©Routledge/Taylor & Francis 2014
Therapy in Action
Behaviour Therapy
Each chapter of the textbook incorporates a novel case study involving a client presenting with a set
of concerns and a therapist addressing these concerns using the therapy discussed in that particular
chapter. Since each therapy is best suited for certain types of difficulties, each case study is unique
in order to ensure that the examples provided are as clear as possible. This session can be viewed by
watching the associated video content of the therapy session in action and this document is designed
to accompany the observation to support your understanding.
The aim of these case studies is to provide the reader with a real-world example of therapy in
action. Unlike many other fields of psychology, counselling and psychotherapy are not exclusively
academic. In order to fully understand therapeutic approaches and methods, the reader must
appreciate how these concepts can be applied in interactions with clients. The best way to present
these interactions is in the form of case studies and we hope that you are able to use these examples
in order to further your own understanding and practice of counselling and psychotherapy.
The therapy session lasts for one therapy hour (50 minutes) and it is presented as the initial session
in a new therapeutic relationship. Prior to this session, the client will have completed an initial
assessment questionnaire and the therapist will have read this paperwork to ensure familiarity with
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the case (please refer to the assessment form online for more information). Please note that these
videos depict REAL interactions – although the session has been arranged for the purposes of the
video and the sessions will not continue after the recording, the interaction within the session is
genuine. No actors are used in this session. The client was one of the authors and the problem
presented was genuine. The therapist is an experienced practitioner in the field. The only ‘fake’
aspect of this recorded session is that the client did not really seek therapy and this is not really the
first session of a series of therapeutic contacts.
After the conclusion of the therapy session, the therapist is invited to answer a few key questions
about the session. This question and answer session lasts no longer than 10 minutes, thus the video
lasts for an approximate total of one hour.
Therapist Credentials
The therapist in the behaviour therapy session was Keith Mathews. Keith is Senior Psychological
Therapist at the Department of Clinical Psychology, Betsi Cadwalladr University Local Health
Board. Keith works in secondary care community adult mental health services, working with
individuals with complex and enduring psychological difficulties. He is trained in cognitive
behavioural psychotherapy, dialectical behavioural therapy, schema therapy and integrative
psychotherapy. He also supervises practising psychotherapists and trainee clinical psychologists. He
has taught cognitive behavioural therapy process skills on the North Wales Doctoral Programme for
Clinical Psychology and currently teaches schema therapy on the same programme. Additionally,
Keith teaches assessment and formulation skills on the Masters in Therapeutic
Counselling programme at Coleg Llandrillo Cymru. Keith is a Senior Accredited Practitioner with
the British Association for Counselling and Psychotherapy
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Client Presentation
The client in the behaviour therapy session was Fay Short. Fay has an acute fear of heights. She has
recently experienced high levels of stress at her workplace and some associated physical symptoms
(including headaches and backache). However, her primary reason for seeking therapy is a desire to
overcome an intense fear of heights. She has previously experienced person-centred therapy for a
short space of time over ten years ago, but this was unrelated to her current fears. She would like to
overcome these fears during therapy so that they no longer impact on her ability to take part in
activities that involve heights.
Transcript of Session
T denotes therapist, C denotes client.
T: Okay. Hi Fay, it’s nice to meet you. We talked on the phone and you told me a little bit about
your background. Just before we get into the details of what the problem is I need to let you know
actually that today’s meeting is confidential as you’d expect, the only exceptions are if there were
things that I was a bit concerned about in terms of your wellbeing, or towards the wellbeing of
others around risk, I would need to talk to you about that with a view to sharing it with the
appropriate people. Is that acceptable to you?
C: Yes, that sounds good.
T: Now before we start off I just want to sort of talk to you about the structure of today’s meeting as
it’s the first time it can sometimes be anxiety provoking as I’m sure you can appreciate. So what
we’re going to do today, we’re going to talk for about 50 minutes, just to try and help me to
understand the background to your problem. And as you’ve come for behavioural therapy today I
want to let you know a little bit about behaviour therapy and how it works, but also to try and ask
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you some specific questions around your problem. So what I thought perhaps we could do is to start
off with basically you tell me a little bit about your problem, how you’re affected by it, and then
perhaps later on we can go on to explore what you feel keeps it going and then after that perhaps we
can talk about the treatment options for you from a behavioural therapy point of view. How does
that sound?
C: That sounds great.
T: Okay.
C: Sounds good.
T: Before we start is there any questions you’d like to ask me at this point, anything you’d like to
know before we set off?
C: No, I think that that makes sense. You’ve clarified the confidentiality and that kind of thing and
yeah, I think it makes sense.
T: Okay, now I’m going to keep some notes because I’d like to be able to sort of refer back to these
as we go through the assessment procedure so that ... I’ve got a hold on the key elements which are
useful in understanding your difficulties.
C: Okay.
T: Okay, well perhaps you could start off by telling me a little bit about the problem, and tell me
how long you have been struggling with this.
C: Okay, erm ... my problem is a fear of heights and I think I have probably always been a little bit
frightened of heights, so I’ve always had that uncomfortableness if you’re kind of ... you like if
you’re on a bridge and there’s gaps in the walkway so that you can see through it, that’s kind of
scary. But I’ve always kind of managed with it and it’s never really stopped me going on high
things although I’d feel quite anxious. But a few years ago, possibly three years ago, my husband
and I went to Cambodia, we were volunteering over there and during the trip we visited some of the
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temples in the Angkor Wat region, and one of the temples there, it has ... it’s practically vertical
going up and it has kind of like a ladder ...
T: Yes.
