a thesis submitted to the university of birmingham for the...
TRANSCRIPT
A Thesis Submitted to
The University of Birmingham
For the Degree of
Doctor of Clinical Psychology
Volume II
By Marc Desautels
School of Psychology
University of Birmingham
Septembre 2008
University of Birmingham Research Archive
e-theses repository This unpublished thesis/dissertation is copyright of the author and/or third parties. The intellectual property rights of the author or third parties in respect of this work are as defined by The Copyright Designs and Patents Act 1988 or as modified by any successor legislation. Any use made of information contained in this thesis/dissertation must be in accordance with that legislation and must be properly acknowledged. Further distribution or reproduction in any format is prohibited without the permission of the copyright holder.
Overview
This thesis is submitted in partial fulfilment of the requirement of the degree for
Doctor of Clinical Psychology at the School of Psychology, University of
Birmingham. The thesis consists of two volumes.
Volume I
This volume comprises of two parts. The first part is a review of the literature that
has contributed to the understanding of the role that siblings play in the development
of emotion regulation. The second part is an empirical study that investigates the
experience of growing up with a sibling who has a learning disability. The literature
review put forward the argument that siblings play a significant role in the
development of emotion regulation. This paper has been prepared for submission to
the journal Family Processes. The empirical study utilises qualitative methodology to
examine the experience of eight people who have a sibling who has a learning
disability and how this has impacted on their life, when they were children and now.
This paper has been prepared for submission to the British Journal of Developmental
Psychology. The Public Domain Briefing Paper is also submitted in this volume.
Volume II
Five Clinical Practice Reports (CPR) are presented in this volume. The first report
details the case of a man with a learning disability, presenting with challenging
behaviours, formulated from a psychodynamic and cognitive perspective. The second
report is a service evaluation of an anxiety management group for people with
learning disability. The third report details the treatment of a nine-year old girl with a
bird phobia. The fourth report is a case study on a seventy-two-year old man
presenting with cognitive difficulties, discussed from a systemic approach. The fifth
report was assessed orally and so the abstract is presented in this volume.
All names and identifying features have been changed to ensure confidentiality.
Acknowledgements
I wish to express my thanks to all my participants for giving me their time and sharing
their stories with me.
To my supervisors, Dr Gary U. Law and Dr Biza Kroese not only for their help and
guidance but also for their support and enthusiasm.
Thank you also for my partner Kevin, without his constant support and devotion, I
would not have got through this intact. Thank you to my parents for their faithful
encouragements and confidence in me. Finally, thank you also to my cat, Maurice,
for keeping journals open at the right place with his paws.
Contents of Volume I
Literature review paper: Page 1 What role do sibling relationships play in the development of emotional regulation? Introduction Page 2 Methodology Page 6 Siblings and Emotion Regulation Page 13 Discussion Page 22 Clinical and Research Implications Page 26 Conclusion Page 29 References Page 31 Empirical research paper Page 35 The experience of growing up with a sibling who has a learning disability Introduction Page 36 Method Page 40 Reflexivity Page 44 Findings Page 45 Discussion Page 62 Conclusion Page 69 References Page 70 List of Tables Table 1 Page 8 Table 2 Page 42 List of Figures Figure 1 Page 23 Figure 2 Page 62 Public Domain Briefing Paper Page 75 Appendices Page 80
Contents of Volume II
Clinical Practice Report 1: Psychological Models Page 1
Martin
Clinical Practice Report 2 : Small Scale Service Related Project Page 31
Anxiety management group programme for people
with learning disabilities- the sum is larger than its parts.
Clinical Practice Report 3 Page 52
The treatment of a bird phobia with a nine-year old girl.
Clinical Practice Report 4 Page 76
Psychological assessment of a 72-year old man
initially presenting with cognitive difficulties.
Clinical Practice Report 5 Page 96
The assessment and formulation of a 49 year-old man
presenting with depression.
Contents of Volume II
List of Tables
Clinical Practice Report 2 Page 31
Table 1. Summary of session agendas. Page 38
Table 2- GAS raw scores Page 39
Clinical Practice Report 3 Page 52
Table 3- SCAS scores Page 57
Clinical Practice Report 4 Page 76
Table 4 Summary of Scores Page 83
Contents of Volume II
List of Figures
Clinical Practice Report 1 Page 1
Figure 1- Martin’s triangle of conflict Page 7
Figure 2- The triangle of the person Page 12
Figure 3- Perpetuating factors Page 21
Clinical Practice Report 2 Page 31
Figure 4- Anxiety thermometer results Page 39
Clinical Practice Report 3 Page 52
Figure 5- Hierarchy of fear Page 55
Figure 6- Formulation Page 58
Figure 7- Tricia’s ratings Page 65
Clinical Practice Report 4 Page 76
Figure 8- Ron’s formulation in family situations Page 91
Appendices Page 97
Clinical Practice Report 1- Psychological Models Martin Abstract
This clinical practice report examines the case of Martin who is a resident of Iliad
House and has a learning disability. Martin was referred to the Psychology Service
because of a series of incidents in the community and at the home where he became
aggressive and at times physically violent. The problems presented by Martin are
examined through two formulations, a psychodynamic one and a cognitive-
behavioural one. The psychodynamic formulation explores Martin’s relationship
patterns and highlights the conflict between his anger at carers for not giving him the
care he feels he needs and his dependency on the same carers for receiving care. This
is done using Malan’s triangles (1995). The cognitive-behavioural formulation looks
at his thinking patterns and how he has developed a way of construing the world
where he believes that people cannot be trusted. This is done by using the model
suggested by Dudley & Kuyken (2006). The two formulations are discussed and
criticised. Their shortcomings, in terms of including the learning disability factor in
their formulation of the issues, are also considered.
1
Background to the case
Referral
Martin (not his real name) was referred to the Psychology Service by his Community
Nurse from the People with Learning Disability Service. In the referral letter, the
Community Nurse states that Martin has issues around his anger and finds it difficult
to control his aggression. He further reports, “There have been several incidents in
the local community where Martin felt he was being stared at and became abusive and
angry frightening several elderly women.” The letter also describes an incident where
Martin attacked a man at the local newsagents and the shopkeeper had to intervene
otherwise Martin could have been seriously hurt. Martin is now not allowed to go out
alone due to concerns about his behaviour. He has also become aggressive with staff
members.
Background information
The information gathering for the assessment was conducted over a period of several
weeks. I firstly interviewed the Community Nurse who referred him as well as the
Psychiatrist who follows him. Interviews were also conducted with the Home
manager, the care staff at Iliad House, the home where Martin resides, and with
Martin himself. I also read through the Psychiatrist’s file. It is important to note that
the information contained in Martin’s files is relatively recent. It would appear that
the Martin’s file from the hospital where he lived for many years was lost and
2
therefore a large part of Martin’s history, social and medical, is unknown. I also
observed Martin at Iliad House.
This is a summary of the information that was collected during the assessment.
Martin was born in 1970 and but not much is known about his family. The
information about his childhood is rather sparse and it appears that he was
institutionalised from his early teens. When the hospital where he was closed, he was
re-housed in a hostel where he stayed for a few years before moving to Iliad House
five years ago. Before I met Martin, the Community Nurse described him as very
‘institutionalised’ (meaning highly dependent, rigid in his routine, no sense of
initiative and a strongly suspected history of abuse) and the Psychiatrist concurred
adding that he was most afraid of ‘being locked up again’.
There are notes in the home file that suggest he still saw his mother and sister on a
regular basis but all visits stopped about four years ago when his sister accused him of
bullying their mother. The notes also report that Martin appeared to be afraid of his
family. Mother and sister lived together and after a move to a different address did
not inform Martin of their new contact details. According to the staff at Iliad House,
Martin does not have any contacts with his family. The staff at Iliad House have all
been employed by the housing association for less than three years and have never
met with either Martin’s mother or sister.
3
According to Martin’s psychiatric file, not only has he a diagnosis of moderate
learning disability but also one of schizophrenia. He was assessed for pervasive
development disorders but did not appear to be on the autistic spectrum.
Martin presents with a mild to moderate learning disability. He is rather sociable and
appears to enjoy meeting new people. He has good verbal abilities and can express
himself in a limited but effective way. His conversations are often one-sided and
amongst the favourite topics covered are the weather forecasts, cigarettes and bus
routes. It is rather difficult to assess whether Martin has a good memory or not; he
often claims to have forgotten what the previous week’s or day’s events were,
especially if there was an incident of aggression, but will sometimes tell things that
happened a few years ago. Martin does not appear keen on volunteering such
information and will often change the subject when questioned further. Martin
enjoys wearing trendy clothes and is concerned by his physical appearance; although
staff have mentioned to me that he often needs to be reminded to take a shower or
change his clothes. He enjoys smoking and going to the pub and appears especially
fond of doing these activities with his key worker.
The presenting issues
From my interviews with various staff and with Martin and my observation sessions,
it appears that he has the following difficulties:
Martin believes that people are staring at him with aggressive intentions and he feels
that people around him want to molest him. This makes him angry and he then feels
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the need to retaliate. For example, he told me that some members of staff do not like
him and that they would hit him if they had a chance. He added that he must defend
himself against them otherwise he might get seriously hurt. The problem has also
occurred in the community but has not repeated itself since Martin has been escorted
on outings. Martin, indeed, told me that “it’s a dangerous world out there” and that he
needs to look after himself otherwise people will steal his money or cigarettes.
Care staff have also reported that there is an element of competition for attention
between him and two other residents of Iliad House (Jake and Marty); from my
observations, I noticed that when a member of staff is working individually with
another resident, Martin will often interrupt their sessions for what appears to be
trivial reasons (e.g. asking about weather forecast or who is on shift later today). I
noticed also, on fewer occasions, that individual sessions with Martin were also
interrupted by other residents.
Martin appears to have a very low threshold of frustration and as a consequence he
gets easily angered by other residents. Martin has also been caught bullying Jake and
Marty, repeating endlessly the only sentence Jake is capable of saying and asking
Marty, who suffers from double incontinence, if he has “shat in his pants, again.”
It has been reported by the home staff that Martin has the habit of wearing several
layers of clothing. For example, he will wear four or five pairs of underpants as well
as layers upon layers of t-shirts. This has been an area of friction between staff and
Martin as the former often feels it is not an appropriate way of dressing. Martin says
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he does not want to get cold. The Community Nurse also mentioned that he wears his
belt so tightly that he has begun to develop pressure sores around his waist.
Martin appears motivated to change his behaviour. He told me that “this has to stop
because it makes me unhappy”. I used a non-standardised tool developed by an
assistant-psychologist (a collection of pictures cut out from magazines representing
various people with different facial expressions) with Martin. He was able to identify
most emotions depicted on the pictures. Martin also appears able to link feelings to
various events; we did a non-standardised cognitive mediation task where I discussed
simplified scenarios based on real-life events and Martin was able to tell me how he
would feel or how he had felt when these events occurred. His emotional vocabulary
is limited but adequate to express basic feelings.
I will firstly attempt to formulate Martin’s problem using a psychodynamic
perspective. This will then be followed by a cognitive-behavioural formulation. A
critical appraisal of the two formulations will conclude this assignment.
Psychodynamic formulation
The following formulation relies on the triangle of conflict and the triangle of the
person as described by Malan (1995). The triangle of conflict shows the interactions
between the defence mechanisms the client uses to protect his ego against the anxiety
generated by the hidden feelings. Malan states that the hidden feelings can be
directed at one or several points of the triangle of the person. This triangle shows the
various relationships of the client with his/her parents and siblings, other people and
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the therapist. This latter relationship is also described as a transferential relationship
where feelings belonging to a previous relationship (usually the one between client
and parents/siblings) is transferred onto the therapist. This is also known as the
‘unreal’ relationship as the pattern of behaviour displayed does not take a full account
of the reality of this current relationship. (Gelso and Hayes, 1998).
Triangle of conflict
Hidden feelings: Fear of disintegration, fear of rejection, anger at being disabled, fear of being unwanted or unloved.
Anxiety: Not being cared for and fear of showing anger in case the level of care is even more reduced.
Defences Projection, projective identification, layers of clothing and secondary handicap.
Figure 1- Martin’s triangle of conflict
Defences
Martin appears to be using a variety of defence mechanisms in his interactions with
people. Some of these defences have however become maladaptive and are distorting
Martin’s perceptions.
Martin uses projection, which can be define as “attributing our more difficult and
unacceptable feelings to others” (Bateman, 1998, p. 46). Martin is projecting on other
people his unwanted aggressive impulses and feelings. As a consequence he feels
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constantly persecuted and under attack. This seems to happen in various
circumstances and the belief that members of staff are persecuting him through their
requests is an illustration of this.
He also uses projective identification, which occurs when unwanted feelings are
projected and ‘deposited’ into another person and through their interactions, the
recipient of those feelings is made to feel, think or behave in a manner congruent to
these projected feelings (Thomas, 1996). This seems to happen in his interactions
with other residents. In lay terms, Martin often winds up Jake and Marty and makes
them attack him. Jake and Marty have been described by staff as rather placid and
friendly characters; the aggression they sometimes show towards Martin is described
as out of character.
The use of this latter defence mechanism is also illustrated in the belief that people are
staring at him. Both staff members and the community nurse have reported that
Martin actually stares at people when on outings. Martin seems to be making people
behave in a manner congruent to his phantasy.
Through the defences of projection and projective identification, Martin gets rid of his
unwanted feelings and impulses. He is not capable of containing them and tries to
evacuate them as quickly as possible. These projections are unfortunately not always
processed by people around Martin; they are not being contained or made more
manageable. In fact, recipients of Martin’s projections tend to act upon them, because
they are frightening, and the projection can go back full circle to Martin. Martin’s
distress is not alleviated but increased as the recipients have added their own fear and
8
aggression. Thus Martin is often being taught that his impulses are so dangerous and
frightening that they cannot be contained by other people.
Martin’s defences are helping him to protect himself by managing his anxiety but
have often made his situation worse.
I would suggest that the layers of clothing worn by Martin might be another defence
that could be linked to the previously discussed defences through Bion’s concept of
containment. Bion (1962) explains that babies will project their emotions onto their
mothers who will them ‘contain’ them and feed them back to the babies in a more
tolerable form. This enables babies to learn to ‘contain’ themselves as opposed to
developing a fear of disintegration from overwhelming emotions. Martin might be
using the layers of clothing to contain himself and prevent disintegration. He might
unconsciously feel that this is needed as people around him constantly fail to contain
his emotions.
Martin uses another defence mechanism known as secondary handicap, which was
originally described by Sinason (1992). This mechanism is used by the individual
when s/he exaggerates the learning disability in order to protect the self against the
painful feelings of being ‘different’. By pretending to have a more profound learning
disability, the individual avoids thinking about his or her circumstances. One of the
consequences of this defence mechanism is that it prevents Martin from thinking or
reflecting on current situations and gain knowledge or wisdom from them. The
anxiety here is a fear of thinking. Thinking, in Martin’s case, would mean
acknowledging the reality of his disability, the pain experienced throughout his life
9
and the difficulties of his current situation. These are, I would suggest, some of his
hidden feelings.
Hidden feelings
Based on my interviews with staff, my observations and my interactions with Martin,
I believe that the content of the hidden feelings revolves around anger and fear. I
would suggest that Martin fears his own feelings and impulses as they appear so
dangerous- they cannot be contain by other people- that they could annihilate or cause
him to disintegrate (hence the need to be physically ‘contained’ by layers of clothing).
This would link with the diagnosis of schizophrenia made by the psychiatrist.
Due to the lack of information contained in the file and the limited amount of material
Martin is able to provide, it is rather difficult to elaborate what the hidden feelings
might be. Leiper (2006) has suggested that a psychodynamic formulation should
always be hypothetical; the following elaboration on Martin’s feelings is even more
hypothetical than the previous discussion.
Martin’s hidden feeling might also be about a fear of rejection because of his
disability, which might find its origins in his relationship with his mother and family.
The arrival of a disabled baby has a massive impact on the parents and can make the
parent-infant relationship more difficult (Miller, 2004) and even lead to rejection. A
hostile relationship where people are rejecting towards his needs leaving him feeling
abandoned and uncontained, and angry to have to look after himself alone, might have
been internalised by Martin. This would have left Martin in a double bind that might
10
still be enacted today; he is still not supposed to express anger towards people he
depends on as they might give him even less care (which they sometimes do as a form
of punishment) and has therefore to evacuate his anger using an alternative method.
