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Steve is a 43-year-old married man with two children and is requesting treatment for feelings of depression and anxiety. Approximately six months previously after losing two major contracts at his software company, Steve’s anxiety began to manifest into panic attacks. Steve’s described the moments where “he feels dizzy, light-headed, flushed, has a feeling of chocking, and fears he is having a heart attack.” The panic attacks are occurring at a rate of two to three times per week. In addition, Steve’s displays perfectionistic behavior where he feels obligated to take on too many tasks in both his personal and professional life which becomes overwhelming at times.
Early Childhood Data
Steve was raised by both his parents, with one older brother. Steve denies any significant trauma. Nonetheless, Steve reported having an “extremely poor” relationship with his parents and being “tortured” emotionally and physically by his father throughout his childhood since the age of 4 four. Furthermore, Steve’s father had an explosive temper, often hitting Steve in the face with an open hand which caused his nose to even bleed at times. Although Steve’s father was highly critical of him, Steve still idolized his father and would always try to please him. In addition, Steve described his mother as inappropriately relying on him for support and nurturance due to her dysfunctional marriage which contributed to Steve feeling responsible for his mother’s well-being.
Prescence of any Core Beliefs/Schemas
Steve’s emotional needs were not met due to living in a hostile environment as described above. Consequently, Steve adopted maladaptive beliefs and behaviors consisting of a core belief that he needs to be responsible for everything, in relation to, to a schema of not being able to trust others. Steve appears to be unaware of this pattern of behavior, he conducts himself in a manner where he assumes other will “let him down” in the workplace and in his personal life with his wife. This is exemplified when Steve mentions he often tells himself that “others will let him down” when faced with tasks that others could take care of at work, and “Judy [his wife] will probably let me down.” Steve’s belief of needing to be the “very best” is another core belief stemmed from his schema that if he is not the best then he is worthless. This is portrayed when Steve mentions his perfectionistic behavior and the depression and anxiety that occurred afterwards when he lost the bid for the contracts.
Due to the Steve’s core beliefs, he has accumulated a set of conditional assumptions. These assumptions activate in context of his relationships and are composed of thoughts like “if I delegate tasks, then others will let me down” and “if I am the very best, then I have worth.” Moreover, Steve’s assumptions include “if I do everything right, then I will not be blamed for anything” and “if I focus on work and helping my family, then I can’t have time for myself.” Additionally, Steve has the assumption “if I got to public places or far from home, then I will have a panic attack” and “if my father died of a heart attack at a young age, then I will die from a heart attack at a young age.” Ultimately, Steve’s assumptions affect his personal and professional relationships and overall well-being negatively.
Compensatory Strategies/Behavioral Factors/Conditioning
As a result of Steve’s assumptions, he utilizes several compensatory strategies. To cope with his assumptions of worthlessness, Steve is seeking validation. In addition, in his professional and personal relationships, Steve refuses to delegate tasks to others. He feels a need to do it himself; he practices strategies such as cutting out meals and hobbies and setting high standards for himself to compensate for the increase in responsibilities. Any failure to meet the high standards is then interpreted as a product of him being worthless.
These compensatory strategies are further reinforced through operant conditioning. For instance, Steve’s distrust in others was positively reinforced when his first wife abused their children. Similar to the case with his family during his childhood, Steve placed trust in a loved one and it was broken, reinforcing the belief that he should not trust others.
As well as, Steve copes with his assumptions through avoidance. Steve avoids anxiety provoking places. Operant conditioning plays a role in the continuation of the avoidance; for example, Steve avoids going to public places and being too far away from his house. The avoidance reduces the anxiety, thus becoming a negative reinforcer. As a result, Steve continues to avoid situations. Overall, this strategy does not permit Steve to properly interact and engage in the world around him which would allow him the chance to learn and properly adapt; therefore, prolonging the avoidant behavior even more.
