Treatment of Social Phobia with Cognitive Behavior Therapy and Psycho-Education - Essay Example

?Treatment of Social Phobia with Cognitive Behavior Therapy and Psycho-Education Target Behavior: Decrease or eliminate Social Phobia CLIENT DETAILS Diagnosis: Social Phobia (Social Anxiety Disorder), Generalized. Client Age: 15 Client Sex: Female Number of Sessions: 20 Treatment Approach: Psycho-education and Cognitive Behavioral Therapy (CBT) Treatment Mode: One session for one hour, once per week. Referral Information Client X is a 15 year old female who was referred to counseling by her Turkish teacher after a conversation with the client’s English teacher. She was referred because of her anxious behavior Client X showed anxiety when she had to stand in front of the class and give a presentation. Total Sessions with Client Client X attended weekly sessions and terminated after 20 weeks. She reported a lessening of her social phobia. Client Presentation Client X came to her first session dressed neatly in her school uniform. She sat at the edge of her chair and avoided eye contact. She sat rubbing her hands together and would only answer questions with one word. As the session continued, she began to sit back in her chair and it appeared she was becoming more comfortable because she began to give more detail in answering questions. Her speech was intelligent and clear. She was oriented correctly in time, knowing the date and time correctly. She became more cooperative towards the end of the initial interview. She appeared nervous and embarrassed talking about her anxiety and giving details about her physical symptoms. Client X did not present with any evidence of thought disorder, delusions or hallucinations. A risk assessment was done and she did not have any signs of risk for suicide. Client X described herself as a “hard worker, a voracious reader, intelligent and well-mannered and shy.” Although anxious, the client appeared friendly towards the therapist and she found it easier to express herself in the session once she felt comfortable. The client seemed to be a “typical” 15 year old in every respect except for her shyness. Relevant Client History Development and Family History Client X did not talk a lot about her family but there are several things that are known. Her father is a cab driver and her mother is a house wife who does not drive. Client X’s mother said that the girl has always been shy but she went through all developmental levels on time and as expected. Client X has a medical history of good health. She has several younger siblings that she helps to take care of when necessary; it is assumed that Client X is the oldest child. Client X’s mother described her as “a good girl” who has never caused any problems. Interpersonal Relationships The client has no close friends and her family has very few close friends. The client stated that she would stay with other girls in the class when she went to recess, but she did not engage in conversation with them. There is one family that has a daughter the client’s age, but they only see each other during family gatherings. This other girl also goes to a different school than the client. The client does her best not to participate in any situation that would help her to make friends. As an example, she does not participate in the year end ceremonies because she says she does not have the time and would rather concentrate on her studies. Her parents do not encourage her to be outgoing and accept that she does not want to be around other children. Psychiatric History The client has no previous psychiatric history and there is no evidence of thought disorder, delusion or hallucinations. A risk assessment was conducted and she showed no risk for suicide. Case Formulation The client is in need of assistance with her social phobia. She will need to have interventions that make sense to her that she can do on a regular basis. She also needs to understand why she has this problem and what she can do about it. The counselor will need to use CBT and psycho-education as a positive move towards helping this client. Discussion of Evidence Based Theories The treatment of social phobia has been two fold. The evidence shows that some medications are useful in treating this disorder and certain types of therapy are useful. Compton et al. (2004) state that Cognitive Behavior Therapy (CBT) works very well with adolescents because they are a compilation of many interventions. Specifically there are five qualities that any CBT intervention has in common: 1. The interventions are based on a medical model which means that the interventions are evidence based on a variety of studies. 2. There is a thorough analysis of the function of the behavior, cognitive and behavioral factors that drive the individual’s behavior. 3. There is an emphasis on psycho-education which means that the individual is educated about what is going on with them and how it relates to their life. 4. They use problem specific interventions that are designed in a way that helps the individual stop the unwanted behavior. 5. The individual receives “relapse prevention and generalization training” as the treatment ends (Compton et al. ,2004, p. 931). These five qualities are some of what makes CBT important to working with teenagers who have social phobias. Soler and Weatherall (2009) add to this discussion by stating that CBT has been approved for working with children and adolescents over the age of six, although it is only effective in half the cases, according to a study that these authors reviewed. However, they state that CBT is the modality that is most researched for children and adolescents. Currently, there does not seem to be a difference in whether the counseling is family, individual or group. Psycho-education is another evidence based theory that is important in working with children and adolescents who have social phobia. This theory is based within CBT and according to Morris, Mensink and Stewart “Psycho-education involves teaching clients about the relationship between thoughts, emotions and physiological reactions” (p. 3). Kearney (2005) states that psycho-education is also a way to inform family and the client about the various aspects of anxiety and how it is “triggered and maintained” throughout the individual’s life (p. 110). This aspect suggests that a client can understand this information well enough that they can later use it to self-monitoring so the client can be cognizant of what they are feeling physically, what they are thinking and so they can figure out what the triggers are and learn to eliminate them. Formal Diagnosis Axis 1: 300.23 Social Phobia (Social Anxiety Disorder), Genralized Axis II: No Diagnosis Axis III: No Diagnosis Axis IV: parental overprotection (mother), academic problems Axis V: GAF= 65 (upon entering into counseling) GAF= 85 (at discharge) Psychometric Assessment Multidimensional Anxiety Scale for Children (MASC) (Child self-report) MASC Anxiety Disorder Index, Total T score: 69, Very much above average Social Anxiety Total T-score: 7t Very much above average Mental Status Exam (see “Client Presentation”) Differential Diagnosis The client does not have any aspects of other phobias. Her fears are specifically related to social phobia because she has anxiety any time she has to stand in front of a group or talk to a small group of people. She does not show any