C: And it’s ... they don’t do health and safety the way they do health and safety in the UK.
T: Apparently not, they don’t a Health and Safety executive have they ...
C: No I don’t think so, and it’s quite rickety. I mean, Angkor Wat was amazing and completely
beautiful and a really incredible place but that particular temple, all the rest of them had very solid
stone steps but that particular one was a very rickety ladder.
T: Okay.
C: My husband went up and normally pride makes me have to go if he’s going but on this occasion
I said no and then when I was watching him go up I saw a man carrying a baby coming down and I
was just so embarrassed that I couldn’t do that that I got up and did it anyway.
T: Right.
C: About half way up I realised that I couldn’t breathe, erm, but by that time those people were
behind me trying to climb, so turning around wasn’t an option. You couldn’t turn round, I would
have had to climb back down and I couldn’t do that because of the people behind me ... and then it
was just a pure panic attack, not able to breathe and by the time I got to the top I was shaking and
crying and, I think, crawling at that point and I managed to get to the top and over the edge and just
sat down on the floor and cried for a while.
T: So you can track it, so just for me to summarise, to make sure I’ve got the right understanding of
it; it’s always been something that you’ve been a little bit wary about and you’ve taken precautions
around heights, you’ve always been aware of it for as long as you can remember I take it?
C: Yes.
T: But it sounds like you really associate the fear starting about this time that you went to the
temples in Cambodia ...
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C: Yes.
T: ... and it sounds like you’ve got a very vivid recollection of what happened. Erm, can you just tell
me a little bit more about actually, because it sounds like you noticed an awful lot of physical
sensations, you noticed lots of feelings, but also there were some thoughts going on as well there,
and when you got to the top of the ladder and you were noticing these really strong feelings which
sounds pretty uncomfortable from what you describe, what happened then? What was the next thing
that happened?
C: Erm, I kind of sat there for a while, and my husband looked terrified, bless him, because he was
very concerned that I’d come up at all, and I was utterly convinced that if I tried to climb back down
I was going to fall.
T: Right, okay.
C: And the thing is I’m pretty clumsy at the best of times, so tripping up and that kind of thing
happens to me very frequently and I was convinced that I would just lose my footing and I’d fall
down. I eventually, once I’d calmed down enough, we had to go back down the ladder, and that was
even worse than going up ...
T: So it sounds like you had really quite intense feelings of discomfort going up the ladder, when
you got to the top it sounds like there was lots of things that you were thinking about in terms about
yourself in relationship to the situation and what you’d just, what you’d just done, but also then it
got worse again anticipating going down the ladder.
C: Yes.
T: Okay. And so just tell me a little bit about what happened as you went back down the ladder.
What was, what did you notice?
C: I think the main thing I probably noticed was how embarrassing it was because the physical,
although in my head I knew, I kept saying 'this is fine' I suppose I’ve always prided myself on being
able to talk myself down if there’s a problem.
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T: Right.
C: So I’ve always thought that, you know, no matter how scared I felt I would be able to control
that because I could just talk myself round. But physically that wasn’t happening, I couldn’t stop the
shaking and the fact that I was shaking so badly and I stop, I couldn’t regulate my breathing and I
couldn’t calm down, and because of that I was very concerned that then I was going to lose my
footing.
T: Right. So there was an awful lot of concern then, really strong intense feelings, and the sort of,
the way that you’d normally cope with that, that wasn’t working ...
C: No, no.
T: ... for you on this occasion. Okay, and erm, well you got down, you’re here today.
C: I made it (laughs).
T: You’re safe and sound, that’s good to know. And as you came down the ladder did those feelings
of discomfort, did they change as you came down the ladder or did it stay the same?
C: I think it pretty much stayed the same. I was just really, really embarrassed because there were
people actually climbing off the ladder, and climbing over the rocks, to get past me because I was
taking so long. So I was utterly mortified that it was taking so long for me to get down.
T: Okay. Yeah, so it sounds like as much as the discomfort about being in that high situation which
sounds like you were really kind of scared, and based on what you were telling me before, that’s
always been something that you’ve been worried about, but actually there was another factor to that
which was actually being aware of other people around you.
C: Yes.
T: Okay, and when you got down what happened with those feelings of discomfort and
embarrassment that you’d experienced?
C: Well I still felt that way quite a lot, obviously I’d calmed down and physically calmed down,
what actually happened was, I’d imagined that having accomplished that one everything smaller
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wouldn’t be so scary, but actually it made it worse. Things that I, temples that I’d previously
climbed and weren’t particularly high, I mean even tiny heights, suddenly I would get very, very
anxious and very panicky about going up them, so for the rest of the trip I was really struggling with
any heights.
T: So it sounds like rather than you’d actually managed to get up that high place that everything else
would be easier, what had happened was that it actually got more anxiety provoking for you in
those situations. And what did you do to try to cope with that? Did you do anything particularly to
try to control those feelings or the worries that you had about heights?
C; Most of the time I clung physically to my poor husband and he had to cope with me for the rest
of the trip.
T: Yeah, and by holding on to your husband, did that have an effect on the levels of discomfort that
you were experiencing?
C: I think it ... I’m not sure, I mean I suppose I was able to do it when I was holding onto him, but I
think it was a weird thing because on the one hand it kind of increases the worry because if I fall
I’m probably going to take him with me and that’s even worse than me falling ...
T: So in some ways it enhanced the anxiety.
C: Yes. On the other hand it’s clinging to anything that feels like it might be safe and secure.
