Demographics
Amy, a 13-year-old girl who was sent for Cognitive Behavioral Therapy by her 40-year-old mother, is the patient under focus. Amy’s family circumstances highlight key pressure points and obstacles in her life. Amy’s parents divorced five years ago, and her father is now a resident of a different continent. Amy used to be close to her paternal grandmother, but now that her parents are divorced, she rarely sees her. Toni, Amy’s mother, works a demanding job and faces financial difficulties.
Amy’s immediate presenting problem includes anxiety, withdrawal, and physical discomfort, in addition to her dropping grades and hair-pulling. Following her banishment from her friend group and online harassment as a result of her mother informing the other parents that Amy and her friends were drinking at a party, these symptoms have developed over the past three months. Amy has become more isolated and avoids activities she formerly enjoyed because she is upset with her mother and believes she is to blame for what happened to her friends.
Amy was recommended for cognitive behavioral therapy because no physical ailments could be found to account for her condition. After an evaluation, Amy arrived at the conclusion that there are no obvious medical causes explaining her behavior. No drugs that could have improved Amy’s mood were prescribed. It follows that psychological treatments like Cognitive Behavioral Therapy might be more effective at treating her problems.
Literature Review
“Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR” by the American Psychiatric Association (2022) is a manual used by specialists in mental health to identify and categorize mental diseases. It offers details on the prevalence, progression, and associated characteristics of mental diseases, as well as descriptions and diagnostic standards. The chapter on the hair-pulling disorder trichotillomania, which is most pertinent to Amy’s case, is the most informative entry, “associated with distress as well as with social and occupational impairment” (American Psychiatric Association, 2022, p. 430). It is important because it highlights an essential aspect of Amy’s described condition – extreme anxiety.
“Can the Child Behavior Checklist (CBCL) help characterize the types of psychopathologic conditions driving child psychiatry referrals?” by Biederman et al. (2020) is a research article that discusses the efficiency of the CBCL. The authors note that the CBCL “can aid in the identification of individual and comorbid mental disorders affecting youth seeking mental health services by providing specific information about the presence and the severity of specific suspected disorder” (Biederman et al., 2020, p. 157). This source is relevant because it provides an evidence-based foundation behind the tools that will be used to assess Amy.
“CBT strategies for anxious and depressed children and adolescents: A clinician’s toolkit” by Bunge et al. (2017) includes a toolkit of cognitive-behavioral therapy (CBT) procedures that may be used in a clinical environment and is intended for professionals who work with anxious and depressed children and adolescents. One particular case study from this book is Lamisha, who is “a 15-year-old girl with generalized anxiety disorder and depressive symptoms” (Bunge et al., 2017, p. 97). It is relevant to Amy’s problem because it showcases the use of cognitive restructuring as an effective way of managing anxiety.
“Trauma-focused cognitive behavior therapy for traumatized children and families” by Cohen and Mannarino (2015) highlights the value of family engagement in the treatment of child trauma and offers crucial information about how TF-CBT functions. The authors emphasize that each component of TF-CBT includes gradual exposure, making it a component- and phase-based treatment. The authors also note that several studies document that “family-focused treatment that integrally includes parents will significantly enhance outcomes for traumatized children” (Cohen & Mannarino, 2015, p. 559). This is important for Amy’s case because TF-CBT will be used as one of the strategies to help her.
“Cognitive Behavioral Therapy for Anxiety Disorders in Children and Adolescents” by James et al. (2013) is a systematic review that assesses cognitive-behavioral therapy’s (CBT) efficacy in treating anxiety problems in kids and teenagers. The review’s objective is to offer this community evidence-based knowledge regarding how well CBT treats anxiety disorders. James et al. (2013) note that “A major challenge for clinical practice is the very limited access that children with anxiety disorders have to evidence-based psychological interventions” (p. 44). This is important because Amy is not accustomed to therapy and requires a careful approach.
