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.

My Client

My Client, a 24 years old female, presented with an overwhelmed feeling about managing her time. Her name is Elle and she is Korean American immigrant. She was born in South Korea. She came to Atlanta, Georgia by herself when she was 16 years old. She used to live with her mother, stepfather, half sister and brother until she came. One of the reasons she came to the U.S is that her mother decided to transfer her custody to her daughter’s biological father who left his own family 16years ago. She was excited to leave for America, the land of opportunity, and she also was sad to separate her mother from Korea at the same time.

It was difficult for her to adopt new family because it was her first time to meet her biological father, step mother, and step sister. At that time, she focused on obtaining her High School diploma although her relationship with her family was conflicted. She decided to leave her family when she was 18 after graduating High School. She moved to New York herself and started to live alone. She was completely independent from her family. She worked two days a week, attended college as fulltime student, and deeply engaged with church as a Christian. From that moment, time management skills became the most concerning factor to maintain her life as a worker, fulltime student, and member of her church. Overall, she satisfied what she had done for the last 4years; obtained bachelor degree, married, worked and depended on religious life. But still she struggled with time management which often frustrated her.

Elle is complaining that she does not have enough time to study and she can’t focus even though she has time. She is more anxious when the due date of her project is coming. To explore the problem, I want to define her meaning of the time. Therefore I was asked few questions related to her family (cultural) time, functional time, and real time. The first question I asked her was how her parent managed their time. It is important question because parents’ behaviors significantly affect their child’s behavior. She answered that her family lived in small Island of Korea. Her stepfather was a fisher man and her mother was a house wife who did not have any anxiety about time. She meant that they worked hard but time is not a matter in their lifestyles. It was a totally different situation that she is experiencing now. Furthermore, her parents’ parenting style was more like neglect that never tells her what to do or have to do. It sounds to me that she did not have chance to learn to do things on time.

The second question was what is she doing on a daily, weekly and monthly basis. It will define how she is functioning based on the time. On weekly, she worked three full days as an esthetician to maintain her financial issue. She also attended graduate school two days and went to church two days. And she has two days to do her studies, housework, and chance to keep other appointment. Most of time she feels pressure to take too many roles as wife, student, worker, and member of her church. These complicated life styles make it hard to focus on her studies even though she has time to study. This lack of study time produces another stresses on other daily activities. She desperately wants to improve the behavior of study because she her priority is to graduate her master program by next year.

My Goal for this client is improve behavior, the amount of time she spends on study and decrease the feeling of anxiety. I assumed that level of anxiety will reduce if she controls her time.I will use indirect observation, self anchoring scale and Clinical Anxiety scale from the WALMYR Assessment Scale (WAS) as well. To observe her study behavior, I asked her to keep a record of the time she spends on studying and bring it to the next session. I made the above chart to keep a record for myself. It counts the frequency and duration which include self anchoring scale as well. The textbook inspired me to make chart. The dates count frequency that how many times she studies during a week. The length of study time will account duration of how long she studies during a week. And the last part is amount of anxiety she feels about her upcoming project which indicates self-anchoring scale. I used 5 scale points that 1is lowest level of the problem and 5 is highest level of problem.

Encouraging her to involve my goal, I restated her concern about time and explained this data gives idea of how she spends time on studies. Fortunately, my client has positive attitude about my idea of keeping a record because she understands that this record will show her exact amount of time she spends on study a every week. The client and I agreed to have one hour session at one o’clock every Tuesday. I am going to use Clinical Anxiety Scale (CAS) which is one of the WALMYR Assessment Scales (WAS) during session. This will help to define the relationship between time management skills and anxiety scale.
Since I don’t have my field placement for this semester, Dr. Fast and my classmates will be my instructor for my assessment.

References
Bloom, M., Fischer, J., & Orme, J. G. (2006). Behavior observation. In Evaluating practice: Guidelines for the accountable professional (chap.5). MA: Allyn & Bacon.
Genogram. (n.d.). Retrieved February 24, 2009, from Wikipedia, the free encyclopedia Web site: http://en.wikipeial.org

My Agency

Since last semester, I have my internship at the KCS (The Korean Community Services of Metropolitan New York) Corona Senior Center and the Flushing Senior Center. My agency provides various services including communal lunch, home delivered meal program, case assistance, education/recreation and information/referral. The main target population of KCS Corona Senior Center has been Korean American seniors who are 60 years old and over.