T: Okay, so it very much sounds like that experience in Cambodia had a real sort of influence upon
you in terms of your relationship to understanding where this problem really started from. It sounds
like there’s always been that background difficulty in terms of wariness about heights but it sounds
like that was the key thing. How’s it been since, since you came back from Cambodia, three years
ago you were saying?
C: Yes. I’ve not really been up anything particularly high, but since that trip we’ve travelled to, I
think, we went to Australia last Christmas and what I did notice, I’m not a very strong swimmer and
I don’t really like being in deep water, but what I really noticed, we went out to sea and we swam
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with dolphins and that was the only thing that would have got me in that water. And what I noticed
in the water, the thing that really panicked me was how high you are because there’s no ground
underneath you. So although I’d always thought that I’d had a fear of water, I wonder actually if
what I have is a fear of heights in water, if you see what I mean.
T: Right.
C: And that really, that really worried me, and then on the plane I’ve never been especially
frightened of flying but we hit a little bit of turbulence and all I could think about was how high we
were and that again was really panicky.
T: So on the return from Cambodia it sounds like, erm, you’ve really got sensitive about heights,
and on these other trips to Australia and in water and in planes, it sounds like you were starting to
notice the relationship between yourself and the perceived ground.
C: Yeah.
T: Whether it is water or in a plane. At home, have you noticed particular problems at home, in your
day-to-day life?
C: I don’t have any enormous problems because I live in a two-storey house and I don’t go up
ladders or do anything like that, if anything, if windows have to be cleaned then my husband does
that because I don’t really like going up high things but I never have really liked going up high
things. At work if we have to go up in lifts, there’s only one building in Bangor that really has a lift
that takes you up high, and that in itself makes me nervous ...
T: Yeah.
C: But generally I don’t go to high things in my day-to-day life so ...
T: And then, just to clarify this, so on a day-to-day basis that you wouldn’t encourage, be
encouraged to go to heights, normally yourself, you’d encourage maybe your husband to go and do
things.
C: Yes, yeah.
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T: And it sounds like you would go to certain places but be kind of wary. Are there places that
you’d overtly avoid, that you’d stay away from because of heights?
C: Well my concern is that when we travel really, something that we really, really love to do is to
travel and visit places and it feels almost inevitable that whenever we go anywhere we end up going
somewhere where there’s an option to go up high and I’m really concerned that this is just going to
get progressively worse and to the point where I can’t actually do things when we travel.
T: So you’re really concerned about where it might end up going? It sounds like you can manage on
a day-to-day basis but particularly about going away, that’s when you’re really concerned about it.
Okay. So tell me Fay, erm, it seems to be specifically around certain situations in specific situations
like going away on holidays. Am I right in that?
C: Yeah, maybe because at home I don’t tend to go up high. I suppose if I lived in a block of flats it
might be a problem, but I don’t so I don’t do anything that involves heights. This summer we’re
planning on walking in Snowdonia and I’m a little bit nervous about that because if there’s any kind
of sheer drops that’s going to really frighten me.
T: And I’m just kind of wondering about actually, you know when you start to think about the sort
of going for walks do you sort of have any sort of anticipatory thoughts or worries about what might
happen, what you’d anticipate you’d experience in those situations?
C: Yeah, I kind of, I very much imagine stumbling most of the time because as I said I do tend to
trip up, I am fairly clumsy and when I’m thinking about say going up Snowdonia I just keep
imagining those scenes that you see in films where there is a sheer drop, and people can walk
perfectly fine on the pathway, but if you slip, if the stones go underneath your feet, or you trip up or
something then you’re straight over the edge, and that does make me really anxious.
T: And so you’re really mindful of potential hazards and what you might do in relationship to those
hazards which could ... okay and when you do that I imagine it gets you pretty worried when you
start to think about it in those ways. Okay, okay. How does it affect your sort of relationships, you
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mentioned your husband going up the ladder and so forth, does it cause some difficulties or do
people do things to try and help you with this?
C: Erm, I get almost as anxious when he does it as when I do it. When we were in Australia there is
a tree that used to be a lookout tree, and they used to send people up there to look out for fires
across the woods ...
T: Right.
C: ... and it’s, I can’t remember the name of the tree but it’s one of those really giants ones in the
valley of the giants, and you can climb up to the lookout point right at the top, and the way you
climb up, there’s basically spikes. It’s not a ladder, it’s spikes ...
T: Like metal spikes driven into it?
C: Yes, all the way around and there’s no safety net so there’s nothing to stop you falling. I can’t
think why anyone on the planet would want to climb this, and there was no way I was going up, and
that’s rare, I mean everything else I will do, but there was no way I was going up and I really didn’t
want my husband to go up, and he really wanted to.
T: And so it’s, your husband’s name?
C: Colin.
T: Colin. So Colin wanted to but you really didn’t want him to.
C: No.
T: So did that influence Colin?
C: No (laughs), he ended going up anyway, and I refused to stay and watch. So his sense of glory ...
I stormed off to the car because I just couldn’t watch it, it was just too stressful.
T: Right, so what you did was got away from it.
C: Yes.
T: Okay. Now I’m just wondering, is that what you do in other situations where there’s heights,
about getting away from it? It sounds like you can, when you were in Cambodia you would do
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things but you held on to Colin, in Australia when you went to the lookout tree you were really
concerned about him going up then it sounds like it caused a lot of discomfort, and it sounds like
you were sort of, what you did to manage that was to get back to the car.
C: It was, it was not watching him do it, it was the thought that if he was going to fall I don’t want
to see it. Normally with heights I will force myself to do it. The fear for me, for that particular one
is, logically when I’m on the ground I can tell myself I’m not actually going to fall, because in most
situations you have a harness or whatever you’re doing, you know, if you’re going up Big Ben
you’re not going to fall and I know that sensibly and logically and it doesn’t stop the pure panic, but
with this particular one had I gone dizzy I really would have fallen because there was no safety and
so going up wasn’t an option.
