The client involved within this case study has consented throughout and his name has been changed to protect his identity, the client will simply be referred to as Dave’. A brief summary of the patient will be given as Will the clients experiences and concerns. Dave is 30 year old gentleman with a diagnosis of schizophrenia, evident with Dave?s presentation was his high levels Of anxiety within social situations; this factor was marked prior to his admission into hospital. In the lead up to his admission Dave had become increasingly reclusive and had retreated to the confines of his flat.
Dave was becoming increasingly reliant on either family or the community mental health services to carry out any activities that would involve him leaving his property. This social isolation in turn had serious implications on his levels on paranoia and greatly distorted his perceptions of the outside world and with those directly involved in his care. Subsequent levels of engagement suffered and poor adherence to his psychiatric medication lead to a significant deterioration in his mental health that warranted detention for treatment.
It is of note that plaint et al (2004) conducted research that highlighted the prevalence on social anxiety in patient populations with Schizophrenia. It was noted just how this debilitating condition is and how social anxiety should be identified ND considered as a separate entity to the individual patient’s individual clinical psychotic symptoms and experiences. Although currently treated and stable on prescribed medication Dave reported finding it increasingly difficult placing himself in any form of situation that would culminate in social contact.
Dave, whom, due to his mental illness was already very self-conscious, had become more so over recent months in the build up to his admission and had, due to his recent brake down admission, given him a severe knock to his already low self confidence. It was evident that Dive’s high levels self- unconsciousness and paranoia were exacerbated by a real fear that people would pick up on the fact that he was a mental health patient and would, as a direct result of this, begin to judge or even laugh, mock or harm him, at the seat of these appeared a low sense of worth.
Dave had found himself worrying intensely days or even weeks before planned appointments such as ward rounds or care plan approach meetings and other daily events such as unit meetings and planned group activities, these factors along with his reluctance to even go on trips to the shops or his local bank were a recurrent sue for Dave whilst on the Unit. These aforementioned issues had real implications for Dive’s progress towards achieving his goal of returning to his flat, acting as a barrier progression and to some extent, a suitable level of recovery.
This apparent lack of engagement on the unit had real implications in regards to his transition and reintegration into back into the community. It was made apparent that Dave would complain of pain in his legs and would appear to mobile poorly prior to any form of planned activity, with nursing staff noting that this appeared to worsen as the deadline for an activity or eating would draw nearer. At times Dave would present with, and complain of, physical symptoms appearing to be short of breath begin tremble and would complain of tightness in his chest.
All of these aforementioned physical experiences where obviously investigated extensively but lead to negative results for any form of physical alignment and raised no course for concern. There are several ways of making sense of this case, Cognitive behavioral therapy is a structured, short-term problem focused psychosocial intervention aimed at individuals suffering from emotional and behavioral disorders.
It is fundamentally a client, therapist collaboration with great emphasis placed on the client therapist relationship, which Was described by Beck as the ‘therapeutic collaboration’ (Appease, 1 995, Westbrook et al 2007 and Barker 2003). The Department of health guidelines outline the validity of CB in its effectiveness for the intervention and treatment of general anxiety disorder, depression and obsessive-compulsive disorder (Department of Health, 2007).
Of fundamental importance to CB is the notion of cognition and behavior; Westbrook et al (2007) describe that, although its own entity, CB is a arraign between elements of cognitive and behavioral theory. The cognitive principle pivots around the influence of cognitions on a person’s emotional reactions and behavior, it appreciates how people see, interpret and react differently to similar events with individual cognitions giving rise to individual emotions. The behavioral principle considers how a person’s behaviors occur in direct response to stimulus and are cyclic in nature.
Great sway is placed on the impact that behavior has on thoughts and emotions and how the modification individual behavior has a significant impact on hanging ones thoughts and emotions (Westbrook et al 2007). Essential to the process within CB is the active challenging of the negative thought processes. Thought processes greatly effect the way in which a person perceives and appraises situations, Wilson and Branch 2006 outline how individuals have a tendency to focus on negative over positive aspects and experiences .
In times of emotional distress and anxiety such thoughts are intensified and are a catalyst to certain emotions and subsequent behavioral responses which, in part drive the thoughts and are cyclic in nature, (Barker 2003). Cognitive Behavioral therapy (CB) was originally developed as an intervention for individuals suffering from clinical depression. It has over the years been tailored to help treat a plethora of psychological disorders with increasing evidence highlighting its effectiveness in clients with schizophrenia (Yorker and Gaylord 2003, Westbrook et al 2007 IPPP).
