Client Profile #2
Name: Aaron B.
Gender: Male
Ethnicity: Syrian-American
Age: 17
Religion: Jewish
Relationship Status: Single
Description of Presenting Issue:
Aaron was referred for counseling by his physician. Aaron is a star athlete on the
high-school track team and attributes all his symptoms to his efforts to be the
best possible runner that he can. He eats little, limiting his diet severely, and now
weighs only 120 pounds, even though he is 5'10" tall. He believes that if he can
lose another 10 pounds, he will be able to run even faster. Aaron keeps lists of
everything he eats, weighing each food item and computing its fat content. In
addition, he tracks his daily training by keeping a record of how many minutes he
runs and how many steps he takes, counting his steps as he runs. Aaron also
has many other lists that guide his life, including a list of every possession he
owns and every person he talks to each day. If he forgets to include an item on
one of his lists, he becomes very anxious and only calms down when he has
recopied the list with the forgotten item at the top of the list. He tends to check his
lists repeatedly, making sure that words are in alphabetical and size order.
Despite his youth, he has few friends and activities other than his running, but is
able to work delivering pizzas.
Occupation History: Part-time pizza delivery
Education History: Currently attends high school; maintains a B+ average
Medical History: Aaron acknowledges that he has developed osteopenia
(thinning of the bones) and also tells you that he has knee and shin pain.
Family History: Aaron is an only child. His mother and father divorced when
Aaron was 10 due to his father’s infidelity. Aaron lives primarily with his mother.
She owns a successful interior design business and travels frequently. Aaron
describes his mother as hard-working, with high standards and expectations.
Aaron’s father works in the finance industry, was remarried four years ago, and
has two children (ages 1 and 3) with his second wife.
Alcohol / Substance Use: Aaron does not smoke, drink alcohol, or use illegal
substances. He occasionally takes Vicodin (a painkiller) prescribed by his
physician for his knee and shin pain.
Page 1 of 1
Rc-PSYC 8722 – M. Geyer
Page 1
Transcribed 12/28/2006 - by Cyber-Com Transcription Services
[00:00:00] – A
MATTHEW GEYER :
Hi, this is Doctor Matthew Geyer. I'm going to
be sharing with you a little bit about the case of Aaron B. and how I
kind of look at it as a cognitive therapist or as a cognitive
behavioral therapist.
[00:00:15] – B
MATTHEW GEYER :
We’re going to discuss some of the, the issues
related to doing therapy with Aaron from this perspective. So, let's
first start off by just kind of reviewing a little bit about Aaron.
[00:00:26] – Can
MATTHEW GEYER :
Aaron is 17 years old. He's a male. His
ethnicity is listed as Syrian American. His religion is Jewish and
his relationship status is single.
[00:00:41] – D
MATTHEW GEYER :
Aaron was referred for counseling by his
physician and he's a star athlete on the high school track team and
attributes all of his symptoms to his efforts to be the best possible
runner that he can. He eats little, limiting his diet severely, and
now weighs only 120 pounds, even though he is 5 foot 10.
[00:01:01] – E
MATTHEW GEYER :
He believes that if he can lose another 10
pounds, he'll be able to run even faster. Aaron keeps lists of
everything he eats, watching each food item and computing its fat
content. In addition, he tracks his daily training by keeping a
record of how many minutes he runs and how many steps he takes,
counting his steps as he runs.
[00:01:22] – F
MATTHEW GEYER :
Aaron also has many other lists that guide his
life, including a list of every possession he owns and every person
he talks with each day. If he forgets to include an item on one of
his lists, he becomes very anxious and only calms down when he is
reoccupied, or, I'm sorry – he has recopied the list with the
forgotten item at the top of the list.
[00:01:45] – G
MATTHEW GEYER :
He tends to check his list repeatedly, making
sure the words are in alphabetical order and sight order. Despite
his youth, he has few friends and activities other than running.
Rc-PSYC 8722 – M. Geyer
Page 2
[00:01:59] – H
MATTHEW GEYER :
Right now, it looks like he's a part-time
delivery boy for a pizza place. He's doing pretty good in school.