T: So the situation is, I was just thinking about the connection between Angkor Wat and the lookout
tree in Australia is precariousness.
C: Yes.
T: That’s one of the things you’re looking out for. Yeah, would that follow?
C: Yes, definitely, yeah.
T: Okay, and it sounds like sort of when you see something as being potentially precarious and
therefore dangerous to you, that’s when you get really uncomfortable and that’s when you start to
stay away from it, or ... and when you stay away from it what happens to the discomfort that you
feel when you’re in contact with those types of scenarios?
C: Erm, I suppose, I guess it must reduce otherwise I wouldn’t do it but I didn’t feel like, like my
anxiety had reduced, I felt, I felt just really really worried until he came back, erm, and essentially I
think if I’m not there not watching it I can pretend it’s not happening and think about something
else until it’s over.
T: Okay.
C: So running away in that sense can be really helpful.
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T: So it’s almost like you distract your attention away from it and you can sort of almost like
mentally escape it ...
C: Yes.
T: ... yes, so you can physically take yourself away from it but actually it’s the mental escape that
can reduce the discomfort that you experience. Okay, and when you sort of notice that from a
physical point of view, what do you notice, is there any change that takes place from say when, if
you could picture yourself about that tree when you anticipate Colin going up it, do you notice any
changes physically within your body?
C: Yes, it’s, you know, you know that feeling you know in a movie cinema when they do a camera
rushing towards like the edge of a mountain and you get that thing in your stomach that goes like
that, that’s the feeling. So when I imagine myself climbing it when, when I think about Colin
climbing it I get that awful kind of ...
T: Right. Yes, so it’s almost like you can get this rising feeling in your stomach, okay.
C: Yeah, but kind of going over the bump in the road, you know, that stomach suddenly goes up
and back down again ...
T: That lurch.
C: Yeah, that’s it, yes.
T: Okay, and when you’re sort of, you know you were telling me about sort of going for walks in
Snowdonia this summer, when you think about that do you notice any changes physically when you
start to consider those options?
C: If I think about, if I think about the walks that’s fine, as I start thinking about the possibility of
having to go past somewhere where there is a drop, then I get a very similar feeling and, and just a
general anxiety.
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T: Okay, okay. So let me just sort of try and put this together, so I can check out that I’ve got the
understanding of your difficulty, so your problems are related to particular situations which you see
as risky to yourself or people that you care about.
C: Yes.
T: And they’re related to height and heights which you feel aren’t safe because of the
precariousness of.
C: Yes.
T: Okay, and it started in Cambodia, erm, as we said it was there, there was a sort of hesitancy and
awareness of heights before but it wasn’t something that you would overtly stay away from. And
then what’s happened since Cambodia is that you’ve started to notice that when you think about
going places that you want to go with your family, with your husband, that you’re starting to
anticipate those situations being problematic.
C: Mm.
T: And when you’re in those sorts of situations what you’ve found is that you fret about it, you get
really anxious and upset about it, and you can reduce that by distracting yourself by not thinking
about it or by getting away from it, yeah?
C: Yes.
T: And that sort of changes your emotions and your physical state, that comes down, but it’s really
quite difficult to notice that as well.
C: Yes.
T: Yes, is there anything that you would add to that, anything that I’ve missed out there that you
think would help me to understand what’s happening for you?
C: I don’t think so, I think that’s pretty much everything.
T: Okay. I just need to make sure I’ve got a clear understanding and it actually makes sense to you
of what I’ve just fed back to you, yeah, okay. So I’m just wondering, the next part is about actually
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helping us to try and understand what’s maintaining this then, what sort of things would you figure
is having an influence upon maintaining this as a problem, because it sounds like you’ve developed
like a phobia.
C: Yes.
T: Would that make sense to you?
C: I think it would yeah, I think I’d describe it as a phobia, a phobia of heights.
T: Yeah, I think, it’s acrophobia, a fear of heights.
C: Right.
T: So what sort of things would you consider would be the things that are keeping this fear going?
What do you think the facts are that contribute to your difficulties from your point of view?
C: I suppose ... I’m not sure I guess, I guess because I’m avoiding it, I guess it, well I don’t do
anything. I suppose if I was going up high all the time I’d probably just get used to it, but I don’t
really do anything at any kind of heights.
T: Right, okay.
C: So because I never really try it I never get used to it, but all I can think is that in Cambodia I did
try it and it made it worse.
T: Yes, I can imagine you feel pretty anxious about the idea of feeling like that again because it
sounds like it was really really scary for you.
C: Yes.
T: But at the same time it sounds like actually doing these things is part of the joy of going away
and doing these things. Okay, and what you get is a pretty quick reduction in your discomfort levels
when, when you stay away from them, yeah? Erm, does any of the things like physical changes in
your body that you notice that has an effect on you, you know when you notice sensations, does that
have an influence upon this fear that you have developed?
C: Erm ...
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T: Are you sort of anticipating sort of 'I don’t want to feel like this' or 'This means that this is going
to happen'?
C: Yeah, I mean, I anticipate that if I, if I go up high I’m going to feel bad and the knowledge that if
I go up high I’m going to feel bad means that I don’t go up high so that I don’t feel bad.
T: So you’ve learnt, the learning is that 'if I go there I will feel like this, so therefore what I need to
do is stay away from that situation to stop myself from feeling like that'.
