, depression, and anxiety.
The final choice of psychotherapy to be used is Exposure Therapy. Exposure therapy has
proven to be very successful in illnesses such as OCD and panic disorder. Exposure therapy is a
sub-type of CBT as it forces the client to face their fears in order to psychologically move
forward and make progress (Corey, 2009). The therapy teaches the client how to use relaxation
techniques as a means for creating relaxation at-will when necessary. Visual and actual
exposures are used to aid the client to face their fears which increases the level of anxiety within
the client (Burns, 2006). The client receives encouragement from the therapist to resonate the
feelings of anxiety until the apprehensive or fearful emotions pass. Exposures are repeated in
subsequent sessions as a way to desensitize the client to the origin of the anxiety.
Mock Therapy Session
Dana will be treated using a combination of CBT coupled with Exposure Therapy. The
CCT approach will be used to develop congruence between the client and the therapist. This is
Dana’s third session with the client.
Long. I’ve been really tired lately, but every time I try to take a nap or go to sleep
it seems like the phone rings. I don’t have caller i.d., so I answer it every time in
case it is your office calling to reschedule or something. (Sighs)
Have you thought about getting an answering machine? Some models let you
screen the calls, which would let you decide who you wanted to talk to. I don’t
think they are very expensive either.
Oh, they aren’t. I sell them where I work…. (long pause) or worked.
Have you talked to your supervisor or someone from work lately?
No, but I know they aren’t going to give me much more time to get my act
together before the bring down the gavel on me and tell me to either come to
work or be fired. (She starts wringing hands and tapping foot)
Dana, on a scale of 1-10, where is your anxiety level at right now when we were
Okay, I think this is a good place for us to start today. Today we are going to
concentrate on learning a relaxation technique that will allow you to enter a
relaxed state when you start to feel anxious and worked up. Then, we are going
to talk more about your work and the panic attacks and try to use the new
Alright. Now I would like for you to get comfortable and close your eyes. I want
you to concentrate on the sound of my voice.
Now, I want you to concentrate on breathing. Breathe in through your nose and
out through your mouth. Take in long, deep, and slow breaths through your nose,
and expel the used air through your mouth. In….and….out. As you continue
breathing, I want you to begin to relax your feet. Now start to relax your ankles,
and knees working your way up to your thighs. Let your lower body go limp. As
you continue breathing, let the air passing out of your mouth expel all the tension.
Now, let your abdomen relax….and continue the relaxation to your fingers, your
hands, your arms, and now your shoulders. Feel the tension and stress leave your
body through your mouth. Breathe it away. Blow it out and far away from your
body. Let your shoulders go, feel the tension release from your neck. Let your
face relax. Allow your jaw to unclench and drop. Feel the frown lines leaving
your forehead. You are in a complete state of relaxation. Keep breathing slowly
in through your nose, and out through your mouth.
Now, I want you to think of a place where you have felt like this before. Dana,
My bathroom is remodeled. I have a big garden tub. It’s full of warm water. The
bubbles are fuzzy and tingly. I have my radio playing by the sink. I’m tired and
Okay. I want you to remember the bathtub, the relaxed feeling, the peaceful
feeling within you right now. Whenever you begin to feel worried or anxious, I
want you to close your eyes and return to this place. You are safe here. You can
relax here….regroup here….and calm down. Now I want you to open your eyes.
(opens eyes and smiles) I feel like I could have gone to sleep for a week.
(smiles and laughs) Dana, on a scale of 1-10, where is your anxiety level
Ha! About a -3. I haven’t felt this good in ages.
That’s wonderful! I want you to remember where and how to get to your safe
place as we continue working here in therapy. You can also use this technique
of relaxation in the outside world, too, or even at home. Now, let’s talk a little.
Tell me what made you decided to leave your job temporarily.
Well, I was ringing up a customer, like I always do. I had taken the customer’s
money and I felt my heart start pounding. I handed the customer her change, and
she said that my hands felt like ice. I tried to smile, but inside I was just hoping
she’d hurry and leave. Then I felt hot and I could feel sweat on my forehead.
(hands starting to clench and breathing becoming more erratic) The customer
asked me if I was feeling okay. When I tried to answer her, my words were all
jumbled and I was confused. Then I ….
Okay Dana, on a scale of 1-10, where is your anxiety level right now?
Dana, I want you to think of your safe place….go there right now….breathe.
Remember, you are telling me about a memory. Memories are things stored
in our mind that have already happened. A memory cannot hurt you. Breathe
slowly, in through your nose and out through your mouth.
(pacing her breathing with eyes wide open)
My heart is pounding really fast and my hands are sweaty.
Dana, I want you to stay with this feeling. (offering calm reassurance)
Now, after the customer asked you if you were alright, what did you do?
I couldn’t talk right and I was really confused. I ran from my register back
I just had to get away. I got my purse and my keys cause I wanted to go to the
hospital. It felt like a heart attack.
Dana: No, but this doctor on TV. told about it once and I was having the same symptoms.
On a scale of 1-10, where is your anxiety level right now?