Anxiety
The anxiety that prompts the use of the defences would stems from this conflict where
Martin feels angry at staff (and past parental relationships) for not responding to his
needs and his dependency on them for care. At an unconscious level, Martin knows
he needs them but feels they are not looking after him properly and feels angry at
them as a result. This creates anxiety which he manages by the defences discussed
above.
The dynamics between the three corners
At the level of hidden feelings, Martin fears rejection. He also feels unwanted and
unloved. There are also feelings of anger at this situation. This creates anxiety as
Martin does not feel that he gets the care (or acceptance/love) he should be getting but
knows unconsciously that if he were to show anger, the little amount of care he gets
could be jeopardised (see figure 1). Martin copes with this anxiety by using the
various defences detailed. This has a protective effect for himself as he projects and
deposits his anger and fear in other people. This was somehow demonstrated to me
when interviewing Martin as he said that he did not understand why he was being
punished when it is “all the other residents’ fault”. In Martin’s mind, the evacuation
of these difficult feelings leaves him with the conviction that he is a loveable but
victimised resident.
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Some of the defences Martin uses are working well and shows a clear link between
the hidden feelings and the defences. For example, the secondary handicap defence is
protecting him against the anger at his disability.
Triangle of the person
Others Staff at Iliad House, people in community and other residents are all dangerous.
The Past: Older sister in control, maybe bullying. Mother or figures of authority unable to protect him. Institutionalisation where various forms of abuse might have occurred.
Therapist: Relates to me as a powerful character able to change many things for him. Positive transference.
Figure 2- The triangle of the person
The past
The information available on Martin’s family relationships is rather sparse. There is a
suggestion in the notes that Martin seems to fear his family. It also appears that his
sister played a significant part in managing Martin’s relationship with his family. She
seemed to have been in control of when the visits would occur. I would also include
in this corner of the triangle Martin’s long history of being institutionalised and the
suggestion that abuse might have occurred in this setting. This may have influenced
the way Martin experiences relationship with figures of authority.
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I would suggest that the conflict Martin is experiencing in many of his current
relationships first occurred in this section. Martin might have felt that his non-
disabled sister got more care or love when they were both leaving at home, leaving
him feeling neglected and angered. Martin would have experienced the same anxiety
where expressing openly his angered would have jeopardised the care he was
receiving. Similarly, we could hypothesised that the same dynamic was repeated
when he was living in an institution where he might have felt that other residents were
getting more care than himself.
Other
Martin’s relationships with the Staff at Iliad House are often difficult. He often
appears to feel threatened by the requests made of him and feels the need to retaliate
in a verbally or physically aggressive manner. Similarly, when Martin is out in the
community, he often feels that people are staring at him with violent intentions.
Relationships with other residents at Iliad House are also difficult as Martin accuses
them of bullying him.
The same conflict and use of defences appear to be occurring here. Martin does not
feel cared for by the staff and feels that other residents might be getting more care
than he does. This makes him angry at an unconscious level and, again, he is afraid of
showing this anger in case in makes matters worse for him. The anger is projected on
and into care staff and Martin believes they are angry at him.
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Therapist
I have only just completed the assessment phase with Martin and therefore our
relationship is still relatively new. Initially, Martin had difficulties understanding
what my role with him was. He appeared very early on to think that I was very
powerful and would be able to sort all sorts of things for him (for example, change his
medication, find him a social worker, move him to another home, make the other
residents ‘behave’, reprimand staff, etc.). The transference appears positive at the
moment and seems to revolve around a strong father figure.
In this relationship, Martin seems to be using mostly his secondary handicap defence.
I have been interviewing him on many aspects of his life and ask about his current
relationships with staff and family. I would suggest that Martin is exaggerating his
disability in order to prevent himself from thinking about the role he might be playing
in the conflicts that are occurring. The exaggerated disability might also be a way of
communicating to me at an unconscious level his needs for care and love; my
countertransference feelings have often been around the themes of feeling sorry for
him.
Combining the two triangles
The triangle of conflict can be transposed in each corner of the triangle of the person.
The same conflict between need for care and anger at not receiving it is, I would
suggest, replayed in each relationship Martin has. This pattern was originally
developed in the Past with his primary carer and family and then re-enacted with other
people. This might actually have been significantly reinforced when institutionalised
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where the care might have been regimented and not tailored to Martin’s need. If there
was abuse of any type, this would have worsened Martin’s internal conflict as he
could have been abused by the very people who were supposed to give him care. In
the relationship with me, Martin is still very much at a stage where he believes I can
provide him with the care he needs. I would predict that he will also become angry
with me when he realises I cannot provide him with all the care he wants. I would
suggest that I am also likely to become a figure of persecution.
Cognitive behavioural theory formulation
The following formulation relies on the five ‘Ps’ model as described by Dudley and
Kuyken (2006). The five ‘Ps’ are Presenting issues, Precipitating factors,
Perpetuating factors, Predisposing factors and Protective factors. This formulation
model is based on various cognitive-behavioural theory (CBT) principles amongst
which are the fact that formulations are seen as working models and therefore always
provisional. They should also offer a framework for intervention by identifying the
cognitive and behavioural mechanism at the root of the problem (Dudley & Kuyken,
2006).
The first part of this formulation model, the presenting issues, requires the therapist to
establish a clear list of problematic issues with the client; once the intervention
completed this list can be used to evaluate the outcome of treatment. The
‘precipitating factors’ describe what the triggering events are in terms of proximal
internal and external factors. The ‘perpetuating factors’ are the elements that
maintain the current problems; they are represented in a cyclical model which is
15
constituted of situation, cognitions, behaviour, physiological response and feelings.
The ‘predisposing factors’ look at how the problems have developed through the
individual’s history. Finally, the ‘protective factors’ are concerned with the
individual’s own resources and sources of support that will help with recovery. This
type of formulation appears suitable for an individual with learning disability as it
highlights the range of strengths and limitations Martin has as well as the nature of the
presenting problems (Willner, 2006).
The amount of information Martin is able to provide about his own cognitions is
reasonable. He is verbal but this skill is limited. He however appears suitable for a
simplified version cognitive-behavioural therapy according to the factors described by
Joyce, Globe and Moody (2006) in that he has the language skills and basic emotional
vocabulary. He also appears motivated to change his behaviour and can link feelings
to events.
Martin finds it difficult at times to express his feelings and thoughts effectively and
therefore it is necessary to emphasise that the following formulation stands at a very
hypothetical level.
Presenting Issues
These can be defined as follow:
• Martin gets agitated when he goes on outing as he says people are staring at
him.
• Martin gets agitated when members of staff ask him to do something.
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• Martin gets upset when other residents are getting attention.
• Martin gets wound up when other residents are teasing him.
• Martin gets aggressive verbally and physically when he is agitated.
Precipitating factors
This section is concerned with Martin’s beliefs about the events that are triggering his
reactions. This follows an ABC model (activating event, beliefs and consequence).
The activating events are varied but share similarities. Events that have triggered
physically violent responses from Martin have often started when a member of staff
asked Martin to do something. For example, moving along on the sofa to make room
for another resident, take a shower, closing the back door, and many others. Other
events have occurred when other residents have teased Martin or when staff were
working one-to-one with someone else. Events that occurred in the community
happened when Martin was in the company of unknown people; for example, when
travelling by public transport or in a shop. In this latter case, Martin constantly
watches people to see whether they are looking at him. Requests from staff,
‘demands’ from other residents and proximity to unfamiliar people have all triggered
reactions from Martin.
Martin’s beliefs often appear revolve around the conviction that people are
threatening him. For example, when staff are asking him to do something, Martin
seems to think that they are being aggressive towards him and that they might even be
physically violent with him. Similarly, when other residents are teasing him, he also
17
appears to think that they are bullying him. In the community, Martin seems to
believe people are staring at him and that they might attack him.
I interviewed Martin on a few occasions when a violent incident had occurred with
members of staff. During those interviews, I used the method recommended by
Dagnan and Chadwick (1997) where the emotional consequence after the event was
clarified, then the antecedents were explored (I asked Martin what had happened) and
finally his beliefs about the situation were discussed. I then attempted to link the
latter with the consequences. On one such occasion, Martin was able to tell me that
he was angry because Linda (care staff) had told him off for leaving the door open.
He said he believed she was angry and was going to punish him, which made him feel
angry for being treated so unfairly. After asking the member of staff what had
happened, she told me she had simply ask Martin to close the back door when he goes
out for a cigarette. The attack, she said, came as a surprise.
On another occasion, Martin came to see me at the clinic by public transport. He was
accompanied by his key worker. When they arrived, he was clearly anxious; he then
told me that people on the bus were looking at him in a funny way. He told me he did
not feel safe and thought something might happen. When questioned further, he said
there were two ladies with tightly held umbrellas who were going to poke him with
them. The key worker commented to me later that Martin had been staring at two
women on the bus and had clearly intimidated them.
During interviews with staff and key workers, they gave me numerous other examples
of similar situations.
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The consequence of this belief system is that Martin not only becomes angry as he
believes that people are being aggressive towards him but also he appears to have
learnt to pre-empt the aggression by being violent himself, verbally or physically.
Martin appears to believe that people are bullying him or being aggressive towards
him. A simple and normal request from staff is seen as a personal attack upon his
person. The triggering events are in themselves rather innocuous but Martin’s
interpretation of these events explain his reaction.
Perpetuating factors
This part of the formulation looks at how the problems are being maintained by
examining the circular relationship between Martin’s various responses and how they
can spiral into a self-reinforcing schedule. To illustrate this part of the formulation, a
genuine incident which happened at Iliad House with Martin will be used (see figure 3
below).
Situation
This is the triggering event. In this case, a member of staff asks Martin if he had a
shower this morning. Martin says ‘yes’. The member of staff, whilst escorting
another resident to the bathroom, notices that the shower cubicle and tray are dry and
therefore have not been used recently. This member of staff goes back to Martin and
asks him to go and have a shower. This event occurred a few weeks I got involved
19
with Martin; we had a few sessions together following it where we looked in details at
what happened that morning.
Thoughts/Cognitions
Using the method suggested by Dagnan & Chadwick (1997) we initially discuss the
emotional consequence of the event and its antecedents. Martin said that he was
annoyed because he was going to be forced to take a shower, which he did not want to
do. His belief about this situation is that he is being threatened and might get
punished for lying.
Behaviour
Martin hits him.
Physiological
Martin is highly aroused and agitated. A stress response of fight or flight is activated.
Feelings
Martin told me he felt angry and cornered; he did not feel like showering on this cold
morning but he did not seem able to voice it to the member of staff. He also said he
was afraid that he might forced to have a cold shower as a punishment for lying and
not showering when told to do so.
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Thoughts They are
threatening me, they are going to
punish me unfairly.
Feelings Anger Fear
Physiological Aroused Agitated
Behaviours Hit them
Situation Staff asking
Martin if he had a shower this
morning.
Figure 3 Perpetuating factors
In this model, thoughts, feelings, physiological factors and behaviours are all
interconnected. The thoughts not only influence the feelings but also have an impact
on the behaviour and the physiological factors, which in turn also affect the thoughts.
The behaviours are also connected to the feelings; Martin hits the member of staff
because he is angry and vice-versa. The thoughts affect the physiological factors by
making Martin aroused and agitated which reinforces in turn his negative cognitions.
The role of the intervention is to break this cycle and stop the problem from
escalating. By working on the thoughts and challenging the negative cognitions, this
cycle can be broken and replaced by a more appropriate response. It aims to help
Martin link an event to its emotional response (Willner, 2006). For example, if
Martin did not construe this request as a threat he could simply say that he would
rather wait to have his shower as it is a rather cold morning.
21
Predisposing factors
The previous section looked at how the problems are being maintained. This section
of the formulation is interested at looking at the onset of the situation. It suggests that
the precipitating factors trigger deep-seated beliefs (i.e. core beliefs) about oneself
that have been learnt through formative developmental experiences. These beliefs are
connected to a range of coping strategies, or rules for living or assumptions, that keep
the core beliefs system intact through the use of compensatory strategies. (Wills &
Sanders, 1997).
In Martin’s case, this is probably the most difficult section of the formulation to
complete due to the lack of information in the file and his limited verbal abilities.
What is discussed here is based on my interviews with Martin and with the staff. I
will, however, make many assumptions in an attempt to unify his experience
Martin’s development experience
Martin had a long history of institutionalisation, which, according to the community
nurse, meant that he was maintained in a highly dependent state with a rigid routine
and with any sense of initiative erased. There is also a suspected history of abuse.
This is likely to have shaped his core beliefs. For example, maybe when Martin was
institutionalised, demands from staff might have been abusive and led to punishment
or aggression. Martin might have come to believe that any request will be followed
by an unwanted or dangerous consequence.
22
Core beliefs
Institutionalisation might have conditioned Martin into believing that people around
him cannot be trusted and will abuse or molest you at the first opportunity. Based on
my various sessions with Martin, especially those that followed violent incidents, it
appears that his core belief revolves around feelings that he can never be safe.
Rules for living/assumptions
Martin appears to be functioning according to the rule: “If I strike first I can offer
myself better protection” or “if people are afraid of me, they will leave me alone”.
Compensatory strategies
Martin maintains himself in a constant state of high arousal ready to defend himself.
The hypothesis here is that the combination of these various factors have created the
situations he finds himself in. Indeed, Black, Cullen and Novaco (1997) found that
people who maintain themselves in such a high state of arousal perceive and select
certain situational cues to fit in their internal schemas cognitive dispositions. This is
another kind of vicious circle Martin is in as people’s reactions to his behaviours and
feelings only reinforce his core beliefs and rules for living. When Martin hits a
member of staff, the rule at Iliad House is that he is not allowed to go out on that day.
Martin is in effect punished. Because Martin believes he was going to be attacked, he
does not understand why he is being punished for defending himself and sees the
23
punishment as undeserved and unfair, which then confirms his core belief that he
cannot trust or rely on people.
Protecting factors
This part of the formulation aims to highlight the personal and environmental
strengths that are preventing the problems to get out of hand. They list the resources
that might be built on during the intervention.
In Martin’s case, there are fortunately a number of strengths available to him. The
following list is not exhaustive but gives examples of relevant resources:
• The staff at Iliad House knows him well and are used to dealing with him;
• The staff is well trained and receives regular supervision;
• Martin has two supportive long-term friends in the community;
• Martin is keen to improve his behaviour;
• The multi-disciplinary team meets regularly
• The community nurse has known Martin for a long time and has a good
relationship with him.
All of the above can be drawn upon in designing and applying the intervention plan
for Martin.
24
Critical appraisal
A formulation is a framework that enables the practitioner to describe and explain the
client’s difficulties by using psychological theories (Johnstone & Dallos, 2006). This
is what I have attempted to do in my two formulations.
The two formulations share common elements that could be synthesised in a more a-
theoretical formulation. In lay terms, it could be suggested that Martin’s relationships
have often been difficult. He appears to have learnt that people are not reliable and
could even be dangerous. From this evolved a need to protect himself and the belief
that people cannot be trusted. This need for self-protection is now so powerful that it
is having an impact on all his relationships and makes him difficult to manage.
There are also significant theoretical differences between the two formulations. The
psychodynamic formulation emphasises more the relationship patterns Martin has
developed over the years starting by assumptions made about the relationship with his
primary carer (mother or other). It shows how the relationship pattern is repeated
with people around him. In contrast, the cognitive-behavioural formulation is more
focused on the thinking patterns Martin displays. It shows that Martin has developed
a way of construing the world through his developmental experience and that this
colours the way he thinks. This latter point can be used however to bridge the gap
between the two formulations; indeed the concept of transference, which can be
explained as a form of conditioning, also explains that Martin will apply a pattern
developed through another relationship on a current relationship. The way he thinks
or construes a relationship is affected by the transferential conditioning.
25
One advantage the cognitive-behavioural formulation has is that it identifies strengths
or resources that are available to the client. These can be used directly in the
intervention and also gives a positive perspective to the formulating exercise.
The psychodynamic formulation, on the other hand, has the advantage that Martin’s
presenting problems can be integrated into the one formulation. For example, the
layers of clothes he wears fits into the theoretical explanation provided by the
formulation. The cognitive-behavioural formulation does not accommodate this issue
and would probably require another formulation to explain this idiosyncrasy.
In terms of weaknesses, I would suggest that the main problem with these two
formulations is that they do not take into account the learning disability Martin has.