“Cognitive-behavioral therapy for anxiety disorders in youth” by Seligman and Ollendick (2011) discusses how effectively cognitive behavioral therapy works for treating anxiety issues in children and teenagers. Assessment, therapeutic interaction, cognitive restructuring, exposure, and skill development are among the shared key elements of CBT. The essay also highlights the value of family participation and relapse prevention strategies in therapy. Seligman and Ollendick (2011) specifically note that “almost all of the CBT treatments for anxiety disorders in youth use some form of cognitive restructuring” (p. 222). This source will provide the basis for one of the strategies for managing Amy’s issues.
“Involving parents in cognitive-behavioral therapy for child anxiety problems: A case study” by Siddaway et al. (2014) investigates the advantages of including parents in cognitive-behavioral therapy (CBT) for child anxiety issues. A balanced focus on parent and child factors led to the successful treatment of an 8-year-old girl with anxiety issues, including school refusal, as described in the case study. The authors argue for an approach incorporating both parents and children in treatment due to the fact that “Laura showed marked reductions in avoidance behaviors and fears and returned full-time to school” (Siddaway et al., 2014, p. 322). The article is relevant because it provides a case study that is similar to Amy’s situation.
“The Therapeutic Relationship in Cognitive Behavior Therapy with Depressed Adolescents: A Qualitative Study of good‐outcome Cases” by Wilmots et al. (2020) covers the significance of the therapeutic alliance in teenagers receiving Cognitive Behavior Therapy for depression. The main theme of this paper is that trust is essential in building “successful therapeutic relationships consisting of therapists who displayed unconditional acceptance of adolescents” (Wilmots et al., 2020, p. 286). The study emphasizes the importance of building a positive therapeutic alliance, the role of autonomy in adolescent psychotherapy, and the predictors of treatment efficacy in adolescent depression.
“Clinical Practice of Cognitive Therapy with Children and Adolescents: The Nuts and Bolts” by Friedberg and McClure (2015) offers a thorough manual for using cognitive therapy in clinical settings with kids and teenagers. The subjects covered in this book are diverse and include assessment, case development, treatment planning, and intervention strategies. Additionally, it covers chapters on particular illnesses, including anxiety, depression, and ADHD, as well as topics like family engagement and treatment compliance. The book posits that “adolescents are generally presented with the treatment model in the same manner as adults” (Friedberg & McClure, 2015, p. 74). This is important because Amy’s problem will be solved using the same approaches that are used for adults.
“CBT with Children, Young People and Families” by Fuggle et al. (2013) explains the fundamentals and real-world applications of cognitive-behavioral therapy while working with kids, teens, and families. Most importantly, this source highlights the benefits of exposure, which is “to enable the client to discover that the anxiety is likely to reduce with increased exposure” (Fuggle et al., 2013, p. 206). Additionally, the book covers specific areas of application, including anxiety disorders, depression, and behavior problems. Overall, the book serves as a comprehensive guide for clinicians working with children, adolescents, and families using CBT.
“Counselling Adolescents: The Proactive Approach for Young People” by Geldard et al. (2019) offers a proactive approach to counseling adolescents. In order to establish a productive and encouraging therapeutic relationship with young people, the authors provide counselors with useful tools and techniques. The authors make an important point that “sometimes it is both appropriate and necessary for the counselor to communicate by using their own inner adolescent” (Geldard et al., 2019, p. 79). This is relevant because it accentuates how to structure therapeutic communication with Amy.
“The Handbook of Counselling Children & Young People” by Pattison et al. (2018) is a comprehensive guide for professionals working with children and teenagers. It includes a range of topics related to children’s and teenagers’ mental health, such as theoretical viewpoints, developmental considerations, evaluation and treatment methods, and moral and legal concerns. The book highlights the importance of developing the therapeutic alliance, as “typically children are referred because of concerns from others and may have no ownership of the referred problem or little motivation to change” (Pattison et al., 2018, p. 128). This is important because Amy herself may not realize that she has problems and needs to work with a therapist.