C: I mean with the lookout tree I even said that if I go up there I will fall because I will panic, so I
was anticipating that I will feel really really panicky and anxious and that the panic and anxiousness
will result in me feeling faint or dizzy and I will fall, so complete anticipation of what will happen.
T: Okay, so there’s, so there’s a cognitive element to this, there’s a thinking element to this as well
in terms of anticipates now, okay. Perhaps this is a good opportunity now to talk about the treatment
with behavioural therapy just to sort of outline what you can expect from treatment. Just before I do
that, what’s your understanding of behavioural therapy, what sort of things have you come across to
help you understand what behavioural therapy is about, that would be helpful?
C: I guess I have a limited amount of knowledge of behavioural therapy but nothing major or in
depth. I guess the idea of plunging your hand into a bucket of spiders to get rid of a spider phobia,
which I think would actually make me want to ... (laughs).
T: Yeah, sounds pretty dramatic ...
C: Yes. I think it’s kind of tricky if your fear is heights, I suppose parachuting might be a way of
flooding that fear. So I guess the stereotypical view of behavioural therapy is all I know.
T: Well, I just want to put your mind at rest, it’s not as dramatic or as scary as that. But what
perhaps might be useful to explain is a little bit about the background of why behavioural therapy is
thought to be really helpful with these things, and in fact it is, it has a track record of helping people
with phobias like you’ve described. Now it’s based on something called learning theory and the
idea is that actually, you’ve actually learned this fear, and it’s happen because of an adverse event
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that you’ve learnt a response to, and it’s maintained by something called reinforcement, and what’s
reinforcement is actually anything that’s reinforcing increases the behavior, so for instance I guess,
erm, if you get praise you’re more likely to try and do that thing again, whatever that praise was
about. Does that make sense?
C: It does, so I guess the fact that of course when I had the very scary experience in Cambodia my
husband was very, very sympathetic afterwards, and very, very kind and attentive ... I mean he‘s
always very kind and attentive, but even more so because he was so concerned about me, so would
that be, would that be praise?
T: Yeah, so that is something that can strengthen a response, and what reinforcement is anything
that makes a behaviour more likely to be repeated. Okay, now that can be really great in our
everyday lives, it encourages us to do things that make us feel proud, it makes us want to do things
more. But when it comes to phobias actually what can happen is actually the reward we get can
sometimes be based on staying away from things that are uncomfortable. So for instance I’d
imagine what you notice when you are approaching heights is when you are presented to that
situation, whether it’s the tree or whether it’s the ladder or whether it’s like some other high place,
you’ve learnt that high places make you feel uncomfortable. Now, what tends to happen with
learning is that we associate things with it, so you’ve come to associate heights with high levels of
discomfort and that’s physical, that’s emotional and that’s also in terms of thinking as well. Now,
what tends to happen when people get into a heightened physical, emotional state that feels
uncomfortable is they learn that by doing certain actions that can reduce that discomfort level, now
what happens then is that avoidances which tend to follow that reduces the discomfort and what
people make is a learning connection. Does that make sense?
C: So by avoiding it I’m teaching myself to fear it.
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T: Yeah. It’s almost like you’re not giving yourself an opportunity to unlearn that fear you
developed in Cambodia. Now shall I explain a little bit about the treatment then, as a result? Does
that make sense first of all?
C: I think it does, yeah.
T: Can you relate that to sort of areas of your life, you know round this fear that you have of
heights? Can you see the connection, or maybe an example of that?
C: So it sounds like when, erm, for example when we were in Australia we did, they call it the
treetop walk, and it’s very safe, and so ...
T: Like through the rainforests.
C: … yeah, and you’re on platforms and although, so I was able to do that because it was clearly
very safe, they had nets underneath it and things like that so that was fine, but it was still very
anxiety producing so it sounds like maybe in terms of me maintaining that fear I was, while I was
walking I was able to ... I guess I was being reinforced ... I suppose my fear was being reinforced
because I was constantly being checked on by my husband, and the more frightened I seemed, the
more he checked on me and made sure I was okay, and held my hand and those kind of things, so I
guess that’s reinforcement. And I never really learned to do anything scary because when it got hard
I just didn’t go to those places. So by avoiding that I was kind of learning that I can reduce my fear
by avoiding that particular situation and never learned that if I go up there it would be …
T: That’s great, it sounds like you’ve got a really good handle on how things get strengthened and
maintained and that’s exactly what we’ll be looking at. Now in terms of treatment of these phobias,
you mentioned before about sticking your hand in a jar of spiders, that’s pretty intense.
C: Yeah, I’d rather not do that (laughs)…
T: Yes, okay.
C: I don’t think it would help with heights anyway.
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T: Well I’ll tell you a little bit about the treatment because it’s actually a little bit more civilised
than that. It’s actually about you and I working together because within sort of behavioural therapy
first of all we need to sort of get some base lines, we need to sort of think about how frequently this
is happening, and because it’s based on scientific principles so what we do is measure to try and get
a record of about how frequently this is a problem for you, how intense you get, how long it lasts
for and what are the triggers and I guess we’ve got a pretty good idea what the triggers are now.
Okay? Now, so the first stage would be about helping to understand how the problem holds
together. So this is an initial stage and we’ll do more work on this as we go through the session and
we’ll refine the assessment as we go through treatment, so it’s an ongoing process. And the key
thing is that you’re a key part of that so we need to work closely together to help us to help you
overcome this difficulty.
C: Okay.
T: Erm, so the first part would be about measuring, so it will be observing about the type of
situations that you start to notice this discomfort in, how you respond to those situations, what
happens when you respond in certain ways, just so that we can really get some idea about how
difficult it is for you now. But also it’ll give us something to judge about what we’re doing is
working or not.
