Clinical Assessment
Bonnie Emerson came in the clinic seeking help with her social anxiety, and was brought in by her parents. Bonnie is a 15 year old Caucasian girl who lives with her parents and is in the 9th grade. Bonnie stated that her problem was that she would "get nervous about everything," even with things at school and doing anything new. She reports to feel "very self-conscious" in the mall and she "constantly worries about what others might think of her." She reported to be "very fearful" of eating in public, using public restrooms, being in crowded places, and meeting new people. She stated that in school she would "fear and avoid, speaking up in class, writing on the blackboard, and talking to her teachers or school principal." Bonnie stated that her strengths was playing the flute, but she dropped out of the school band because her "anxiety took over" when participating in band performances. She states to fear talking to unfamiliar adults (store clerks), answering the phone, or when ordering pizza. She reports being worried about "possibly saying the wrong things or not knowing what to say or do, which can lead others to think badly of her." She reported that these fears would be so "intense" that she experienced a "full-blown panic attack." She stated feeling "accelerated heart rate, chest discomfort, shortness of breath, hot flashes, sweating, trembling, dizziness, and difficulty swallowing." She also reported having headaches and stomachaches when she would anticipate a situation that she found difficult (5 times a week). Bonnie's parents stated "even though it's May, she's worried and had stomachaches about starting 10th grade in the Fall." Her parents state that she is "terrified" to be in public places, and that she would make her younger sister (13 years old) to order her food at the restaurants. Her parents stated that she had a "safe" person, her best friend, who would help Bonnie attend parties from her high school, but that she has not gone to a party since junior high. Her parents reported that the "last straw" happened two weeks ago, when there was a family gathering. Her parents stated that there was a "large number of relatives, that she had a panic attack and locked herself in her bedroom for the entire day until the last guest had left." Bonnie reported to have felt "depressed, fatigued and had problems concentrating" after she broke up with her boyfriend, when she found him dating another girl. She also stated to have trouble sleeping during this time, and that all these feelings lasted for 2 months in the last year. She states that a month ago her "depressed mood lifted," which is related to dating a new boy. Parents stated that her social anxiety "increased drastically" a year before coming into the clinic.
Family History
Bonnie has a sister that is 13 years old, and lives in a middle-class home. Her father is a building contractor and her mother is a bank teller. She states to have a good relationship with her parents, because "they are always supportive of me." She states that when she told them about her social anxiety that "they pushed me to socialize more." Her parents reported no history of anxiety problems in their immediate relatives. Bonnie stated to "get along quite well with her sister."
Education/Employment History
Bonnie reported being in the 9th grade, and that she enjoyed playing the flute. She stated that got out of school band because of her fear of performing.
She states to have two best friends from school, and that they eat lunch together by themselves. She states to have mainly B's and C's at school, and her parents state that she achieves those grades with "little effort." Bonnie denies having any jobs or employment history.
Legal History
Bonnie denies any legal history.
Medical History
Bonnie states that her last checkup was within a year. She states to have headaches and stomachaches (7 times a week) before going to school. She states that she is "used to her headaches and stomachaches and states to take no medication for them.
Mental Status Exam (MSE)
Bonnie appears to be her age, and has some bags under her eyes. She is well dressed and groomed. She appears to be clean and neat. She has little eye contact. She appeared to be restless when talking about her fear and anxiety. Her speech was soft spoken, clear and coherent. She was fully oriented and knew the purpose of the evaluation. Her intellectual functioning is unimpaired, even though her grades are average (B's and C's). Her memory is unimpaired and remembers how she feels in new situations. Her fund of knowledge is average, she is still in high school and is in the 9th grade. Her mood was anxious and worried, she kept "fidgeting" her legs and rubbing her hands together between her legs. Her affect appeared worried and sad about how she keeps feeling anxious and fearful. There are no apparent hallucinations, and no apparent self-perceptions. There are no apparent associations and her concentration is intact, she was able to answer the questions and was cooperative. There are no apparent delusions and has some excessive worries about new situations and places, and what people may think of her. Bonnie denies any suicide ideation and homicide ideation.
