Annette’s Case Study

Provide a formulation/conceptualisation of the client’s difficulties based on the

principles of EACH of the two frameworks (Attachment theory and CBT) that you have

chosen (800 words).

The case describes condition of a female teenager who is suffering from body image issues

due to her concerns about fitness. Annette is thirteen years old with normal body weight. Her

cognitive functioning shows that she has an average level of intelligence with low level of

introspective abilities. Her mother works with a fitness company and also is continuing her

studies. Annette’s mother signed her up for the therapy session to address her unhealthy

eating habits and body image issues.

Annette’s idea about her body image reflect that she sees herself as a fat person who will

never be good enough for the society to be call beautiful. It is also believed by her that she

should present herself in the society as a different person with new identity by wearing new

clothes and accessories. She also has doubts about her company by thinking that the reason of

her unpopularity in school is that she cannot hang out with popular girls. She does not

socialize with boys because she thinks that they are immature.

Cognitive Behaviour Therapy

Cognitive Behaviour Therapy and Attachment theory will be used to conceptualize this case.

Cognitive Behaviour Therapy is defined as; “Cognitive behavioural therapy (CBT) is a

psycho-social intervention that aims to improve mental health. Cognitive Behavioural

Therapy focuses on challenging and changing unhelpful cognitive distortions and behaviours

with improving emotional regulation” (Beck, 2011).

Annette has some Negative automatic thoughts about her mother as well since she thinks that

the reason behind everything going wrong is her mother’s interference. Conceptualizing

Annette’s case from perspective of Cognitive Behaviour Therapy, this thinking pattern is
called “Personalization” in which a person always blames others for their own failures and

undesired events. In consequent of all these factors, she has made certain ideas about herself

and she blames her real self to be cause of her poor socialization skills. She also has negative

body image. Despite of having normal weight, she thinks that she is fat. This pattern of

thinking is called Labelling. She feels like it is necessary for her to conceal her real self and

she looks for every possible way to keep that real self-hidden. All her focus and energy goes

into making up a personality that she does not have in reality. She worries about her dress

that even though she tries to blend in by dressing up like her friends and peers, she still stands

out because of her real self which is not acceptable for Annette. This pattern of thinking is

called Jumping to Conclusion.

Her thinking style also reflects “should and must’s” pattern since she thinks that her mother is

supposed to spend her money on Annette and should bear all her expenses. Despite this

demand, Annette still despise her mother’s interference in her life and wants her mother to let

her be free to be the person she wants show the world. She feels angry when her mother asks

her to do something in a certain way and sees it as her mother’s authoritarian and controlling

behaviour. She wants to be a popular girl in school who has a boyfriend like all the other

popular girls and to become that girl, she joined cheerleading squad. She also thinks that to be

a popular girl in school, she must be skinny. She has tried cutting out her meals in order to

minimize her in take but nothing is given her the results she wanted from her body. She also

observed some girls doing binge eating and then purging in school where they eat a lot of

food due to anxiety and then vomit to alleviate pressure of food.

Attachment theory

Attachment theory was also used to formulate and conceptualize this case study. Attachment

theory is “A psychological model attempting to describe the dynamics of long-term and

as a general theory of relationships; it addresses only a specific facet” (Landa & Duschinsky,

2013)

In Annette’s case, it is observed that she has resentful behaviour towards her mother as she

calls her “an idiot” and blames her for every seemingly negative event occurring around her

or to her. According to Attachment theory, such behaviour is executed by the teenagers who

have had Anxious-avoidant attachment with their parents during their childhood. According

to the theory, “An infant with an anxious-avoidant pattern of attachment will avoid or ignore

the caregiver showing little emotion” (Ainsworth & Bell, 1970). Children with such

attachment during childhood show Dismissive-avoidant behaviour during their teenage or

adulthood. It is stated that in Dismissive-avoidant behaviour; a high level of independence is

desired by the adults and they seem to avoid attachment. People exhibiting such behaviour

see invulnerable, self-sufficient, and not needing immediate relationships or get attached to

someone such as spouse, parents, siblings or friends. They suppress their emotion and

distance themselves from their relatives in order to deal with anxiety created by situation of

atatchement. (Carvallo, Mauricio, & Gabriel, 2006).

the client’s mental health difficulties and challenges (300 words)

Cognitive Behaviour Therapy

General Implications

Following are the areas in which Cognitive Behaviour Therapy has its significant importance:

“Anxiety disorders, Schizophrenia, psychosis and mood disorders, with older adults,

Prevention of mental illness, Gambling addiction, Smoking cessation, Eating disorders, and

Internet addiction” (Churchill & Hunot, 2001).