The two models appear to have been elaborated with the needs of a non-learning
disabled population. For example, it was impossible for me to gather much
information about Martin’s past; the files were missing and Martin does not appear to
remember much of his past to give me the information I was looking for. Therefore
the perpetuating factors, especially the thoughts and feelings, and predisposing factors
in the cognitive-behavioural formulation and similarly the ‘past’ section of the
triangle of the person and the hidden feelings in the psychodynamic formulation all
have to remain at an even more hypothetical level than in a formulation for a non-
learning disabled individual. I have tried to use the little evidence I have to support
my assumptions but this remains a weak area of the formulations.
26
This might be remedied by doing a more thorough search through the archives of the
old hospital but it would be rather expensive in terms of time and costs. The end
result might also prove itself to be disappointing in what it might reveal. The remedy
to this shortcoming might be done at an institutional level where a consistent and
effective filing system could be put in place. This could also take the form of keeping
a ‘life history’ book, which would combine photo album, scrapbook and journal for
each person.
Another aspect of these two formulations related to the previous one is that they do
not take into account of how the individual’s deficits, in other words how the learning
disability in itself, impact on the presenting issues. There is no space in the
formulations to include a physiological elements or physiological limitations that
could contribute to the behaviour. It might not be within the remit of a psychological
formulation to include these factors but they might nonetheless have a direct link to
the presenting issues. A neuropsychological element to the formulations might
remedy this shortcoming.
In summary, the two formulations demonstrate that Martin has a difficulty in
deciphering people’s intentions when interacting with him. The psychodynamic
formulation tries to explain it in terms of relationship patterns whilst the cognitive-
behavioural formulation attempts to demonstrate that the problem lies in Martin’s
thinking patterns. Martin’s way of construing the world appears to be erroneous. The
two formulation models fail however to take into account Martin’s learning disability.
However, these formulations do not claim to provide the ultimate fully comprehensive
27
answer to Martin’s issues but endeavour to provide a constructive framework to base
a sound psychological intervention on.
28
References
Bateman, A. (1998). Defence mechanism: general and forensic aspects. In C. Cordess and M. Cox (Eds.) Forensic psychotherapy: crime, psychodynamics and the offender patient (pp. 41-51). London: Jessica Kingsley. Bion, W. (1962). Learning from experience. London: Heinemann. Black, L., Cullen, C., & Novaco, R.W. (1997). Anger assessment for people with mild learning disabilities in secure settings. In B. Stenfert-Kroese, D. Dagnan, & K. Loumidis (eds) Cognitive-behaviour therapy for people with learning disabilities (pp.33-52). London: Routledge. Dagnan, D., & Chadwick, P. (1997). Cognitive-behaviour therapy for people with learning disabilities: assessment and intervention. In B. Stenfert-Kroese, D. Dagnan, & K. Loumidis (eds) Cognitive-behaviour therapy for people with learning disabilities (pp. 110-123). London: Routledge. Dudley, R., & Kuyken, W. (2006). Formulation in cognitive-behavioural therapy: ‘there is nothing either good or bad, but thinking makes it so’. In L. Johnstone and R. Dallos (Eds.) Formulation in psychology and psychotherapy: making sense of other people’s problems (pp. 17-46). Hove: Routledge. Gelso, C.J., & Hayes, J.A. (1998). The psychotherapeutic relationship: theory, research and practice. New-York: John Wiley & Sons. Johnstone, L., & Dallos, R. (2006). Introduction to formulation. In L. Johnstone and R. Dallos (Eds.) Formulation in psychology and psychotherapy: making sense of other people’s problems (pp. 1-16). Hove: Routledge. Joyce, T., Globe, A., & Moody, C. (2006). Assessment of the component skills for cognitive therapy in adults with intellectual disability. Journal of applied research in intellectual disabilities, 19, 17-23. Leiper, R. (2006). Psychodynamic formulation: a prince betrayed and disinherited. In L. Johnstone and R. Dallos (Eds.) Formulation in psychology and psychotherapy: making sense of other people’s problems (pp. 47-71). Hove: Routledge. Malan, D.H. (1995). Individual psychotherapy and the science of psychodynamics (2nd edition). London: Arnold. Miller, L. (2004). Adolescents with learning disabilities: psychic structures that are not conductive to learning. In D. Simpson and L. Miller (Eds.) Unexpected gains: psychotherapy with people with learning disabilities (pp.83-97). London: Karnac. Sinason, V. (1992). Mental handicap and the human condition: new approaches from the Tavistock. London: Free Association Books.
29
Thomas, K. (1996). The psychodynamics of relating. In D. Miell and R. Dallos (Eds.) Social interaction and personal relationships (pp.157-211). London: Sage and Open University. Willner, P. (2006). Readiness for cognitive therapy in people with intellectual disabilities. Journal of applied research in intellectual disabilities, 19, 5-16. Wills, F., & Sanders, D. (1997). Cognitive therapy: transforming the image. London: Sage.
30
Clinical Practice Report 2- Small Scale Service Related Project Anxiety management group programme for people with learning disabilities- the sum
is larger than its parts
Abstract
A group of four people with learning disabilities were recruited to take part in an
eight-week anxiety management psychoeducational programme. The programme
followed a cognitive-behavioural group approach and included elements of teaching,
relaxation, cognitive restructuring and problem solving. Progress was monitored
using the Glasgow Anxiety Scale (Mindham & Espie, 2003) and a non-standardised
‘anxiety thermometer’. Qualitative feedback was also obtained via a group evaluation
questionnaire. This report also discusses issues such as engagement and group
dynamics. Results from measures showed no changes in levels of anxiety but
participants reported benefiting from taking part in the group. It is argued that the
therapeutic experience of belonging to such a group should not be underestimated.
31
Introduction
According to the Office for National Statistics (ONS), one in six adults will
experience mental distress at any one time (as cited by Mind, 2006). Similarly, the
Mental Health Foundation estimates that 10 to 25% of the general population will
suffer from mental health disorders at some point in their life (Mental Health
Foundation, 1999). The ONS also suggest, according to their surveys, that anxiety is
one of the most common forms of mental distress in the general population.
Anxiety is also the most common forms of psychological distress in people with
learning disabilities (Deb, Thomas & Bright, 2001). Although there is a significant
body of literature on anxiety in the general population and on its treatment of choice,
cognitive-behavioural therapy (NICE, 2004), there is a surprising lack of published
studies on their applications to populations of people with learning disabilities
(Raghavan, 2004).
There are several possible reasons for this lack of research in anxiety in people with
learning disabilities; Lindsay, Neilson and Lawrenson (1997) identified three of them
as being: 1- people with learning disabilities are a devalued population and therefore
of limited interest to the clinical/research community; 2- because of their
impoverished cognitive abilities, it makes it difficult to measure whether
improvement, or lack of it, is directly linked to a psychological treatment; 3- a
potential assumption that the research findings obtained from the general population
are directly applicable to a population of people with learning disability and therefore
no need to do specific studies on this population.
32
There have been however a few studies that have shown promising results in treating
people with learning disability who are suffering from anxiety problems (see Dagnan
& Lindsay, 2004). Dagnan and Jahoda (2006) indeed suggest that there are good
reasons to recommend cognitive-behavioural therapy for people with a learning
disability in that “many of the cognitive processes that mediate psychological and
mental health problems in people without intellectual disabilities are also present in
people with intellectual disabilities” (p.92). Indeed, Joyce, Globe & Moody (2006)
have shown that people with learning disabilities who are able to label emotions, link
events and emotions and self-report can benefit from cognitive-behavioural therapy as
long as they get good support from the therapists.
Using those positive and optimistic trends and in the spirit of the white paper
“Valuing People” in providing accessible services, a group intervention for people
with learning disabilities and anxiety was designed. The group format was chosen not
only for financial reasons but also because group therapy is believed to benefit
individuals who have similar experiences and needs. Group participation offers hope,
feelings of belonging, and an opportunity to learn from the experience of others (
Yalom, 1985). There is also evidence that people with learning disabilities can
benefit from this treatment format (Mishna & Muskat, 2004).
A psychoeducational programme was designed using the main components, principles
and procedures of cognitive-behavioural therapy for the treatment of anxiety. It
roughly followed the programme designed by Kennerley (n.d.) but was revised and
adapted to be suitable for a group of participants with learning disabilities, as
suggested by Willner (2006). It included elements of education about the causes and
33
effects of anxiety and teaching on a variety of relaxation methods, as well as the
standard cognitive restructuring, problem solving, goal setting and assertiveness
training. The benefits of using a systemic approach are various; following a
structured programme enables the therapists to monitor what parts of it are
functioning well or less well and to change sections that need improving. A systemic
approach also allows easy replication by other therapists. The components of the
programme acknowledged that anxiety is a multidimensional problem and therefore
all levels (for example, physiological, social, occupational and behavioural) were
considered in the planning (Keable, 1997). The aims of the group were:
1. To enable individuals to monitor their levels of anxiety and to better manage
and cope with their anxiety symptoms;
2. To teach/advise/practice skills which can help with anxiety symptoms;
3. To make use of materials and resources for use in the group that are
‘understandable’ and ‘user friendly’; and
4. To allow individuals to share their experience of anxiety with others who
experience similar feelings.
This study aims to evaluate the effectiveness of such an intervention for people with
learning disabilities who are suffering from anxiety problems using a quantitative
approach and a more reflective approach on the processes involved in delivering such
a programme.
34
Method
Participants
Participants were recruited with the help of community nurses, psychiatrists and
clinical psychologists working in Learning Disability Services. Letters and
information sheets were sent to these professionals inviting them to refer any suitable
clients in the specified area. The inclusion criteria were simple in that clients had to
have: a mild to moderate learning disability, difficulties coping with anxiety, enough
verbal ability, in English, to participate in such a group and the ability to get to the
venue independently. The ‘mild to moderate’ criterion refers to a significant, but not
severe, impairment of intellectual functioning and intermittent or limited need for
assistance in terms of adaptive/social functioning (BPS, 2000).
Although recruitment letters were sent several weeks in advance, only four suitable
participants were recruited. An initial assessment was done with the referrer over the
telephone to assess the suitability of each participant. Once this was completed, an
invitation letter was sent to the participants.
The group consisted of four males aged between 21 and 35 years (mean age 27 years).
They all had a learning disability with varying degrees of ability. All participants had
anxiety issues such as difficulties leaving the house or panic attacks. One of the
group members dropped off after the first session due to medical issues. Two other
members attended regularly and the third one missed two sessions. Of the three
members who attended regularly, two were in part-time employment and the third one
was unemployed.
35
Measures
Several measures were used to monitor progress. The main measure to assess anxiety
was the Glasgow Anxiety Scale for people with intellectual disability (GAS-ID)
developed by Mindham & Espie (2003). This scale was specifically developed for
people with learning disability and showed to be psychometrically robust (Mindham
& Epsie, 2003). The GAS-ID was administered at session number one and at the final
session.
Participants were required to complete a weekly diary monitoring their anxiety levels.
A sheet with a box for each day of the week was distributed at each session and
participants were invited to record their daily anxiety level by sticking a coloured dot
(red for always, green for sometimes and blue for never) on each day box. The
principles behind this exercise was to check whether the participants found certain
days of the week more difficult than others and thus help them with appropriate
strategies and to monitor week by week the effects of the programme on their anxiety.
An ‘anxiety thermometer’ was also used at the first, fifth and eighth sessions to record
their general level of anxiety. This was a self-report non-standardised measure.
Finally, at the last session, an evaluation questionnaire combining quantitative and
qualitative items was used to assess the usefulness of the anxiety management group.
All measures are in Appendix three, Five and Six.
36
Group structure and content
The intervention consisted of eight sessions of two hours, with an available extra half
hour for debriefing when needed. A fifteen-minute break was also scheduled after the
first hour.
Two facilitators ran the group (a trainee clinical psychologist in year one of his
training and an assistant psychologist). Each facilitator took it in turn to lead the
group every other session, with the assistance of the other. One of the facilitators (the
assistant-psychologist) missed sessions six and seven for health reasons. Following
each group, a debriefing session was held for half an hour and notes were taken on the
morning of the following day. The facilitators received weekly supervision from a
qualified clinical psychologist.
The group intervention used a cognitive and behavioural approach in a group format.
The content of the intervention was based on published literature on group and
individual treatment of anxiety in clients with learning disability (Turk & Frances,
1990; Lindsay, Neilson and Lawrenson, 1997) and clients without learning disability
(Keable, 1997). This type of group had already been run by previous trainees and
assistants and their notes were also consulted to benefit from their experience and
advice.
Components of the intervention included psychoeducation about anxiety and group
discussions on experiences of anxiety (Keable, 1997), relaxation techniques
(Kennerley, n.d.), cognitive restructuration and lifestyle advice (Turk and Frances,
1990; Keable, 1997) and relapse prevention (Marlatt, 1982; Kennerley, n.d.). See
Table 1 for summary of session agendas and Appendix One for more details
37
Table 1. Summary of session agendas.
Session 1 Introduction, ground rules, structure, monitoring progress and measure (Glasgow Scale), brainstorm on words used to describe anxiety.
Session 2 What is anxiety? Definition and common myths; what makes you anxious and how is it affecting your life, introduction to relaxation.
Session 3 Body reactions to anxiety and how these contribute to anxiety, benefits of relaxation and relaxation session.
Session 4 What causes anxiety and what maintains it? Identification of personal behaviour of participants that contribute to maintaining their anxiety.
Session 5 The anxiety spiral and how to break it. Group exercise on positive thinking and alternative ways of thinking.
Session 6 How to stop being anxious. Distraction techniques and lifestyle issues.
Session 7 Relapse prevention. Planning of positive coping strategies for each participants.
Session 8
Course review, measure and feedback form, presentation of attendance certificates.
Participants were expected to complete a weekly diary monitoring their levels of
anxiety and had simple homework to complete.
Analysis of psychometric measures
An informal ‘thermometer of anxiety’ was used to measure levels of anxiety; this was
used on the first, fifth and last sessions. Figure 4 shows a graph of the results
obtained for the thermometers. Except for client a, there does not appear to be any
downward trends, which suggests that anxiety levels for the two other clients did not
change as a result of the group.
38
Graph of anxiety thermometre results
0102030405060708090
1 5 8
Sessions
Perc
enta
ges
of fe
lt an
xiet
y
Client aClient bClient c
Figure 4: Anxiety thermometer results
The Friedman test for related designs was administered on the anxiety thermometers
results. The ordinal data provided by the thermometers were also non-parametric.
Again, it was not significant (p>0.264, df=2), which suggests that the levels of anxiety
did not change during the group sessions.
The Glasgow Scale of Anxiety (GAS) (Mindham & Epsie, 2003) was the main
psychometric tool used during the anxiety management group. The GAS was
administered twice: at the first session and the last session. Table 2 shows the raw
scores obtained.
Table 2- GAS raw scores
First Session Last Session
Client A 13 11
Client B 30 21
Client C 43 40
39
The GAS is an ordinal scale that provides non-parametric data. The Wilcoxon test for
related design was performed on the GAS results for the group participants. The
result for the two-tailed test was not significant (p>0.109), which suggests that the
group did not have an impact on the participants’ anxiety.
The weekly diaries were unfortunately not useable for statistical analysis as the few
which had been completed were illegible.
Thoughts on the group
Engagement
One of the advantages of an anxiety management group is that it enables the
Psychology Service to provide an intervention for several people at a lower cost in
terms of staff and time. However, for the participants to benefit from such a format,
they need to be able to engage fully in the group activities.
Participants were carefully selected to ensure that they would have the ability to get
the most out of the group. Two of the inclusion criteria were specific in terms of
being able to engage with the group: a good enough verbal ability (in English) and the
capacity to get to the venue independently.
A first indicator of engagement is the attendance pattern displayed by the participants.
The group started with four people, Mahindra, Mohamed, Ashok and Faisal. Ashok
left the group after the first session; this was due to medical reasons. Of the three
40
remaining participants, only Mahindra attended every single session. The two others
missed one and two sessions.
The three participants had different levels of learning disability. Mohamed and Faisal
had a mild to moderate learning disability whilst Mahindra’s disability was more
moderate in that he needs more assistance in terms of adaptive/social functioning. It
became clear in the group and when reflecting in supervision that not every member
was able to get the same out of the group. Faisal had been in a similar group before
and was keen to make the most of it. He would often be ahead of the two others in
terms of grasping the material presented.
Mohamed, although suffering from anxiety, never acknowledged this in the group.
