Josh was a successful 34 year old Account Manager for a well known advertising company. Married to Julie they had one child, Ben, who was eighteen months old. Josh was close to his family of origin and, in particular, his twin brother. He described his parents as loving and said the only problem he experienced was being diagnosed as Dyslexic when he was 16 . In many ways his diagnosis was a relief as it made sense of the academic struggle he experienced. Josh made it to University leaving with a good degree and was soon fast-tracking through the employment market. He was currently being considered for yet another promotion and money was not a problem.

Presenting Problems

Using the comprehensive BASIC ID Multimodal Assessment Model we were able to identify a number of problems that were troubling Ben.


Tension Tension headaches. Tension in shoulders. Palpitation. Sleep problems



Behaviour Takes on too much work but does not complete Increasing avoidance of giving presentations.
Affect Anxious when giving presentations. Anger when personal deadlines are not met regardless of the reason.
Imagery Images of performing badly
“I have to do well otherwise it means I am a failure” “I am not as good as other people because I have a disability and am therefore faulty goods and am likely to fail”
Interpersonal Finds it hard to say ‘No’ Does not ask for support
Drugs/biology Poor nutrition – does not eat Breakfast Drinks 10 cups of coffee, Very little water consumption, Uses a considerable amount of headache pills to control tension and headaches No exercise

In addition to the above by using the “Locus of Control” and “Type A” questionnaires we are able to ascertain that Josh tended to put pressure on himself by being an over achiever who took responsibility for everything. Discussion took place regarding the psychological effects of being Dyslexic and it soon became clear that Josh had always felt a failure because of his early academic difficulties. He was fearful of failure and this affected his ability to say ‘no’ to people and to be more realistic about what he could achieve. He tended to discount his abilities and achievements always focusing on what he “should” be doing. A good working relationship was established.

As Josh was being seen for a Stress Management programme it was important to explain to him what Stress was, how it affected people and what the long-term implications could be. This included providing Josh with a biological model of stress as well as a way of identifying the stressors that were affecting his life.

The Programme

We agreed to meet for six one-hour sessions on a weekly basis. The first session considered changes to Josh’s lifestyle. Josh agreed to:

  1. Have a piece of wholemeal toast and a banana for breakfast and to eat this sitting down at the table before leaving for work.
  2. Cut down on his caffeine intake slowly over the following two weeks. The pros and cons of a total detoxification programme were discussed. However, given that it was likely that Josh would experience withdrawal symptoms he opted for a gradual reduction programme. This involved replacing half of his normal coffee consumption with fruit teas and water during the first week and then halving that again during the second week. Josh also agreed to increase his water consumption to 8 glasses a day.
  3. Visit his doctor to get his headaches checked out. Although it was likely that they were being caused by tension it was still wise to ensure that no organic reason was present.
  4. Undertake a few neck and shoulder stretching exercises during the day.
  5. Park the car a mile away from the office to increase his daily exercise as well as walking up the stairs at work (2 flights) rather than taking the lift.

At the next session Josh reported that these changes had been more easily incorporated into his life than he had thought. In fact he had enjoyed walking so much that he now parked his car about a mile and a half away from the office as he found the walk gave him time to wind down as well as being good for him. He now had a bowl of fruit on his desk and, as there was a kitchen at work, had started to take in healthy meals that could be cooked quickly at the office. His water intake was not up to eight glasses day, more like 4/5, but still a great improvement and the doctor had given him a clean bill of health.

During sessions two to four the more difficult areas of tackling Josh’s thinking style and behaviour were dealt with. Josh held a core belief about being a failure and this was the driver behind much of his unhealthy behaviour and his anxiety and anger. By using techniques from the cognitive-behavioural school of therapy time was spent identifying, disputing and challenging his thinking style. A variety of anxiety and anger management techniques were introduced and Josh was encouraged to experiment with his behaviour at work and at home. For example, by going home on time two nights a week.

During session four, Josh was introduced to an exposure programme and was encouraged to stop avoiding giving presentations. Further cognitive work was done on his fears as well as practical interventions in the form of breathing exercises and appropriate coping imagery. Josh had the opportunity to take on a project that would mean undertaking a considerable number of presentations over a short period of time. After discussion Josh thought that this would provide him with an opportunity to conquer his avoidance, particularly as he now had a range of strategies to call upon to help him. He also reported that his sleep problems had stopped, as had his palpitations. He continued to maintain his healthy lifestyle.

During session five, Josh was introduced to some assertiveness techniques that included asking for support and saying ‘no’. He reported that the imagery and relaxation work had really helped and that he found himself actually looking forward to a giving a presentation. As there was only one session left Josh was asked to prepare for the next meeting by considering how he would have evaluated himself prior to undertaking the stress management programme. He was to consider where he felt himself to be now and what aspects of his life he felt he still needed help with.

During session six we went back to his original list of problems and considered, using a rating scale of 0 (no problem) to 8 (major problem) the differences in his ratings at the beginning and end of the programme. Josh rated major improvements in all the areas mentioned and also told me that his wife had commented on how much more relaxed he seemed. Josh felt he was now able to be more realistic about what could be achieved and in what time scale and had joined a local gym where he went straight from work two nights a week. He said that he still found himself worrying about whether he was good enough, but that when he noticed himself doing this he told himself that “if he could talk himself into being anxious he could talk himself out”. In particular, Josh said he had enjoyed using the biodots as a way of monitoring his physiological state throughout the day. He now felt he had more energy and cleared the same amount of work in less time.

We agreed that it would be helpful if Josh had a follow-up appointment for three months time. We also agreed that if Josh needed to see me before then he could contact me.

[boxibt style=”success”]About the Author

Gladeana McMahon

BACP Fellow, Senior Registered Practitioner, Accredited Counsellor and Supervisor. BABCP Accredited Cognitive-Behavioural Psychotherapist. UKCP CBT and UKRC Individual Counsellor Registered.

As well as being a Psychotherapist, Gladeana is a Life/Business Coach and Commercial Trainer as well as Lecturer on Diploma and Masters programmes in Counselling at the University of East London. She has written, contributed to or edited more than 16 books on counselling and personal development. Her most recent, “Coping With Life’s Traumas” was published in the Autumn of 2000. Gladeana is Associate Editor of Counselling, the Journal of the British Association for Counselling and Psychotherapy and is also BACP’s Deputy Head of Media Relations. Gladeana is the Managing Editor of Stress News, the quarterly Journal of the International Stress Management Association (UK). Email:

To contact Gladeana McMahon