He has developed some thinning of the bones which is possibly due to
his poor nutrition. I'll also tell you he has some knee and shin
pains. He's been referred by his-his family physician and I'm pretty
certain that what he's wanting here is that, he wants us to kind of
consult on what's going on with Aaron.
[00:02:32] – I
MATTHEW GEYER :
The strengths of cognitive behavioral therapy are
several for the case like Aaron. First is we can actually go in and
focus on symptom relief for Aaron. We don't have to worry about
going back and analyzing or getting into the deep meaning of any of
his problems. We can focus in immediately on getting him some
symptom relief. The other nice part about cognitive behavioral
therapy is it's pretty flexible and there's a built-in flexibility
into any cognitive behavioral intervention to-to suit the client's
needs.
[00:03:10] – J
The other thing I like about the cognitive behavioral orientation is
we can pull in the use of family. We can pull in Aaron's family to
help us out with the change process and family members can be such
powerful allies during this course of care.
[00:03:27] – K
MATTHEW GEYER :
Some of the limitations of cognitive behavioral
therapy? Well, it's not designed for a whole bunch of depth of selfunderstanding. We're not going to start exploring the inner-sanctum
of Aaron's psyche. It's designed primarily for the symptom relief
and for behavioral change. Now, they'll-they'll be a little, a
little bit you can do with some exploration of the core beliefs, but
it's not going to be anything like the traditional psychoanalysis.
[00:03:56] – L
MATTHEW GEYER :
The other limitation? Well, cognitive behavioral
interventions assume that the client is motivated for change. Now,
motivation is not exactly very well defined here and sometimes that
motivation may not be what we think it is, but, hey, the client may
be and he may have or she may have her own ideas about change needs
to look like. So, we need to keep that open. So, that-that is kind
of a limitation for us and you've got to kind watch that.
[00:04:23] – M
Rc-PSYC 8722 – M. Geyer
Page 3
MATTHEW GEYER :
Well, there are some specific cultural, gender
and age issues that we need to address with Aaron before even really
getting into any sort of therapy. One of which is the cultural
issue. Now, Aaron is listed as being a Syrian American and he's also
listed as being Jewish. And, these, these two things can have some
cultural impact, but we need to find out how much Aaron has invested
into his Syrian culture or his Jewish culture. He may not even
identify himself as being primarily Syrian, as primarily Jewish. We
don't know.
[00:04:59] – N
MATTHEW GEYER :
We also need to assess during the first several
sessions how much his culture really does impact who he is, because
there are a lot of folks out there – their belief systems, they don't
really understand where they came from and the impact of that family
culture can definitely still be with somebody who doesn't necessarily
claim it. So, we're going to need to take a look at that.
[00:05:24] – O
MATTHEW GEYER :
Gender issues. Well, there are some possible
issues here related to male body image. We're not really sure yet
going in but we're going to have maybe, oh, we're going to have to
explore it, yeah. We're going to need to in the future to evaluate
how Aaron kind of sees his role as being a man and some of those
beliefs that are impacted from being labeled as a quote man and how
he views himself.
[00:05:48] – P
MATTHEW GEYER :
Age issues, well, we know that Aaron is preparing
for high school graduation and adulthood. He's, you know, probably
experiencing some of these same developmental issues that are related
to adolescence and we're probably going to need to evaluate those.
For instance, it's known that adolescents tend to feel pretty
invulnerable. They feel like they can pretty much do anything, so he
may not realize the impact of his behavior on his body and the
longterm consequences associated with it. It may just be one thing
that we need to kind of take a look at.
[00:06:22] – Q
MATTHEW GEYER :
That brings us up to the legal and ethical issues
that need to be attended to with Aaron. Well, going back to the
whole age issue, well, confidentiality is a big issue at this point
because, see, Aaron is 17, which makes him not quite yet an adult.
