2. CASE OUTLINE
Client: A.M.
15 years old.
Background:
- Diagnosed with Asperger’s syndrome.
- Referred to CBT for anxiety.
Impact: - “Fail to prepare, prepare to fail”
- Reliant on parents
- No friends
- Anger and aggression
Considerations:- Overlap between ASC and anxiety
- Motivation
- Transitions
Anxiety ASC
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3. CBT EVIDENCE BASE
CBT is a psychotherapeutic intervention that addresses unhelpful
thoughts and behaviours, by understanding the physical and emotional
impact on the individual (Wills, 2008).
The client becomes their own therapist.
More evidence for CBT than any other psychosocial intervention.
Multiple randomised control trials and meta-analyses: anxiety disorders,
depression, eating disorders and substance misuse.
The evidence base for CBT with young people is growing.
NICE guidelines for social anxiety.
Ref: Wills, 2008; Kuyken et al., 2011; Padesky, 1993; NICE, 2012; Wilson and
Branch, 2006; Department of Health (DH), 2001; National Institute for Health
and Clinical Excellence (NICE), 2013; Ahrens-Eipper 2005; Muris et.al, 2008.
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4. THEORETICAL MODELS UTILISED
Goal setting
Psycho-education work around anxiety
Personalised case formulation tool – core belief
Self-focused attention fuelling his worries.
Experiences
- Being different to others
- Being bullied
- Lifelong struggle to adapt to social norms. “Why cant
people just say what they mean?”
Applied the Clark & Wells Social Phobia protocol
Ref: Greenberger and Padesky, 1995; Bieling and Kuyken, 2003; Williams
and Garland, 2002; Clark and Wells, 1995; Clark 2002. 4
People
think I am
stupid
5. SOCIAL SITUATION
Going to the local shop alone
SELF-FOCUS
-See myself as stupid
-Can’t make any
mistakes
-Can’t draw any
attention to myself
SAFETY BEHAVIOURS
-Avoid paying by taking parent along
-Ignore people and say nothing
-Avoid eye contact
-Head down
-Parents instructed on how to
behave
-Leave quickly
ANXIETY SYMPTOMS
-Feeling sick
-Face goes red
-Hard to speak
-Heart races
-Stressed
-Fists clenched
THOUGHTS
-I won’t have enough money and will get shouted at
-Everyone will see this and know I am stupid
- I can’t forgive myself or forget, neither can anyone else
- I don’t look autistic so people won’t know why I messed up
Based on Wells 1997, www.getselfhelp.co.uk www.get.gg
D.C’s Social Anxiety Model
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6. WORK UNDERTAKEN
Thoughts/images related to his fears.
Alternate views/theories.
Practiced social situations in sessions.
Highlighted strengths.
Tracked Progress – GOALS, SRS & CORS.
Behavioural experiments.
1/ Weekly trip to the local shop alone.
2/ Created a survey.
3/ Shifted his focus of attention.
Ref: Bennet-Levy et. al, 2004
Social Phobia Equation
Overestimate risk
Underestimate coping ability
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7. OUTCOME
No aggression past 6 months
Better communication between family
Calmer
Goes to shops alone
Played pool after college - unplanned
Attended CAMHS Service User Forums; one on his own
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8. REFLECTIONS
Stedmon and Dallos, 2009: Reflection is about refining therapeutic
practice by exploring results, feedback and skills
Paused CBT to do psychoeducation work on ASC: NAS website and
videos
Adjustment at a slower pace.
More able to generate and consider alternate beliefs after doing BE.
What would I do differently:
- ASC psychoeducation work first.
- Focused more on the behavioural aspect of CBT, which in itself leads
to change in cognitions.
Refs: Bennet-Levy, 2006
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10. REFERENCES
Ahrens-Eipper, S. (2005).Applying the Clark-Wells model of social phobia to children: the case of a “dictation
phobia.” Behavioural and Cognitive Psychotherapy: 34, pp. 1-4.
Bennett-Levy, J. (2006) Therapist skills: a cognitive model of their acquisition and refinement. Behavioural and
Cognitive Psychotherapy, 34, pp. 57–78.
Bennet-Levy, J., Butler, G., Fennell, M.M Hackman, A., Mueller, M. And Westbrook, D. (2004) Oxford guide to
behavioural experiments in cognitive therapy: cognitive behaviour therapy: science and practice. Oxford: Oxford
University Press.
Bieling, P.J. and Kuyken, W. (2003) Is cognitive case formulation science or science fiction? Clinical Psychology:
Science and Practice, 10(1), pp. 52-69.
Clark, D.M. & Wells, A. (1995). A cognitive model of social phobia. In R.Heimburg, M. Liebowitz, D.A. Hope, &
F.R. Schneier (Eds) Social phobia: diagnosis, assessment and treatment, (pp.69-93). New York: Guilford Press.
Greenberger, D. and Padesky, C.A. (1995) Mind over mood: a cognitive therapy treatment manual for clients.
New York: Guilford Press.
Department of Health (2001) Treatment choice in psychological therapies and counselling. London: Department of
Health.
Kuyken, W., Padesky, C.A. and Dudley, R. (2011) Collaborative case conceptualisation: working effectively with
clients in cognitive-behavioural therapy. New York: Guilford Press.
Muris, P., Mayer, B., Adel, M., Roos, T., Wamelen, J. (2008). Predictors of Change Following Cognitive-Behavioral
Treatment of Children with Anxiety Problems: A Preliminary Investigation on Negative Automatic Thoughts and
Anxiety Control. Child Psychiatry and Human Development DOI: 10.1007/s10578-008-0116-7
National Institute of Health and Clinical Excellence (2012) Depression and anxiety – computerised cognitive
behavioural therapy (CCBT): NICE guideline (TA97). London: National Institute for Health and Clinical Excellence
National Institute of Health and Clinical Excellence (2013) Social anxiety disorder: recognition, assessment and
treatment. NICE Guideline (CG159) London: National Institute for Health and Clinical Excellence
Padesky, C.A. (1993) Socratic questioning: changing minds or guided discovery? A keynote address delivered at
the European Congress of Behavioural and Cognitive Therapies, September 24th, London.
Stedmon, J. and Dallos, R. (2009) Reflective practice in psychotherapy and counselling. New York: Open
University Press.
Wells, A. (1997). Cognitive Therapy of Anxiety Disorders: a practice manual and conceptual guide. Chichester:
Wiley
Williams, C. and Garland, A. (2002) A cognitive-behavioural therapy assessment model for use in everyday
practice. Advances in Psychiatric Treatment, 8, pp.172-179.
Wills, F. (2008) Skills in cognitive behaviour counselling and psychotherapy. London: SAGE Publications
Wilson, R. and Branch, R. (2006) Cognitive behavioural therapy for dummies. Chichester: John Wiley & Sons, Ltd
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