signs of separation anxiety disorder, Posttraumatic Stress Disorder or Anorexia/Bulimia disorder. The client meets all of the criteria of Social Phobia and none of the ones for Avoidant Personality Disorder. There are no medical conditions that are apparent in this diagnosis and the client understands that her fear is unreasonable, but she does not understand what to do about it. Treatment Objectives The client will need to have psycho-education so that she can understand why she has this disorder and the triggers that cause her anxiety; her family will also need this information so they can help her when she is not in counseling. Another treatment goal will be that she needs to reduce the persistent fear of her class participation, especially when she needs to do an oral presentation. The counselor will approach social gatherings by helping the client work through graded exposure therapy. The client will also learn to reduce the anxiety related to social interaction and situations that she will encounter with people by using behavioral reinforcement and cognitive restructuring. These interventions will be used to first help the client examine her current beliefs that people are judging her or that she will be embarrassed in front of them, and then the counselor will help her restructure these beliefs so that she has a more positive association with others. The client reports somatic symptoms that include sweating and shortness of breath. These will be restructured through the use of relaxation training and breathing control techniques. An overall goal will be to help the client learn resilience in facing social situations and in encourage her to participate in various activities. This will be done through social skills training. Treatment Plan 1. Increase client’s confidence in giving oral presentations to her classmates. --Social skills training 2. Help client identify the triggers for her anxiety and provide relapse prevention strategies --CBT will be used --Increase social activities gradually --Restructure thought patterns 3. Decrease somatic symptoms that happen because of the anxiety. --CBT --social skill training --graded exposure training Application of Appropriate Interventions 1. Psycho-education on the nature of Client X’s anxiety for Client X and her family. All conversations with client were done using psycho-education and/or CBT in order to help client understand her anxiety and what she could do about it. This was also used to help her restructure her thinking around the anxiety. 2. To reduce persistent fear of class oral participations and at social gatherings. Graded exposure therapy was used in this situation. This was done by helping the student attend small group meetings with children of her age. The client decided that she would first begin to go to group therapy and learn to speak up at least one time during the process. She gradually was able to talk once in awhile with her peers. 3. To reduce anxiety related to social interaction and situations by using behavioral reinforcement and cognitive restructuring through modification of negative beliefs. The client was able to understand how to reduce her anxiety through the use of relaxation techniques. She was also able to start talking in class once we had done the restructuring and the grade exposure techniques. Client stated that she was feeling better and was able to do a little more with her class mates. 4. To reduce somatic symptoms by using relaxation training and breathing control. Through the use of breaking control techniques and relaxation training the client was able to control her anxiety better she reported. She was also able to stop some of her anxiety in a few situations before it started because she remembered her triggers and was able to immediately start her breathing control. 5. To develop resilience in facing social situations and participating in various activities through Social Skills Training. The client is still working on this issue. She has learned to do many of the techniques and does them well, but she still is a bit anxious in some social situations. A follow-up with her in three months will be done to see how her resilience is when she is facing new social situations. Summary of Outcomes and Evaluation of Treatment The interventions that were used helped the client understand what she had to do in order to change. When she began to use relaxation and social skills training and the techniques actually worked, her confidence in herself improved. The client learned to understand why her thinking was as it was, and she found through working through social situations that her thoughts were not true. She was able to make a couple of friends during the time of the therapy. CBT training worked very well for her because it allowed her to change without anyone knowing that she was changing. The client was hesitant to change her interaction with other children at first because she thought she would be rejected. However, group therapy allowed her to interact with “strangers” and find that some of them liked her. She understood that some people would like her and some would not, but this did not have anything to do with her. Although the client was successful in many situations, it is the Provisional Psychologist’s view that she should continue therapy to build up resilience in working with people. She needs to understand that she can go into any social situation and decide how she want to react in the situation. Limitations and Future Modifications During the first couple of sessions the client was restless and would not make eye contact. She had to gain confidence in the sessions before she was able to understand that they would actually help her. This attitude changed as the provisional counselor and the client began to examine the things that were happening to her in school and how what she was learning in therapy was helping. For this client, it is very important to make sure she understands why we are working on certain things because of her insecurity in public situations. References American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. Text Revision. VA: American Psychiatric Association. Compton, S.N., March, J.S., Brent, D., Abano, A.M., Weersing, R. and Curry, J. (2004). Cognitive-Behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: An evidence-based medicine review. Journal of the American Academy of Child and Adolescent Psychiatry, 43 (8), 930-959. Hougaard, E., Madsen, S. S., Hansen, L. M., Jensen, M., Katborg, G. S., Morsaa, L., & ... Piet, J. (2008). A Novel Group Therapeutic Format in Cognitive Behavioral Treatment for Clients with Social Phobia in a Training Setting: A Case Study of One Treatment Group with Nine Clients. PCSP: Pragmatic Case Studies in Psychotherapy, 4(4), 1-52. Retrieved from EBSCOhost. Kearney, C.A. (2005). Social anxiety and social phobia in youth: characteristics, assessment, and psychological treatment. (Series in anxiety and related disorders). NY: Springer. Morris, E.P., Mensink, D. and Stewart, S.H. (n.d.). A brief Cognitive-Behavioral treatment for social anxiety disorder. CBT Manual for Social Anxiety. Retrieved from Google Scholar. Soler, J. and Weatherall, A. (2009). Cognitive behavioural therapy for anxiety disorders in children and adolescents (Review). The Cochrane Collaboration: Cochrane Online Library, p. i-35. doi: 10.1002/14651858.CD004690.pub2 Read More