He was however probably the keenest member of the group as this was the only time
he went out of the family home during the week. He mentioned on several occasions
that Wednesday was his favourite day of the week because of the group. He showed
limited interest in the material presented but was keen to hear what the others had to
say and listen to their experience. His motivation was more about attending the group
as a social event rather than an opportunity to deal with his anxiety.
Mahindra was the most disabled of the group. The community nurse who had
referred him to the group had stated that he was having problems travelling on his
own (unless it was to go to work and back) because of his anxiety. When asked about
this, Mahindra denied any problem travelling and claimed he went all over the city on
his own. This was then checked with his parents who confirm what the nurse had
41
reported. This meant that in the group sessions, Mahindra showed little interest in the
material presented. Similar to Mohamed, he enjoyed listening to the others.
On reflection, the participants all engaged well with the group process and its social
aspect but found it more difficult to connect with the material presented. Maybe this
was related to their unacknowledged anxiety problems.
Group dynamics
The attendance pattern an effect on the group dynamics; when the oldest member of
the group, Faisal, was absent, the younger two had more difficulties remaining
focused on the tasks. This was also due to the fact that Mahindra had a more severe
learning disability than the others and found it difficult to follow the group’s
activities. Faisal and Mohamed both had a very mild learning disability and could
therefore engage with the material more easily. When the group became a pair (with
Faisal missing) Mahindra would often be disruptive by changing the topic of
conversation or requesting breaks.
The dynamics were also affected when the female facilitator was absent. Two of the
participants commented that ‘it was cool to be all the boys together’.
Despite the low numbers of referrals and participants, it was decided that the group
would be run anyway. The initial target number was six. Running a group with half
of that number was not ideal. Although it enabled the facilitators to give more
42
individual attention, it also meant that the group dynamics were often reduced to
exchanges between one participant and the facilitators.
A sense of safety and security appear to have been established early on in the group.
Mohamed was well known in the learning disability services as someone who was
difficult to engage and who was not keen on professional help. This was not the case
in the group. Mohamed was the most talkative member and used the group well to
express frustrations and current issues affecting him, which went beyond the anxiety
problem. The group appears to have given him a safe place to talk.
Although Mahindra was not interested in the material presented, he always listened
carefully to what Mohamed was saying. He was very supportive towards Mohamed
and often made comments to demonstrate it. He did not follow Mohamed’s example
but when discussed in supervision, it was concluded that he might benefit more from
belonging to a group like this one rather than from its content.
The group’s initial aim was to help participants manage their own anxiety. Although
this might not have been achieved, the group provided the participants with a place
where they were able to talk and find social support. This ended after the course was
over but it appears to have given the participants a positive experience.
Group evaluation questionnaires
The group evaluation questionnaires were completed by only two participants as the
third one was absent when they were administered. They provided general feedback
on the venue, organisation and content.
43
Both participants felt that the accommodation was not ideal. The first few sessions
took place in the common room of a health centre and despite the notice on the doors,
the sessions were interrupted a few times.
The length of the sessions was deemed adequate although both participants would
have like more than eight sessions. They also thought that the number of participants
was about right and that the facilitators were accessible.
The content of session items got a mid-range score and both participants identified the
tea breaks as the most interesting part of the sessions. The question of what part of
the sessions they enjoyed least drew no response.
Both participants felt that coming to the group had helped them with their anxiety and
were keen to recommend it to other people.
Facilitators’ observations
The three participants clearly had various anxiety related issues but were at very
different levels in terms of their experience of it. Faisal was able to grasp the
concepts more quickly than the others and was also able to apply them to his own
situation. It became clear however during our sessions that Faisal actual living
conditions were a genuine source of anxiety and led us to refer him to an advocacy
service.
44
Although the aims of the group were explained in depth in the first meeting, Mahindra
never appeared to have understood what the group was about. He attended every
session. When he was questioned on his anxiety problems, he never acknowledged
them, which was at times frustrating for the facilitators.
Mohamed was similar in his attitude to anxiety problems in that he never directly
acknowledged his difficulties but never denied them. He often talked about things
that were concerning him and that shows he was being anxious. He was however
keen to keep a brave face and did not admit to being distressed by them.
This situation was discussed on many occasions in supervision. One of the thoughts
that were expressed was that maybe acknowledging the anxiety problem was deemed
too dangerous by the participants. If the denial is a defence, removing it without
replacing it with a more appropriate defence might be too overwhelming for them to
cope.
The material presented appeared to be a challenge to the members of the group.
Although it was adapted for a group with learning disability, some of the concepts,
such as linking thoughts and feelings, remained difficult to grasp. This required a lot
of energy and effort from the facilitators.
The weekly diaries were not successful. Only Faisal managed to complete his on a
regular basis. Mohamed often forgot to complete them or claimed to have left it at
home despite regular prompting. Mahindra found it difficult to understand how to
complete it although it was explained to him every week.
45
Discussion and conclusion
The conclusion that can be reached from the statistical analyses of the measures given
to participants is rather limited due to the very small size of the group. The two
measures show clearly that the anxiety management programme did not have an effect
on the participants. This might have happened for several reasons.
Although the participants were carefully selected, there were significant discrepancies
in terms of individual abilities in the group. Some of the participants were able to
follow more easily than others who needed more input from the group facilitators.
This meant that some of the group discussions we had were more limited as only one
or two members were able to participate. It may be that these difficulties would have
been evened out in a larger group but it seems that in a smaller group, it would be
better to have participants with similar level of abilities. The assessment procedure
might benefit from assessing the participants directly instead of relying on the
referrers.
Another factor which is likely to have affected the outcome of the programme was the
reliance of the facilitators on the materials that had been used in earlier groups. The
programme was not manualised as such but the previous facilitators had left detailed
notes of the plan they followed in their group. It became clear after a few sessions
that the material needed to be customised to this particular group and that it was a
mistake to rely on content that had been prepared for another group. For example, the
previous group had been very keen on learning relaxation techniques whilst our group
46
was not enthusiastic about it. We had to change the teaching format of our sessions
on relaxation to make it more accessible to our group.
The concept of anxiety was a difficult one to grasp for our group. Although we spent
the second session talking about what is anxiety and what other words are used to
describe it (for example: stressed out, worked up, worried, etc.) and the third session
on body reactions to anxiety, the participants still found it difficult to understand what
anxiety is. The material used was simplified and thought to be adequate for the group
but on the whole it appears to have been insufficient. More time should have been
spent on talking about the participants’ experience of anxiety in order to ground their
understanding in their own experience.
The limited understanding of anxiety shown by the group participants was probably
related to the fact that two of the participants said they were not suffering from
anxiety despite what had been said by the referrers and evidence provided by the
carers. It might be that, as mentioned previously, acknowledging the anxiety
problems or showing an understanding of what is anxiety might have exacerbated the
current situations.
There were several advantages in using a set of comprehensive measures in evaluating
the outcomes of the group. The GAS-ID provided the facilitators with an objective
measure that not only described the anxiety symptoms but also quantified them
objectively. By contrast, the anxiety thermometers, being a subjective measure, gave
an indication of how the participants perceived their levels of anxiety and also
enabled them to say how they felt they were doing with the programme. The
47
evaluation questionnaires completed the measurement exercise by asking the
participants their views on taking part to the group and identify what they felt had
been the most useful parts.
The statistical analyses of the objective (GAS-ID) and subjective (anxiety
thermometers) measures did not show any changes on the levels of anxiety in the
group but the evaluation questionnaires suggest that the participants found the group
to be beneficial. Indeed, the participants seemed to have appreciated having a forum
where they were able to talk about their difficulties openly and be taken seriously.
Mohamed, for example, talked about his difficult relationships with neighbours and
the fights he regularly get involved in. Faisal talked about his difficult living
conditions and his marital problems.
As mentioned in a previous section, Mohamed was known in the Learning Disability
Directorate as someone difficult to engage and not keen on professional intervention.
This was not our experience of Mohamed in the group as he used it extensively to
express his frustrations and difficulties. Faisal used the group in a similar manner and
Mahindra always appeared interested in what the others had to say. He showed good
listening skills and compassion. This suggests that the programme content was less
significant than the experience of belonging to the group. There clearly was a social
aspect to the event, that the participants thoroughly enjoyed, but there also seemed to
be a therapeutic element to it. This was unfortunately not considered when the group
was set up and therefore no measurements were taken. The evidence, gathered from
verbal feedback expressed by the participants, remains anecdotal but suggests there
was a positive therapeutic outcome to the group. Indeed, the participants reported
48
reduced feelings of isolation, increased confidence in group situations and a general
feeling of increased optimism with their difficulties.
The evaluation questionnaires reported that the tea breaks were the most interesting
part of the sessions. This is partly explained by the point made in the previous
paragraph but it might also be a reflection on the paucity of social activities available
to people with learning disabilities. Being able to meet with other people of more or
less the same age and background in the context of a specific activity was clearly
valued by the participants. In this sense, the group had a positive outcome in breaking
the social isolation felt by the three group members.
The use of a group intervention with people with learning disability who are suffering
from anxiety should not be underestimated in its potential positive outcome.
Although the statistical analyses from this review showed no improvement in the
participants’ level of anxiety, most of them reported benefiting from attending the
sessions. The therapeutic aspect of belonging to a group should be taken into
consideration when planning for such a programme. With materials suitably adapted
to the group members and robust preparation by the facilitators, an anxiety
management programme is more than likely to have a beneficial impact on its
members.
49
References
British Psychological Society (2000). Learning Disability: Definitions and Contexts. Leicester: British Psychological Society. Dagnan, D., & Jahoda, A. (2006). Cogntive-behavioural intervention for people with intellectual disability and anxiety disorders. Journal of Applied Research in Intellectual Disabilities, 19, 91-97. Dagnan, D., & Lindsay, W. (2004). Cognitive therapy with people with learning disabilities. In E. Emerson, C. Hatton, T. Parmenter, & T. Thompson (eds.) International Handbook of Research and Evaluation in Intellectual Disabilities pp. 517-530. Chichester: Wiley. Deb, S., Thomas, M., & Bright, C. (2001). Mental disorder in adult with intellectual disability. 1: Prevalence of functional psychiatric illness among a community-based population aged between 16-64 years. Journal of Intellectual Disability Research, 45, 495-505. Joyce, T., Globe, A., & Moody, C. (2006). Assessment of the component skills for cognitive therapy in adults with intellectual disability. Journal of Applied Research in Intellectual Disabilities, 19, 17-23. Keable, D. (1997). The Management of Anxiety: A Guide for Therapists. New York: Churchill Livingstone. Kennerley, H. (n.d.). Managing Anxiety: A User’s Manual. Oxford: Waneford Hospital. Lindsay, W., Neilson, C., & Lawrenson, H. (1997). Cognitive-behaviour therapy for anxiety in people with learning disabilities. In B. Stenfert-Kroese, D. Dagnan, & K. Loumidis (eds) Cognitive-Behaviour Therapy for People with Learning Disabilities (pp. 124-140). London: Routledge. Marlatt, G.A. (1982). Relapse prevention: a self-control program for the treatment of addictive behaviours. In R.B. Stuart (Ed.), Adherence, Compliance and Generalization in Behavioural Medicine (pp. 329-378). New-York: Brunner/Mazel. Mental Health Foundation (1999). The Fundamental Facts. London: Mental Health Foundation. Mind (2006). Statistic 1: How Common is Mental Distress. http://www.mind.org.uk/Information/Factsheets/Statistics/Statistics+1.htm (accessed on 04/09/2006). Mindham, J., & Espie, C.A. (2003). Glasgow Anxiety Scale for people with an Intellectual Disability (GAS-ID): development and psychometric properties of a new measure for use with people with mild intellectual disability. Journal of Intellectual Disability Research, 47(1), 22-30.
50
Mishna, F., & Muskat, B. (2004). "I'm not the only one!" Group therapy with older children and adolescents who have learning disabilities. International Journal of Group Psychotherapy, 54(4), 455-476. NICE (2004). Anxiety: Management of Anxiety in Adults in Primary, Secondary and Community Care. Clinical Guidelines 22. London: National Institute for Clinical Evidence. Raghavan, R. (2004). Learning disability and mental health: reflections and future trends. Journal of Learning Disabilities, 8(1), 5-11. Turk, V., & Frances, E. (1990). An anxiety management group: strengths and pitfalls. Mental Handicap, 18, 78-81. Willner, P. (2006). Readiness for cognitive therapy in people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 19, 5-16. Yalom, I.D. (1985). The Theory and Practice of Group Psychotherapy. New-York: Basic books.
51
Clinical Practice Report 3- Single Case Experimental Design
The treatment of a bird phobia with a nine-year old girl
Abstract
This single case experimental design report presents the case of a nine-year old girl
named Tricia who was suffering from a bird phobia. She was referred to the Child
and Adolescent Mental Health Service by her GP. An assessment was conducted
using various psychometric questionnaires and a hierarchy of fear was built with
Tricia. This hierarchy and the problem formulation were used to design an
intervention based on behavioural principles. Measurements were taken before the
intervention and at each session. Relaxation techniques and self talk were taught and
practiced at each session. A gradual exposure to birds was introduced. The
evaluation was conducted using the measurements taken as well as self report, parent
observations and therapist observations. These showed that Tricia made progress in
tackling her anxiety. A discussion on the strengths and weaknesses of the formulation
and intervention follows.
52
Referral
Tricia was referred by her local GP who simply stated in her letter that she had a
severe bird phobia. Tricia is nine years of age and is from an Afro-Caribbean
background.
Initial interview
The aim of what is called in the service an ‘initial meeting’ is to collect more
information about the case and ensure that it is suitable for the Child and Adolescent
Mental Health Service (CAMHS). Enough information is usually collected to make a
preliminary formulation.
Tricia came to the Initial Meeting accompanied by her mother, Irene. They were met
by a clinical psychologist who later passed on the case to me. Irene described the
problem as having started two or three years ago. She said she could not think of a
precipitating event and admitted that the whole problem is a mystery to her. Tricia
could not say how it all started. Tricia is afraid of birds and this has affected the
family life. When there are birds around, Tricia will panic and runs away in any
direction. Irene said that this kind of behaviour worries her as Tricia will not pay any
attention to where she is going when she is running away. She said that Tricia has run
in the middle of busy roads and there is a safety concern here. The phobia has also
prevented the family from doing many leisure outings as they have to choose
activities that take place in an area where there are no birds.
53
Tricia’s mother also disclosed that she is not keen on birds herself although does not
fear them. She describes them as flying vermin.
Beside the bird phobia, the psychologist noted that Tricia appears well adjusted with
no signs of depression or other anxieties. She is doing very well at school where she
also has many friends. Tricia appears to be a popular child. Family life is stable and
the parents are together; Irene and Tom have been married for over fifteen years.
Tricia has a younger sister, Tina, who is seven years old and Irene reported that they
usually get along well.
The family has been coping with Tricia’s phobia by avoiding places where there
might be birds and, when they encounter some, Tom and Tina will shoo the birds
away whilst Irene holds on tightly to Tricia. Although Irene is clearly concerned
about this difficulty, she admits feeling rather impatient at times with Tricia and not
able to understand what is wrong with her.
First Meeting
Tricia’s case was unfortunately on the waiting list for over five months. She was
referred to me soon after the beginning of my child placement. Tricia came to our
first meetings accompanied by her mother and her sister. My supervisor was also
present for this first session.
Irene reported that nothing had changed since the Initial meeting; Tricia still had her
bird phobia.
54
Tricia’s cognitions with regards to birds were explored and she reported being afraid
that a bird might ‘poo’ or land on her head and also said she felt they were looking at
her. Her fears seem to revolve around being attacked by them. She said also that she
is afraid of feathers and claws. She does not like it when they flap their wings. This
led nicely to building a hierarchy of fear (see Figure 5).
Treatment goals were discussed with the family and were kept simple. Irene and
Tricia simply want the latter to be able to go into town, to the Central Library or the
markets, without being disturbed by the birds. They were both aware that Tricia
would probably never become a great bird lover, but they merely want her to be able
to go about town and get on with activities without any problem.
