A Snap-shot of My Practice

PROCESS RECORDING

Student: Mira Kim Client's First Name: Elle Date: March 17, 2009

Presenting Issue(s): Elle, a 25 year old female, presented with an anxious feeling about managing her time. She is married, attends school as fulltime, and works as part time. She is complaining that she does not have enough time to study and she can’t focus even though she has time. I assume that her anxiety about time will be reduced if I convince her not to perfect her work rather than just increase her studying time. The following process recording is our 4th assessment. I tried to apply the cognitive behavior treatment for generalized anxiety disorder and perfectionism from Dugas and Koerner (2005) and Ferguson and Rodway (1994).

Terms:Worker: W, Clinet: C, Gut feeling: GF, and Thinking :T

W: How are you today?
(T: It is an ordinary greeting question but I hope she feels welcome to come here)

C: I am fine, Thank you
(T: Her facial expression does not seemed fine, she looks tired. I know that most people responded automatically that they are fine.)

W: Okay that’s good to hear that. Did you bring the chart that you promised to me to keep the record of time you study and what you feel?
(GF: It is embarrassing to me to ask other people what to do because I am afraid that they are not ready.)

(T: I think that I have to hide my own embarrassment in order to show my competence as social worker.)

C: Yes, I am keeping the record and bring it with me. (she gave to me)
(F: I appreciated that she is following my plan voluntarily.)


W: You study 5hours and you describe that your anxiety is intensive for this week! You don’t mind if I am ask you to complete the Clinical Anxiety Scale before we talk about other issues.
(GF: Again, it is embarrassing to me to ask client what to do. I try to restate what are duration and her self anchored scales presented on the chart.)
(T: She seemed that she wants to talk rather than to fill the Clinical Anxiety Scale. I have to track this measurement to see difference between before and after the intervention.)

W: (after he finished Clinical Anxiety Scale) What makes you feel intense anxiety this week? Is that the reason that you studied less than previous week?
(T: This is the forth times I meet her and I have unexpected result that her anxiety level gets higher this week than two previous weeks! I understand that it can happen during baseline session and I hope that it gets better after I start my intervention.)

C: I feel anxious and depressed at the same time from last week. I received my midterm paper and I got B grade which was lower than I expected. I don’t understand why I got this grade. I won’t pass this class if I make another mistake. I am not sure I can get a job after I graduate during this economic crisis.
(GF: I also felt little depress last week because it was cloudy and raining during last week. I assumed that the weather also affected her mood as well as economic crisis today.)
(T: She worried about her uncertain future after she received her grade. It is hard to distinguish between feeling of anxiety and anxiety disorder. But I see her catastrophic thinking which is cognitive distortion. I assume that these dysfunctional thoughts were increasing anxiety of her imperfect performance.)

W: I understand that you did not deserve for a B grade but B is not a bad grade. Do you think your worries affect positively your other business?
(T: I found relevant research of cognitive behavior treatments for anxiety disorder but I don’t know how to apply to her real life. It is said that the level of anxiety will decrease when worry is decreasing. How can I make her not worried about the fact that she got B? I want to tell her that uncontrollable worries do not help to solve problem that she worried about?)

C: I know this worry grasp me and affect me negatively in my daily life. I can’t start final paper for that class because I am afraid that I won’t make my future better.
(GF: It is amazing that she has insight of the central characteristic of anxiety, and I worried that her cognitive distortion prevents her from doing homework.)


W: What would you expect to see in your life in two years?
(T: I used miracle question to give her hope which enabled her to do her homework.
This is not cognitive behavior treatment but I think it helps to solve the problem when you see the problem from the other point of perspective.)

C: I will graduate from my graduate school and have job. I think my unnecessary worries block me from moving forward. I need to do homework rather than thinking.
(GF: I am glad to hear that she understood my point.)
(T: I hope that she understands that her unexpected grade has nothing to do with her long term goal.)

W: I want you to think about difference between worries about current problem and worries about potential problem.
(GF: It is overwhelming to me to explore other people’s life as an imperfect human.)



References

Dugas, M. J., & Koerner, N. (2005, Spring). Cognitive-behavioral treatment for generalized anxiety disorder: Current status and future directions. Journal of Cognitive Psychotherapy: An International Quartely, 19(1), 61-81.

Ferguson, K. L., & Rodway, M. R. (1994, July). Cgonitive behavior treatment of perfectionism: Initial evaluation studies. Research on Social Practice, 4(3), 283-308.

My Intervention

My Client Elle, a twenty five year old female, is anxious about her time management. My goal for this client was to decrease the level of her anxiety by developing her time management skills, because she worried not accomplishing her work on time. But I realized that her perfectionism may involve cognitive distortion after reading Dr. Fast’s comment on my goal. I was only focused on developing her time management skill which frustrated my client without understanding nature of anxiety. The anxiety about time will be reduce if I convince her not to try to be perfect on her work rather than just increasing her studying behavior.

Perfectionism
To understand perfectionism and cognitive distortion, I reviewed Cognitive Behavioral Treatment of Perfectionism: Initial Evaluation Studies (Ferguson and Rodway, 1994). Authors emphasized that perfectionism is mood disorder which is often confused with similar issues such as compulsiveness, type A behavior, and workaholism. According to Ferguson and Rodway (1994) there are ten cognitive distortions which describe “characteristic of perfectionistic thinking: dichotomizing, over generalizing, magnifying negatives, discounting positives, fortune telling, minimizing and magnification, emotional reasoning, moralizing, labeling and personalizing” (p. 284-285). I assumed that these dysfunctional thoughts were increasing anxiety about her imperfect performance.