To understand Korean immigrants in United States, I review the Strangers to these shores : race and ethnic relations in the United States and the book provides the basic understanding of Korean American history and strengths. The purpose of this book is to reduce bias which is easily lead conflict. According to Parrillo, there are three major events that brought Korean immigrants United States historically. The first large group of Korean immigrant to the United States came between 1903 and 1905 by The Hawaii Sugar Planters’ Association. The main reason was they need laborers to replace the Chinese who were excluded by the 1882 legislation so they recruited 7,226 Koreans. Later on the Refugee Relief Act in 1953 was increase the population. The last event to increase Korean population in United States was the liberalized immigration law of 1954 that opened the doors to Asian immigrants and allowed relatives to join family members already in the United States. The book describes the history of Korean immigrants. As a Korean immigrant with an internship in Korean Community Service, this information is vital to know. It reminded me that international policy, such as open door policy to other nation, takes important role in immigrant society until now.

According to Parrillo, there are three unique characteristics of Korean Immigrants: religions, occupation and education. To understand Korean population, religions is key component. Almost 70 percent of the Korean American population identifies itself as Christian which is significantly higher percentage than the 30 percent Christian population in Korea. In addition the churches in immigrant society contribute many role as providing religious and ethic fellowship, a personal community, and a family atmosphere within an alien and urban environment. In Korean American occupation, 40 percent of the males operate their won businesses. It is the highest of all ethic or racial group, including whites compare to the 12 percent of self employing rate national wide. At the last Korean are more highly educated than most other nonwhite group. However their income is lower than native born Americans and their earnings are similar to those of other Asian American Group even though they have number of college graduates.

To focus on the Korean American senior population, most in the agency are first generation immigrants who have had language barriers as well as conflicts with acculturation. There are two different groups of seniors who have come to the USA. The first came to USA before their old age. They have been strong willing to raise their children in a better environment. They do not hesitate to provide a selfless devotion toward the well-being of their children. Their mere interest is seeking a better life for themselves in old age. It is based on their sense of strong kinship and their value of family. The second group of people came to USA in their old age. The role of women in the Korean American community has been changed significantly after arriving to the USA. The traditional roles of women in Korea are housewives but women who initially immigrated to the U.S. had to work. In the USA, a majority of married Korean women participate in an intensive business run by family members, which typically demand long hours. At the same time, they desperately need someone to help with child care and housework. That is why seniors usually are invited the United States to take care of the children and help house work in the family.

Despite the difficult situations, the Korean American seniors often remain in the USA even though sons and daughter are living in Korea. They enjoy the welfare benefits of the U.S. government. In Korean tradition, adult children of seniors have to provide direct for assistance their needs. Adult children help them in dealing with their physical, social and economic needs. Yet, immigrant Korean families may have difficulties in providing what aged parents need. That is why they stay in the USA during their old age. They also have to integrate the new culture and traditional roles. For example, of filial piety where seniors may expect their children to assume full responsibilities for parental needs. Yet, changes are taking place in all levels of society involving family characteristics and the roles of parents and children.

The language barrier is the most challenge for Korean-American seniors. It was interesting to work with senior member especially in communication. Without their file which recorded their personal information and previous issues and follow-up, it was hard to have information what we need. The seniors always need basic assistance, because of their language barrier. To assist senior member, I need to know all the social service that agency provide. For example, senior members bring all kinds of their letters which are comprised of medical bill, social security, and so on from home and then ask for assistance. Sometimes they understand how to respond to them but are afraid to do it their own. I like to assist them through the field of social work.

One senior member’s letter required action to be changed to the Medicare Part D plan. I needed to log on to the Medicare website and confirm that they are currently enrolled in order to find out whether the letter is a commercial one or if it is actually important. In most cases they do not have prior knowledge of the Medicare system and what they are enrolled under. Then I assist the client when they want to avoid calling the insurance company to change or renew their plan. Korean American seniors cannot make phone calls by themselves due to the language barrier and their lack of information. However, to provide assistance to the senior, I need to understand services that agency provide which is income support, health care, nutrition, housing, transportation, socialization, and legal services.

References

Parrillo, V. N. (2006). Strangers to these shores : race and ethnic relations in the United States(8th ed.). Boston: Pearson/‌Allyn and Bacon.