Diagnosis
Bonnie stated to feel fear and anxiety when anticipating a new interaction or situation. She reports to feel anxious by having headaches and stomachaches when going to school every morning (5 days a week). She states that she avoids going to public places, like the mall, because she worries about what everyone is thinking about her. She states to stopped going to school band and playing the flute because she fears doing the band performances. Her parents report that she avoids going to parties because she is anxious of what people will think about her, but that she can attend if her "safe" person is there (one of her best friends). Her parents state that her social anxiety has "increased drastically" a year before coming to the clinic. Bonnie states to have "full-blown" panic attacks, in a form of "accelerated heart rate, chest discomfort, shortness of breath, hot flashes, sweating, trembling, dizziness, and difficulty swallowing." Due to the impact in Bonnie's social and daily functioning, she was diagnosed with Social Anxiety Disorder (Social Phobia) 300.23 (F40.10). Bonnie denies to feel the sense of losing control or "going crazy" when having these panic attacks, and denies to have unexpected panic attacks. Due to these reports, we can rule out Panic Disorder. Although Bonnie meets criteria A for Panic Disorder, she does not meet criteria B for Panic Disorder. Bonnie stated feeling "very depressed," and that she "did not sleep well, felt very fatigued, had problems concentrating, and felt worthless," for two months during the past year when she found out her ex-boyfriend was dating another girl. She also stated to stop going to school band, even though she enjoyed playing the flute. She states to no longer feel that way in a year. Bonnie does not meet criteria for Major Depressive Disorder, since she has not lost all interest or pleasure in her activities most of the days, or nearly every day. She states to still meet with her friends every day during lunch. She states to still have a good relationship with her sister, and that she still has a good relationship with her parents. Since her symptoms have not been present during the same 2-week period, we can rule out Major Depressive Disorder.
Crisis Plan
For Bonnie's crisis plan we want to look into if her crisis is life threatening. Once, she has identified if it is a life threatening situation Bonnie will do the following: when she is experiencing her "full-blown" panic attacks, and it's a life threatening situation then Bonnie will contact her "safe" person to make sure that she is in a safe place. Once Bonnie has contacted her "safe" person (best friend or parents), she will practice some breathing techniques to slow down her heart rate and shortness of breath. Her breathing exercises will look like: breathing all the way in, until she fills her lungs and holding it for 3 seconds, then letting go of that breath as far out as she can, like if she is pushing something away with her breath. Part of her crisis plan will also include, for Bonnie to take time that same day to take a five minute walk in a familiar place and a safe place with either her "safe" person and/or with one of her parents.
Evidence-Based Treatment Plan
Based on the research, different forms of Cognitive Behavioral Therapy (CBT) and Cognitive Therapy (CT) have shown the best support for adolescents with Social Anxiety Disorder. The first article, Cognitive Therapy for Social Anxiety Disorder (CT-SAD) in Adolescents: A development case series, aimed to see the adaptation of CT-SAD in adolescents. There were five adolescents (11-17 years old) that showed remission by the end of the course. These five adolescents showed severe anxiety at baseline, which allows me to generalize this study and its treatment to Bonnie. As Bonnie is also diagnosed with SAD and is in that age range, this method of treating SAD can be beneficial for her and her family. I would also want to assess Bonnie with the Clinician Severity Rating, as they did in the study, to see where her severity really lays.
Part of the CT-SAD treatment includes developing a Clark and Wells model which would view a social situation in which Bonnie avoids or fears, negative thoughts, her self-focus image of herself, safety behaviors and anxiety feelings and things from the past (Leigh and Clark, 2015). Second Bonnie will go through an experiential exercise (leigh and Clark, 2015) that consist of having two conversations with a stranger and it will be recorded. In the first one she will focus on the model previously noted, and the second conversation she will focus externally and try to not focus on how they are coming across the other person (Leigh and Clark, 2015). The next step would be to video record and photograph how Bonnie is coming across the stranger, and the second of how she thinks she is coming across the stranger. Another step of her treatment in CT-SAD is to engage in behavioral experiments, which consist of dropping their safety behaviors and see externally by getting new information about their anxious predictions (Leigh and Clark, 2015). Leigh and Clark (2015) also focused on that "anticipatory worry" and "post event rumination" and explain how these are unhelpful and then focus on their beliefs. They also incorporated "school-based behavioral experiments" to see how teachers could aid in their treatment.
Since Bonnie found herself no longer going to school band, these experiments seem to be helpful. In Bonnie's case, we would want to have an agreement that parents, teachers and Bonnie would need to be included in their treatment plan, to generalize. I would address these experiments and exercises, by first getting consent from all individuals that are willing to be part of her treatment course. Since Bonnie does have a difficult time talking to strangers and initiating conversations, I would want to have a role play with her in order to help her visualize how those two conversation would go.
Another therapy would be Cognitive Behavioral Family Therapy (CBFT). Maid, Smokowski and Bacallao (2008) in Family treatment of childhood anxiety viewed different factors of how parenting has a role in adolescents developing anxiety disorders. These factors include: parental acceptance, control and modeling of anxious behaviors. Being able to pin point Mr. and Mrs. Emerson's parental acceptance can show us how Bonnie was perhaps thought to deal with things emotionally and/or behaviorally, and Bonnie's attachment style. Parental control deals more with how much regulation Bonnie's parents had with her in her childhood. This point is important because we want to see how autonomous Bonnie learned to be. The last factor they focus on is modeling, which means how parents dealt with their child's dealing with a problem or difficult situation. Understanding Mr. and Mrs. Emerson's parenting style and how they dealt with Bonnie is situations she is now having a difficulty with would be beneficial to her treatment and future assessment. Overall, by figuring out these three factors Maid, Smokowski and Bacallao (2008) wanted to see any negative interactions which could be linked to the development of anxiety disorders.