C: Right.
T: Okay, so that’s the first step, then the next step after we get this information together, one of the
common ways of treatment in behavioural therapy is something called graded exposure. Now I’ll
explain what that means. Exposure would mean about being introduced to the situations that you
feel fear about.
C: Okay.
T: Okay, so it’s about being introduced to the thing you’ve learned to stay away from.
C: Right.
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T: Would you like to ask me any questions? Anything you want to know about?
C: So would we actually go out somewhere and go up something high? Is that what you mean or ...?
T: Well, that’s the graded part. Now yes we can do that, but it’s on a negotiated basis. Now the
other thing we can do is imaginal exposure as well. So often, you know, with situations we can’t fly
out from Bangor to Australia every, every ...
C: Darn! (laughs)
T: Well, ethically that wouldn’t be permitted (laughs). But what we can do, is we can use
imagination and use exposure to things that we think about as a means of exposing to situations
which are quite difficult to access, such as flying and heights like that. We can use both imaginal as
well as real-life exposure and we can use them both together. So, for instance, what people might do
is if you think about this hierarchy, this graded hierarchy of exposure. Erm, it’s about like the first
rung of the ladder is the most easy thing. The thing is a little bit difficult for you which creates
anxiety but you feel that you can manage.
C: Okay.
T: Okay, and the idea is that what we do is we actually construct a ladder, and the idea is for you
metaphorically to climb that ladder.
C: Right.
T: And in some realities, because it is a height phobia, maybe you’ll also climb that ladder in due
course. Now, how we do that is that we help people to develop some ways of managing their
anxiety first, so we’d help you with some relaxation techniques, and then we’d introduce you to the
agreed first level. And what we’d encourage you to do is by exposing yourself to that situation
either in what’s called 'in vivo' live, in real life, or in imagination and we would keep you at that
level until your discomfort levels subsided to a level that sort of allowed you to face that situation
without feeling fearful.
C: Okay.
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T: Okay?
C: So I might imagine say something quite baseline, so maybe imagine standing at an open window
on a first floor ...
T: Sure.
C: ... and I would imagine that and relax until I can deal with that.
T: That’s right. And usually what happens, and the reason why behavioural therapy is what’s called
'empirical' or 'evidence based' is because what we know from a lot of psychological research is that
when people are introduced to things that they fear, if they stay there long enough without using an
escape, that discomfort will come down. So that discomfort is both emotional and physical
discomfort will reduce.
C: Okay.
T: Now the trick with behavioural therapy is that we don’t move on until that has come down.
C: So you won’t pass out then.
T: Well no, but what we’ll do is actually we’ll look at some of your predictions and some of the
feared situations you avoid because of the fear of that happening and we would help you to test out
some of those worries by introducing you to those situations so that you could learn that those
feared things don’t happen.
C: Right, okay.
T: So, for instance, what it might look like, it might be initially about, er, like you say about
imagining yourself looking out of a first floor window, if that is a situation that you are currently
fearful of, and you might stay away from, or certainly not invite. And then it might be then about
maybe going to a second floor window, and so on. But fundamentally it’s about helping you to re-
engage with the situations that is stopping you, or at least getting you concerned about actually it
might stop you from living the lifestyle that you would like to live.
C: Okay.
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T: Okay. Does that make sense?
C: I think it does yes. I think the example you gave of grading it and moving up makes a lot of sense
and being able to do it either in my mind or in reality, that sounds good.
T: Okay. So okay, and what we would do is we would do that together, and sometimes it’s helpful,
you know, if I as the person working alongside you was to do that before you and I could show you
how to do it, so you can notice my response, and sometimes that’s useful because it gives you like a
model in your mind to base your behaviour on.
C: So hopefully you don’t have a fear of heights then? (laughs)
T: No, I don’t have a fear of heights. I’ve done lots of exposure with heights, I’m okay. Yeah, but,
but that’s just to say that because it’s something that I’m not particularly worried about I mean I
think there’s always reasonable concern about heights because of course, you know, there’s
potential hazards there. We don’t want you to be totally free from anxiety, we want you to be free
from disabling anxiety.
C: Right.
T: Okay, and just for you to know, you know there are things that I’m afraid of too, and my natural
inclination is to stay away from it, so it’s a normal learning process, and what we need to help you
to realise is that actually a lot of people will use avoidance as a way of trying to manage their fears
and discomfort. We all do it to a certain extent. It’s only when it is problematic in terms of getting
on with your day-to-day lifestyle choices that it becomes problematic and becomes a phobia.
C: Okay.
T: Okay. Now, you’ve talked about avoidance so the hierarchy would be based upon current
situations that you avoid. Now, as I say, we can’t get you over to Cambodia and Australia, so we
would need to base it either in real-life situations in your day-to-day living, and also maybe the
starting point would be for you to start to observe and to take notice of situations that you’re staying
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away from because of these fears and concerns, and that can be a starting point for us to start to
construct this hierarchy.
C: I guess, I guess then something to consider might be say cleaning the outside windows at my
house. So at the moment my poor husband has to do it, so we have a ladder that can go all the way
to the top. It’s only a two-storey house but even to clean the top of the first floor, the ground floor
windows you would have to go up the ladder a little bit, and I’m not even keen on that.
T: Right, so even though you might not be at a height which is physically dangerous to you
potentially, it’s ...
C: It’s, it’s ... I can do it if I have to do it, if he wasn’t available to clean the windows I would have
to do it, so I can do it but it does make me anxious. Erm, so perhaps that would be something that
could ...
