Ellen also completed the Beck Anxiety Inventory (Beck, 1988) and the Fear Questionnaire (Marks and Matthews, 1979). She did not show any significant score on the anxiety inventory, scoring just 4 – these symptoms relating to specific incidents in the week. Ellen said she did not suffer with any tension as a matter of course in everyday life. Similarly Ellen did not score highly on the Fear Questionnaire either except for the specific situation of being in the store from which she was dismissed. In this case she scored maximum in terms of avoiding the situation. She also described how she did not think she would have any success at all in going in there. Ellen described a supportive family set up that she said was “nothing other than normal” – the family were financially comfortable and Ellen had the two jobs for vocational reasons rather than financial necessity. Her daughter is 26 years old and works in a shop in the town also and her husband is a long distance lorry driver. Relationships within the family are described as warm and happy and she also has a good network of friends locally. Ellen’s mother and father are deceased and she has no siblings, but Ellen describes her upbringing as “happy” and “usual” with no problems as such – similarly she enjoyed school and had no problems there although did not achieve a high level of academic success. Ellen is not worried about that, however, and said she was pleased with how her life had turned out. Ellen is not on any medication at all and does not wish to be on any – preferring to talk about her problems instead, hoping that this will help.
Ellen was also asked to keep a record of her thoughts and feelings by using a recording sheet (see Appendix A). She found that this was difficult and had not been able to get used to writing the sheets provided. After telephoning me it was decided that simply using a small diary book and writing down events significant to her could be used in the next session to tease out the thoughts and feelings. The use of idiosyncratic diaries has been studied extensively but is specifically mentioned in Greenberger and Padesky (1995) where there are some guidelines on getting patients to write thoughts and feelings in their own words rather than using jargon such as “depressed” or “anxious”. Her cognitions appeared to centre on worrying thoughts about her reputation in work. Ellen said she worried that people would remember the incident of being dismissed as it was in the press and worried that people might think “maybe there was something in it.” Or “there’s no smoke without fire.” She thought that if she was in the store in question people might talk about her and these thoughts were distressing, although she does recall colleagues being very supportive at the time.
In compiling a list of problems for Ellen it appeared that worry about her reputation was her main worry. She also felt worried that she would have to give up work in order to avoid this. She had already discussed this with her current manager who told her that doing this would “just reinforce her worries and make them worse” and that she was a good worker and wanted her to stay. We did discuss the relationship between her distressing thoughts, resulting physical feelings, behaviour and that avoiding issues would indeed reinforce her thoughts. The use of a small portable whiteboard to provide diagrams of this idea and later for use in describing a formulation proved invaluable in this case.
As part of Ellen’s assessment she was given her first homework exercise as being to go in to the store in question in another town. Ellen described that her fear was centred on the store in her hometown where this incident occurred, and that this was not a problem in any other store. Ellen said, for example that she had not been to this store at all in any location for the past three years, but was visiting the town of Caernarfon this week. It was decided to confirm this by asking Ellen to go in to the store to see if this was a problem for her. Guided imagery (see Padesky and Greenberger, 1995) was used in this session to practice and predict how she would feel going into the stores in Caernarfon and in Pwllheli. Using self-rating scales again Ellen predicted that there would be no problem at all going in to the store in Caernarfon but felt that going in to the store in Pwllheli would be very stressful. Indeed, Ellen reported back to the next session that there was no problem with going in to the store in Caernarfon at all confirming that her fears and anxiety symptoms seemed to be specific to the store where the incident took place.
Formulation
Ellen did not feel she was anxious as a rule, but felt that she did “over-worry” about the thoughts she had in work – she felt that this problem began with the incident in the department store. In the absence of any obvious precipitating factors from early history and development, and after discussing this in supervision sessions, it was felt that the incident itself was so traumatic and high profile that it is not surprising that Ellen has worrying thoughts or feels stressed about this when certain comments are made in work. Padesky and Greenberger (1995) discus the notion of “hot thoughts” and comments which Ellen interprets as critical of her in work would seem to fit with this description. Beck (1976) describes a model of the development and maintenance of emotional disorders. From supervision this seemed to be the most useful model to choose in developing a formulation of the situation with Ellen and her distressing “hot thoughts” in work situations - see diagram (a) below
Diagram (a) Beck (1976) Development and Maintenance of Emotional Disorder
Collaboration with Ellen resulted in a formulation that differed in aspect to the one described by Beck – and in supervision it was felt it was important to clarify and justify this. It was important for therapy to be idiosyncratic and this way is more meaningful to Ellen who wanted to separate the physical symptoms and add thoughts in on the diagram. This showed how therapy could progress and made the explanation for what was happening to her relate to the therapy that would follow – see diagram (b) below.