10 Extremely scary Bird on my head Crows 9.5 Going to markets Seagulls
(aka Pigeonland) 9 Going to Central Library 8 Walking near birds 7 Seeing a bird in a tree Ducks 6 Photos of birds Magpies/budgies 5 Feathers on pavement 4 Drawing of birds 3 Drawing birds 2 Talking about birds 1 Birds in cartoons on telly Robins 0 not scary at all When there are no birds around
Figure 5- Hierarchy of fear
55
Fear and anxiety surveys
During the first meeting, two anxiety scales were completed by Irene and Tricia. The
Spence Children’s Anxiety Scale (SCAS) (Spence, 1994), which provides an overall
anxiety measure, and the Fear Survey Schedule for Children- Revised (FSSC-R, 97-
item version) (Ollendick & Yule, 1983), which assesses a variety of fears that
children might experience, were administered. Tricia’s mother also completed the
Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997), which is routinely
administered to all parents in this service. This questionnaire is a brief behavioural
screening tool which comprises the following subscales: emotional distress, conduct
problems, hyperactivity/inattention, peer relationship problems, and prosocial
behaviour. The extended version of the SDQ used here also asks whether the
respondent thinks the young person has a problem, and if so, enquires about the
distress and social impairment of the problem on the child and provides an impact
score.
The results of the FSSC-R were surprising. Tricia scored 42 on the FSSC-R which is
well below the mean score for girls of her age (75.15 with a standard deviation of
29.41). On the SCAS, all her scores were well within the standard deviation for each
sub-scale for a girl of her age (see Table 3 below). Tricia’s total score is 31 which is
also below the mean score for clinically anxious children which is 42.
56
Table 3- SCAS scores Panic
attacks
Separation
Anxiety
Phys.
injury
fears
Social
phobias
Obsessive
compulsive
General
Anxiety
Total
Tricia’s
scores
5 5 4 7 4 6 31
Raw
means
4.93 5.85 4.14 7.39 6.33 7.09
Standard
deviation
4.81 3.80 2.95 3.92 3.71 3.68
The results on the SDQ showed an abnormal score for the emotional distress scale and
abnormal score on the Impact of any difficulties on the child’s life scale. All the other
scales showed normal scores.
These results indicate that Tricia is a rather calm child with generally low anxiety.
This suggests that she is suffering from a very specific phobia that has quite an impact
on her life and the life of her family. According to the DSM-IV (APA, 1994),
Tricia’s problem could be identified as a ‘specific phobia’. The technical name for
bird phobia is ornitophobia (Csotti, 2003).
Problem formulation
Information was gathered from the initial interview and first meeting. The difficulty
Tricia is experiencing was formulated following a behavioural model which uses a
combination of classical and operant conditioning principles. These principles
explain the development and maintenance of Tricia’s phobia. Evaluative conditioning
theory (EC) suggests that a phobia will develop through the pairing of neutral material
with a negative stimulus resulting in a change in the emotional charge of the neutral
57
stimulus associated with the negative stimulus (Martin & Levey, 1987). The result is
a strong personal response that can be described as a ‘gut reaction’ which will then
modulate a person’s avoidance behaviours. Various studies have shown that EC is
relevant in the aetiology of many anxiety disorders (e.g. Lascelles, Field & Davey,
2003; Olantunji, 2006; Olantunji, Lohr, Sawchuck & Westendorf, 2005;).
It became clear during the assessment that Tricia and her family maintained the
phobia through avoidance behaviours, such as avoiding areas where there are birds,
shooing them away when they are too close or Tricia running away from them. This
had the consequence of stopping a natural extinction of the behaviour by preventing
Evaluative conditioning Neutral stimulus (NS) Neutral response Birds � no problem Unconditioned Stimulus Uncond. response Bird flying off � Anxiety Loss mum and birds flying
Neutral stim. + Uncond. Stim. Uncond. response Birds+ loosing mum � Anxiety
When Tricia sees birds or thinks there are birds, she gets very anxious.
Conditioned Stimulus Conditioned resp. Birds → Anxiety
Negative reinforcement People shoo birds away for Tricia. Family avoids going places where there are too many birds. Tricia runs away.
No opportunity to unlearn the conditioned fear.
Avoidance behaviour
Anxiety: Unpleasant physiological arousal, increased heart rate, increased breathing, sweating, unpleasant thoughts.
They are going to poo on my head. The birds are going to attack me. Cognitions
Figure 6- Formulation
the un-pairing of the two stimuli (birds and fear) (Malloy & Levis, 1988).
58
It is not clear how this bird phobia may have developed. There might have been
several small incidents where Tricia got frightened when there were birds around. It
may be that the fear Tricia experienced in those occasions was paired with birds.
These incidents may have been individually unnoticeable but the combination of them
might have been sufficient to create the bird phobia (Martin & Pear, 1999). This
could be the reason why both Tricia and her mother cannot remember a single
incident that would explain the phobia. The small incidents could be, for example,
Tricia, when aged six, having lost, momentarily, sight of her mother and being
surrounded by pigeons taking off. This example is fictitious and is used to illustrate
the process of conditioning that might have affected Tricia.
Rationale for Intervention
There is ample research literature to support a cognitive behavioural intervention,
such as exposure or desensitisation, in the treatment of children’s phobias (Moore &
Carr, 2000; Gros & Anthony, 2006).
Behavioural treatments of phobia share the same objective of ‘unlearning’ the
association between the conditioned stimulus (such as birds, in Tricia’s case) and the
conditioned response (fear and physiological arousal). Most techniques involve
gradual exposure to the conditioned stimulus until a certain habituation occurs in the
client. The exposure should be gradual, repeated and prolonged to optimise treatment
outcomes (Carr, 1999). During the assessment, a hierarchy is built with the client to
establish a list, from least scary to most scary, of phobic situations (Carr, 1999). At
the bottom of the list, the client identifies all the situations she or he avoids because
59
they trigger an anxiety response. These are then ordered in a hierarchical order of
easy to difficult where the most difficult should include contact with the conditioned
stimulus (see Figure 5 on page 46). The client will initially be exposed to a situation
identified at the bottom of the list, which should be a situation that triggers anxiety but
that they can tolerate. Repeated exposure is done until the client’s anxiety level has
decreased to a low level. The same procedure is the repeated with the other situations
on the list leading the client to confront gradually their fears, tolerate an acceptable
level of anxiety and be exposed to the phobic stimulus.
There is sufficient evidence in the literature to support cognitive behavioural therapy
(CBT) for treating childhood psychological problems (Carr, 2000; Kendall &
Treadwell, 1996; Silverman, Kurtines, Ginsburg, Weems, Rabian, & Serafini, 1999).
There is evidence that cognitive distortions are associated to with psychological
difficulties in children, but their role in the aetiology and maintenance of these
problems is not clear (Stallard, 2002). Most models of intervention have been based
on research conducted on adult populations and the interventions have simply been
transferred onto children without researching their appropriateness for that age group
(Stallard, 2002). This needs to be taken into consideration when formulating a child’s
problem from a CBT perspective. It is also important to consider whether the child
treated has acquired sufficient cognitive abilities to use CBT effectively; research has
indeed suggested that, although CBT is more effective than a waiting list condition, it
produces better outcomes for children aged eleven and above (Durlak, Furnhan &
Lampman, 1991; Stallard, 2002).
60
Tricia’s treatment had a strong emphasis on the behavioural exposure aspect (gradual
desensitisation) with elements of CBT in the use of statement of self-competence
(self-talk). This is a stress inoculation procedure which has been shown to help
reduce fear in anxiety provoking situations by blocking the frightening thoughts the
child usually has (Graziano & Mooney, 1982).
Planned Intervention
Based on the formulation and our first meetings, the CBT approach was selected and
explained to Tricia and her mother. A programme of gradual exposure was derived
from the hierarchy built in the first meeting. It was agreed that the aim of the
treatment was not to turn Tricia into a bird lover but simply to enable her to function
normally when she is in an environment where there are birds.
Each session was planned to focus on one aspect of the hierarchy (see Figure 5
above). It was decided not to set a specific number of sessions in order to keep some
leeway. As the intervention was also delivered during the summer holiday, it was
thought that there might be last minute cancellations and therefore flexibility might be
needed.
Each session also had an element of relaxation, as recommended for the treatment of
phobia (Carr, 1999). This was also set as a regular homework. Time was spent in
each session looking at the self-talk Tricia was using when thinking about birds and
suggestions of alternative positive self-talk statements were generated in a
collaborative manner (Silverman et al. 1999). Because Tricia’s mother felt that she
61
was used to seeing cartoons with birds on television and also as they often talked
about birds at home, we all agreed that we should start the intervention with the third
point in the hierarchy, as this would be slightly more challenging than usual.
At the beginning of each session, three subjective measurements of distress were
taken (subjective unit of distress- SUD). The three questions used for these were
based on Tricia’s potential proximity to birds; the window referred to in question 2
was three metres away from Tricia’s chair. Using a scale of nought to ten (nought
being not scared at all and ten being extremely scared), Tricia had to answer the
following questions:
1- How do you feel about talking about birds?
2- How would you feel if a bird was to land outside the window?
3- How would you feel if a bird was to land a meter away from you?
These three questions were asked initially over a period of five weeks before the
intervention started in order to establish a baseline measure.
Using the same scale, SUDs were taken during the exposure to each situation. A first
measurement was taken at the first stage (for example, feather three metres away from
Tricia) and the measurement was taken again after relaxation and self-talk. When the
score obtained was below six, the stimulus was brought closer.
62
Intervention
The duration of each session was planned for around one hour. However as the
sessions all took place at the end of the day, which fitted better with their school
commitments and other activities, it was agreed that some of them would be longer
than an hour to allow for the prolonged nature of exposure. Here is a brief summary
of the sessions:
Session One: This session focused on introducing relaxation, and Tricia and therapist
to draw a variety of birds. The aim of the session was to start developing a good
therapeutic alliance.
Session Two: A booklet with drawings of birds had been prepared. Each page had
two pictures of bird. Relaxation exercises were done in between pages to reduce
anxiety.
Session Three: A feather was placed at the far end of the room and gradually brought
closer to Tricia. Tricia was able to hold the feather in her hand at the end of the
session. Relaxation exercises were done at each step.
Session Four: A booklet with photographs of birds was prepared. Each page had
various photographs of birds. Relaxation exercises were done between pages to
reduce anxiety.
63
Session Five: An outing on the clinic’s grounds was done (the clinic is surrounded by
a park and has a large green). Birds were observed from a distance and then Tricia
went closer to them. 100 metres was achieved. Relaxation exercises and self-talk
were used.
Session Six: The outing on the clinic grounds was repeated. 50 metres was achieved.
Session Seven: The outing on the clinic grounds was repeated. We were not able to
get closer than 20 metres. Tricia however appeared significantly less anxious as she
laughed on many occasions.
Outcome
The case was based on a time series A-B design and the outcome was evaluated using
the following methods:
1. Visual inspection of the anxiety ratings collected at each session;
2. Statistical analysis of the weekly SUDs collected during the baseline period
prior to the intervention and during the intervention;
3. Self and parental reports;
4. Therapist’s observations.
Visual inspection
Figure 7 shows a graphical representation of Tricia’s Subjective Units of Distress over
the twelve weeks of contact (1-5 = assessment; 6- 12 intervention).
64
The three lines show that there was a high level of anxiety for all three conditions and
that these remain stable for most of the baseline period (intervention started at week
six). The anxiety was most severe for the situation where a bird would land within a
meter of Tricia.
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12Week
SUDTalkingWindowOne Meter
Figure 7- Tricia’s ratings
The question about talking about birds was the first one to change during the
intervention. Tricia was anxious about simply discussing birds in general. As she
explained herself, she knew that we would not merely be talking about birds in our
sessions but that these discussions would lead to something scarier. Therefore, she
felt apprehensive about coming to the clinic and chatting about birds with the
therapist. As her confidence and trust began to build and a therapeutic relationship
developed, she felt more relaxed about talking about birds and this led to what looks
like a significant decrease in SUD ratings.
65
The question about having a bird land within three meters of Tricia (bird landing
outside the window) was stable during the baseline period and in the early stages of
the intervention. The ratings obtained for these first eight weeks were consistently
eight out of ten. This began to change at intervention session five (week nine) when
we went out on the clinic’s grounds and Tricia got within 100 metres of the birds. The
question was asked before doing the task and Tricia was aware of what was planned
for the session that day. This might explained why she gave a higher than usual score
for that session. Approaching the birds seemed however to lower her fear and a
decrease in the ratings was then observed in subsequent sessions.
The question about having a bird land within one meter was the most anxiety
provoking condition for Tricia. The ratings obtained during the baseline period were
scored ten out of ten for all of the baseline period and for the first four weeks of the
intervention. They only began to change, and only slightly, at session nine, following
the outing on the clinic’s grounds. This suggests that her anxiety levels are still very
high but that they are beginning to decrease.
Statistical analysis of the weekly SUDs
Advice on the analysis of the data obtained was sought from the Trust’s statistician.
Testing for autocorrelation was not recommended. Davies (2007) argues that testing
for autocorrelation with only one participant will not produce adequate results as more
participants are needed to distinguish between autocorrelation and trend. Davies
(2007) suggests instead the use of the Runs test which checks the randomness
hypothesis of a data sequence, such as the one collected during this assessment and
intervention.
66
The Runs test performed to the three sequences of data showed that the scores
obtained were not randomly distributed. For the question of talking about birds, the
randomness hypothesis was not significant (p= 0.134, two-tailed). Similarly, the
question about a bird landing outside the window, the randomness hypothesis was
also not significant (p= 0.009, two-tailed). Finally, the question about a bird landing
within one metre of Tricia, the randomness hypothesis was not significant either (p=
0.009, two-tailed). (See Appendix Seven for SPSS output). This suggests that the
scores obtained are not the result of random ratings on Tricia’s part and may reflect a
change in her anxiety levels.
As suggested by Davies (2007), a nonparametric test for related samples was
administered to examine further the differences in anxiety scores and during
intervention. Davies (2007) asserted that such a test is reasonable to use as the
autocorrelation of the data cannot be established since there is only one participant.
Wilcoxon test for related samples did not show any significant difference between the
two conditions (assessment and intervention) for two of the questions and showed a
significant difference for one.
The question on talking about birds did show a significant difference between
baseline and intervention, Z= -2.032, N- Ties= 0, p= 0.042, two-tailed. The question
about having a bird land within three meters of Tricia did not show any significant
difference between the baseline measures and the intervention ones, Z= <0.001, N-
Ties= 3, p= 1.000, two-tailed. The question about having a bird land within one meter
67
did not show any significant difference either between baseline and intervention, Z= -
1.000, N- Ties= 4, p=.317, two-tailed. (See SPSS output in Appendix Seven).
This suggests that the intervention used on Tricia was partially successful in making a
difference to her level of anxiety.
Self and parental reports
Although significant changes cannot be concluded from all the statistical analyses,
Tricia’s mother, Irene, and Tricia herself reported noticeable changes in her
behaviour.
The session we had following intervention session five, where we went on the clinic’s
grounds, Irene reported that Tricia had gone with her cousin to the Central Library
without any difficulties, despite the fact that there were hundreds of pigeons around.
This was one of our treatment goals. Tricia said that she did notice the birds, but kept
her mind busy talking with her cousin. This distraction technique seemed to work
well for her. She was very proud of herself and was even more keen to carry on with
the intervention. Irene also reported that Tricia appeared more relaxed generally and
believed that this has had a positive impact on the family as the two daughters, who
generally get on well, had not be arguing for a while.
Therapist’s observations
Although Tricia’s ratings remained very much the same, she did appear more and
more relaxed as the sessions went on. She always appeared tensed, especially in the
sessions where we went on the clinic’s grounds. After a few minutes of relaxation
68
and self-talk, she would do the task I requested her to do without too many
difficulties. I managed to develop a good relationship with her and use her sense of
fun to make the activities more pleasant. The anxiety remained, but the immediate
fear of bird seemed to diminish. For example, she was initially reluctant to
accompany me when I went away to put slices of bread down to attract the birds. She
came with me to help after the first time and I took a very long time to accomplish my
part of the job. Tricia knew that I was doing it on purpose and began to laugh and
waited for me without any difficulties. Once the bread was down and I was done, she
retreated from the spot quickly but was still laughing. During sessions six and seven,
once we had been in the grounds for about twenty minutes and the birds were eating
the bread, Tricia announced that she would walk towards the birds and asked me to
stay behind. She walked closer to the birds (about twenty meters away from them)
and was clearly determined to achieve her goals. This was a new and positive
development.
