Case Formulation – Priscilla

Biographical

Priscilla is a 42year old female. She is living with her husband of 15 years. She has been working as an events manager for the same company for 10 years. She finds her job challenging but rewarding. She is an only child. Her best friend from childhood, whom she feels very close to like a sister, was recently killed in a car accident. She has had no previous mental health issues.

Positive Attributes

Priscilla appears to have a very supportive family and has good relationships with both her husband and her mother. She has a good job that she finds rewarding and acknowledges her skills in time management, organisation and negotiation. She has come to counselling seeking help on her own will.

Questions to ask for next session/s

-       How was/is her relationship with her parents?

-       How is her relationship with her husband?

-       Does she see these events happening as beyond her control?

-       What is Priscilla doing when she gets dizzy and feels tense?

-       Has she experienced these symptoms and problems before? How has she coped previously?

-       What is she thinking when she feels stressed, gets dizzy and tense?

-       Where (in which body part) does she feel tense?

Presenting Problems

Cognitions

“If I don’t calm everyone down and make them happy the show will flop and I’ll lose my job.”

“If I lose my job I will be disappointing my mother and also my husband. I will be a failure.”

“There is too much to do at work and now at home. Everything is piling up on me.”

“Everyone is counting on me.”

“I can’t handle it when things go wrong.”

Emotions

Priscilla is feeling very tired from the lack of sleep. She has only been sleeping 2-3hours a night. She is also feeling very worn out as there is a lot of responsibilities and things to do both at home and at work. She is anxious to get everything done on time and at a good standard and is worried at the amount of things she needs to do and in the time frame.

Behaviour

Priscilla has been arguing more with her husband. She finds it very hard to have a conversation with her husband that does not spiral out of control. As such she has not been engaging with her husband as much. She is irritable and over reactive at work.

Physiological

Priscilla has experienced dizzy spells and finds her muscles and posture very tense. She is jittery, restless and feels on edge most of the time, unable to sit still and focus on one thing for too long.

Assessments

Becks Anxiety Inventory (BAI) – Beck, Epstein, Brown & Steer (1988)

This is a 21-item questionnaire designed to determine whether a client has anxiety and if so the severity of it. This would be the first assessment administered to Priscilla to distinguish her symptoms and behaviours from a depressive or anxious state. It would also give a general idea on the severity of her anxiety if it exists.

Depression Anxiety Stress Scales (DASS) – Lovibond & Lovibond (1995)

This is a 42-item questionnaire designed to measure the negative emotional states of depression, anxiety and stress within a client. The principal value of using these scales in Priscilla’s situation is to determine and clarify the locus of emotional disturbance. If the test show that Priscilla is more stressed than anxious or more depressed than stressed then the intervention and treatment plan can be tailored as such to suit her specific needs.

Coping Inventory of Stressful Situations (CISS) – Endler & Parker (1990).

This assessment consists of 48 items that measure coping styles such as task oriented, emotion oriented and avoidance coping (distraction and social diversion). It would be useful to determine Priscilla’s dominant coping style such that the intervention can be tailored to focus towards that certain style. If she was to score high on the task oriented coping then behavioural or cognitive problem solving tasks would be more familiar for her whereas if she was an emotion oriented in coping she would respond better to cognitive changes through fantasy and role play. If Priscilla showed strength in coping by avoidance then involving her social support network may be most useful.

Trimodal Anxiety Questionnaire (TAQ) – Lehrer & Woolfolk, 1982

This is a 36-item questionnaire that measures the traits of an anxious client. This would be useful for Priscilla if previous assessments indicate she shows anxiety as it determines the level of anxiety in three domains: somatic/physiological, cognitive, and behavioural. From this the intervention and treatment plan can be tailored to directly address these problem areas such as working to relieve muscle tension and relaxation.

Developmental and Maintenance Processes

Predisposing

Her best friend from childhood, whom she treats as a sister was recently killed in a car accident. Priscilla has also had increased responsibilities at home as her housekeeper is away. She has also been engaged in a stressful and volatile situation at work where many different parties with different goals look to her for directions and decisions.

Precipitating

Priscilla has chosen to attend therapy as she has been having difficulty connecting with her husband. She finds that she is quite on edge, snapping and arguing at him more than usual. She is experiencing dizzy spells, finds it difficult to concentrate on specific tasks and is unable to sleep more than a few hours a day.

Perpetuating

I hypothesize that with the increase in responsibilities there is also an increase in pressures and expectations. It appears that Priscilla worries about her performance and about pleasing all the stakeholders. Worrying about it constantly makes her feel anxious, edgy and unable to concentrate. It also occupies her frequently and she is unable to connect with her husband in an adequate way. This leads to friction between them and she seeks to avoid interacting with her husband lest it lead to confrontations. This increases her worries.

Case Formulation

It appears that Priscilla is feeling very stressed and anxious from the increased responsibilities both at work and at home. This has contributed to her feeling increased muscle tension and an increased breathing rate leading to dizziness when she is encountered with a new ‘disaster’ or problem at work and home. She worries how her physical state is and how it will impede on her work performance and often stays up late worrying and unable to sleep. Thus she is tired and irritable.

Goals

Together with Priscilla we broke down her problems into three areas as mentioned above: physiological, emotions and behaviour. Within these problem areas we specified what exactly was unusual and impeding her usual routine and way of life.

Physiological

Tension in muscles – Recognise when muscles and body tense. Decrease this tension.

Dizziness – Recognise breathing patterns and notice when breathing increases which can cause dizziness and light headiness. Learn skills to breathe in a timely, slower manner.

Emotions

Worn out – Determine reasons why Priscilla is feeling worn out and to make some time for her to relax and to unwind.

Tired – to get a good night’s sleep (5-7hours) every night.

Pressured – examine when Priscilla starts feeling pressured. Determine ways to lessen feeling of pressure such as delegating more and taking on less tasks.

Behaviour

Withdrawing from husband – recognise when Priscilla withdraws from husband and figure out the situation surrounding this when it happens. Find ways of re-connecting with husband again.

Treatment

By targeting Priscilla’s physiological problems so that she is feeling more relaxed, experiences less dizziness and what may appear as “panic attacks” may then lead to her feeling more able to fall asleep at night and thus feeling less tired and worn out. This as well as cognitive restructuring may also help her address how she is coping with increases in her workload and her relationship with her husband.

Session 1

Gather an overview of Priscilla’s situation. Identify together with Priscilla specific problems. Discuss her expectation and goals for therapy. Provide psycho education surrounding anxiety and panic attacks. Explain to her that being stressed or being in a stressful environment can cause an individual to tense up in their muscles and body. This can cause uncomfortable sensations such as headaches, backaches and tightness in the chest. This can in turn cause an individual to worry, which can increase the tension. Having this tension and worrying about it can be tiresome and often these individuals will complain of being tired.

Explain what can happen when an individual is stressed is that they can start breathing faster and deeper. This is called hyperventilation and is the body’s normal reaction to threat as the oxygen received is used to supply the muscles ready for the ‘fight or flight’. However, if the muscles don’t use up the oxygen then symptoms such as rapid heartbeat, feeling faint and dizzy can occur.

Emphasise that some level of anxiety is normal and can assist daily functioning. However, in Priscilla’s situation her anxiety has increased to such a level that it is impeding her relationship with her husband and also causing recurring physiological symptoms.

It seems important to address Priscilla’s physiological problems first, equipping her with some basic skills to allow her to practice and utilise over the week til the next session. The progressive muscle relaxation (Jacobson, 1938) can help Priscilla identify the difference between a tense muscle and a relaxed muscle. Sometimes that tension can be carried in the body for such a long time that an individual may not even be consciously aware of it anymore.

Ask Priscilla to set aside 10minutes at least twice in the next week for this relaxation. Suggest doing this at the end of the day before bed as a way of relaxing into sleep. Write down how she felt before, during and after this relaxation. Note any changes in mood, symptoms and interaction with others during the week.

She is very efficient at managing her time and appears to take well to having homework and being able to set time for her relaxation practice. Although she may not understand exactly how therapy will help she appears willing to set time aside during the week to try the skills.

Session 2

Go through the relaxation homework from the past week. Look at how effective it was. Discuss how it may not have helped and some possible ways of combating this such as setting aside specific time of the day to practice muscle relaxation, changing from afternoon to morning (or vice versa) and correcting procedure. Practice the correct procedure within the session.

Discuss with Priscilla the case formulation and together develop and implement goals and treatment plan. The short-term objectives are to help her deal with her symptoms more effectively through relaxation and breathing. The long-term objectives are to improve her relationship and bonding with her husband and to reconnect with her co-workers.

Increase Priscilla’s awareness of hyperventilation and the symptoms surrounding it. Practice monitoring breathing within session and talk about stimulants that can trigger hyperventilation such as tobacco, tea and coffee. Discuss how being stressed can cause an individual to hyperventilate which can cause symptoms to show up. Although these symptoms are frightening in themselves, they are not actually harmful. As such the onset of these symptoms can increase the individual’s stress levels, which can then form a repetitive cycle. Breathing in this manner can be very tiring which may have contributed to Priscilla’s feelings of tiredness. Determine when and how often she experiences these symptoms to figure out what may be triggering the over breathing.

Practice monitoring her breathing and breathing from the stomach and not the chest. Aim to slow breathing down to a breathing rate of 8 to 12 breaths per minute.  Experiment breathing before and after muscle relaxation and discuss the differences. Walk through the re-breathing technique that can be used if the symptoms don’t go away after a few minutes. Practice this for no more than four or five times.

Ask Priscilla to set a time every day to practice muscle relaxation and to monitor her breathing throughout her day. Draw up and introduce the concept of daily thought record where she keeps a record of her emotions and thoughts. Define the difference between emotion and thought. Run through an example of a daily thought record. She will also write down when she starts feeling stressed or anxious, what happens to her body when this occurs and her breathing and relaxation skills she uses at the time. Daily thought record to consist of: Event/situation; emotion; thought; bodily sensation; skills used to combat.

Priscilla is a well-organised person and I predict that she will appreciate the opportunity to set time aside for these concrete activities and skills she has learnt. She may even be surprised how well the relaxation of her muscles have helped her overall in more than one aspect of her life.

Session 3 & 4

Go through the daily thought record. Together with Priscilla try and determine a pattern to her stressors and anxiety. Discuss how, if at all, the breathing and relaxation skills helped.

Together look at the thoughts she had during the week.  Use examples of some of the worrying thoughts she had and look at any evidence that does and does not support it. We shall then take a cost-benefit approach to each cognitive thought Priscilla recorded during the week. Talk through how each thought is a pro/con in the short/long term. How did having that thought help her in the short term, which may then have disadvantaged her in the long term? Go through the likelihood that her thoughts at the time were plausible and then discuss how she may have come to believe and have those worries.

Introduce topic of accepting uncertainty. Worrying can be seen as a way of predicting and preparing yourself for future events, preventing the unknown from happening and controlling the outcome. However, all possible outcomes cannot be foreseen and some outcomes are unrealistic and not plausible at all. Identify and challenge some of Priscilla’s worries that do not tolerate uncertainty.

Set homework task for Priscilla for that week. Alter the Thought Diary so that it now consists of: description of situation, anxiety level, automatic thought, pro/cons of thought, alternative thought, anxiety level after. Go through the process with her so that she is clear on the task. Continue with relaxation exercises every day and breathing skills as required.

As with many people Priscilla may be surprised at how many thoughts she has at certain times and how negative or skewed some of those thoughts can be. She may even find the thought diary to be useful and quite relaxing being able to jot down things during the day. She is familiar with the thought diary as she is constantly using her own diary for schedules, meetings and work.