So, we're going to need to really discuss what confidentiality means
with Aaron and also with his parents because his parents actually
hold the rights at this point. We're going to need to discuss the
Rc-PSYC 8722 – M. Geyer
Page 4
... parent with parents about the privacy and what privacy means in
the course of care. We're also going to need to explain to Aaron
that in no circumstances would we-we keep our mouth shut about things
like hurting yourself or hurting somebody else, or if you've been the
victim of an assault, you know, as a kid. You know, we're going to
have to report those things. Abusive things need to be reported.
[00:07:12] – R
MATTHEW GEYER :
We're going to have to do that with the parents
in the room and hopefully the parents would say – Hey, you know what,
we're cool with some privacy here as long as, you know, these-these
lines aren't crossed. And, we can, we can probably talk about those
with the parents. If his parents do not grant Aaron the ability to
have some stuff kind of private, that could be a real problem with
the whole course of care, because I'm not sure how much Aaron, wouldwould trust the therapist if privacy wasn't kind of granted.
[00:07:39] – S
MATTHEW GEYER :
We also need to discuss with the parents and with
Aaron what information is going to be referred back or revealed back
to the referring physician. What information does Aaron feel
comfortable with sharing and what do the parents want shared. So,
we're going to have to pretty much discuss those things and kind of
explain how that's all going to happen.
[00:07:59] – T
MATTHEW GEYER :
Of course, in dealing with the releases of
information or where we're going to release information back to the
referral source, we're going to have to do all the necessary forms to
allow us to actually give that information back. The other thing
that I've always found in my practice is I always use a
confidentiality form where I write out absolutely everything and have
all parties involved sign it. It's kind of like a contract. Kind of
a good practice that I think kind of helps people understand what's
going to happen.
[00:08:31] – U
MATTHEW GEYER :
So, let's kind of move on now to the over ... the
overall therapeutic goals with Aaron. The first thing I want to
really stress is we're going to have to really kind of find out what
Aaron wants. You know, and the goals are going to depend on what
Aaron really wants and believes his need for care is. Aaron may have
the initial goal for being something like, you know, I need to be a
better athlete and this would entail getting everyone off my back.
You know, and those kind of things can be really valuable. And, if
you have a client who comes in like that and gives you that – hey,
Rc-PSYC 8722 – M. Geyer
Page 5
that's great information.
[00:09:09] – V
MATTHEW GEYER :
So, you know, we could take a look at some of the
things that keep him from being a better athlete like all those
doctor's appointments and the parental attention and coming here to
see this therapist. Wow. Those things distract him from his time
practicing. So, that might be his actual goal for care is to get
everybody off his back to free up more time, to go down and practice.
[00:09:32] – W
MATTHEW GEYER :
I want to stress that we must remain flexible
with Aaron. The goals of ongoing care might need adjusting and
adjusting and readjusting and so on and so forth. We really don't
know at this earlier stage, at this early stage of the whole care
process what's really going on with Aaron. So, we need to remain
flexible.
[00:09:50] – X
MATTHEW GEYER :
We also as therapists need to remain comfortable
with that change. Sometimes the goals that we come up with as
therapists just aren't the goals for the client. We need to be
comfortable with that.
[00:10:00] – Y
MATTHEW GEYER :
Now, there is another issue I have and that's his
drug use or his substance abuse. We're going to have to kind of take
a look and see where he, where he's at with this. If he meets the
criteria for chemical dependence or substance abuse, we're probably
going to need to evaluate the need for – well, substance abuse
treatment. Now, if you're comfortable with providing that care
yourself and you have adequate supervision too, of course, you can
proceed. But, you also may need to refer on or you may need to get
the physician involved with – with looking at some of the drugs that
are being used.
[00:10:40] – Z
MATTHEW GEYER :
So, we're going to have to take a look at that
stuff and maybe get Aaron involved with it too. It might be kind of
touchy there, so, probably want to proceed with a little bit of
caution.