Well, the human brain runs on different chemicals which each have a specific job.
A panic attack occurs when there is too much of the adrenaline chemical re-
leased. Adrenaline puts the brain into a “fight or flight” mode. After the
chemical is released, the brain puts all the bodily systems on “red alert”, so to
speak. The extra chemical in the brain essentially puts your body into a
Well, that’s one of the misconceptions about panic attacks. You aren’t going
to die, even though it might feel inevitable at that moment. Once you under-
stand that you will be okay, then you will be better equipped for using the
relaxation technique like you learned today to get on top of an unpredicted
episode of panic. The best way to combat a panic episode therapeutically
is through distraction. If you can divert your thinking to something, other
than the current physical feelings and worry, like the birds outside or a
television program, then the “false alarm” will stop going off and the
adrenaline will stop being released. In the end, the panic attack will cease.
Maybe less frequently, or the panic attacks may even stop altogether. It is
not for me to determine. I have great confidence that you will be able to
overcome this issue and be able to regain your whole life back as you have
indicated to me that you want to do.
I just hate feeling like I’m in a prison because of this. I feel so confined.
Fortunately, that is only true metaphorically. My job is to help you find the
right keys in order for you to release and free yourself.
The treatment goals for Dana focus on aiding her to develop a better understanding of her
diagnosed conditions. Psycho-education can be helpful during psychotherapy. Sometimes, fear
is generated simply because something is unknown or foreign to an individual. Dana can gain
much knowledge from the Exposure Therapy and the CBT sessions. As she makes significant
progress, Dana can move into a more CCT process allowing her to express her feelings and
emotions with regard to her psychological health and Bipolar Disorder illness.
In a therapeutic position, it would not be farfetched to hope to see Dana become self-
sufficient again through being able to return to work. It is essential that Dana grow and nurture
her level of self-esteem as it appears that she possesses some residual guilt for her psychological
flaws. The issue of infidelity in her previous relationship should be explored more effectively to
ensure that Dana has been allowed to put closure onto a painful and emotionally traumatizing
experience. Dana should be encouraged to seek out future a future relationship which would
give her a supportive environment in her isolated world. She should also be supported in finding
friends with whom she can talk, spend leisure time, and pursue fun activities. Dana has a bright
future ahead of her so long as she continues to be cooperative and functional within the
Criticisms of Psychotherapy Techniques
Every topic has a critic. This is also true in the psychotherapy spectrum. Cognitive
Behavioral Therapy (CBT), Client-Centered Therapy (CCT), and Exposure Therapy have all
encountered skeptics along the way. Critics of CBT contend that a therapist’s views and ideas
are not always right, and the therapist should not thrust their views onto a vulnerable client
(Corey, 2009). Some participants in CBT have reported feeling lead by certain questions and
dictated over by the treating therapist. Truthfully, CBT is not about criticizing the thought or
emotion, but rather it is a method by which a structurally unsound equation is being tested and
Critics of CCT feel that this method is one whereby all therapist should function
regardless. Some suggest that this form of therapy turns the therapist into a liar by demanding
the therapist to withhold opinions from the client. Some psychologists feel that CCT gives the
client too much ground too fast. Psychological boundaries are needed within any given therapy
session, but the CCT sessions seem to be without a peripheral guideline (Pomerantz, 2008).
There is also the ethical dilemma concerning the client’s free will and expression when faced
with the issues of mandated reported under the informed consent. Some clients may feel
betrayed or lied to if certain information were relayed to a third party due to the mandated
reporting laws. Consequently, this would leave the client psychologically traumatized and less
Finally, the critics of Exposure therapy suggest that the therapy moves too far too fast.
They feel that it pushes the clients into emotional situations that they may not be psychologically
ready to handle. Trained psychotherapists are taught and educated as to the readiness of each
individual client. Therapists are also consciously aware of their client’s history before
undertaking an exposure session. If at any time the client feels that he, or she, cannot endure any
further exposure, then the client is free to halt and cease the exposure (Burns, 2006). No one is
forcing the clients to do anything that they are not willing to try. Facing one’s fears can be scary
and produce anxiety, but with the encouragement and accompaniment of a specially trained
therapist, the experience can prove to be successful.
Various psychotherapies are designed to help aid and treat clients with an assortment of
mental disorders. Upon making contact with a therapist, a client must provide a detailed history
including family, physical health, and psychological history. This information better enables the
therapist to help the client address the problematic areas and to define the problem areas.
Lesbian women are categorized as a diverse group, but in actuality, they are as much a human
being as anyone else. Treating agencies must inform the clients of the laws concerning informed
consent before any therapeutic sessions can commence. This serves to protect the therapist, the
client, and society. Psychotherapies such as Cognitive Behavioral Therapy, Client-Centered
Therapy, and Exposure Therapy are known for their effectiveness in treating illnesses like panic
disorder, Obsessive-compulsive Disorder, and some aspects of Bipolar Disorder. Psychotherapy
techniques can greatly enrich and change the quality of life experienced by the diversely grouped
client, but a caring and well trained therapist will work diligently to aid the client in reaching the
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