Implications in this case Study

In this case study, Cognitive Behaviour Therapy helped to identify the problems faced by the

client at emotional cognitive and social level. It also helped in formulating and

conceptualizing the case at all four stages of therapeutic treatment to address and treat

abnormal behaviours of the client. The treatment method adopted from this therapy helped to

address both the physical and psychological wellbeing of the client in a systematic pattern

through task assigning and prioritizing health concerns.

Impacts of Attachment theory

General Implications

Attachment theory is a major scientific theory of socio-emotional development and a huge

line of research area is based on this theory in modern psychology. Research and Attachment

theory have concluded important findings that concern early child development and

encouraged the development of early child-parent relationship support programs.

Historically, this theory have had important implications for institutionalized and
hospitalization of children with focus on those who had day care of poor quality (Sable,

1992).

Implications in this case Study

In this case study, the Attachment theory helped to identify Annette’s behavioural patterns

with regards to her childhood that affected her current self. The theory also helped to identify

causes of her resentful behaviour and relationship pattern with her mother. The theory also

gave direction towards family therapy for both Annette and her mother with the evidence that

they both needed counselling to make their relationship better.

of the two frameworks that you have chosen. Make sure that you include the specific

elements and stages of each intervention/therapy approach, together with explanations

of how they are intended to achieve their aims (900 words).

Cognitive Behaviour Therapy

Cognitive behaviour therapy was used in this case study which was based on four stages.

Stage I

Stage one of the therapy aimed to establish rapport with Annette for therapy. The purposes of

building the rapport during the therapy include Positivity, creating mutual attentiveness and

coordination. Another purpose of Rapport is to make a harmonious relationship between the

client and the therapist to understand feelings of each other during the therapeutic process. It

is very important to make the client feel safe and comfortable during the therapy. If rapport in

no experienced by the client and the therapist, both of them will feel hesitate to disclose

information honestly and be open to experiences.

The therapy also focused on elaborating cognitive patterns behind abnormal eating

behaviours. It is important to construct normal eating behaviours. In the beginning of the first

stage of therapy, the client will be weighed and her Body Mass Index (BMI) will be

calculated. To monitor her weekly weight, a graph will be used. Every next session will begin

with discussion of her weekly Body Mass Index which she will record weekly on a sheet. She

will also be assessed using two questionnaires; “The Clinical Impairment Assessment” (CIA)

by (Bohn & Fairburn, 2008) and “Eating Disorder Examination Questioner” (EDE-Q) by

(Fairburn, Cognitive behavior therapy and eating disorders, 2008). This will give an overview

of curing process of eating disorder and significance of therapy during one month.
Annette will also be given homework tasks which will be based on record of her eating

schedules. After seeing her eating schedule, the therapist will generate an appropriate

schedule for her which she will have to follow. The purpose of this will be to identify her

change the behaviour. It is important to address the client’s reluctance towards therapeutic

treatment to motivate her towards better health conditions. Moreover, it is essential to address

and treat her problems that are directly affecting her physical health such as eating disorder.

Stage II

It is the transitional stage of the therapy. This stage aimed on conducting a review between

the client and the therapist continuing implementation of the procedures that had been started

in stage I. The client and the therapist will work together in this stage for understanding of

cognitions and events that are underlying factors for Annette’s psychological and physical

condition. Many therapeutic techniques involve analysing and working on baseline reasons of

a disorder and Cognitive Behavioural Therapy is one of those. Without understanding the

underlying reasons the therapist cannot treat the client’s issue since the predisposing factors

of any disorder cannot be overlooked.

Stage III

This stage is very crucial part of the therapy. Annette and the therapist will focus on factors

that are causing her eating disorders. Aims of this stage will include addressing her issues

related to her concerns about her body shape and weight. To address these issues, following

five steps will be followed;

 Identifying over evaluated areas of the body

 Regular check-up of the body

 Addressing the term “being fat”

 Investigation of the underlying factors of over-evaluation

Another aim of this stage will be to determine her in-take limitations. Annette and the

therapist will determine the rules of diet which will be followed by Annette. Lastly, the aim

of this stage will be to determine the occasional changes and cheat-days in diet restrictions in

which the client will be allowed to break the dietary rules for one day in a week or two weeks

depending upon improvement of her condition. It is very important to decide the cheat-days

during the strict diet period. One of the biggest challenge in following the strict diet or

treating the eating disorders is to develop new habits that support one’s goals regarding health

without breaking the diet plan or relapsing. Incorporating cheat days is one of the ways go

easy on the client so that the diet plan doesn’t seem a burden due to sudden and strict

executions of diet.

Stage IV

This is the final stage of the therapy that will be based on an assessment and evaluation of all

the steps and their significance that would have been taken during this therapy. Follow up

sessions will be planned and chances of relapse of the issues will be discussed. The purpose

of having follow up sessions is to discover new ways for improvement over time, celebrating

success, collecting new and updated data about the client and develop further planning.