[00:10:53] – AA
MATTHEW GEYER :
One of the neat things I think that comes up with
therapeutic goals with clients in the cognitive behavioral realm is
that what's kind of cool about the relationship is that the client
Rc-PSYC 8722 – M. Geyer
Page 6
comes to us as being, and is recognized as being the expert on their
lives. And, they're coming to us the expert in psychology or selfchange. So, it's almost like a meeting of two experts and if you
kind of look at it that way, it might make sense a little bit more
when you start taking a look about the relationship in cognitive
behavioral care, and this definitely would impact the goals because
as a cognitive behavioral therapist and with any kind of therapist,
really, you need to have a respect for your client and your client's
wishes. And, sometimes that means letting a person be wrong, which
is sometimes tough to do.
[00:11:45] – BB
MATTHEW GEYER :
So, how would I proceed with this client? Well,
at first, I’m going to kind of stress to myself and also probably to
Aaron and his parents during the earlier stages here, that we're
going to keep evaluating how he is doing. It's going to be an
ongoing evaluation throughout the process. The initial diagnosis or
proposed process might need to be reevaluated and it might need to be
changed throughout the whole course of care.
[00:12:10] – CC
MATTHEW GEYER :
During the first session, I'm definitely going to
do a complete mental status and I'm going to get a really good
personal and family history. I also really want to kind of to hone
in a little bit on the physical history of Aaron's development, where
he got involved with his athletic talents and what those mean to him
– kind of tell me a little bit about where that came from.
[00:12:32] – DD
MATTHEW GEYER :
I'm also going to need to figure out what is
motivating Aaron to attend this session. Is he really invested in
the change process? Does he believe he even has a problem? And,
what are the consequences of his behaviors if not changed? And, more
importantly, maybe, and something that maybe we forget is what are
the benefits? What-what's there that's reinforcing this behavior for
Aaron? And, we're probably going to want to find this out earlier on
in the whole care process. May not be in the first session but
definitely in the first couple we're going to want to find out what
those benefits of the behaviors are.
[00:13:06] – EE
MATTHEW GEYER :
Need to really focus on something that a lot of
folks don't understand is important to the cognitive therapist and
that is the relationship. Cognitive therapists and cognitive
behavioral therapists realize that the trust is the actual foundation
of any therapeutic relationship and without that trust, that's not
Rc-PSYC 8722 – M. Geyer
Page 7
really going to be a good therapeutic experience for our clients.
[00:13:34] – FF
MATTHEW GEYER :
We're also going to need to communicate a belief
in Aaron, that Aaron has the ability to-to engage himself in the
change process and improve his life. We're going to, we're going to
want to kind of really emphasize that with Aaron because giving a
person the ability to change and know that somebody else believes
that they can change is kind of a powerful experience.
[00:13:56] – GG
MATTHEW GEYER :
Also, this earlier session, I'm going to probably
try to elicit the assistance of the family. I want to know if the
parents are really going to be allies in this process or not. If
they are good allies, and I'm assuming they would be, I might
eventually have to ask them to-to help me with setting up some
contingencies for Aaron at home. For instance, if he doesn't do what
he's supposed to do in the – in the whole care process, let's say he
blows off a therapy – a therapy session. Well, maybe his parents
could help out by saying well, if you're not going to go to therapy,
then you don't get to go to your sporting events. Those kind of,
those kind of things, the parents can really help out with and they
really can be strong allies, so you might want to elicit them early.
[00:14:42] – HH
MATTHEW GEYER :
What would the goals be of therapy? Well, at
first, again we're going to stress this is going to be based on what
Aaron wants and see how we can work that. But, we're going to focus
on symptom relief. We're going to really want to look at reducing,
hopefully some of the intrusiveness of the obsessions and the
compulsions and hopefully get Aaron to the point where he is going to
be able to resume some of his healthier habits and we're going to do
these incrementally. We're not going to bombard him all at once –
that's bad form and usually just overwhelms a person.
[00:15:12] – II
MATTHEW GEYER :
We're going to need to be flexible. If the
immediate issues or problems successfully resolve, we may want to
start exploring some issues related to the development and
reinforcement of his core beliefs and that can be a powerful
experience, too. And, now, that's not going to happen in the earlier
phases of care. That will be probably be at least a couple months
down the path at least before we can really start looking at core
beliefs. But, it would probably be worthwhile with Aaron, especially
with him entering into adulthood soon.
Rc-PSYC 8722 – M. Geyer
Page 8
[00:15:39] – JJ
MATTHEW GEYER :
So, what specific strategies or techniques might
I use as a cognitive behavioral therapist? Well, I'm going to want
to first work towards symptom relief and getting Aaron involved in
the treatment process. I'm going to need to evaluate his interests
and his purposes for being seen and attempt to get him motivated.
Might want to take a look a little bit also at doing some
motivational interviewing. That's a pretty powerful tool to get
people invested who may not exactly be where we want them to be in
the motivation spectrum. So, if you're interested in-in any sort of
... human services work, you know, picking up a book on motivational
interviewing is a – is a must. But, that's a side note.
[00:16:19] – KK
MATTHEW GEYER :
Another thing I'm going to do with Aaron is I'm
going to offer him some psycho-educational information on self-care
as it relates to athletic performance. Stuff is going to be coming
off the Internet, anything I might have around the office that I can
kind of key him in on – try to use that, too.
[00:16:36] – LL
MATTHEW GEYER :
I'm going to continue to evaluate and reevaluate
his progress and his treatment goals and that's going to be
throughout the course of care. We're going to need to evaluate the
inclusion or the need for inclusion of the family in Aaron's
treatment. If Aaron's health deteriorates, that might be one of
those things that we just are going to pull the family in and want to
take a look at some good contingency, some behavioral stuff,
basically. You know, if Aaron doesn't start getting better, then he
starts losing some of the things that he likes and building in ways
for him to get that back. Again, that's only if his health starts to
deteriorate. Hate to go route but, you know, if a person's health is
deteriorating and they're not going to be – they're not going to be
too good psychologically in the future, either.
[00:17:21] – MM
MATTHEW GEYER :
We're going to really want Aaron involved in some
age-appropriate social activities and I'm probably going to use some
homework to get him involved with that. Going to also use some
homework to get him involved just with doing some other – some other
stuff. Probably look at some, some scaling questions and maybe some
journaling, and those kind of homework assignments to help him out.
But, I'd really like to use homework to get him involved with some
age-appropriate peer groups.
[00:17:47] – NN
Rc-PSYC 8722 – M. Geyer
Page 9
MATTHEW GEYER :
Techniques – going to use the self-rating scale
to assist with progress monitoring. It's going to allow Aaron and
myself also to see, you know, the benefits of improved self-care.
May use, I'm probably going to say will use, the rational emotive
behavior therapy format by Albert Ellis. This ABC model is really
user friendly and it seems to, well, it seems to be well-received by
many, many folks. So, I'm going to kind of teach him that, teach him
how it works and hopefully that will facilitate the change process,
too.
[00:18:18] – OO
MATTHEW GEYER :
May also use some thought stopping techniques to
assist him with the reduction of the obsessive thinking. I've used a
rubber band on the wrist before. Whenever a client had the obsessive
thought, he'd snap or she'd snap the-the wrist and kind of hopefully
break him out of the cycle. I've also used a lot of journaling to
help out with some of the obsessive thinking in the past. That helps
me to kind of see what's going on also with the client, but that's a
– a whole other discussion we'd have to have.
[00:18:46] – PP
MATTHEW GEYER :
Again, I'm going to try to use the family to
assist with the reduction of the symptoms and possibly for assisting
with longterm change plans. And, if you're, you're hearing a theme
there with me getting the family involved, well, it's one of my
biases. I think families need to be involved with kid's care.
[00:19:01] – QQ
MATTHEW GEYER :
And, of course, I'm going to use homework with
feedback for each session. And, hopefully, give Aaron some positive
reinforcement for completing that homework.
[00:19:11] – RR
MATTHEW GEYER :
So, at this point, I'm pretty comfortable withwith the discussion so far and this is how I'm going to kind of view
Aaron from a cognitive behavioral standpoint. Of course, these
things will change. I've kind of stressed that through. There's
going to have to be some flexibility. Thanks for listening and take
care.
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