Diagram (b) Ellen’s Case Formulation
Treatment Plan
The treatment plan would involve the re-evaluation of Ellen’s beliefs. There would also be some work to do on Ellen’s fear of going into the local department store where the incident took place – this would include some graded exposure and work on controlling anxiety symptoms and challenging negative thoughts in vivo. A typical Agenda for sessions can be seen in Appendix B, where a template was used and items added for that session at the start in collaboration with Ellen. A letter sent to Ellen’s GP describing the assessment and treatment details is included as Appendix C.
Interventions
Ellen’s diary revealed some interesting examples of automatic thoughts that were used in sessions to re-evaluate beliefs surrounding them. “Here comes trouble!” was a comment from her manager that caused her to feel worried and anxious. The meaning behind this comment was discussed as was the way Ellen interpreted it. Ellen was able to re-evaluate this comment in that she felt it could also be interpreted as endearing. By using Socratic questioning as described by Padesky (1993a) it was possible to deduct that if Ellen was a “real” trouble maker then the originator of the comment would actually be quite unlikely to say it – in fact, Ellen agreed that it could just be an endearing comment. The fact that it was said could mean that the person making the comment thought a lot about her. The evidence for this is also non-tangible of course but Ellen was able to appreciate that re-evaluating this thought in a more realistic way could make her feel different. Similarly, Ellen was able to challenge other thoughts in a similar fashion by questioning the reality of them. For example, she questioned how likely it was that two years later people would still be talking about the dismissal incident. A transcript of a typical exchange during the therapy session is seen in Appendix D.
The use of guided discovery during sessions with predicted scores compared with outcome scores helped prepare for the graded exposure. Ellen predicted a higher expectation of anxiety during guided discovery then in the actual situation. Ellen fed back that this was useful for the feelings of anxiety she felt in the situations.
The graded exposure to the local department store did not actually take long and involved Ellen going accompanied by her daughter, daily in the first instance and alone the following week. This approach is described in Wolpe (1961), Wolpe (1982) and explained in Hawton et al (1989). The approach included guided imagery sessions in the GP surgery and also on the telephone if necessary, preparing for anxiety symptoms. The option of telephoning the therapist to feed back about her “homework” is generally available as standard to patients referred to the CTS. Ellen used self-rating during imagined exposure. She predicted that she would score 8 in anxiety feelings when entering the store accompanied by her daughter, where 0 was relaxed and 10 was the worst anxiety it could be. She also scored 8 in rating her predicted success in doing this task. In vivo, Ellen’s scores were much better. She did use the controlled breathing and reported remembering her challenges to some of her thoughts. Ellen scored 4 on the self-rating scale and scored 0 (zero) on her confidence of doing the task. The scoring of this would continue throughout treatment. Ellen was to repeat this every day during her lunch break. Another issue arising from supervision in this aspect of the treatment was that Ellen might have been using her daughter as an avoiding mechanism as opposed to a co-therapist! It was suggested that going in to the store alone would be the next step. Ellen telephoned to say she wanted to try going in to the store alone the next day and, by telephone, we prepared for this. Ellen was reminded of the importance of staying in a feared situation until the anxiety has dissipated. Ellen also agreed that this was to be done several times to enhance the effect. Ellen also used the checklist “Ten Rules for Coping With Panic” by Mathews, Gelder and Johnston (1981) – see Appendix E. Ellen also used a controlled breathing exercise as described in Greenberger and Padesky (1995) to alleviate shallow breathing as a result of Ellen’s stressful thoughts – along with an explanation about the physiology of the carbon dioxide/oxygen imbalance which occurs as a result of shallow breathing. This helped Ellen, as she was able to practice this away from the sessions.
The Role of Supervision
The use of supervision with this case was very important. The justification for adaptation of an existing model by Ellen to fit with her feelings was useful. Pwllheli is also in a rural area, where there is a shortage of supervisors. Whilst it was possible to arrange face-to-face supervision on a monthly basis there was also use of Internet (MSN Messenger) and e-mail supervision. This is something that has been discussed by the professional body BABCP – Lewis (1999). The use of guided imagery/discovery and prediction scores was an aspect of this case that was borne out of supervision sessions. The importance of this is described by Milne (2003) who concluded that supervision in CBT was effective, and that transfer of skills from supervision to therapy sessions was marked.
Conclusion
This is an example of a case referred by general practitioner with no more information pre-initial meeting than name and address. In many ways this was not a disadvantage and as a practitioner this author feels comfortable with that, given that there is adequate supervision in place and the confidence of the general practitioner in question. Indeed, it could be said that there is something of an advantage with a referral unsullied by previous opinion, which may tempt one into following red herrings.
