Eight Sessions, Three Approaches, One Family
Kavita, 24, has social anxiety: she avoids eating in public, fears being judged, and has missed two job interviews. She has not been assessed by a psychiatrist and is not on medication. After eight sessions of cognitive-behavioural therapy with a trainee counsellor, she can now attend a small tutorial but still avoids the canteen. Her CBT homework includes thought records and a fear hierarchy. Her mother insists on 'medicine from a psychiatrist'; her aunt says, 'Just give her confidence, don't dig into her childhood.' The trainee's supervisor suggests adding client-centred elements; another staff member suggests psychoanalysis. Kavita says she is exhausted by homework and wants 'someone to listen'. The clinic offers 12 free sessions and then must refer. The trainee has two sessions left.
1. What should the trainee do with the remaining two sessions? Compare CBT, client-centred therapy and psychoanalysis in terms of goals, methods and feasibility, and justify a plan.
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With two sessions left, the trainee should consolidate and plan continuity, not start a new long-term therapy.
CBT: goals are to reduce avoidance and modify threat appraisals; methods include thought records, behavioural experiments, and graded exposure. Kavita has already made gains (tutorial attendance). Two sessions can review the fear hierarchy, set one feasible canteen step, problem-solve homework burden, and write a relapse-prevention plan. Starting a new modality now would dilute the dose.
Client-centred therapy: goals are congruence, self-acceptance, and autonomy; methods are empathy, unconditional positive regard, and reflective listening. It fits Kavita's request for 'someone to listen' and can be integrated briefly - for example, exploring her exhaustion and her goals - but it does not by itself provide the structured exposure she needs for social anxiety. The supervisor's suggestion is best used as an adjunct, not a replacement.
Psychoanalysis: goals are insight into unconscious conflict; methods are free association, dream analysis, transference work; it is long-term. It is not feasible in two sessions, has weaker evidence for social anxiety, and the aunt's 'childhood' comment misunderstands what CBT does. It would be inappropriate to begin now.
Plan: tell Kavita the rationale; ask what she wants from the last two sessions; consolidate CBT; add empathic listening; arrange referral for continued CBT or a psychiatrist if needed; give a written summary. Reasoning: match therapy to problem, evidence, dose, client preference, and continuity of care.
2. How should the trainee handle the family's demand for medication and the aunt's advice? Address informed consent, confidentiality, competence and referral.
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Medication demand: the trainee should not debate 'medicine versus therapy' as a loyalty test. She should explain, in plain language, that medication is prescribed by a psychiatrist after assessment; that for social anxiety, CBT and medication can be used together; that the choice depends on severity, preference, and history. With Kavita's consent, the trainee can help arrange a psychiatric consultation and prepare questions. She must not recommend a drug, dose, or tell the family that medication is unnecessary.
Aunt's advice: acknowledge the concern behind it - she wants Kavita to be confident, not 'dug into'. Explain that CBT is here-and-now and skills-based; it does not require childhood excavation. If Kavita wants exploratory therapy, that is a legitimate preference to discuss and refer for, but it should not be imposed by relatives.
Ethics:
- Confidentiality: Kavita is an adult. Do not disclose session content to her mother or aunt without her consent. Explain the limits (risk of harm).
- Informed consent: explain the ending of the 12-session clinic, the referral plan, and what will be shared with the family.
- Competence: the trainee works under supervision; if the case exceeds competence, refer.
- Non-abandonment: do not simply stop at session 12; provide a written plan, an appointment, and a crisis contact.
- Documentation: record the plan and consent.
Reasoning: respect for autonomy, beneficence, non-maleficence, and fidelity. Family involvement should support Kavita's choices, not override them.
3. What evidence would show that CBT is working, and what would show it is not? Distinguish symptom change, avoidance, and client agency.
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Evidence that CBT is working:
- Symptom change: lower self-rated anxiety and fear ratings on the hierarchy; fewer catastrophic predictions.
- Behavioural change: attends the tutorial regularly; eats in the canteen with one friend; schedules a job interview; reduction in safety behaviours.
- Cognitive change: can identify 'they will judge me' as a thought rather than a fact; generates alternative explanations; uses thought records outside sessions.
- Functional change: less missed work/study; improved sleep; broader daily routine.
- Client agency: Kavita sets goals, chooses exposure steps, and reports what she wants; homework is negotiated, not imposed.
Evidence that it is not working, or not enough:
- No change after an adequate dose; worsening anxiety; increased avoidance; dropout; new symptoms; distress from homework without benefit.
- Attendance without engagement - compliance to please the therapist rather than internalised learning.
- Improvement only in the therapy room, not in daily life.
Do not conclude from a single good session, a raised fear thermometer, or a self-report alone. Use multiple measures (self-report, behaviour, therapist observation, perhaps a collateral report with consent) and review the formulation. Distinguish compliance (doing it because the therapist asks) from internalisation (doing it because it matters). If progress stalls, consider referral, a different modality, or a psychiatric review.