Discussion
The end of this child placement came before the rest of the intervention was
completed. Although Tricia and her family had been regular attenders, the school
holidays, normal family life events and problems with room availability at the clinic
prevented her from coming to her appointments on a weekly basis. This meant that
the number of sessions used for the intervention was limited and it felt at times like
the momentum was lost. Indeed, Tricia’s parents reported towards the later sessions
that they were hoping for faster improvements and disclosed that they were feeling a
bit frustrated with Tricia and the Service.
69
The choice of questions to evaluate the intervention is questionable. Although it
could be argued that they provide an accurate picture of what the client is actually
feeling, in Tricia’s case they often reflected more a general state of anxiety as
opposed to a truthful and well considered answer to each specific question. As
discussed above, Tricia more or less consistently gave a high score to the question
that referred to talking about birds because she knew it meant something else was
coming; she was actually not anxious talking about birds but rather was anxious about
the rest of the session. The validity of this measure is questionable. A different
question that explores the general feeling of anxiety, for example “how do you feel
about coming here today to work on your phobia” might have been a more valid one.
Another difficulty with the use of such subjective questions to measure change was
that they might have reflected more a ‘learnt’ anxiety response rather than an actual
behaviour. I often asked Tricia how she was feeling about going in the clinic’s
grounds before going out there (this was not one of the evaluative questions) and she
often answered she was terrified simply to go out. However, once out there, she
would rate her anxiety on a scale of nought to ten as five or six and did not appear
terrified in the way she had initially predicted. Although we did not go to the end of
the intervention together, this led me to question the validity of the distance questions
used. She might have gone closer to the birds with a tolerable level of anxiety but
when asked at a later stage how she would feel about doing this, she might have
resorted to a learnt anxiety response and rate it as a highly distressing experience.
There often seem to be a discrepancy between the subjective anxiety rating and the
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actual behaviour. However, it could also be argued that the questions remain valid
and would be an accurate measure of cognitive shift for Tricia.
Choosing a CBT intervention also had limitations. Research has shown that it works
better with children aged eleven and older as they have more developed cognitive
abilities ( Durlak, Furnhan & Lampman, 1991; Stallard, 2002). Tricia was nine years
old during the intervention and her ability to access her cognitions was limited. When
asked about her thoughts on birds, these were restricted to “pooing on her head” or
“attacking me”. It was not possible to go any further than this with her at this stage.
The cognitive part of the intervention was therefore limited. Self talk was used as
well as self observation, but the effectiveness of these is difficult to assess.
The limited amount of data gathered made it difficult to reach any conclusion when
using statistics to test the intervention. Needless to say that more data would have
made the statistical testing more robust and the conclusions derived from this clearer.
This was however not possible because of the length of the placement and the
difficulty of meeting Tricia for weekly appointments.
The qualitative part of the evaluation has certainly been more useful in this case.
Observations made by Tricia’s mother as well as those made by the therapist show
that the intervention had an effect. Tricia’s confidence in the intervention visibly
increased at every session and this helped in reducing her levels of anxiety. Although
her mother expressed some frustrations at times, she also noticed that something was
happening with her daughter. This kind of outcome is not noticeable in the statistical
analysis but began to make a difference in the everyday life of the family.
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One of the limitations of the constructed formulation used for this intervention is that
it does not take a broad view of the family’s dynamics and wider environment. The
intervention focused very much on the immediate phobic behaviour and its related
cognitions, but did not explore what role this phobia might play in the family context.
Tricia appeared to be a well adjusted child and for this reason, looking at the role of
the phobia was not deemed a priority. This is not something the family appeared
willing to explore either. This is something that might need to be addressed
depending on the outcome of the intervention. Nevertheless, the role of the family
should have been included in the formulation, as it has been showed that children who
suffer from anxiety are likely to have parents with similar difficulties (Ginsburg,
Silverman & Kurtines, 1995) as was potentially the case with Tricia’s mother who
acknowledged not liking birds and being terrified of spiders. The formulation and
intervention should have also considered how the family interactions might contribute
to the maintenance of the phobia. Although avoidance behaviours were included, the
intervention did not take these into account. This could have been a significant area
to address as Shortt, Barrett, Dadds & Fox (2001) have demonstrated that children
might experience some situations as more threatening because of their parents’
reactions to the perceived threat. Therefore the intervention could have been designed
to involve the whole family at each step and a better look at the parents’ cognitions
and behaviours with regards to Tricia’s phobia.
Tricia was not able to complete the intervention with me and will carry on with the
help of my supervisor.
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References American Psychological Association (1994). Diagnostic and statistical manual of mental disorders (4th Edition). Washington: APA. Carr, A. (1999). The Handbook of child and adolescent clinical psychology. London: Routledge. Csotti, M. (2003). School phobia, panic attacks, and anxiety in children. Philadelphia: Jessica Kingsley. Davies, P. (2007) Personal communication, 11 September 2007, Institute of Child Health, Birmingham Children’s Hospital Trust, Birmingham. Durlak, J.A., Furnham, T., & Lampman, C. (1991). Effectiveness of cognitive-behaviour therapy for maladapting children: a meta-analysis. Psychological bulletin, 110, 201-214. Ginsburg, G.S., Silverman, W.K., & Kurtines, W.K. (1995). Family involvement in treating children with phobic and anxiety disorders: a look ahead. Clinical Psychology Review, 15(5), 457-473. Graziano, A.M., & Mooney, K.C. (1982). Behavioral treatment of night fears in children: maintenance of improvements at 2.5 to 3-year follow-up. Journal of Consulting and Clinical Psychology, 50, 598-599. Gros, D.F., & Anthony, M.M. (2006). The assessment and treatment of specific phobias: a review. Current Psychiatry Reports, 8(4), 298-303. Kendall, P., & Treadwell, K. (1996). Cognitive behavioural treatment for childhood anxiety disorders. In E. Hibbs and P. Jensen (Eds) Psychosocial treatments for child and adolescent disorders: empirically based strategies for clinical practice (pp. 23-42). Washington, DC: American Psychiatric Association. Lascelles, K.R.R., Field, A.P., & Davey, G.C.L. (2003). Using foods as CSs and body shapes as UCSs: a putative role of associative learning in the development of eating disorders. Behavior Therapy, 34, 312-335. Malloy, P., & Levis, D.J. (1988). A laboratory demonstration of persistent human avoidance. Behavior Therapy, 19, 229-241. Martin, I., & Levey, A.B. (1987). Learning what will happen next: conditioning, evaluation and cognitive process. In G.Davey (Ed.) Cognitive Processes and Pavlovian Conditioning in Humans (pp. 57-81). Chichester: John Wiley & Sons. Martin, G., & Pear, J. (1999). Behavior Modification: what it is and how to do it. Upper Saddle River, New Jersey: Prentice Hall.
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Moore, M., & Carr, A. (2000). Anxiety disorders. In A. Carr (Ed) What works with children and adolescents: a critical review of psychological interventions with children, adolescents and their families (pp.178-202). London: Routledge. Olatunji, B.O. (2006). Evaluative learning and emotional responding to fearful and disgusting stimuli in spider phobia. Anxiety Disorders, 20, 858-876. Olatunji, B.O., Lohr, J.M., Sawchuk, C.N., & Westendorf, D.H. (2005). Anxiety Disorders, 19, 539-555. Ollendick, T.H., & Yule, W. (1983). Fear Survey Schedule for Children Revised. In I. Sclare (Ed.)(1997) Child Psychology Portfolio: Anxiety, Depression and Post-Traumatic Stress in Childhood (pp. 19-34). Windsor: NFER-Nelson. Shortt, A.L., Barrett, P.M., Dadds, M.R., & Fox, T.L. (2001). The influence of family and experimental context on cognition in anxious children. Journal of Abnormal Child Psychology, 29(6), 585-596. Silverman, W.K., Kurtines, W.M., Ginsburg, G.S., Weems, C.F., Rabian, B., & Serafini, L.T. (1999). Contingency management, self-control, and education support in the treatment of childhood phobic disorders: a randomized controlled trial. Journal of consulting and clinical psychology, 67(5), 675-687. Spence, S.H. (1994). Spence Children’s Anxiety Scale. In I. Sclare (Ed.)(1997) Child Psychology Portfolio: Anxiety, Depression and Post-Traumatic Stress in Childhood (pp. 4-18). Windsor: NFER-Nelson. Stallard, P. (2002). Think good- feel good: a cognitive behavioural therapy workbook for children and young people. Chichester: John Wiley and sons.
Clinical Practice Report 4- Case Study Psychological assessment of a 72-year old man initially presenting with cognitive difficulties
Abstract
This paper considers the case of Ronald Rowling (not his real name), a 72-year old man who
initially presented with word finding difficulties. He was referred by his general practitioner
to the psychiatrist for the elderly who then referred him to the psychology service. A first
battery of neuropsychological tests was administered and, after a four-month break, some of
the tests were repeated and a new one was administered. Background information and
history were gathered during those sessions. Although referred for a memory test, the main
issues appeared to be about anxiety and low mood rather than cognitive impairment. The
details of these assessments are described along with the outcome. A formulation of his
current difficulties is offered. The paper concludes by reflecting on the learning experience
of undertaking such an assessment.
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Referral
Mr Ronald Rowling (not his real name) is a 72-year old man who was referred to the
Psychology Service by the Consultant Psychiatrist for the Elderly following an initial referral
by Ron’s GP. The Psychiatrist has requested a memory test for this patient. The presenting
issue was described as difficulties finding words or names and using the wrong nouns to
describe familiar objects (for example, he would call a toaster a dustbin). The GP’s referral
letter states that a full physical examination had been performed and beside scarring on his
brain (see discussion below), which might explained his word finding difficulties, and a
previously reported potassium deficiency, she could not explain his current difficulties.
Clinical Interview
The initial clinical interview was done less than six months ago by another psychologist who
has since left the service. The information gathered in this section was collated from the
reports written by this psychologist and from my own clinical interviews and testing with
Ron.
Background history
Mr Rowling was born in the Wolverhampton area where he has spent most of his life. He
describes his family as a hard working working-class family. He is one of six children, three
brothers and two sisters (see genogram in Appendix Nine). He was the fourth child. Ron
says both his parents worked and all the children had to be independent from an early age.
He says his parents cared for him but not much time was spent being ‘a happy family’. He
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adds that they all had to work as soon as they could, doing paper rounds and odd jobs for
neighbours and local shops.
When Ron was in his early teens, he was recruited by the local vicar to join the boxing club.
Ron said he enjoyed this very much and it brought a much-needed sense of pride to the
family as he did very well competing at a local, national and, later on, international level.
Ron was an international boxer for around 20 years and also trained other boxers when he
retired from competing. Towards the end of his boxing career, he was knocked unconscious
during a match. A few years later, he was experiencing recurrent headaches and word
finding difficulties. He had appointments with a private neurologist who told him he had
bruising or scarring on the brain and that nothing could be done to repair the damage. The
word ‘dysphasia’ (word finding difficulties) was also mentioned during those consultations.
This seemed to leave a strong impression on him as he said he has been constantly ‘keeping
an eye’ on himself ever since.
He joined the Army to do his national service when he was in his early twenties and remained
in the forces until he was thirty years old. During this time, he had the opportunity to train as
a chiropractor. When he left the Army, he set up his own private chiropractic clinic and
gained an excellent reputation as a practitioner. He worked full-time until very recently but
following pressures from his wife, he has now reduced the number of hours he spends
working.
Ron describes himself as a ‘no nonsense type of chap’ who is highly successful. He is very
proud of what he describes as his ‘modest origins’ and subsequent thriving career. He says
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he is a good provider and both his sons went to university. They are both married and have
children of their own; Ron talks about his grand children with glowing satisfaction. His wife
relies heavily on him for managing the finances and being ‘her strong man’. He confided in
me that he now feels like he is letting her down at times and that he does not want to talk to
her about it in case it makes things worse. He sees himself as a fighter who is still more than
capable of teaching a thing or two to younger people. Ron says he has never been sick or
missed a day of work in his life.
Presenting problem
Ron says his memory troubles have been present for at least 25 years. He adds that he was
never too worried about them, as his quality of life was not affected. However, in May 2006,
whilst on holiday, he lost consciousness whilst standing in line at the evening buffet. He was
seen by the resort GP who attributed the fall to a potassium deficiency. Ron added that his
wife did not show much sympathy and, in fact, appeared rather cross with him for spoiling
their holiday. He says his memory difficulties seemed to have got worse since that incident.
He says he often feels like his head is filled with cotton wool or sawdust and sometimes feels
like he is in a far away place, as if he were separated from people around him. This has led to
four fainting episodes over a period of six months. He also reports being more forgetful and
more difficulties with word finding (dysphasia). He says he easily looses his train of thought
but this was not apparent in our meetings. Ron did not have word finding difficulties in our
sessions and did not loose his train of thought.
During the interview, Ron revealed that these difficulties occur mostly when he is at home
with his wife. Ron added that his wife gets rather impatient with him when he can’t find a
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word or when he uses the wrong noun to describe something. He says his levels of anxiety
surge up when this happens. It became apparent during the interviews that the main problem
was not a cognitive impairment but rather an anxiety and low mood issue, one he is
especially experiencing when his wife is around.
Ron, although he describes himself as semi-retired, actually works full-time seeing over 75
patients per week. When asked about his performance at work, he says that nothing has
changed there. He says he has no difficulties in remembering new patients’ names and has
not lost any confidence in his capacity to work effectively and provide his patients with a
professional level of care. He says that he often discusses cases with his practice partner,
Roger, and although Roger is not aware of his cognitive difficulties, he has expressed no
worries with regards to Ron’s work. In fact, Ron added that he never experiences cognitive
problems at work.
Ron added that he had two patients who he saw for years for back problems and they both
had some form of dementia. He said that as he saw them regularly every three months, he
was able to witness the devastating effect of the illness on these two men. This appears to
have a significant impact on Ron.
He says that his mood is sometimes low and he feels anxious at times, especially in family
gatherings or social events, which he usually attends with his wife. This was apparent,
especially in our first meeting. Ron seems very sad and appeared rather fatalistic; he told me
he felt doomed and felt like giving up on life at times. When I asked more specific questions,
he said he was not suicidal but felt that his interest in life was diminishing as it felt “a bit too
much” (sic) at times.
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Assessment
Ron came to the Psychology Service for a total of six appointments; four weekly
appointments were given followed by a four-month gap. Although the most significant
difficulties did not seem to be neuropsychological in nature, routine neuropsychological tests
were administered. Two more appointments were then attended over a period of three weeks.
This ensured that the neuropsychological tests were done in close temporal proximity but
with enough time between them to avoid fatigue (Lezak, 1995). The tests used on Ron are
listed below according to the area of function that each examines:
Psychiatric symptomatology
Hospital Anxiety and Depression Scale (HADS) (Snaith & Zigmond, 1994)
Tests for dementia
Cambridge Cognitive Examination Revised (CAMCOG-R) (Roth, Huppert, Mountjoy, &
Tym, 1998).
Mini Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975).
Test for memory
Wechsler Memory Scale- 3rd Edition (WMS-III) (Wechsler, 1998).
Test of general intelligence
National Adult Reading Test- 2nd Edition (NART) (Nelson & Willison, 1991).
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The last two tests were administered by the psychologist who has since left the service. The
CAMCOG-R was administered twice, the first time by her and the second time by myself.
Outcome
Ron completed the HADS, which is a self reported measure that examines anxiety and
depression. He obtained a score of 6/21 on the anxiety scale and 3/21 on the depression
scale. Both scores fall into the non-clinical range (between 0 and 7).
The NART, which was administered by the previous psychologist, is designed to estimate
pre-morbid intelligence levels in adults presenting with cognitive difficulties. Ron made 21
reading errors, which suggests the following IQ scores, all within the average range:
Predicted Verbal IQ: 103
Predicted Performance IQ: 105
Predicted Full Scale IQ: 105
These results might however underestimate Ron’s IQ if he is in the early stages of dementia.
Patterson, Graham and Hodges (1994) found in their study that the NART tended to
underestimate premorbid IQ by one standard deviation or fifteen IQ points. Similar
conclusions were also obtained by Taylor (1999). At the time of the interview, the other
psychologist who administered this test noted that Ron appeared to function at a level
consistent with the NART findings. If Ron is in the early stages of dementia, this could mean
that his premorbid IQ might be higher and therefore the deterioration in his cognitive abilities
might not be noticeable for people who do not know him well as he is still functioning at an
average level.