Ellen had not come to the attention of the psychiatric services but left untreated the stress could have continued to build and she could have ended up as such, or perhaps being placed on medication. Instead, Ellen’s prognosis is hopeful and she is continuing to do well in treatment.
This case also shows the importance of supervision in developing an idiosyncratic formulation, keeping track of time management, keeping the momentum of therapy and using co-workers. Providing it can be justified, collaboration with the patient in this way can lead to adaptation of existing models and finding something unique.
Andrew Lancelot Words: 2928
References
Beck, A.T. (1976) “Cognitive Therapy and the Emotional Disorders.”, International Universities Press, New York.
Beck, A.T., Epstein, N., Brown, G., & Steer, R.A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893-897
Greenberger, D. and Padesky, C.A. (1995) “Mind Over Mood: Change How You Feel by Changing the Way You Think.” New York, Guilford.
Hawton, K., Salkovskis, P.M., Kirk, J. and Clark, D.M. (1989) “Cognitive Behaviour Therapy for Psychiatric Problems.” Oxford University Press.
Lazarus, A.A. (2000) “Multi-modal Replenishment.” Professional Psychology – Research and Practice, 31(1), 93-94
Lazarus, A.A. (2000) “Multi-modal strategies with Adults.” In. Carlson, J. and Sperry, L. (Eds.) Brief Therapy with Individuals and Couples. (pp.106-124). Xvii, 571pp.
Lewis, K. (1999) British Association of Behavioural and Cognitive Psychotherapies’ Annual Conference Report – Bristol ‘99
Marks, I.M. and Matthews, A.M. (1976) “Brief standard self-rating for phobic patients.” Behaviour Research and Therapy, 17, 263-267
Mathews, A., Gelder, M.G. and Johnston, D.W. (1981) “Agoraphobia: Nature and Treatment.” Tavistock Publications, London.
Padesky, C.A. (1993a) “Socratic Questioning: Changing Minds or Guiding Discovery?” Keynote address at the meeting of the European Congress of Behavioural and Cognitive Therapies, London.
Padesky, C.A. and Greenberger, D. (1995) “A Clinician’s Guide to Mind Over Mood.” New York, Guilford.
Palmer, S. and Dryden, W. (1994) “Counselling for Stress Problems.”, Sage.
Williams, C., Williams, S. and Appleton, K. (1997) “Mind Maps: An Aid to Effective Formulation.” Behavioural and Cognitive Psychotherapy, 25, 261-267
Wolpe, J. (1961) “The systematic desensitisation treatment of neurosis.” Journal of Nervous and Mental Diseases
Wolpe, J. (1982) “The Practice of Behaviour Therapy.”, (3rd edn.). Pergamon, New York.
Appendices
A – Thought Record (from Mind Over Mood – Greenberger and Padesky)
B – Agenda for the Sessions
C – A Letter to Ellen’s GP describing Assessment and the plan for therapy
D – Transcript of Part of Therapy Session
E – Ten Rules For Coping With Panic
Appendix B:
Agenda
- Homework/Exercises Review
- Time and Date for Next Session
Ffon: 01758 614624
Gwasanaeth Triniaeth Cymuned
Ffordd Ala
Pwllheli
LL53 6PW
11th April 2003
Dr. Robyns-Owen
General Practitioner
Treflan Surgery
Cardiff Road
Pwllheli
Dear Dr Robyns-Owen
Re: Mrs. Elizabeth Larkin, Gwynfa, Glan Cymerau, Pwllheli, Gwynedd.
Thank you for referring this lady to me. I am now in a position to write and update you about the assessment and treatment plan, and the beginning of the therapy process.
Mrs. Larkin was referred for work related stress and anxiety. She did not score highly on the Anxiety inventory or Fear questionnaire. After assessment it would appear that her stress symptoms are being caused by her interpretation of some comments made to her in work as being critical of her. This would cause her physical and psychological distress and is linked to the incident from her past where she was dismissed from Woolworth’s.
There is a marked fear of going back in to the Woolworth’s store in Pwllheli. Mrs. Larkin has expressed a wish to overcome these fears and engage in psychotherapy to re-evaluate her thoughts and beliefs regarding the stressors in her workplace. This will involve some graded exposure work and also some cognitive therapy to re-evaluate her thoughts and beliefs on the matter.
I will write and update you further when Mrs. Larkin has engaged in therapy – if you have any further questions please do not hesitate to call me on the telephone number above.
Yours sincerely
Andrew Lancelot
Community Psychiatric Nurse
Appendix D: Transcript of an Example of an Exchange in Therapy Session: