Thursday 8 July 2010

Case example 1, Part 2

My work with Richard continued on various fronts for about 12 weekly sessions, after which he came less regularly to monitor progress. The areas of principal focus were always agreed collaboratively and explicitly, although I provided strong guidance and direction, based on my experience of the kind of issues he was struggling with.

Level 3:
We initially focused primarily on trying to weaken some of the maintaining cycles of Richard’s social anxiety problem, in order to give him some relief, hope and energy. He borrowed a copy of “Overcoming Social Anxiety: A Self-help Guide using Cognitive-Behavioural Techniques”, and found this useful in educating himself about the problem and the ways in which it can be addressed.

The classic Social Anxiety pattern, as described a couple of weeks ago, consists of tendencies
• To worry and mentally rehearse before social events
• To practice a range of “Safety Behaviours” in social settings
• To carry out a self-critical “post mortem” after social events.

Richard did not do a lot of the pre-event rehearsal and anticipation, because of his huge avoidance of (and avoidance in) social settings, but he was quite capable of self-punishing post-mortems, “chewing over” almost any interpersonal encounter in a negative way. We worked together to try and get a sense of what was going through his mind when he was feeling anxious during and after social situations, and discovered that the following Negative Automatic Thoughts were common for him:

“I’m different”
“They don’t like me”
“They’re only being nice”
“I look/sound stupid”
“I made a mess of that”

He could also identify typical cognitive distortions such as All or Nothing Thinking, Discounting Positive Feedback, Mind-reading, Emotional Reasoning, and Catastrophising.

We agreed that, in order to reality-test some of these in an experiential way, he must, at some point, begin to drop some of his safety behaviours, and see what happens. Some of his main safety behaviours were:
• Avoiding eye-contact and conversation – he would spend minimal time in the staff room, preferring to stay busy, volunteering for every possible activity with pupils
• Sticking to task-oriented, work-related conversation
• Avoiding social outings (pubs, parties etc).

Fortunately he had never developed the habit of using alcohol to cope with social situations or with his loneliness, so this was not an issue.

Level 1:
Lots of support was needed, as Richard was very fearful of even thinking about changing any of these patterns. The therapeutic relationship was very important in this regard, as well as in the use of Immediacy, by providing positive feedback as to how Richard was coming across in the therapy relationship.

Level 2:
This opened up the possibility of rehearsal and practice. Richard feared that his social skills were poor, but in fact they were mostly fine, apart from the lack of practice that comes from too little time spent with people and too much time spent with a computer.
Reality-testing his fears took a lot of courage, so we also did some motivational work on risk assessment and cost/benefit analysis.

Level 3:
Fortunately, when Richard took the risk to make a little more eye contact, and to ask colleagues about their holidays etc, he was amazed at how much less awful it was than he had feared it would be. Of course, this result was in large part due to appropriate cognitive preparation and therapeutic support.

Level 4:
Richard made so much progress that he began to be puzzled as to how his problems could have been so deeply ingrained, so we talked again about the maintaining cycles and blocks to experiential learning. We also spent some time again talking about the early maladaptive schemas that were probably part of the roots of his difficulties. His father had had very rigid rules for the family, and no friends were allowed to visit the home. This had always embarrassed Richard greatly, and his sense of shame and his withdrawal had gradually reinforced each other to the extent that even when he left home to go to college, he still felt very different from everyone else. This in turn left him still very dependent on his parents for his age, and one of the Level 2 skills we needed to work on was Assertiveness.

Level 5:
We also discussed the fact that people vary in their sociability, both in amount and in style, and that it was important that he develop his own way, rather than try to be too much of what he thought he “ought” to be. I also reassured him that relationships could be difficult for everyone at times, and that now that he was getting more confident and considering the possibility of dating, the fun was only starting!

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