Cbt Case Study

CBT causal agent Study Identifying Information For the purposes of the mooring study the client will be c entirelyed Jane. Jane is a 22 yr old single white British female who lives with her parents in a house forthside the city. She is heterosexual and has had a boyfriend for seven years. She savours unable to discuss her issues with her boyfriend. Her parents both take on mental health issues and Jane does non feel able to talk to her mother approximately her conundrums. She has an older comrade she has a good kind who lives with his girlfriend, a four hour drive away.Jane is educated to degree level, having studied Criminology and is currently working part clock time for her father managing his client considers for a business he runs from home. A typical sidereal day involves organising all utility and creating spreadsheets for each clients accounts. Jane states she would uniform to rag to a full time job and be normal give care her friends. Jane has a small circ le of friends from university who she states sacrifice all gone onto full time employment. Jane also has a puppy she spends time spirit after and fetching for regular walks.Assessment Jane was refer redness following a health check at her GP surgery. She had been appointive Citalopram 20mg by her GP for anxiety symptoms and scourge storms she had been having for 2 years. Jane has no previous contact with mental health services. Janes father had a diagnosis of Bi-Polar Disorder, her brother has Depression and her boyfriend has a diagnosis of neurotic Compulsive Disorder which he is continuing interposition for. Janes anxiety/ scourge has increased over the past two years.She had read ab prohibited cognitive Behavioural Therapy on the Internet and was willing to see if it was serve well ease her anxiety symptoms. Jane tell that the problem started due to family issues in 2007. Her brother and father were estranged due to a financial disagreement and this resulted in Janes brother leaving the coun translate with his girlfriend, causing Jane to be follow very distressed. Also during this time she was taking her final exams at University, Jane states this was when she experienced her frontmost dread attack.She had spent the evening in the first place her brother re importanting the country, drinking alcohol with friends, she remembers feeling hung-over the next day. While travelling in the car to the airport, with her brother and his girlfriend, Jane states she started to feel unwell, she found it hard to breathe, mat hot, trapped and felt standardized she was going to obscure. Jane stated she felt gangrenous and stupid and had since experienced other disquietude attacks and increased anxiety, anticipating panic attacks in social situations.Jane had reduced w here(predicate) she went to, purpose herself unable to go eachwhere she may exact to meet bleak people. Her last panic attack happened when Jane visited her GP for a health check and ricketyed during the appointment, Jane has blood phobic neurosis and she stated she had not eaten since the day in the lead and was extremely anxious around the any medical interventions. Jane believes it was a panic attack that ca utilise her to faint.The GP prescribed her 20mg of Citalopram, a few weeks prior to her initial assessment with the healer. When Jane and the therapist met for the initial session Jane described herself as feeling inadequate and as if she was trapped in a cycle of panic. Although Jane felt unhappy she had no suicidal ideation and she presented no risk to others. Jane stated she had become more than than anxious and that she had panic attacks at to the lowest degree twice a week. Prior to and during therapy, Jane was assessed using various measures.These enabled the therapist to formulate a hypothesis regarding the acrimony of the problem, also acting as a baseline, enabling the therapist and Jane to monitor progress throughout treatment. (Wells, 1997). The measures use in the initial assessment were a daily panic diary, Wells (1997) and a diary of obsessive- compulsive rituals, Wells (1997) a self rating scale completed by the client Jane. Other measures use were, The Panic Rating Scale (PRS) Wells (1997), the Social phobic disorder Scale, Wells (1997), used by the therapist to clarify which specific disorder was the main problem for Jane.Having collated information from the initial measures, a problem magnetic dip was created so the therapist and Jane could decide what to focus on first. This list was based on Janes account of the worst problems which were given priority over those problems which were less distressing. Problem List 1. Anxiety/Panic attacks 2. Obsessive hand swoshing. 3. My relationship with my family. 4. Not having a full time job. 5. My relationship with my boyfriend Having collaboratively decided on the problem list, the therapist helped Jane reframe the problems into goals.As the problem list hig hlighted what was wrong, changing them into goals enabled Jane to approach her problems in a more cogitate way (Wells, 1997), the therapist discussed goals with Jane and she decided what she wanted to get from therapy. It was important for the therapist to ensure that any goals were realistic and achievable in the timeframe and this was conveyed to Jane (Padesky & Greenberger, 1995). Jane wanted to reduce her anxiety and expressed these goals- 1. To ensure wherefore I impart panic attacks. 2. To have an anxiety free day. 3. To reduce the amount of time worrying . To reduce obsessive hand washing at home. Case Formulation Jane stated that for virtually a year she had been retell certain behaviours, which she believed prevented her from having panic attacks. This involved Jane washing her hands and any surrounding objects at least twice. Jane had a fear of consuming alcohol/drugs/caffeine/artificial sweeteners, she stated she had had her first panic attack the day after drinki ng alcohol and had read that all these substances could increase her anxiety. Jane had not drunk alcohol for 18 months as she felt this caused her anxiety and made her nable to control the panic attacks. Jane stated she feared that if any of these substances got on her hands and past into her mouth she would have a panic attack and faint. These beliefs increased Janes anxiety when Jane was unresolved to any environment where these substances were present. This unfortunately was most of the time, Jane stated that every time she saw any of these substances consumed or even placed near her, she became anxious and had to wash her hands and any surrounding items which she may come into contact with again.These pencil eraser behaviours maintained the cycle of panic, Jane would always continue the routines that she believed prevented a panic attack. The worst case scenario for Jane was the panic would never stop and I will go mad, causing my boyfriend to leave me. Jane felt this would m ake everyone realise what she already knew, that she was worthless. Her last panic attack happened when Jane had visited her GP this caused Jane feelings of shame. Theres all these people achieving, doing great things and I kindlet do the most basic thingsThe therapist used the Cognitive Model of Panic (Clark, 1986), initially developing the three key elements of the fashion model to help socialise Jane to the thoughts, feelings and behaviour cycle (see diagram below) Cognitive Model of Panic Bodily sensations Emotional response theory about sensation Clark (1986) Using a panic diary and a diary of obsessive-compulsive rituals, Jane was asked to march on a record of situations during the week where she felt anxious, and this was discussed in the next session.Jane stated she had not had any panic during the week, when discussing previous panic attacks during the session, Jane became anxious and the therapist used this incident to develop the following formulation. Heart crush fast/increase in consistency temperature Fear/dread I feel hot, I cant control it Clark (1986) Jane stated she felt like she was sweating, she had difficulty breathing felt faint, had feelings of not existence here and felt like she was going crazy.All these symptoms suggested that Jane was experiencing a panic attack and Jane met the criteria for Panic Disorder, defined in the DSM IV and states that panic attacks be recurrent and unexpected, at least one of the attacks be followed by at least one month of persistent concern about having additional attacks, worry about the implications or consequence of the attack, or a significant change in behaviour related to the attacks (APA, 1994). During the sessions the therapist go along to socialise Jane to the model of panic (Clark, 1986) together Jane and the therapist looked at what kept the cycle going.The therapist keep to use the model formulation, with the addition of Janes catastrophic interpretation of bodily symptoms, to illu strate the connection amid negative thoughts, emotion, physical symptoms. Social situation I will be unable to stay here Everyone will notice I am not coping Im going to faint Sweating/breathing fast/dizzy Clarks (1986) Cognitive Model of Panic.Progress of Treatment The therapist hypothesised that Janes symptoms continued due to Jane not understanding the physiological effects of anxiety. The results were a misinterpretation of what would happen to her bit being anxious, and this maintained the panic cycle. Although Jane time-tested to avoid any anxiety by using safety behaviours, she eventually increased the anxiety she experienced. academic session 1 After the initial assessment sessions, the therapist and Jane concord to 8 sessions, with a review after 6 sessions.Jane and the therapist discussed that on that point may only be a small amount of progress or change during the sessions due to the Byzantineity of Janes diagnosis and agreed to focus on understanding the cycle o f panic (Clark, 1986) From the information gained from the formulation process, the therapist tried psycho education. The therapist was attempting to illicit a shift in Janes belief about what, how and why these symptoms were happening. The therapist discussed with Jane what she knew about anxiety and from this the therapist discovered that Jane was unsure of what anxiety was and the effects on the carcass.For the first few appointments the therapist knew it could be beneficial to concentrate on relaying information about anxiety, (Clark et al, 1989) focusing