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
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.
This is very good work.
ReplyDeleteI am pleased that you have reconceptualized your work around reducing perfectionistic behavior. I think this will be much more useful to the client.
You have found relevant research, related it to theory, and derived practical interventions from it.
Do you have a copy of the self-anchored scale you used? I am doing a similar intervention in social work school based on Ferguson & Rodway's article.
ReplyDelete