In regards to the treatment of depression CB was found to be as effective as medication when employed to treat a depressive episode, further more, the use of CB as an intervention can aid in preventing and protecting an individual against further elapse (Barker 2003). CB theorizes models for human understanding and functioning by considering the relation of cognition and behavior. It sets out how this relation of cognition and behavior is intrinsically linked to the way in which an individual might act out in response to his or her thoughts and experiences.
It identifies that behaviors and cognitions do not occur alone, but are in fact reactive of one another. To aid in illustrating the links between cognition and behavior a simple diagram can be used, and is simply referred to as the vicious daisy and serves to show the cyclic nature of cognition and behavior. CB works by allowing the therapist and client to cognitively conceptualize and target an individual problem thus enabling the identification of specific intervention options to apply to it (Barker 2003 Pl 81).
Barker (2003) explains how CB has an important effect in terms of the future management strategies and how the aim of this therapy is to educate and equip an individual with new set of skills aimed at combating their individual symptoms or underlying problems. There are various stances and models of treatment that can be utilized in this situation. When you consider the use of CB versus deiced model it is important to note that reliance on medication alone could act reinforcing the medical model of the illness.
This factor in itself could serve to drive further relapse and medical intervention if skill acquisition and education associated with CB is not considered in unison, thus leading to reliance on the system than on oneself. Of vital importance to therapeutic process in CB is a formulation relating to the development and maintenance of problems. The case formulation should be comprised in the early stages of the therapy (Barker 2003). Barker (2003) notes that interventions can be dewed as a ‘haphazard application of techniques’ with the absence Of a clear formulation.
Much evidence identifies that all forms of psychotherapy are more likely to succeed and be driven, if the bond between the client and the therapist is strong (Chaps et al 1993). Paddies (1995) outlines that a good therapist is one that is genuine, exuding a sense of warmth, respect and empathy. As discussed previously, in the case of CB, the relationship between the client and therapist is of up most importance when ensuring and aiding a good level of success and its success is on born out of collaborative irking (Waller et al 2007 and Paddies 1995).
To formulate an assessment of Dive’s problem and to gather the relevant information needed, meetings were held once per week over a period of two months. The ultimate aim of these meetings was to enable Dave to correlate links between his emotions, behaviors and environmental triggers, with the goal of enabling motivation . Initial emphasis fetishes sessions was placed on devising a hypothesis and gathering information on Dive’s issues. Westbrook et al (2007) outlines how the early and part of the assessment process takes form with the use of tortured questioning when conducting an interview.
In the initial session with Dave, open, closed, process and recall questions were used to elicit the relevant information. The use Socratic questioning which Paddies (1995) described as ‘the cornerstone of cognitive therapy’ was also employed for gleaning information. The use of Socratic questioning enables and aids in raising the clients awareness of their own thoughts and behaviors, to draw on old, or discover and explore new views and strategies for themselves rather than looking to the therapist for solutions (Westbrook et al 2007).
Each session was structured in its approach to ensure that the time spent within the therapy was used wisely. At the start of the session it was explained to Dave that some time would be spent discussing his thoughts on his current situation and concerns in an attempt to identify the problem and how it might have manifested itself with the view of recapping and exploring issues raised in greater detail at a later date. A review of previous sessions would be conducted at the commencement of each meeting to maintain focus and continuity.
When conducting the first formal meeting with Dave to commence heresy, the therapist posed the question ‘What is your current concern? ‘. Dave replied by identifying that he felt that he was under constant scrutiny form others ‘everyone looks at me’, describing how he felt that people viewed him as ‘a waste of space’ and ‘stupid and worthless because I am mad’, this factor made it difficult for Dave to even think of placing himself in social situations.
When asked where this was most likely to occur, Dave identified that he had felt at his most vulnerable when in situations where he had to engage strangers in conversation, giving the example having to talk to a shop r garage assistant when buying tobacco, highlighting where, when and with whom the problem might occur, thus highlighting a certain area for work through problem solving. At the end of session summary of Dave?s experiences were made to ensure that all problems raised were understood correctly, thus painting clear and concise picture of all the Issues raised.
To aid in assessing and illustrating areas for improvement and the progress of the therapy and its progress, psychometric measures were considered. This enabled the accurate recording of information throughout the and gave a Lear indication of the effectiveness of interventions employed. Hawthorn et el (1989) outline how the correct usage of monitoring tools can improve and promote change thus increasing the therapeutic effect of the intervention by raising the individual awareness. The distress and anxiety scales were employed.