on Janes specific beliefs anxiety, the therapist wanted to try to reduce the problem by helping Jane do the connection between her symptoms. As Jane believed, she was going mad, the therapist was trying to help Jane understand the CBT model of anxiety and to alter Janes misunderstanding of the symptoms. The therapist and Jane discussed Janes belief that she would faint if she panicked, Jane had fixed beliefs about why she fai nted.The therapist attempted to enable Jane to describe how her anxiety affected her during a usual panic. Instead Jane began to describe symptoms of social anxiety, this suggested to the therapist that the main problems could be a combination of /social phobia and obsessive behaviours the following dialogue may help to illustrate this. T. When you begin to become anxious, what goes through your issue? J. I need a backup plan I need to know how to get out of there. Especially if its in an office, or a small room. T. What would happen if you did not get out? J. I would panic, and then pass outT. What would the reasons be for you to pass out? J. Because I was panicking. T. Have you passed out before when you have panicked? J. I have felt like it. T. So what sensations do you have when youre panicking? J. The feeling rises up, I feel hot and I cant see straight. I get red flashes in front of my eyes, like a warning. My vision goes hazy. I ideate everyone is looking at me. T. Do you t hink other people can see this? J. Yes. T. What do you think they see? J. That Im struggling and I cannot cope or, I try to get out of the situation by pretending I feel ill before they notice. T.What would they notice, what would be different about you? J. I stick out like a beacon, Im sweating, loads of sweat and my face is bright red. T. How red would your face be, as red as that No Smoking sign on the wall? J. Yes Im dripping with sweat and my eyes are really staring, feels like they stick out like in a cartoon, its ridiculous. T. How long before you would leave the situation? J. Sometimes the feeling goes, like I can control it. But I could not leave. There would be a injury and then I could not go back, the anxiety would increase in that environment or someplace similar.The therapist persisted with this example and tried to use guided discovery to help Jane get a more balanced view of the situation. (Padesky and Greenberger, 1995) T. So you would not go back? J. I would if I felt safe, like with my boyfriend or I could leave whenever I wanted to. Its the last straw if I have to go. It makes it even harder. T. You say that sometimes it goes away. Whats different about then and times when you have to leave? J. Its like I however know I have to leave. T. What do you think may happen if you stay with the feelings? J. That I will pass out. T. hat would that mean if you passed out? J. It would be the ultimate. It would mean that I could not cope with the situation. T. If you could not cope what would that mean? J. I cant function, I cant do anything. Im just no use. T. How much do you believe that? Can you rate it out of 100%? J. Now. About 60% if I did faint it would be about 100% T. Have you ever fainted due to the sensations you have described to me? J. No. I have fainted because Im squeamish. I foolt like blood. Or having any kind of tests at the GP. T. So do I understand you? You have never fainted due to the panic sensations?J. No. Ive felt like it. T. So youve never passed out due to the symptoms? What do you make that? J. I dont know, that would mean that what I believe is stupid. Its hard to get my head around it. Session 2-3 The therapist used a social phobia/panic rating scale measures to ascertain the main problem this was increasingly difficult as throughout each session the patient expanded on her symptoms. The therapist managed to understand that the patient avoided most social situations due to her beliefs about certain substances this caused the obsessive hand-washing.This then had an impact on Janes ability to go anywhere in case she could not wash herself or objects around her. Jane also believed fainting from blood phobia had the same physical effects as panic, and she would faint if she panicked. It was complicated and the therapist attempted to consort out a formulation. I SEE A somebody DRINKING ALCOHOL ITS GOING TO GET ON MY HANDS AND INTO MY MOUTH I flavour SICK, IM GOING TO FAINT I FEEL DREAD, I FEEL ANXIO US, SWEATING I MUST WASH MY HANDS TO STOP THE PANIC GETTING WORSE.Session 4 The formulation shows the extent of Janes panic and how her safety behaviours were impacting on all aspects of her life. The therapist attempted again to use information about the causes of anxiety and its effects on the body. The therapist explained what happens when you faint due to blood phobia, this was an attempt to supply Jane with recurrence evidence for her catastrophic interpretations of her panic. The therapist also used evidence to contrast the effects on the body when fainting and when panicking.After two sessions, the therapist continued to provide and attempted to relay the facts about the nature of anxiety/panic/fainting with the inclusion of behavioural experiments. Educational procedures are a valid part of overall