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The WMS-III was also administered by the previous psychologist. The results below were
the only ones included in Ron’s files; I could not find any of the test sheets. The WMS-III
provides a profile of immediate, delayed and working memory skills. These scores can be
compared to the estimated IQ to assess for significant differences. Ron’s overall scores on
this assessment are within the average range, between the 32nd and 39th percentile. This
means that between 61 and 68% of people the same age would achieve a higher score. These
percentile scores are lower than the estimated IQ score, which is at the 50% percentile.
Please see table 4 for summary of scores.
Table 4 Summary of Scores Index Score (mean= 100) Percentile
Wechsler Memory Scale
Immediate memory 93 32
Delayed memory 96 39
Working memory 93 32
Despite the difference between his scores, it is difficult to separate the effects of memory
difficulties from language difficulties caused by his long standing dysphasia, as language is
used to access memory.
The CAMCOG-R is one subtest taken from the Cambridge Examination for Mental Disorder
in the Elderly (CAMDEX-R). It is a neuropsychological test sensitive to the effects of
dementia. It measures a broad range of cognitive functions. The test was administered twice
with a four-month gap in between. Ron scored 87/105 the first time the test was
administered. The cut-off point for an indication of dementing illness is at 81 points. The
psychologist who administered the test wrote in her note that Ron was very anxious during
the administration of the test and suggested that it should be re-administered at a later stage as
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she felt that his performance might not reflect his current cognitive abilities. The second time
the test was administered, Ron scored 92/105. Ron’s dysphasia might have also affected the
results of the CAMCOG-R. However, the expressive language scales of the CAMCOG-R
are not the most sensitive in detecting potential dementia (Williams, Huppert, Matthews,
Nickson, & MRC CFAS, 2003) as other subscales such as memory and attention (on which
Ron performed adequately). The CAMCOG-R does not take into consideration any previous
impairments and Ron’s scores are still within the norms (Williams et al., 2003) for someone
his age and level of education. Both results clearly indicate that his cognitive functioning
operates within the normal range for somebody his age. There is clearly an issue with the test
re-test procedure here but no literature appears to be available on this question. Detailed
results of both tests are in Appendix Eight.
The MMSE is a brief screening tool for dementia and tests a limited set of cognitive
functions. All the items of the MMSE are included in the CAMCOG-R so when this test is
administered, a score for the MMSE is also obtained. The first score Ron obtained on the
MMSE was 24/30, which according to the NICE and SCIE guidelines (2006) indicates the
possibility of mild dementia. However, the second time the test was administered, four
months later, Ron scored 29/30, which suggests no cognitive impairments.
The tests suggest that Ron is functioning according to what is expected for someone his age.
The psychologist who administered the first CAMCOG-R reported in her notes that Ron had
appeared anxious during the test; his wife was present in the room at the time. This was also
not long after he lost consciousness for the first time whilst on holiday. As he mentioned that
he had been rather shaken by that event, it is not unreasonable to assume that he was still
‘mentally recovering’ from this incident. He also reported during the second meeting that
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having his wife beside him gave him a sort of ‘performance anxiety’(sic). These two factors
might explain why the score he obtained for the second CAMCOG-R, which was
administered without his wife in the room, was higher than the first one.
As mentioned above, his results on the WMS-III were slightly below what was expected but
this could be explained by his word finding difficulties as opposed to memory impairments.
A career in boxing might have put Ron more at risk of developing neurological deficiencies;
Reiter and Deprospo (2003) reported that multiple concussions might put amateur and
professional boxers more at risk of developing what is known as dementia pugilistica; the
symptoms of this condition includes tremors, lack of co-ordination, unsteady gait and
inappropriate behaviours. Ron did not display any of these and said that he suffered from
concussion on only one occasion.
In summary, the tests show that Ron is not experiencing any significant cognitive
impairment. This seems to disappoint Ron. I re-emphasised that his word finding difficulties
might be the result of the scarring on his brain identified by the private neurologist but that
based on the test results and the information he gave me in our meetings, his current
difficulties appeared to be more the result of anxiety and low mood than anything else. I
explained that he is going through many transitions and that he seems to find these
challenging and difficult to accept. He is not as capable as he used to be but finds it difficult
to reconcile himself with this and as a result tries to work harder to compensate what he sees
as weaknesses. This does not always work and has the effect of making him feel more
anxious and sometimes defeated. I told him that this anxiety might aggravate what he feels to
be symptoms of dementia (his perceived memory difficulties) as a way of confirming to him
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and others that there is something wrong with him. I offered him the opportunity of one-to-
one sessions to discuss his current difficulties and the anxiety it creates and also suggested a
referral to the family therapy service. Ron declined both offers. He was re-referred back to
the Psychiatrist for further tests, which will investigate the physical side of his symptoms.
Formulation
A formulation was created based on the material obtained in the interviews and what the test
results suggested. As it was concluded earlier on that his main difficulties were around
anxiety and low mood, the formulation was constructed around these difficulties and includes
their potential impact on his cognitive problems.
Pearce (2002) suggests that a capacity for change is required when circumstances change and
that stress often occurs when families are moving from one stage of the life cycle to the next.
Symptoms are likely to occur when there is disruption in this capacity for change or where
there is more than one transition happening at the same time. Ron appears to be experiencing
such stress as he is facing some challenging transitions. His symptoms, such as memory
difficulties when his wife is around, seemed to have become more present, or more felt, since
he experienced his loss of consciousness during his holiday. Perhaps being confronted with
physical symptoms which he cannot explain was suggestive of his own ‘newly acquired’
vulnerability or mortality, a realisation that would be anxiety provoking for both him and his
wife. Although not discussed in the interviews with Ron, the relational problem they seemed
to be experiencing, such as not sharing fears and worries and frustrations at changing roles,
appear to support this hypothesis that the couple is going through a difficult transition period.
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Montgomery (1995) suggests that “cognitions associated with anger, anxiety, depression, or
other negative moods or states will compete for attention and thus interfere with the orderly
processing of information, learning, and competent performance.” (p.459). This appears to be
a significant problem for Ron.
Ron’s personal beliefs are affecting his levels of anxiety. From an early age, he learnt that he
needed to be self-resilient and needed to work hard to be valued in the family. He also learnt
that he had to look out for himself as no one else was there to do that for him. His experience
as a boxer, which was very successful and important to him, made him feel powerful and
valued. His family pride in him boosted his self-confidence and the adversity he encountered
throughout his life was always dealt satisfactorily, in his opinion. Thus, at a certain level,
Ron believes he should be invincible.
This was also experienced in his career as a chiropractor. When Ron opened his practice, he
was very well connected with the world of professional sports because of his own boxing
career and built up a very successful practice in no time because of his good reputation.
From the material gathered in the interviews, he appears to have been an excellent
chiropractor who was able to treat successfully many difficult conditions. He says he felt in
control and very capable. He added that his clients come from all over the country and
sometimes from abroad to see him specifically. Again, this reinforced his personal belief of
being a powerful and capable problem-solver. His sense of self-worth appears to have
become linked, not surprisingly, to his therapeutic successes.
Having never been unwell in his life, the fainting episodes are a new experience to him.
These are clashing with his beliefs of invincibility and are increasing his anxiety levels. He
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has witnessed the damages dementia can do to otherwise healthy individuals and this has
frightened him significantly. These new experiences do not fit with his belief of being in
control and being invincible. Furthermore, as a chiropractor, he is used to examining,
diagnosing and treating his patients; this makes his current situation even more frustrating as
he says that no one has been able to give him a straight answer as to what is happening to
him. He said many times during the interviews that he wants to know what is going on with
him and what he needs to do to have it fixed.
Ron’s world is gradually changing as he is getting older. He is not the man he once was and
works hard at trying to regain some of his past capacities. This does not always work and as
a result, Ron is left feeling defeated and depressed.
In terms of family context, it seems that the roles assigned to Ron and his wife are rather
traditional and rigid. Ron worked hard all his life and still does to provide a comfortable
lifestyle to his family. He saw himself very much as the head of the family and the one who
is supposed to look after his wife and children. He had to be strong and showing weaknesses
or vulnerability was not an option. The beliefs are still powerful as he mentioned that his
sons regularly come to him for his help in all sorts of matters. There is another belief about
how one should get on with life and be able to cope whatever happens. This was suggested
when Ron mentioned that his wife was getting impatient with him for not getting his problem
sorted quickly; Ron interpreted this as evidence that he was not coping as well as he used to.
As Pearce (2002) mentions, the physical effects of ageing and its associated illnesses raise the
potential thought of reliance on others and can bring the threat of changes in autonomy.
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Ron is indeed facing many changes that are contributing to his low mood and anxiety. He is
72 years old and although he has always been extremely fit, the ageing process now appears
to be catching up and is challenging his personal beliefs and family situation. His work is a
significant source of self-esteem for him which also gives him a strong sense of purpose. As
he said himself, until very recently, he still did the same amount of work he did thirty years
ago, almost suggesting that he has not aged at a professional level. He is aware that he will
not be able to carry on at the same pace for much longer as complete retirement looms ahead.
Although he has reduced the number of patients he sees in a week (from 100 to 75) he finds it
difficult to fill the two afternoons a week he now has at his disposal. Being a pensioner with
no money-earning activities is not appealing to Ron. It is a significant change and one that he
finds depressing.
The society and culture in which we live also provide its influence and Ron seems to be
feeling its effect. Curtis and Dixon (2005) suggest that there has been a shift in perceptions
of old age since the Second World War. Medical progress, compulsory retirement (although
recent anti-ageist legislation might slowly change this) and the welfare system have
contributed to a redefinition of old age as a period of leisure, not productivity, and a period of
decline and decrepitude rather than a period of contemplative wisdom. Old age has become
associated with burden and unproductiveness, which is reflected in Ron’s own attitude. As
Rayner (2005) suggests, Ron faces quiet threats from two different directions: first, there is
the potential deterioration in his bodily functions, especially the brain and his memory.
Second, there are the social expectations that he is useless because of his age, irrespective of
his current abilities.
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Although Ron has some mild cognitive impairments diagnosed several years ago, the
neuropsychological tests that were administered failed to show any other significant or new
impairments. Ron clearly is experiencing some kind of physical difficulties which
manifested themselves through the fainting episodes he had. These have clashed with the
various beliefs affecting Ron’s life. He seems to feel unable to come to terms with the
transitions he is going through. His wife does not appear very sympathetic to his current
predicament and also appears unable to cope with the changes they are facing.
Montgomery’s (1995) suggests that cognitions of a negative nature will affect the
individual’s capacity for information processing by dividing his attention from the task. In
Ron’s case (see figure 8), the beliefs he holds with regard to himself and to his family, which
are shared by his wife, is creating anxiety and low mood as they clash with his current
circumstances. This appears to be mostly manifested in situations where his wife is present
as she can have a modulating effect on Ron’s perceptions of his abilities. Ron already has
some cognitive impairments that were caused by what the private neurologist identified as
scarring on the brain and these impairments are worsened by the anxiety he is experiencing.
When there is no anxiety around, for example in work situations, Ron is able to function
normally and without any cognitive difficulties.
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Societal beliefs
• Physical Symptoms
• Ageing process
Anxiety Low mood
• Personal beliefs
• Family scripts
Ron’s wife
• Fear of dementia
• Beliefs about ageing
(word finding difficulties)
Cognitive Dysfunction
Figure 8. Ron’s formulation in family situations
Recommendations
In reporting back to the Psychiatrist who had referred him, a number of recommendations
were made. Firstly, it was suggested that the Ron meets with the Psychiatrist to discuss his
physical difficulties in the light of the outcome of the neuropsychological tests. Secondly, I
suggested that he comes back to the psychology service in twelve months for another
neuropsychological assessment, in order to monitor any changes in his cognitive abilities.
Thirdly, I reported that Ron had been offered the opportunity for some psychotherapeutic
input in the form of either one-to-one sessions with me or a referral to the family therapy
service. Both offers were declined by Ron who did not see the need for such interventions. I
wrote to the Psychiatrist that these offers were still open to Ron and his family should he
reconsider his decisions following his meetings with him.
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Reflective Practice
The experience of undertaking such an assessment was a new one to me. Ron was one of my
first clients in this placement and I felt rather anxious when I was given the task of assessing
him. Although it was something I wanted to do and furthermore something I had identified
as one of my main placement goals, it was not something I especially felt interested in; this
goal was the product of an identified gap in the list of competencies I need to achieve in order
to pass the course. Neuropsychology always appeared to me as very clinical or biological
and something that would ignore the phenomenological experience of human life- I am
definitely more interested in one-to-one psychotherapy than questionnaires and psychometric
tools.
Although I read relevant instruction manuals on the various neuropsychological tools I used
and textbooks on assessing cognitive abilities in older adults, I felt a lack of confidence in my
own abilities to do the assessment. I was very well prepared intellectually and had quite a
good understanding of dementia at a very theoretical level. The bridge between theory and
practice was the one I now needed to cross. I did tell Ron I was a trainee clinical
psychologist as I did not want him to believe I was a fully qualified expert in the field. Ron
did not seem to mind; in fact, he seemed so wrapped up in his issues that I do not believe he
paid any attention to that part of my introduction.
I was also very well aware that Ron had seen another psychologist the first time he came to
our service. I did wonder how he would feel about being seen by someone else and thus
having to re-explain all his concerns from the beginning. I asked Ron the question during the
first meeting and he explained that he did not mind and actually felt freer this time to discuss
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his issues as his wife was not around and he said he also felt that a man would be more able
to understand him (the first psychologist he saw was a woman).
The main difficulty I experienced in this assessment with Ron was that he wanted to have
clear answers. I did explain to him that the tests would give us some indications but that we
would not get a clear and precise diagnosis, which I think, with hindsight, is what he wanted
to have. I believe this showed how anxious he was about his current experience and although
I did administer an anxiety test (the HADS) I feel I could have spent more time discussing his
worries with him. This was especially significant as all the test results suggested there were
no cognitive difficulties; it did not give him something tangible to justify his ‘condition’. I
think that this might have made matters slightly worse for him as he would not have a clear
explanation that he could give to his wife. It is only later in supervision that I realised I
should have spent more time talking about his anxiety and maybe approach it from a different
angle, such as discussing the relationship with his wife.
This has been a valuable lesson for me in terms of assessment work, which was the topic of
discussion in many supervision sessions. I have learnt from this experience that there is an
emotional side to this type of work; it is not just about measuring cognitive abilities but also
about feeding back results tactfully and monitoring reactions in clients. Ron was an anxious
man who was looking for answers and maybe for a way to get sympathy from his wife;
although I provided him with what the psychiatrist had asked me to do, I could have been
more sensitive to his motivations to undertake such testing. I am left wondering whether he
would have accepted the offer of extra psychotherapeutic help if I had been more receptive to
his needs.
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References
Cronen, V., & Pearce, B. (1985). Towards an explanation of how the Milan method works: an invitation to a systemic epistemology and the evolution of family systems. In D. Campbell, & R. Draper (Eds.) Applications of systemic family therapy: the Milan approach. London: Grune & Stratton. Curtis, E.A., & Dixon, M.S. (2005). Family therapy and systemic practice with older people: where are we now? Journal of Family Therapy, 27, 43-64. Lezak, M.D. (1995). Neuropsychological assessment (Third edition). Oxford: Oxford University Press. Montgomery, G.K. (1995). A multi-factor account of disability after brain injury: implications for neuropsychological counselling. Brain Injury, 9(5), 453-469.
National Institute for Health and Clinical Excellence, & Social Care Institute for Excellence (2006). Dementia: Supporting people with dementia and their carers in health and social care. London: NICE and SCIE.
Nelson, H.E., & Willison, J.R. (1991). National adult reading test. Windsor: NFER Nelson. Patterson, K.E., Graham, N., & Hodges, J.R. (1994). Reading in Dementia of the Alzheimer Type : A Preserved Ability? Neuropsychology, 8(3), 395-407. Pearce, J. (2002). Systemic therapy. In J. Hepple, J. Pearce, & P. Wilkinson (eds.) Psychological therapies with older people: developing treatments for effective practice (pp. 76-102). Hove: Brunner-Routledge. Rayner, E. (2005). Old age. In E. Rayner, A. Joyce, J. Rose, M. Twyman, & C. Clulow (Eds.) Human Development: an introduction to the psychodynamics of growth, maturity and ageing. (pp. 275-286). Hove: Routledge. Reiter, H.H., & Deprospo, L. (2003). Neuropsychological aspects of boxing. International Journal of Sport Psychology, 34(4), 340-343. Roth, M., Huppert, F.A., Mountjoy, C.Q., & Tym, E. (1998). The Cambridge examination for mental disorders of the elderly- revised. Cambridge: Cambridge University Press. Snaith, R.P., & Zigmond, A.S. (1994). Hospital Anxiety and Depression Scale. Windsor: NFER Nelson. Taylor, R. (1999). National Adult Reading Test performance in established dementia. Archives of Gerontology and Geriatrics, 29(3), 291-296. Wechsler, D. (1998). Wechsler Memory Scale (3rd Edition, UK version). London: The Psychological Corporation.