Session 5

Discuss how Priscilla went in the past week in monitoring her thoughts and providing alternate thoughts. Check with Priscilla if there are any worries that she may still carry with her. Focusing on role-play and imagery, explore the worst possible outcome that could happen if those persistent worries were played out.  Explain that sometimes our worries take on a fantasy-like perception in such a way that it is unrealistic and much worse than the worst possible outcome.

Discuss and look at Priscilla’s pattern of persistent worries. Utilising Priscilla’s skills in organising and time management discuss the possibility of allowing for “worrying” to happen at certain specific times such as in the morning or right after work. Suggest letting all her worries come out at this time and putting them in a box when she is finished. Allowing her to freely “worry” in these times gives her the space she needs to think through and deal with her worries but also restricts the time she has to do this. Encourage a quiet moment for relaxation after this as well. If she finds herself worrying during the day ask her to attempt to prolong it until the specified time. Emphasise that this box needs to be placed aside when she comes home so she is able to be fully available to her husband and her home needs. Introduce and explain safety behaviours. Identify her safety behaviours such as withdrawing from her husband to avoid conflict.

Role play a scenario in which Priscilla is given a few thoughts or worries on a card and is asked to have those occupy her mind as she interacts with me in a daily normal routine situation. Discuss how it felt to have her mind occupied whilst trying to connect with me and frankly share how it felt to be the person trying to connect with an “occupied” person. Reverse role-play if needed. Allow some time for Priscilla to voice and sort through her thoughts and then ask her to place them in the box and put them aside. Go through a quiet moment of relaxation and then role-play again. Discuss the effects of this.

Ask Priscilla to set aside time for her worry box and then relaxation each day. Continue her thought diary and ask her to make note of how she feels interacting with her husband when and if she does this. Talk about the next session and how it may possibly be the last session together. Ask her to voice her thoughts about this and address any fears she may have.

Priscilla may be surprised at the feelings she evokes during role play. She may not realise how she has been behaving with her husband for awhile now. She may also feel that this is already happening less as through relaxation and the thought diary she grows more aware of herself.

Session 6

Discuss with Priscilla how her week went with the exercises she did and any issues she had since then. Explore her relationship and interaction with her husband after the implementation of all her newly acquired skills of relaxation, breathing and the worry box. Work together to come up with some ideas on how she could form a closer connection with her husband such as setting aside some time alone, doing recreational activities together and also delegating some of the household chores and workload so the pressure is lessened. Discuss doing some physical exercise alone or together with her husband as a way or releasing tension and spending time together. Regular exercise during the day can be beneficial for elevating mood and improving sleep.

Go through an overview of the sessions and take another look at the formulation. Discuss how incorporating the relaxation, breathing, altering thoughts and thought processes has or hasn’t helped Priscilla overall. Discuss how she feels about therapy and whether she felt her goals have been met. Discuss possibility of further sessions.

I feel that perhaps at the end of session six Priscilla may be feeling more equipped to deal with the stressors in her life. She has some concrete skills that she is able to utilise and has a more open understanding of herself and her interactions and thoughts. Perhaps if the sessions have opened up more vulnerabilities and issues she may be interested in further therapy.

References

Beck, A. T., Epstein, N., Brown. G. & Steer, R. A. (1988) An Inventory for Measuring Clinical Anxiety: Psychometric Properties. Journal of Consulting and Clinical Psychology, 56, 6, 893-897.

Lovibond, S. H. & Lovibond, P. F. (1995) Manual for the Depression Anxiety Stress Scales. Sydney; Psychology Foundation.

Endler, N. S., & Parker, J. D. A. (1990a). Coping Inventory for Stressful Situations (CISS): Manual. Toronto, Canada: Multi-Health Systems.

Lehrer, P. M., & Woolfolk, R. L. (1982) Self-report assessment of anxiety: Somatic, cognitive, and behavioural modalities. Behavioural Assessment, 4, 167-177.

Jacobson, E. (1938) Progressive Relaxation. University of Chicago Press, Chicago.