Typical Automatic Thoughts/Distortions
Steve’s automatic thoughts also impact his cognitive functioning. The thoughts are based on his core beliefs and cognitive assumptions and portrays the level of his cognitive functioning. Throughout his daily life, Steve has automatic thoughts reactive to various external stimuli which portrays his feelings of anxiety and depression. The automatic thoughts are apparent in several settings. These settings where his automatic thoughts are distorted include moments when his daughters have problems. When his eldest daughter mentioned she felt sad and down, Steve had the automatic thought of “I need to fix this.” In addition, when opportunities arise to do something for himself, he has the automatic that of “I shouldn’t.” These automatic thoughts are based on his core beliefs that he needs to be responsible for everything and leads to an emotional response of increased anxiety and depression.
Brief Summary of the Conceptualization
Steve’s developmental environment which consisted of a physically and emotionally abusive father and an emotionally dependent mother resulted in him establishing a core belief of needing to take responsibility for everything in relation to a schema of distrust towards others. This belief system has impacted his social and emotional functioning negatively. Due to these beliefs, Steve has assumed rules and conditional assumptions such as “If I delegate tasks, then others will let me down.” These assumptions or rules then lead to compensatory strategies that include cutting out meals and free time, setting high standards for himself, taking on more responsibilities, striving to be the “very best,” and avoidance. Additionally, Steve does things like never saying “no” to his daughters and “doing everything right” due to his need for validation. The effects of these strategies reinforce his maladaptive behaviors and increases his anxiety and depression which are now manifesting into panic attacks. In general, Steve’s behaviors are being sustained by operant conditioning and are continued by means of practices which encompasses Steve’s automatic thoughts and subsequent
Goals of Treatment
Decrease depressive and anxiety symptoms
- Improving self-esteem and self-concept
- Increasing Self-Care
- Reduce High Expectations
- Delegating Tasks
Improving Interpersonal Skills
- Learning when to say “no”
- Reducing the value of being liked by other
Decreasing the depressive and anxiety symptoms is one of the focal treatment goals overall. This may be accomplished by increasing the amount of time Steve allots for self-care. This can be in the form of participating in a hobby or just doing something in general that he would enjoy, or simply masking sure he is taking care of his physical health (e.g. not skipping meals). By improving Steve’s self-care his mind and body can become less stressed. In addition, this can be tied with performing activities that help Steve fully understand how he views himself and his role. Through self-report measures, Steve can visualize how he truly feels about himself and start to make adjustments. An example of this is using the Rosenberg’s Self Esteem scale, after seeing his score (0-30) Steve can determine what would he need to do for his score do be one point higher and so forth.
Concurrently, having Steve perform behavioral experiments where he allows someone to help him with a task and process the results will allow Steve to begin to change his core belief of needing to be responsible for everything, what is an appropriate reaction for when someone does let him down, and build his interpersonal skills. This also gives Steve the opportunity to build trust, make more time for himself, and reduce the high expectations his sets for himself. Role playing is another tool that can be used to increase Steve’s interpersonal skills. For example, Steve needs to understand the value in saying “no” to his daughters, and that by doing so that will not dislike him because of it and this can be done with the therapist through roe playing. Last, psychoeducation is important for Steve to learn about his situation what is happening to him, why it is happening to him, and that it is normal for people to react in a similar manner after experiencing one or several stressful events. When learning psychoeducation with regard to panic attacks and coping skills it is important to convey the role of panic and physiological changes that occur and how they are intertwined, so that one can properly adapt.
How Progress will be Monitored/Tracked
Due to the nature of anxiety and depression, self-report measures will be utilized to monitor Steve’s progress. An ongoing self-monitoring can develop into more objective awareness (Barlow, 2014). This development aides the therapist in getting a clearer picture because the responses change from one’s like “I feel horrible. This is the worst it has ever been—my whole body is out of control” to “My anxiety level is 6. My symptoms include tremulousness, dizziness, unreal feelings, and shortness of breath—and this episode lasted 10 minutes.” The Daily Mood Record is an example of a self-report measure that can be used to monitor levels of anxiety, depression, and worry about panic. This can also be done by the client making a daily journal for his/her treatment. Due to Steve’s task-oriented behavior, he should not yield any problems completing this type of measure. Additionally, it may benefit Steve to note triggering events, the cognitions, behavior, and emotions related to the event and how often and what type of tools he uses to cope. This will allow the therapist to check-in with what Steve has learned and how he has changed throughout the course of treatment. This can be checked each week.