T: And again you, Fay, would be instrumental in deciding where that was in the hierarchy. And
again, you know, just to picture that image, it might be something along the lines of you going up
those first two or three steps of the ladder and staying there until your discomfort levels drop down.
And that’s when the exposure would stop, and we’d do that frequently. And again because these
sessions are a place for us to sort of get together to focus our thoughts about how to shape the work
we’re doing, and to sort of gather information and to use that to further our knowledge about how
we can help develop a treatment plan for you, then, erm, most of the work will be done outside of
the sessions.
C: Right.
T: Yeah? So it might also be worthwhile thinking whether Colin could come to some of the sessions
so we could talk to him about actually what we’re doing, and perhaps how he could help with that.
And part of that might be about things like when you’re feeling really anxious and want to hold his
hand, but we would need to look at how that might be one of the things that might be maintaining
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your fears, so as you were saying before. So do you think Colin might be happy to come to the
sessions?
C: Yeah, I imagine he would.
T: Okay. Now what I haven’t talked to you about so far is actually about what goals you would like
to achieve. What would you like as an outcome of these sessions so that you’ve got a clear sense of
where we’re heading to, and why you’re heading there?
C: Well we’re obviously, as I mentioned we’re hoping to go up Snowdonia. This summer we have
the same friend we visited in Australia is coming to visit us, and I’d really like to be able to show
him the area and so we would like to do Snowdonia and I’m never going to be a climber and that’s
fine, but I would like to be able to not just take the safest path, to be able to comfortably maybe take
a slightly different route that involves even going over rocks. I mean, not climbing, not like
equipment climbing, but maybe more kind of scrambling, I don’t know what you would even call it,
but not feeling that I have to be on a really safe path all the way there.
T: Right.
C: So I guess accomplishing that, feeling safe and secure and not feeling so anxious about it would
be good.
T: Okay, so perhaps what we could think about is longer term goals such as achieving that, so that
you can go with your friend from Australia and you can go across these sort of landscapes in North
Wales and feel comfortable enough to be able to do that without undue fear.
C: Yes.
T: And also perhaps what we need to think about is more immediate goals as well so that we can
help you get rewards and see yourself making progress as well. Now of course the hierarchy lends
itself to that because you can see yourself making progress as you do that. But also thinking about
perhaps things in your lifestyle that you might like to consider that are more immediate and more
accessible perhaps in the short to medium term.
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C: I guess cleaning my upstairs windows, which doesn’t sound like a very enjoyable experience, but
it’s something that essentially Colin has so many other things to do, working in the garden and he
works full time that it would be really helpful if he didn’t feel the need to have to do things as well.
So being able to go up a ladder to clean the windows on the second storey and those kinds of things
would be good.
T: Do you have children Fay?
C: No.
T: You don’t. Okay, so there’s no children that might be observing?
C: No.
T: Okay. Now I’ve got a few other questions. Have you had any sort of therapy or treatment for this
previously?
C: No.
T: You haven’t, so this is the first time?
C: For this. Previously I’ve had person-centred therapy but not specifically for the phobia, I don’t
think it came up at all.
T: Okay. So have you had any other medical treatment I would need to know about?
C: No.
T: Okay. And is your GP aware that you’re coming for help?
C: Yes.
T: Okay, and has he prescribed you anything?
C: No, no.
T: He hasn’t. Okay. And, I don’t mean to pry, but just in terms of things like alcohol intake, do you
drink?
C: A glass of wine with dinner every now and again.
T: Okay.
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C: I’m not teetotal but I don’t really drink much.
T: Okay, and the reason I’m asking that is sometimes people might use things like alcohol and
sometimes illicit or prescription drugs as a way of reducing their discomfort around these situations.
C: I think it would probably make me worse because if I knew I wasn’t very steady on my feet and
high up that’s even worse (laughs), so no, nothing.
T: So you’re staying away. Okay. Right, okay, so let me just summarise then in terms of the things
that you’ve told me so far, and this is just the preliminary session so we’ll get to talk about them in
some more detail and we can maybe set some homework tasks in terms of observation at the end of
the session. But my understanding is that you’ve been wary of heights for as long as you can
remember, it developed really as a problem after the visit to Cambodia and the temples, and you
started to associate heights with feeling incredibly physically uncomfortable. You coped by making
sure that Colin was close to you and that you could hold on to him, and that sort of alleviated the
worst of the fears and allowed you to do things.
C: Yes.
T: To a certain extent. And you noticed it really again when you were flying, when you were in
situations like deep water, and also when Colin was going up the tree. And what you found is that
by staying away from situations where Colin’s going up a tree or situations like you feel these
lurching feelings in your stomach, that can help you to reduce that discomfort.
C: Yes.
T: Okay, and, erm, what I discussed with you about how sort of behavioural therapy has come from
learning theory and that how behaviours are learned and strengthened by certain responses. And
we’ve highlighted and you’re really great the way that you were able to put how by actually staying
away from things that brought your fear down.
C: Yeah.
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T: And the discomfort down, and that would the reward in terms of strengthening and reinforcing
that behaviour. Okay, so the treatment is actually to try and reverse that learning, okay, and the way
that’s done is by introducing you to what we call the 'conditioned stimulus', that’s psycho jargon,
psycho babble for things like you’ve learned to fear.
C: Right.
T: And how we do that is by introducing you in a very collegiate, collaborative way to the things
that you fear. And the treatment is about reintroducing those things and helping you to get exposure
to those in a controlled, gradual way. Okay. And the things we would need to do in the sessions is
first of all to help you to measure and understand the extent of the problem so that you’ve got some
reference points to know what is working so that we can refine the treatment plan accordingly,
okay. How does that sound to you?