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Williams, J.G., Huppert, F.A., Matthews, F.E., Nickson, J., & MRC CFAS (2003). Performance and normative values of a concise neuropsychological test (CAMCOG) in an elderly population sample. International Journal of Geriatric Psychiatry, 18, 631-644.
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Clinical Practice Report 5- Oral Presentation The assessment and formulation of a 49 year-old man presenting with depression
Abstract
This presentation considers the case of Nick, a 49 year-old man referred by the psychiatrist to
the Psychology Service for chronic depression. Nick was initially referred by his GP and had
received cognitive-behavioural therapy from a specialist therapist five years before. Nick
does not remember much of the content of the sessions but recall that they were not helpful.
He reports having felt depressed for as long as he can remember and believes that there are
childhood issues at the root of his problem. At the time of the first appointment, Nick was
going through separation with his wife and was drinking heavily. A full assessment was
completed and schema therapy was deemed to be the appropriate treatment. Three schemas
were identified: Mistrust/abuse, emotional deprivation and defectiveness. A formulation was
developed. Nick’s early experience of his parents were not ‘loving’ and were characterised
by distance and feeling like he was a disappointment. Schemas are activated in his current
life through his relationship with his wife and also people at work. They are maintained by
the pattern of his relationships and often opting for solitary activities. This, in turn, reinforces
Nick’s core beliefs, which revolve around feeling like a fraud and that people cannot be
trusted. Coping styles used by Nick are also discussed as part of the formulation as well as
what the treatment would have consisted of. The presentation ends with a critical self
appraisal of the Trainee’s performance with this client.
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Appendices Appendix I – Summary of sessions Session One: Introduction to the anxiety management group Welcome and introductions. Do you know why we are here? This is an anxiety management group. We will be talking about anxiety, how it makes us feel and how to cope with it. Group plan: 8 weeks, 2-4pm, optional half hour breaks
2. What is Anxiety What makes you anxious?
3. What happens to your body when you get anxious Relaxation exercises
4. Understanding anxiety Why do I get anxious
5. The anxiety spiral Thoughts and behaviour that make us anxious
6. How to stop feeling anxious How to be assertive
7. How to prevent anxiety starting Developing coping skills
8. Review of the group What did you learn from the group Ground rules: You will be encouraged to participate in the group as far as you feel
comfortable You may leave the room if you need a break, but please return
You don’t have to discuss things that make you uncomfortable Try to do your homework every week, as they will help you to cope with anxiety
Confidentiality and video-recording Brainstorm of words associated with anxiety. Please give an example of a situation that makes you anxious. Looking at pictures of emotions and cutting from magazines. BREAK Completion of Glasgow scale and Anxiety thermometer. Introduce daily/weekly diary and colour stickers. Identify someone who can help you with your homework and relaxation exercises. Homework: What makes you anxious? (Drawing or writing). Weekly diary. Summary of next session. Questions and Debrief.
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Session Two: What is anxiety? Review of last session. Collection of weekly diary. Summary of today’s session. Teaching: What is anxiety? Anxiety is very common (1 in 10 people)
It’s a natural way of coping with a threat, danger or worry A little bit of anxiety can be helpful You can learn to cope with anxiety
Misconstrues about anxiety (not a disease, not madness) Feedback from homework task: What makes you anxious? BREAK Exercise: What makes you anxious? Feelings and thoughts (e.g. frightened, sad, can’t cope) Bodily sensations (e.g. heartbeat, faint, sick) Consequences (e.g. bad sleep, eat too much/little, anger) How has anxiety changed your life? How do you cope with anxiety at the moment? Stressful situations, life events, worries. Relaxation exercise: Tense and relaxed. Summary of today’s session: Everyone feels anxious sometimes. It’s ok to have these feelings. Homework: How does your body feel when you are anxious? (Body outline). Weekly diary. Summary of next session. Questions and Debrief.
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Session Three: Body reactions to anxiety and relaxation Review of last session. Collection of weekly diary. Summary of today’s session. Group exercise: How does our body feel when we are anxious? Large body outline on flipchart. Feedback from homework. Teaching: How bodily sensations can make us anxious. BREAK Teaching: Why is relaxation helpful? Helps us feel less tense Can be used in a stressful situation You need to practice everyday 3 exercises to try: Tensing and relaxing muscles Behavioural relaxation training Relaxation exercise: Breathing exercise and guided relaxation.
Quiet place, time, comfortable position Body, head, mouth, throat, shoulders, hands, feet, eyes, breathing How do you feel? Do you feel relaxed?
Summary of today’s session. Homework: Practice relaxation everyday. Weekly diary. Summary of next session. Questions and Debrief.
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Session Four: What causes anxiety and what maintains it? Review of last session. Collection of weekly diary. Summary of today’s session. Feedback from homework: Did you practice relaxation? How was it? Teaching and Practice: Why do I get anxious?
Bodily sensations Learned behaviour
Lots of worries or life event
Teaching: Why do I still feel anxious (maintaining factors)? Avoidance and triggers and unhelpful behaviours? Pictorial illustration of avoidant behaviour. BREAK Exercise: What do you avoid doing?
What triggers your anxiety? Unhelpful things you might do (before, during and after).
The wrong type of help (e.g. eating, drinking, smoking). Summary of today’s session. Homework: Continue to practice relaxation. Weekly diary. Summary of next session. Questions and Debrief.
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Session Five: the anxiety spiral and how to break it Review of last session: Why do we get anxious and how it’s maintained? Collection of weekly diary. Completion of anxiety thermometer. Feedback on homework task: Did you practice relaxation? Group exercise: Difference between thoughts and feelings List of words and sentences – Identify thoughts and feelings Examples on flipchart – Going shopping
Walking by someone in the street Seeing a dog
Break Teaching and practice: Discuss how thoughts affect our feelings and behaviour Individual experiences – Identify thoughts, feelings and behaviour Group exercise: Positive ways of thinking Alternative thoughts Homework: Practice relaxation and positive ways of thinking. Summary of next session Questions and Debrief
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Session Six: How to stop being anxious Review of last session: “The Anxiety Spiral and Positive Ways of Thinking” Collection of weekly diary. Feedback on homework task: Did you use positive thoughts when feeling anxious? Distraction techniques – Go for a walk Do some exercise Listen to some music Talk to someone Physical and Mental Relaxation Slow breathing More specific – Mental games: take attention away (e.g. recite a poem, sing a song,
count forwards or backwards) Environmental focus: focus on things around you (e.g. count number of red cars, guess what people do for a living)
Bridging object: happy thought (object, souvenir or photo) Break Lifestyle: Water, caffeine, alcohol (effects on the body) Sleeping Regular exercise Balanced diet Smoking Group exercise: What do you do that is not helpful when you are anxious? Homework: Decide which distraction technique you like the most and use it this week when you begin to feel anxious. Summary of next session. Questions and Debrief
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Session 7: Relapse prevention. Review of last session: “How to stop feeling anxious” Collect weekly diary. Feedback on homework task: Using distraction techniques when feeling anxious Devise an individual plan of positive coping strategies for each person, including: • What makes you anxious? • Thoughts, feelings, behaviours and bodily symptoms associated with particular anxiety-provoking situations • Positive ways of thinking • Physical/mental relaxation and slow breathing techniques • Other positive coping skills – Distraction techniques and positive lifestyle goals Break Complete individual coping plans Summary of next session. Questions and Debrief
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Session Eight: Review and ending. Review of last session: “Relapse Prevention” Collect weekly diary. Presentation of completed “Individual Plans for managing and coping with anxiety” Completion of Glasgow scale and Anxiety thermometer. Review of group program Break Group discussion – What has been most useful? What was not so useful? Completion of individual feedback questionnaires Presentation of “Certificates of Attendance” Questions and Comments
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Appendix II Group Evaluation We would like to find out what you thought about coming to the anxiety management group.
We would be pleased if you would answer some of the questions below. It is really important
that you are honest about your feelings. What you tell us can help to make changes and make
things better for the next group.
1. What did you feel about the room?
1 2 3 4 5 6 7 8 9 10 2. Each session lasted from 2 o’clock to 4 o’clock. What do you think of the
length of each session?
1 2 3 4 5 6 7 8 9 10 Would you have preferred them to be shorter or longer?
Less Time
The Same
More Time
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3. We met for 8 weeks. Was this a good number of sessions?
1 2 3 4 5 6 7 8 9 10 Would you have preferred to meet for more sessions or less?
THE SAME MORE LESS
4. There were 4 group members – xxxxxxxxx. Do you think this was a good
number of people?
1 2 3 4 5 6 7 8 9 10 5. How easy was it to speak to the group facilitators - Marc and Brinder?
1 2 3 4 5 6 7 8 9 10
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6. How useful was:
A. Learning about how anxiety affects us?
1 2 3 4 5 6 7 8 9 10
B. Learning about relaxation?
1 2 3 4 5 6 7 8 9 10
C. Learning about how our thoughts, feelings, and actions affect each other?
1 2 3 4 5 6 7 8 9 10
D. Learning about how to stop having anxious feelings?
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1 2 3 4 5 6 7 8 9 10
E. The homework tasks?
1 2 3 4 5 6 7 8 9 10 7. Which bits did you enjoy the most?
• Hearing information about anxiety • Drawing • Role play • Learning about relaxation • Group discussion • Tea breaks • Homework • Filling out questions • Other
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8. Which bits did you least enjoy?
• Hearing information about anxiety • Drawing • Role play • Learning about relaxation • Group discussion • Tea breaks • Homework • Filling out questions • Other
9. How easy was the information to understand? Easy Difficult 10. Has coming to the group helped you with your anxiety (panic, stress, worry, worked-up)?
1 2 3 4 5 6 7 8 9 10
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11. What have you learnt that has been useful in helping with anxiety (feeling stressed, worried, worked-up)? 12.If your friends had similar problems with anxiety (stress, worry, panic, worked-up), would you tell them to come to a group like this one? YES Maybe No 13. Would you like to make any other comments?
Thank you for completing this questionnaire.
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Appendix III Anxiety Management Group Invitation Letter Dear Colleague We are writing to inform you of a new anxiety management group to start in early February 2006 for service users in the XXX area. The group will be run for approximately 8 weeks from Wednesday 15th February 2006 at the Somewhere Heath Health Centre. Each session will last approximately two hours with breaks and an optional half hour debrief session. It is important that any clients you are thinking of referring possess reasonably good verbal skills. If you feel any of your clients may benefit from attending or would like to discuss the group further, please complete a referral form or contact John Smith or Jane Doe at the XXXXXXX, Tel: XXXXXXXXX. All referrals must be received by Tuesday 31st of January. We look forward to hearing from you. Yours sincerely John Smith Jane Doe
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Appendix IV Referral Form Referral to Anxiety Management Group Name of Referrer: ……………………………………………………………………………………………. Base: ………………………………………………………………… Tel: …………………………………………. Name of client to be referred: ……………………………………………………………………….. Address: ………………………………………………………………………………………………………………….. Tel: ……………………………………………………………………………………………………………………………. Date of Birth: Age: Gender: M / F GP: Ethnic group: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Clients living situation: Independent living Residential Home Lives with carer Other (please specify) Level of disability: borderline mild moderate Other diagnoses? Eg. Autism, Down’s Syndrome Any physical disabilities? (Please detail) Mobility issues? Language Skills: Please describe your client’s language abilities: Written skills: Is your client able to write and read and at what level? (Please give details)
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Transportation: Is your client able to travel or organise transport to the allocated venue? How does your client behave in social situations? Eg. Passive, sociable, shy but enjoys being in company. Client’s anxiety: What is the type of anxiety they are experiencing? How long has this been a problem? Are there particular triggers for their anxiety? What is the frequency of their anxiety? How long do these feelings tend to last? Have interventions been tried previously? What are their current coping strategies?
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Does your client have any weekly commitments that would interfere with attendance to the group? Eg. Employment, professional appointments, college, day centre. How do you see your client benefiting from the group? Have you discussed this referral with your client? Yes No If Yes, how does your client feel about the referral? Any additional information you feel is important for us to know? Please send completed referrals forms to: John Smith & Jane Doe
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Appendix V Anxiety Thermometer Name: Date:
ANXIETY THERMOMETER Self Report: High Anxiety
Low Anxiety Place a cross on the thermometer indicating how anxious you feel
Appendix VI Anxiety Management Weekly Diary
Name: Week:
Thursday Friday Saturday Sunday Monday Tuesday Wednesday
KEY: = NEVER = SOMETIMES = ALWAYS
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Appendix VII Single Case Experimental Design SPSS Output
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Appendix VIII Case Study CAMCOG-R Output
First CAMCOG-R administered in 2006 1. MMSE : 24 (out of 30), 0 missed (out of 19 items) 2. Blessed scores Abbreviated Mental Test : 8 (out of 10), 2 missed (out of 10 items) Dementia Scale : 0 (out of 17), 11 missed (out of 11 items) 3. CAMCOG scores CAMCOG : 87 (out of 105), 0 missed (out of 59 items) - orientation : 8 (out of 10) - comprehension : 8 (out of 9) - expression : 17 (out of 21) - remote memory : 5 (out of 6) - recent memory : 4 (out of 4) - new learning : 12 (out of 17) - attention/calculation: 7 (out of 9) - praxis : 11 (out of 12) - abstract thinking : 6 (out of 8) - perception : 9 (out of 9) Executive Function : 17 (out of 28), 0 missed (out of 7 items) All missing items are recoded to 0 (i.e. incorrect) producing a conservative estimate of performance. CAMCOG-R Profile ---------------- | % of maximum Sub-section |0 20 40 60 80 100 -------------------------|-------|-------|-------|-------|-------| CAMCOG-R overall |********************************* ( 87/105) orientation |******************************** ( 8/ 10) comprehension |************************************ ( 8/ 9) expression |******************************** ( 17/ 21) remote memory |********************************* ( 5/ 6) recent memory |**************************************** ( 4/ 4) new learning |**************************** ( 12/ 17) attention/calculation |******************************* ( 7/ 9) praxis |************************************* ( 11/ 12) abstract thinking |****************************** ( 6/ 8) perception |**************************************** ( 9/ 9) Executive function |************************ ( 17/ 28) Second CAMCOG-R administered in 2007 1. MMSE : 29 (out of 30), 0 missed (out of 19 items) 2. Blessed scores Abbreviated Mental Test : 6 (out of 10), 3 missed (out of 10 items) Dementia Scale : 0 (out of 17), 11 missed (out of 11 items) 3. CAMCOG scores CAMCOG : 92 (out of 105), 1 missed (out of 59 items) - orientation : 10 (out of 10) - comprehension : 9 (out of 9) - expression : 17 (out of 21) - remote memory : 5 (out of 6) - recent memory : 4 (out of 4) - new learning : 13 (out of 17) - attention/calculation: 8 (out of 9) - praxis : 12 (out of 12) - abstract thinking : 6 (out of 8) - perception : 8 (out of 9) Executive Function : 17 (out of 28), 0 missed (out of 7 items) All missing items are recoded to 0 (i.e. incorrect) producing a conservative estimate of performance.
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CAMCOG-R Profile ---------------- | % of maximum Sub-section |0 20 40 60 80 100 -------------------------|-------|-------|-------|-------|-------| CAMCOG-R overall |*********************************** ( 92/105) orientation |**************************************** ( 10/ 10) comprehension |**************************************** ( 9/ 9) expression |******************************** ( 17/ 21) remote memory |********************************* ( 5/ 6) recent memory |**************************************** ( 4/ 4) new learning |******************************* ( 13/ 17) attention/calculation |************************************ ( 8/ 9) praxis |**************************************** ( 12/ 12) abstract thinking |****************************** ( 6/ 8) perception |************************************ ( 8/ 9) Executive function |************************ ( 17/ 28)
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Appendix IX- A simple genogram of Ron’s relationships (Case study)
Died 1998 Age 92
Died 1977 Age 77
Died 2001 Age 74
Ron
Elder brother died of lung cancer.