Cognitive Behavioural Therapy for Substance Abuse

It is stated that; it is found out by the studies that Cognitive Behavioural Therapy alone is

effective for treating psychotic disorders of less severity such as “depression

and anxiety, posttraumatic stress disorder (PTSD), tics, substance abuse, disorders

and borderline personality disorder.” Cognitive Behavioural Therapy is recommended to be

used by combining it with medication for more severe conditions of psychotic disorders.”

(Hollon S & Beck A, 2011)

Attachment theory will help in formulating a far reaching and broad view of client’s

cognitions, and functioning. The theory will enrich the understanding of therapist towards the

client and under on the basis of this theory, rapport will be built as the theory focuses on the

therapeutic relationship between the client and the therapist instead of encouraging method of

implementing a particular form of treatment without detailed consultation with client and her

family. Use of some forms of psychoanalysis-based therapy is also encouraged by

Attachment theory with relational psychoanalysis.

therapeutic strategies that you have proposed (500 words).

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy is a very important and helpful tool that works either alone or

in combination with other therapeutic techniques. It has significant importance in treating

mental disorders such as depression (Rollinson, et al., 2007), post-traumatic stress disorder

(Wilson, 1996), and eating disorders (Fairburn, Cooper, & Doll, 2009). Cognitive

Behavioural therapy does not always benefit individuals with mental health condition. It can

be effective tool for helping anyone who needs help to manage stress. Cognitive Behaviour

Therapy is also used to address emotional issues such as identifying symptoms of mental

illness, preventing a relapse of symptoms, altering medication to treat mental illness, learning

techniques to cope with stress, identifying ways towards emotional management, Resolution

of relationship conflict and learning ways for communication, coping with loss of grief and

overcoming violence or abuse related trauma, coping with medical disorder and managing

chronic symptoms of illness (Miller & Holden, 2010).

It is evident from researches that Cognitive behavioural therapy (CBT) has extensive uses for

clinical practices. It is found from the research that CBT is significant for a range of

psychological issues that include depression and anxiety (Churchill & Hunot, 2001). For mild

to moderate level of depression, and its prevention from relapse, it has been found that

Cognitive behavioural therapy is as effective as medication for depression such as

antidepressants (Hollon, DeRubeis, & Evans, 1992). A study that compares supportive

therapy, family therapy and Cognitive behavioural therapy states that Cognitive behavioural

therapy is more efficient in rapid treatment of symptoms and is at higher rate of remission as

compared to other therapeutic methods (Brent, Holder, Kolko, Birmaher, & Baugher, 1997).

Studies that compared CBT in for primary care to basic treatment states that individuals
receiving primary care through brief therapy of CBT showed higher rate of recovery that

persisted for 12 months.

Attachment theory

Although this theory has provided base for modern research, yet there has been little

application of this theory in clinical practice except for “Parent-Infant Psychotherapy”. Thus

this theory is still at the stage of development in terms of its application in clinical setting and

research work on it. This prominent gap in psychotherapy practice makes it different from

other systematic and clinical practices such as; “classical analytic, ego analytic, behavioural,

and gestalt theories”. Although many of its elements have been translated to language of

clinical application such as “formation of a real relationship with the patient”, attachment

theory still seems to have formless and vague space in clinical setting due to lack of some

factors such as clinical intuition.

The principles of attachment theory regarding real relationship with the client or patient

contradict with principles of psychoanalytic theory and this has always kept attachment

theory behind psychoanalytic theory in clinical application (Hamilton, 1985). However, some

concept of attachment theory stated by (Bowlby, 1977) and other clinicians are proven to

have been used extensively in clinical therapies.

5) Reflect on how your own personal beliefs and experiences have shaped your choices

and responses in developing this coursework (300 words).

During solving this case study I found many interesting aspects of the therapeutic techniques

that I used. I had brief understanding of cognitive behaviour therapy from the study course

but I got more command and understanding over this therapeutic technique by using it in

practical manner. In my view we over look a lot of details in theory while studying but using

the theory in solving enlightened me to use minor detail from the case for the purpose of
diagnosis and selection of appropriate therapeutic method accordingly. From my experience I

can conclude that there is a lot of difference between theoretical approach and practical

approach any to technique.

another thing that I learned by solving this case is that the therapeutic approach or a theory do

not necessarily have to be approved by research literature in terms of their high affectivity,

rather their significance for case study should be more focused on. Use of attachment theory

in this case is an example of this. I also learned that a client who is referred to the therapy

does not always have to go through the therapy alone rather and individual therapy can turn

into family therapy based on data from case study and necessity of involving a family

member for the purpose of collective behavioural improvement determined by the therapist.
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