cognitive restructuring strategies, collective with questioning evidence for misinterpretations and behavioural experiments (Wells, 1997) The therapist asked Jane to explain to the therapist the function/effects of adrenalin, to see if Jane was begin to understand and if there had been any shift in her beliefs about panic.The following dialogue may help to illustrate the difficulties the therapist encountered T. Over the last few sessions, we have been discussing anxiety and the function of adrenalin. Do you understand the physical changes we have looked at? Does it make sense to you? J. Yes. Something has clicked inside my head. I feel less sick now, I understand more about whats going on. It makes things a little bit easier, just it takes time for it to sink in. T. Do you think you could explain to me what you understand about anxiety/adrenalin? J.As I interpret it is, I like to think of it as, Im not anxious its just my adrenalin, Its just the effects of adrenalin effecting my body but its hard to get from there, to evaluate the adrenalin is not going to harm me. I know logically its not. But its still hard. T. Thats great youre beginning to questio n what you have believed and are thinking there may be other explanations for your symptoms. J. Yes. But I still think its to do with luck. I have good or bad luck each day and that predicts whether I have a panic or not. I think Ill be unlucky soon.Session 5-6 The therapist continued to try use behavioural experiments during the sessions to provide tho evidence to try to alter Janes beliefs about anxiety. The therapist agreed with Jane that they would imitate all the symptoms of panic. Making the room hot, exercising to increase heart rate and body temperature, hyperventilation (ten minutes) Focusing on breathing/swallowing. This continued for most of session 5. As neither the therapist nor Jane fainted, they discussed this and Jane stated it was different in the session than when she with other people.Jane also stated she felt safe and trusted the therapist, she did not believe she could be strong enough to try the experiments alone, as it was too scary The therapist asked Jane t o draw a picture of how she felt and put them on the diagram of a person, this then was used to study with anxiety symptoms, while talking through them with the therapist. The therapist and Jane created a survey about fainting and Jane took this away as homework to gain further evidence. The survey included 6 different questions about fainting e. g. What people knew about fainting/how they would feel about seeing someone faint, etc. Treatment Outcome The treatment with Jane continues. The next session will be the 6th and there will be a review of progress and any improvements. There has been no improvement in measures as noted yet. The therapist intends to use a panic rating scale (PRS) Wells, (1997) during the next session. The therapist will continue to see Jane for two more sessions, looking at what Jane has found helpful/unhelpful. Discussion Overall the therapist found the therapy unsuccessful.Although Jane stated she found it helpful, it was difficult for the therapist to se e the progress due to the many layers of complexity of Janes diagnosis. The therapist has grown more confident in the CBT process and understands that as a trainee, the therapist tried to incorporate all the new skills deep down each session. The therapist was disappointed that they were unable to guide Jane through the therapy process with a let out result. The therapist would have like to have been able to fully establish an understanding of Janes complex symptoms earlier on in the therapy.The therapist believes that Janes symptoms were very complex and the therapist may have been more successful with a client with a less complicated diagnosis. The therapist would then be able to gain more information via the appropriate measures to enable the formulations in a concise manner. This has been a huge learning curve for the therapist and has encouraged them to seek out continuing CBT supervision within the therapists workplace. This is essential to continue the development of the th erapists skills.The therapist feels that although this has not had the final result that the therapist would have wanted, it has been a positive experience for Jane. There appeared to be a successful remedy relationship, Jane appeared comfortable and able to communicate what her problems were to the therapist from the beginning of therapy. The therapist hopes this will encourage Jane to engage with further CBT therapy in the future and the therapist over the final session hopes to be able to support Jane in creating a therapy blueprint, reviewing what Jane has found helpful.Certificate in CBT September December 2009 CBT Case Study Panic/Social Phobia/OCD WORD COUNT 3,400 References APA (1994). Diagnostic Statistical Manual of Mental Disorders, Revised, 4th edn. Washington, DC American psychiatric Association Padesky, C. A & Greenberger, D. (1995). Clinicians Guide to Mind Over Mood. innovative York Guilford Padesky, C. A & Greenberger, D. (1995). Mind Over Mood. New York Guilfor d Wells, A (1997). Cognitive Therapy of Anxiety Disorders. Chichester, UK Wiley