For a more in-depth measure of the anxiety there are several standardized self-report inventories that can be used. “The Anxiety Sensitivity Index and the Multidimensional Anxiety Sensitivity Index–3 have the additional benefit of being standardized and widely accepted as a trait measure of threatening beliefs about bodily sensations (Barlow, 2014). Moreover, the indices have good psychometric properties and the ability to differentiate panic disorder and agoraphobia from other anxiety disorders.
For depressive symptoms, the Beck Depression Inventory-II is a commonly used standardized measure. This standardized measure is able to discern symptoms of depression, including the affective, cognitive, behavioral, somatic, and motivational components, as well as suicidal wishes (Barlow, 2014). Using this measure as opposed to the Daily Mood Record gives the therapist more insight into the cognitive functioning of the client. Ultimately, a combination of standardized measures may be more beneficial along with the addition of a journal or Daily Mood Record which can be collaboratively discussed with Steve.
Interventional Strategies and Any Outcome Literature Relevant to the Problem
Steve will benefit from cognitive therapy. Cognitive-Behavioral Therapy (CBT) has shown to be effective in the treatment of anxiety and depression. In one study, a meta-analysis supported the effectiveness of CBT for panic disorder and depression, in comparison to, pharmacological or combination treatments (Butler et al.2006). A combination of cognitive restructuring with interoceptive exposure showed the strongest effect and is standard practice for the treatment of panic disorder. Given Steve’s history of depression, CBT would especially be beneficial for its long-term effectiveness after the cessation of treatment and the prevention of relapse. Steve shares several qualities of an ideal client that can benefit from cognitive therapy which include his level of awareness, ability to carry out responsibilities, is employed, does not show excessive anger towards himself or other, and is able to identify precipitating events for depressive episodes (Barlow, 2014).
With CBT as the model of treatment, cognitive restructuring and interoceptive exposure techniques will be utilized. Cognitive restructuring will be engaged through record keeping, positive self-talk, and mindfulness training. This will help Steve not only increase his awareness of distorted thoughts, but also how he can begin to change his core beliefs and automatic thoughts. Interoceptive exposure will allow Steve to extinguish his conditioned anxiety and learn that he can survive the anxiety. Moreover, therapist-guided imagery can be used to help induce the physical responses. Going through a hierarchy of fear Steve will adjust to each situation starting from the least feared situation, to the most feared situation.
Contextual/Environmental Factors and Issues Related to the Therapeutic Relationship
Steve appears to be an open and motivated individual, evidenced by his self-referral for therapy and his willingness to disclose personal information. Therefore, Steve shows a participative disposition for engaging in treatment. Nonetheless, there are some factors that may present themselves to be barriers. For instance, Steve has developed already begun to reduce or completely cut out things such as free time and eating meals; thus, he may consider going to a session something he needs to cut out when taking on many responsibilities. Steve displays “people pleasing” behavior at times, as evidenced by his concern that his employees won’t like him if he gives them more work. If Steve fails to complete homework given, he may choose not to come to a session for fear of displeasing the therapist. Steve also does not appear to have a strong support system based on how he describes his relationship with his parents as “extremely poor” and he noted experiencing the marriage as stressful.
Through a humanistic approach showing empathy, normalizing, and being collaborative, a strong therapeutic alliance can be established. It may be helpful to also validate Steve’s feelings whenever possible. This will aid Steve in feeling more comfortable and supported throughout the treatment process.
Weekly homework assignments will be given; however, determining the parameters of the homework assigned will be a collaborative effort. Initially, homework will be to refine goals and start some basic monitoring of his behaviors to increase awareness of his current situation and determine what is important to work on. Homework may include some behavioral experimentation. For instance, one time where he thinks someone will let him down; instead of eliminating the opportunity for the individual to help, delate the tasks to the person and monitor his reactions. Setting aside some time each week to go to the gym or do some causal reading is another type of homework activity that Steve can benefit from to start prioritizing himself.
- Barlow, D. H. (2014). Clinical handbook of psychological disorders: A step-by-step treatment manual (5th Edition). New York, NY: Guilford Press.
- Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17-31. https://thechicagoschool-CHI.on.worldcat.org/oclc/107536365
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