C: That sounds good, yeah.
T: Okay.
C: It makes sense.
T: Okay. Now, is there any questions you would like to ask me before we finish today’s meeting?
C: You mentioned homework, and I was just wondering is that the going away and kind of trying
things out, is that what you mean by homework?
T: Well, I don’t want you to just go away and do something ad hoc, what the homework is going to
be is very specific homework, and the starting point for the homework would be to give you an
observation sheet, and what the observation sheet would be about noticing about situations that you
notice a fear response in, and then behaviourally what you do and then as a consequence what
happens when you do that. Okay? What I’d also do on that sheet, which I’ll give you shortly before
we leave, is also to record the level of discomfort that you experience in relationship to those
situations.
C: Right.
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T: Okay. And there’s a little sort of thing called 'FIDO' okay, so FIDO’s not a little dog, it’s actually
a way to help us remember what we’re looking for. What we’re looking for is how Frequently this
is a problem, how Intense emotionally and physically the problem is, how long it lasts for, the D is
the Duration, and the trigger is the Onset, the things that you notice starts the problem going.
C: Okay.
T: So I’ll give you a very structured sheet for you to follow and what would be really great, Fay, is
if you could keep a record of that and when we meet next we’ll go through that and we’ll use that
information to shape the treatment plan.
C: Okay.
T: Okay. How does that sound?
C: That sounds brilliant.
T: Okay. So, nice to meet you.
C: Thank you.
T: Thank you Fay.
Analysis of Session
The therapy session can be sectioned as follows.
Introduction
Introduction outlining basic contractual details, especially the limits of confidentiality
Focus specifically on the problem presented by the client and an outline of the intended
coverage in the session (map of the session)
Invitation to ask questions
Story
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Client is invited to explain how the problem began, how the problem has developed over
time, and how the problem impacts on current life
Focus on actions carried out during experiences of the problem, including specific
behaviours that are maintaining the problem
Goals
Behaviour therapy is explained in terms of how reinforcement and punishment can shape
and maintain behaviour
Explained how exposure to problem situations and structured reinforcement of appropriate
behaviour can reduce problems
Identified a specific goal for therapy in the near future
Ending
Summary of the session by the therapist
Reflection on how the session was experienced by the client
Explanation of how behavioural problems will be addressed in future sessions, including
homework and treatment plan
Invitation to return for future sessions
Key questions to consider in relation to this therapy session
How could the nature of this client be understood from the behavioural perspective?
What is the current behaviour that is causing a problem for the client?
Has any previous classical conditioning established the current problem behaviour?
Has the client experienced a pairing between a neutral experience and an emotive
experience leading to the natural invocation of the problem behaviour?
Are there any stimulus–response associations currently maintaining the problem
behaviour?
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Has any previous operant conditioning established the current problem behaviour?
Has the client experienced reinforcement or punishment to shape the current problem
behaviour?
Are there any consequences currently maintaining the problem behaviour?
What is the nature of the therapeutic relationship in this behaviour therapy session?
Does the therapist focus on behaviour?
Does the therapist explore thoughts and feelings and, if so, are these discussed in
behavioural terms?
Does the therapist adopt the role of an expert?
Does the therapist use passive or active psychoeducational strategies?
Does the therapist collaborate with the client to solve the current problem?
Which behaviour techniques are demonstrated in this therapy session?
Does the therapist introduce any exposure techniques, such as systematic desensitisation
or flooding?
How does the therapist encourage reconditioning in the client?
Does the therapist introduce any contingency management techniques, such as time out,
token economy or contingent attention?
How does the therapist encourage the reinforcement of positive change in the client?
Does the therapist recommend or advise any specific programme of training to unlearn
the old problem behaviours and learn new solution-focused behaviours?
Personal experience of the client
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I was very anxious about this session because it was my first experience of behavioural therapy and
my first experience of receiving therapy while being filmed. Keith reassured me in the first few
minutes and I did manage to forget about the camera after we began talking.
I feel that the rapport with Keith was very positive. I felt comfortable talking to him about my
experiences and I felt that he listened to me in an empathic manner. This was rather surprising
because I had expected behaviour therapy to be less empathic than my previous experience of
person-centred therapy. I did feel that I talked too much, especially at the start of the session. I felt
that this did not fit my expectation of a behaviour session – he was less directive than expected and
I was somewhat relieved to find that he was not going to demand that my fears were immediately
flooded!
This session focused specifically on my behaviour during and after my scary experience in
Cambodia. In particular, we explored those behaviours that I use to ‘protect’ myself and I realised
that these behaviours have actually been maintaining my problem. For example, Keith explained
that my tendency to avoid heights helps to reduce the discomfort and anxiety in the moment, but
will actually teach me to avoid in the future because I am being reinforced for my avoidance. This
was a surprise to me because I had never considered my behaviour in this way before – in fact, I
always thought that it was very sensible for me to avoid heights given that I am so afraid. Keith also
explained that my use of my husband as a support network could also be maintaining my problem –
I had never considered that his comfort might be reinforcing my fears, but this made sense when it
was explained in the session. On reflection, I feel that I learnt an awful lot about myself during this
session.
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I was very happy that Keith took the time to explain exactly what I could expect from behavioural
therapy. This was very reassuring and his descriptions sounded considerably less scary than I had
anticipated. He explained how the behaviours that had been maintaining my fear could be changed
to reduce my fears in the future, and this gave me confidence to try out the exercises that he
suggested. I left the session feeling reassured and optimistic about working with Keith on my
phobia.
Fay Short
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