CBFT consist of 16 sessions, in which the parents and the child/adolescent would have to attend (Maid, Smokowski and Bacallao, 2008). They explain that the treatment is separated into two sections, the first one being training and then the application. Part of the treatment was to teach parents the FEAR acronym, which stands for F: feeling frightened, E: expecting bad things to happen, A: Attitudes and actions that will help, R: results and rewards (Maid, Smokowski and Bacallao, 2008). They also want to help them identify and talk about their feelings and emotions that could be present. The second part of CBFT consist of a "more difficult" process for the child since is consist of "confrontation with the anxious stimuli" (Maid, Smokowski and Bacallao, 2008). This pertains to dealing with exposure to those fearful situations they struggle with and also role playing those scenarios and later having in vivo interactions. However, the parents are also taught to be the child's "in vivo coach" in order to teach the parents coping skills that they can support their child with (Maid, Smokowski and Bacallao, 2008). Another intervention they used in the study was communication therapy and for this they used the Satir method. Satir's method indicates that the family should be educated in the role they have with each individual and how to change those patterns of communication that "reinforce anxiety" (Maid, Smokowski and Bacallao, 2008). In Bonnie's case, incorporating Satir's method would be beneficial for her because we want to look at how her parents pattern of communication could be reinforcing her anxiety symptoms.
The next study to look at would entail long term follow up of exposure-based cognitive behavioral treatments in an individual or group setting (Saavedra, Silverman, Morgan-Lopez, and Kurtnes, 2010). This study consisted of a long term follow up (8 to 13 years post-treatment) in 67 participants of the ages of 16-26. Saavedra, Silverman, Morgan-Lopez, and Kurtnes (2010) targeted the outcomes in anxiety symptoms and also in depressive and substance abuse. The interventions used in this study that resulted in long term remission of the participants symptoms, were "behavioral facilitative strategies," or "cognitive facilitative strategies." Saavedra, Silverman, Morgan-Lopez, and Kurtnes (2010) found empirical evidence for the long term remission of symptoms of CBT that target childhood anxiety disorders and depressive and substance abuse disorders and problems. In Bonnie's case this study help to see the efficacy in the CBT and CT that Bonnie will be taking place in her treatment course.
Treatment Course
Based on the research, the beginning of Bonnie's treatment will focus on CT to help her with her thought process. Also being able to have that conversation with a stranger and it be role played first at the clinic, should be able to give her a better image of how interacting with a stranger could be less anxiety provoking. Targeting this exercise can also help towards Bonnie's excessive worry of what others might think of her. By helping Bonnie go through the motions of this exercise it should help her to understand her thought process at the moment and then how her thought process can change in order to increase those social interactions. For example, by doing this exercise, we can also target a scenario in her band practice, which leads us to the next phase of her treatment.
The second phase of her treatment would be more exposure to those situations, by using CBFT. As Bonnie's parents are trained to be her in vivo coaches, this can provide coping skills that her parents can pass on to her, and also allow for Bonnie build that trust in her parents support. As the research shows, that the parenting communication and patterns can be associated to anxiety disorders (Maid, Smokowski and Bacallao, 2008), then by doing these exercises we can facilitate that healthy communication that can reduce the reinforcement of her anxiety.
The third phase would focus on examining whether Bonnie and her parents are ready for termination. At this phase I would assess one more time, and check the efficacy of the interventions. At this phase we would also talk about the post-treatment exercises that Bonnie can do outside of treatment. As mentioned in her crisis plan, part of her exercises could also incorporate deep breathing and walks to increase her awareness of her surrounding, feeling, and thoughts.
Diversity:
Some of the diversity issues to be concerned about would be how the therapist culture or ethnicity and approach would affect Bonnie's goals. Since Bonnie is a Caucasian adolescent, we would want to see what is best fit for Bonnie and her parents for the course of her treatment. Since her treatment course is quite experiential, we would want to consider how the family thinks of this matter.
Laws & Ethics:
Bonnie's parents would be asked for consent to proceed with these interventions and to do the assessments throughout her treatment course. Another concern would be when doing these exercises, such as the exposure therapy we would want to consider who is around the school during these times. We would also want to consider if exposure therapy would be to traumatic for Bonnie. Part of treatment course incorporates exposure therapy, however, as mentioned, role plays would be the prerequisite before she is able to go through the actual exercise. Another consideration would be the training of the therapist who would work with Bonnie and see how every method is being delivered. As we continue to consider the concern in exposure therapy that Bonnie would have to undergo, we want to look at the harm risk that she may also undergo. As stated in her crisis plan, Bonnie is to determine if it is a life threatening situation in which in the case of the role plays and the exposure therapy part, Bonnie would be accompanied by at least one adult.
Lastly, to look into the boundaries of this therapeutic relationship between the therapist and the client, we would want to see how this treatment plan could work for Bonnie. As mentioned before we would want to get consent first from parents and Bonnie.