Assessment
Amy will first undergo a thorough clinical interview to learn more about her current difficulties, developmental history, family history, and pertinent psychosocial factors. The next stage is to conduct standardized self-report tests for Amy to evaluate her emotional and behavioral functioning, such as the Child Behavior Checklist (CBL). The CBCL, which is intended for kids between the ages of 6 and 18, is frequently used in clinical and research contexts to evaluate kids’ emotional and behavioral issues (Biederman et al., 2020). A full list of behaviors that can be rated by parents, caregivers, or instructors is included in the CBCL.
Anxiety, despair, anger, and social withdrawal are just a few of the many emotional and behavioral issues that the evaluation tool is specifically made to identify. As a result, it can be a useful tool to evaluate Amy’s 13-year-old emotional and behavioral issues. In order to have a more complete knowledge of Amy’s circumstances, the third phase entails obtaining supplementary information from Amy’s mother (Cohen & Mannarino, 2015). Amy’s mother will be questioned, and this will reveal important details about Amy’s developmental background and any potential familial influences on her academic achievement. In particular, the interviews will be used to determine whether Amy’s grandparents or parents displayed comparable problems.
Formulation
According to the evaluation of Amy, the initial hypothesis and formulation are that Amy is withdrawing and suffering anxiety as a result of the strain of her parent’s divorce, her father’s absence, her financial situation, and her recent expulsion from her friend group. Also, Amy is probably a sensitive person, which can make her emotional problems worse (Siddaway et al., 2014). These elements have probably had a role in her current emotions of social isolation, guilt, and responsibility.
Predisposing factors are circumstances or events that exist before the problem forms and may make a person more susceptible to getting a mental health disorder. Amy’s family history of divorce is a risk factor that may have influenced the development of her current symptoms of anxiety and withdrawal (Bunge et al., 2017). Divorce is a significant source of stress in life, and children whose parents have divorced are more likely to experience mental health issues like anxiety and despair. The absence of Amy’s father may have also had an effect on her emotional health because losing a parent figure can result in emotions of abandonment and loneliness (Cohen & Mannarino, 2015).
Amy might have also been upset at losing contact with her paternal grandma. Grandparents can have a big impact on children’s lives by giving them emotional support and a sense of security. For children, losing touch with a grandparent as a result of a divorce can be stressful and make any emotional problems worse.
Finally, Amy’s sense of insecurity might have been influenced by her family’s financial struggles. Anxiety, hopelessness, and helplessness are major mental health problems brought on by financial stress. Amy can have financial issues if her living situation changes, she loses assets, or she has trouble obtaining resources.
Precipitating factors are the recent occurrences or circumstances that set off or aggravate someone’s present symptoms or issues. The expulsion from her friends’ group and the ensuing online harassment Amy endured were the initiating events in her situation. Her emotional health has been significantly impacted by these events, which have made her feel more alone and distant from the social activities she once enjoyed. Amy probably feels abandoned, humiliated, and mistreated by her friends, which may have influenced her self-deprecating ideas and perceptions of her circumstances (Friedberg & McClure, 2015).
Also, Amy is upset with her mother and holds her responsible for what happened to her friends. Her mother’s recent financial struggles and her family’s history of divorce may have contributed to heightened stress and tension at home, which could be the cause of this emotional reaction. Amy might feel neglected or unsupported by her mother, which could have made her negative feelings worse and made it harder for her to deal with the recent occurrences.
The factors that keep Amy’s anxiety and withdrawal symptoms ongoing are referred to as maintaining factors. In Amy’s instance, her unfavorable attitudes and perceptions of her mother, herself, and her circumstances are keeping her symptoms from getting better. For instance, Amy may continue to feel guilty and anxious if she thinks she is too responsible for her parent’s divorce (Fuggle et al., 2013). Similar to the above, if she feels as though her mother is unable to support her, this may heighten her sense of insecurity and make her withdrawal symptoms worse.
Also, Amy’s hair-pulling habits can be a mechanism for her to deal with her stress, which might be maintaining her symptoms. Self-soothing habits like pulling on one’s hair are frequently employed to control emotions (American Psychiatric Association, 2022). If Amy pulls her hair every time she feels anxious or upset, this behavior may become ingrained as a coping mechanism, making it more challenging to interrupt the cycle of anxiety and withdrawal.
Predisposing and precipitating variables can have a negative effect on a person’s mental health, while protective factors can help to lessen or reduce this effect. Amy’s involvement in CBT therapy may assist her in creating coping strategies to control her anxiety and withdrawal symptoms. CBT is an empirically supported therapy that concentrates on altering unfavorable thoughts and beliefs as well as unhelpful behaviors (James et al., 2013). Amy might discover how to recognize, confront, and replace her unhelpful views with more logical and realistic ones through CBT. She might also learn how to create efficient coping mechanisms to control the symptoms of her anxiety.
Amy’s mother’s assistance and participation in her care may be helpful for her recovery (Siddaway et al., 2014). By encouraging their child to participate in treatment, offering emotional support, and practicing the skills they have acquired in therapy at home, a supportive and involved parent can aid in the promotion of a favorable treatment outcome. The existence of other benevolent adults in Amy’s life may lessen the effects of her home situation. These adults could be members of the extended family, mentors, coaches, or teachers. They can help Amy by offering emotional support, advice, and positive role models. The presence of these people in Amy’s life can reduce her social isolation and provide her with a sense of connection and belonging.
Treatment Plan and Treatment
Amy’s treatment plan will include cognitive-behavioral therapy with an emphasis on cognitive restructuring, trauma-focused therapy, and exposure therapy in accordance with the evaluation and formulation. Amy’s anxiety and withdrawal symptoms will be treated by addressing the reasons that keep them from getting worse, such as her unfavorable self-perceptions and beliefs about her mother and her circumstances. Amy’s anxiety and withdrawal symptoms will be treated as a priority.
Amy may benefit from learning coping mechanisms to control her anxiety and addressing the unfavorable attitudes and beliefs that fuel her withdrawal through cognitive-behavioral therapy (Geldard et al., 2019). Psychoeducation, cognitive retraining, exposure treatment, and relaxation methods are frequently used in CBT for anxiety (James et al., 2013). These methods can assist Amy in learning to relax and control the physical symptoms of anxiety, as well as recognize and challenge harmful thoughts and beliefs and face her anxieties in a controlled manner.
Another significant therapy objective is to help Amy become more adept at managing stress and increase her capacity to do so. This can be accomplished via a variety of methods, such as problem-solving skill development, mindfulness exercises, and relaxation methods. Amy’s self-worth and self-esteem can also be improved, which can be an important therapy objective (Pattison et al., 2018).
Anxiety and sadness can be exacerbated by low self-esteem and feelings of inadequacy, so resolving these problems may be crucial to Amy’s general emotional health. Using techniques including cognitive restructuring, behavioral activation, and assertiveness training, CBT can be an effective method for addressing negative self-talk and boosting self-esteem.
Another significant therapy objective is to increase Amy’s social support and enhance her social skills (Seligman & Ollendick, 2011). Amy could benefit from social skills training to hone her communication, assertiveness, and conflict resolution abilities. Amy can also feel more connected and supported by developing a social support network of uplifting and encouraging people, which will lessen her sense of isolation and enhance her emotional well-being all around.
With a focus on cognitive restructuring, trauma-focused therapy, and exposure therapy, the treatment will be given over the course of 12 to 16 weekly 60-minute sessions. A key aspect of cognitive-behavioral therapy is cognitive restructuring, which entails assisting patients in recognizing and disputing their unfavorable attitudes and beliefs. One of the goals is to discover Amy’s negative thoughts. She might be thinking, “I’m not good enough,” or “It’s all my fault,” for instance.