Also considered was the Lobotomize social anxiety scale employed by Plaint et al (2004) in their research into impact of social anxiety within a cross section of clients suffering with schizophrenia. Plaint et al (2004) found it useful in identifying suitable pharmacological and therapy based interventions. However, of note, the Lobotomize social anxiety scale appears more suited to study outcomes within clinical trials and appears not as well suited for the purpose of self-reporting.
In contrast to this the Beck’s anxiety scale is structured and formulated in such a way that makes it an ideal tool for self-reporting symptoms and experiences of anxiety and distress. It was clear that Dave displayed a great deal of insight into issues surrounding his levels of anxiety and was more than able to identify how these thoughts and fears had a restrictive influence on him and were in part ruling his life and everyday functioning. It was decided by both parties that an agenda would be agreed and set for each meeting.
The main agenda for successive sessions would focus and prioritize on principle identified problems and concerns (Westbrook et al 2007). During subsequent sessions further information was gathered, this information aided in the case formulation, giving a picture of early life experiences and Dive’s core belief. Dave outlined that he had been targeted and bullied at school and criticized by his parents whilst at home, as a result of this Dave had formed the core belief that he was “worthless”.
The formulation process enabled the identification of certain rules and safety behaviors that Dave had constructed around himself such as avoiding public places, ignoring and shying away from contact with others. It was clear from the first session that Dive’s sense of worth would be the target of the therapy throughout, these negative thoughts were examined collaboratively. Highlighted, as discussed, was Dive’s fear of going to public places such as Supermarkets or the local shops was a major concern for him fueled by the belief that members of the general public viewed him in a negative light.
As a resultant of this Dave was predisposed to remain on the Unit. Dave agreed, and felt that his main focus for change was issues surrounding him being unable to access items for his daily needs. To aid in this a treatment plan was agreed, this was to be centered around a behavioral experiment. The aim of this experiment was to test and assess the validity of Dive’s current beliefs, with the view of enabling and encouraging the exploration of thoughts and feelings thus accessing alternative explanations . An experiment was designed in which Dave would, With the therapist, attend the local garage to arches tobacco.
The aim of this was to test and challenge and re-evaluate Dive’s perception of how others might respond to him. Prior to this experiment Dave had been having periods of escorted leave within the hospital grounds but had felt unable to go further field to avoid placing himself in any situation that might involve contact with strangers. Prior to going to the garage Dave, used a self rating scale for distress. This placed his belief that someone would act adversely towards him at 6 out of 8 on a beliefs scale with 1 being at a lowest level of belief and eight at the highest.
This was to be conducted again after the experiment to gather data and evidence (Greenberg and Paddies 1995). Although in agreement it was evident that Dave was very anxious at thought of carrying out this experiment. Time was spent with Dave prior to this, well as in previous sessions, discussing the physiological aspects of anxiety and ways of best managing and elevating this. The exploration alternative outlooks were considered, such as, it would be highly unlikely that people would pay any attention to Dave, as they would be more worried about paying extortionate amounts of money for their fuel over anything else.
Both parties agreed that to minimize levels Of anxiety they would enter the local garage with it relatively empty. Dave was able to enter the local garage without issue and made his purchase whilst observing that the assistant and other people in garage paid very little attention to him other than acknowledging him when he had made his request for his tobacco and had made the subsequent payment for his items. This resulted in the active challenging of Dive’s prediction that people would react to him negatively thus drawing unwanted attention and ridicule.
Dave was able after the experiment to draw the inclusion that most people pay little attention to one another whilst out in public as they are more likely to be concerned with their day to day business rating himself as 4 out of 8 on a beliefs scale. The above experiment served as a baseline of other and future work to challenge Dive’s beliefs through evoking change through exposure and self exploration. In conclusion the use of cognitive behavioral therapy could only be of benefit with most facets of mental health when used either on its own or in unison with other treatments.
When relating to the study conducted by Plaint et al (2004), It appears that the treatment of social anxiety within the clients suffering with schizophrenia is heavily reliant on the use of medication despite evidence to suggest the benefits of some psychological interventions. As outlined by Westbrook et al (2007), the use of CB as an intervention can be adopted and tailored for the treatment of a plethora of psychological disorders within in both primary and secondary mental health services.