Anxiety
According to Dugas and Koerner (2005), there are four main cognitive distortions of “Generalized Anxiety Disorder: intolerance of uncertainty, positive belief about worry, negative problem orientation, and cognitive avoidance” (p. 61).
Intolerance of uncertainty is central cognitive distortion of generalized anxiety disorder and it can be defined as negative reaction to uncertain situations and events. Authors’ research shows the relationship between intolerance of uncertainty and worry. Intolerance of uncertainty is significantly more related to worry than to obsession, panic symptoms, and depression. And worry is more attached with intolerance of uncertainty than with perfectionism, need for control and intolerance of ambiguity. Authors also suggest that intolerance of uncertainty is a causal risk factor for generalized anxiety disorder.

A positive belief about worry is one of the cognitive distortions of generalized anxiety disorder (GAD). Patients with GAD show higher levels of positive beliefs about worry than the general population and they believe worrying helps to solve problems and increase motivations.

Poor problem solving is defined as people who have GAD who are experiencing difficulties solving everyday problems, because they have a negative problem orientation. Negative problem orientation is a dysfunctional cognitive set that sees a problem as a threat and clients become upset and frustrated when trying to solving problem. It is also holding a pessimistic view of outcome.

The last cognitive distortion is cognitive avoidance which can reduce anxiety in the short term. Dugas and Koerner (2005) suggest that individuals with GAD may be wanting “to avoid the evocation of threatening mental imagery and associated aversive somatic arousal” (p. 64).

Outcome measures
A single subject design will be used to measure the interventions. I am going to use three instruments; Clinical Anxiety Scale (CAS) which is one of the WALMYR Assessment Scales (WAS), self anchoring scale and form for frequency and duration of her study behavior.

The Clinical Anxiety Scale (CAS) is 25 items designed to measure an individual’s anxiety feeling. Each item is rated on a 5 point scale; 1=Rarely or none of the time, 2=A little of the time, 3=Some of the time, 4=A good part of the time, and 5=Most of the time.

Self Anchored Scales (SAS) is used to measure client’s amount of anxiety. According to Ferguson and Rodway (1994), Self Anchored Scales help to provide best judgment on client’s own situation. I used 5 scale points where 1 is the lowest level of the problem and 5 is the highest level of problem. There are scales that indicate amount of anxiety you feel about upcoming project; 1- Little or no anxiety, 2- Some anxiety, 3- Moderate anxiety, 4- Strong anxiety, and 5- Intensive anxiety.

The form for frequency and duration of study behavior is designed to record client’s behavior. According to Bloom, Fischer and Orme (2006), the dates count frequency of how many times she studies during a week. The length of study time will account duration of how long she studies during a week.

Cognitive Behavior Treatment for Anxiety
I am going to use some of cognitive behavior treatment from Dugas and Koerner (2005). The authors described step by step intervention and it includes: “1. Presentation of treatment rationale (learning to cope with uncertainty); 2. Worry awareness training; 3. Re-evaluation of the usefulness of worrying; 4. Problem-solving training; 5. Cognitive exposure; and 6. Relapse prevention” (p. 67). I will focus on the first four steps to intervene my client to reducing level of anxiety.

Presentation of treatment rationale includes discussing the diagnostic criteria for anxiety with my patient in the first few sessions. I am going to emphasize central characteristics of anxiety which include uncontrollable worry. Dugas and Koerner (2005) suggest that decrease in worry also decreases in anxiety symptoms indirectly. The treatment’s goal is to recognize and accept the role of intolerance of uncertainty, not to eliminate uncertainty.

Worry awareness training helps client to recognize worry and distinguish between worries about current problems and worries about potential problems. Those worries about current problems are that my client, Elle worried that she did not have enough time to accomplish her homework. And those worries about potential problems are that she thinks that there is possibility that she going fail the class.

Reevaluation of the usefulness of worrying is helping client to identify her beliefs about the usefulness of worry. Elle worried about doing her homework which is useful because she can finish her homework on time and list the advantages and disadvantages of holding theses beliefs. It helps client reevaluate the actual usefulness of worrying.

Problem-solving training is helping client to solve current problem that she worried about. According to authors, there are five steps applying a standard problem solving: “1. Identification of the patient’s problems orientations; 2. Problem definition and goal formulation; 3. Generation of alternative solutions; 4. Decision making; and 5. Solution implementation and verification ” (p. 68).

References

Bloom, M., Fischer, J., & Orme, J. G. (2006). Evaluating practice: Guidelines for the accountable professional. MA: Allyn & Bacon.

Dugas, M. J., & Koerner, N. (2005, Spring). Cognitive-behavioral treatment for generalized anxiety disorder: Current status and future directions. Journal of Cognitive Psychotherapy: An International Quartely, 19(1), 61-81.

Ferguson, K. L., & Rodway, M. R. (1994, July). Cgonitive behavior treatment of perfectionism: Initial evaluation studies. Research on Social Practice, 4(3), 283-308.