Open-ended questions will be used to guide her as she examines the evidence supporting and refuting her beliefs. Amy will also keep thought journals, which entails writing down her irrational and unbalanced beliefs before addressing them. Amy will be able to establish a more realistic and balanced perspective by confronting her unfavorable thoughts and beliefs, which can help her feel less anxious and more upbeat.
A type of treatment called trauma-focused therapy is created expressly to support those who have gone through a traumatic event or sequence of events. The terrible experience for Amy was being harassed online and being expelled from her buddy group. A range of approaches are used in this sort of treatment with the goal of assisting the patient in processing and overcoming the traumatic event in a secure and encouraging setting. Cognitive processing therapy is a different approach that might be applied in trauma-focused treatment. In order to lessen the misery brought on by these ideas and beliefs, this entails working with the person to identify and confront any unfavorable beliefs and thoughts connected to the traumatic incident.
A form of cognitive-behavioral therapy called exposure therapy includes gradually exposing the patient to the feared stimuli or circumstances in a safe and controlled setting. Amy might benefit from exposure therapy to help her face and get rid of her avoidance tendencies. The therapist might begin by gradually introducing her to low-risk scenarios that she has been avoiding, such as visiting the mall or going to a social event. The therapist may progressively increase the level of exposure as Amy grows more at ease in these circumstances, possibly by going to a larger social event or going to a busy public location. Gradual increases in exposure intensity over time make up a particular sort of exposure therapy known as graded exposure. The end result of exposure treatment is for the patient to be able to confront previously feared stimuli or situations without feeling anxious or engaging in avoidance behaviors.
Amy’s case will make use of the Child Behavior Checklist as a gauge for tracking progress and assessing results. The CBCL is a popular instrument for identifying emotional and behavioral issues in children and teenagers. It can offer important details on Amy’s emotional and behavioral functioning and her development during the course of treatment. Anxiety, sadness, behavior issues, and social skills are just a few of the different facets of mental health that will be evaluated using self-report questionnaires, clinician assessments, and behavioral observations.
Amy’s treatment program would really include a number of interventions, such as cognitive restructuring, trauma-focused and exposure therapies, and social skills development. There will be about 12 treatment sessions with Amy, each lasting 60 minutes. The first three sessions will be spent establishing a therapeutic relationship and rapport with Amy. She will also have a more thorough evaluation of her symptoms, past, and family dynamics during these sessions.
Cognitive restructuring approaches, such as recognizing and contesting unfavorable thoughts and beliefs, will be used in the following five sessions (Bunge et al., 2017). Amy will gradually be exposed to situations and activities that she has been avoiding because of her anxiety and withdrawal symptoms during the last four sessions using exposure therapy and trauma-focused therapy techniques. The CBCL will be used to track outcome information at future check-ins with Amy and her mother to evaluate progress and alter treatment objectives as necessary.
Process Issues
It will probably take Amy several sessions before she feels comfortable enough to express her thoughts and experiences because she is likely to find it difficult to open up. Amy benefited from the therapist’s patience, lack of judgment, and support in feeling heard and understood. Amy got more at ease expressing herself as the treatment went on and was able to divulge more intimate details. This is why it is crucial to follow the advice of Geldard et al. (2019) to establish rapport by demonstrating empathy and understanding of adolescents’ feelings. It could, however, also result in unwanted transference, which should be prevented by building a good and encouraging relationship.
Ethical Issues
One potential ethical concern that could arise with Amy is linked to confidentiality. Amy’s parents are legally permitted to examine her medical files and treatment information because she is a minor. Nonetheless, Amy could feel awkward discussing certain topics with her parents, such as her feelings and ideas regarding the divorce or her experience with online teasing. In this case, it is critical to set up distinct boundaries and make Amy’s parents and Amy aware of the boundaries of secrecy. In order to protect Amy’s safety and well-being, parents must be included in the therapeutic process. Nevertheless, they must also respect Amy’s right to privacy and collaborate with her to choose the appropriate amount of disclosure.
