What are the Clinical Concepts and Their Applications

From the history taking, it was apparent that the client had experienced various negative adverse life experiences including experiences of grief, violence, and trauma. The client experienced sexual abuse as a child, miscarried a baby at age 16, and experienced physical and emotional abuse from a partner which led her to flee from her own country. At such a young age, she was uprooted from her family, community, and cultural support and became a refugee in Canada. In addition, since moving to Canada she experienced two abusive relationships with intimate partner violence, one in her late teens and one in her 20s. She acknowledged these traumas; however, when gently invited to talk about them, the client declined. Specific diagnostic questions about PTSD (e.g., how often do you have intrusive thoughts and memories about the trauma experiences?) were diverted by the client. Therefore, the impacts of the client's trauma history on her current symptoms and life were not extensively explored. Given her visible emotional distress while reporting trauma experiences (e.g., crying at times and reporting as a matter-of-fact at other times), as well as her negative affect and her avoidance of trauma-related thoughts, feelings, and reminders, it can be hypothesized that she was suffering from some symptoms of post-traumatic stress. It is not uncommon among trauma survivors to alternate between avoiding and being flooded with trauma memories and experiences (Herman, 1992). Although she reported that her symptoms of anxiety and depression only started when she moved to Canada in 2006, it is likely that the history of trauma and growing up in an unsafe environment might have been related to her presenting symptoms and avoidant behaviors. Her ongoing struggles of interpersonal relationships and changes in personality characteristics such as low self-esteem, self-blame, negative assumptions about herself and the world, decreased interest in activities, and self-isolation also signaled symptoms of PTSD (Cloitre et al., 2012).Given her preference of not focusing on past trauma experiences, it appeared to be crucial to respect her preference and provide present-focused and client-centered approaches. Honoring the client's goals and listening to the client's wishes and stories are critical especially for someone like this client who has experienced multiple traumas and violence where she lost power and control over the various situations in her life (Herman, 1992). Alliance, goal consensus, and empathy were found to be pan-theoretical and trans-pathological factors that enhance treatment efficacy in psychotherapy (Norcross & Lambert, 2019). For this client with the comorbidities of depression and anxiety as well as plausible PTSD, it would be important to pay attention to these trans-pathological aspects in selecting and delivering treatments. Building alliance, conveying empathy, and exploring and monitoring the client's goals were illustrated in detail later in the treatment process.Initially, the treatment goals identified by the client consisted of decreasing symptoms of anxiety and depression including low self-esteem and learning how to cope with presenting stress such as managing her finances and her small business, feeling insecure of her current status in Canada, and better attending to her son's needs. While exploring her goals for therapy, several avoidance behaviors were identified such as isolating herself from friends and family, avoiding "play dates" for her son, spending long periods of time in bed, procrastinating her goals of developing her business, and applying for permanent residency status. Also, her negative view of herself (i.e., I am not a good mother) was apparent. This exploration in the initial sessions helped both the client and therapist to clearly see how the cognitive filtering and avoidance behaviors contributed to symptoms of depression and anxiety and interfered with goal achievement.In addition to empirically supported evidence supporting CBT for people with the comorbidity of PTSD, depression, and anxiety as well as the client preference (i.e., non-trauma focused) and stated goals, the therapist also considered contextual contingencies in selecting treatments. The agency where the therapist was working while having served this client used CBT as the primary treatment approach with a structured CBT training program using a manualized CBT (Nathan, Rees, Lim, & Smith, 2019; Nathan, Rees, Lim, Smith, & O'Donnell, 2019), and ongoing supervision, optimally supporting the therapist to support the client in need. The services offered at this agency were short-term, offering 12 sessions as the maximum amount the client could access at each referral. Also, the client was referred to the therapist within the time limit where the therapist would complete the training internship in 3 months. These contextual contingencies in the service provision system were added to the rationale of choosing the 12-week individual CBT.