Summary and Conclusions
Amy was referred for therapy since her anxiety and withdrawal symptoms were interfering with her everyday activities and social connections. After being evaluated, it was determined that Amy’s symptoms were most likely brought on by the stress of her parents’ separation, her lack of support from her father, her financial struggles, and her recent exclusion from her social circle. She also demonstrated unfavorable attitudes about herself, her mother, and her circumstances, which exacerbated her symptoms. The examination has revealed that Amy’s symptoms were mostly caused by these risk and triggering factors and that her maintaining factors comprised unfavorable attitudes and beliefs.
Amy’s symptoms are treated, and her coping mechanisms, self-esteem, and social support are strengthened through the use of cognitive restructuring, trauma-focused treatment, and exposure therapy. It is important to keep an eye out for any transference or countertransference problems in the therapy partnership. Confidentiality and the possibility of a conflict of interest if the therapist’s roles as Amy’s therapist and her mother’s job were not adequately managed were ethical considerations.
There are a number of possible recommendations for Amy’s therapy and continued care based on the case study. They include urging Amy’s mother to keep giving her emotional support and participating in her care, as well as urging Amy to take part in social events to broaden her social network. It might also be beneficial to provide Amy’s family with psychoeducation about the effects of divorce on kids and how to support them. To ensure continuing improvement and address any potential setbacks, it is advised that Amy’s symptoms be continuously monitored and that she often checks in with her therapist. Finally, encouraging Amy to practice self-care practices like exercise and meditation may aid in the management of her anxiety and stress.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR. American Psychiatric Association Publishing.
Biederman, J., DiSalvo, M., Vaudreuil, C., Wozniak, J., Uchida, M., Woodworth, K. Y., & Faraone, S. V. (2020). Can the Child Behavior Checklist (CBCL) help characterize the types of psychopathologic conditions driving child psychiatry referrals?Scandinavian Journal of Child and Adolescent Psychiatry and Psychology, 8(1), 157-165. Web.
Bunge, E. L., Mandil, J., Consoli, A. J., & Gomar, M. (2017). CBT strategies for anxious and depressed children and adolescents: A clinician’s toolkit. Guilford Publications.
Cohen, J. A., & Mannarino, A. P. (2015). Trauma-focused cognitive behavior therapy for traumatized children and families. Child and Adolescent Psychiatric Clinics, 24(3), 557-570. Web.
Friedberg, R. D., & McClure, J. M. (2015). Clinical practice of cognitive therapy with children and adolescents: The nuts and bolts. Guilford Publications.
Fuggle, P., Dunsmuir, S., & Curry, V. (2013). CBT with children, young people and families. Sage.
Geldard, K., Geldard, D., & Foo, R. Y. (2019). Counselling adolescents: The proactive approach for young people. Sage.
James, A. C., Reardon, T., Soler, A., James, G., & Creswell, C. (2013). Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews, (11), 1465-1858. Web.
Pattison, S., Beynon, A., & Robson, M. (2018). The handbook of counselling children & young people (2nd ed.). Sage.
Seligman, L. D., & Ollendick, T. H. (2011). Cognitive-behavioral therapy for anxiety disorders in youth. Child and Adolescent Psychiatric Clinics, 20(2), 217-238. Web.
Siddaway, A. P., Wood, A. M., & Cartwright-Hatton, S. (2014). Involving parents in cognitive-behavioral therapy for child anxiety problems: A case study. Clinical Case Studies, 13(4), 322-335. Web.
Wilmots, E., Midgley, N., Thackeray, L., Reynolds, S., & Loades, M. (2020). The therapeutic relationship in Cognitive Behaviour Therapy with depressed adolescents: A qualitative study of good‐outcome cases. Psychology and Psychotherapy: Theory, Research and Practice, 93(2), 276-291. Web.
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