Background of the Client
The client is a fifteen year old student called Joann. She has had trouble in school since her second grade. Joann reported class work problems and difficulties in test taking, as well. In earlier grades, she complained about difficulties in reading words and concentrating. However, as she grew older, the problems got worse; Joann experienced frequent headaches and reported occasional fainting spells.
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These symptoms started when Joann was just about to complete her fifth grade, and they have persisted to date. Her teachers also noticed that excessive panic during tests also characterizes her school days. This panic often manifested as a physical illness, and came about when Joan needed to do group assignments or quizzes. She also had a fear of classroom questions throughout her childhood.
Joann’s academic performance seemed unaltered by these situations because her report cards were always above average, with A’s and B’s as her mean grades. Once in a while, Joann would get a C; furthermore, Joann attended school regularly, but she never enjoyed her experiences. Previously administered standardized tests also indicated that she had above average academic skills. Some of the tests that she did include: TerraNova and Metropolitan Achievement Tests.
Presenting the problem
This adolescent is a highly anxious one. The trait stems from Joann’s fear of tests, quizzes, and group assignments. She also has certain physical problems that include frequent headaches and occasional fainting episodes; they often manifest prior to these high-stress situations.
Joan tends to react negatively to compliments on her performance. She tries to neutralize any of these compliments by cutting down her efforts. Joann has the same reaction when adults try to give her reinforcement or compliment her for her exceptional work. This individual enters into a state denial when another person comments about her high-quality performance in an activity.
This adolescent feels isolated; she dislikes school and claims not have a favorite subject. However, she does relatively well in other non academic activities such as volleyball or basketball. Teachers and other instructors have not noticed any emotional distress in these areas. Joan continues to experience the same social and emotional problems that she had in the past; these include falling physically ill prior to: exams, group assignments and quizzes. Furthermore, she still suffers from frequent headaches and fainting spells. She also faces significant challenges with question-answering in class.
Assessment or Diagnosis of the problem and justification of the assessment
The adolescent under analysis suffers from performance anxiety that manifests as test anxiety and fear of classroom participation. This individual, therefore, possesses a social phobia, which the American Psychological Association (APA) recognizes in its DSM IV criteria (American Psychological Association, 2000). A person with performance anxiety, such as Joann, differs from others who experience universal fear because she experiences immense distress and disabling impairment in unrealistic dangers.
Common manifestations of performance anxiety include the fear of theatrical performance, the fear of eating in public, or the fear of writing in front of a large group of people. In this case, Joann has a fear of talking in public when asked to respond to classroom questions or participate in group assignments. Additionally, she has a problem with test taking. This is also another performance situation because she has to prove herself before the concerned assessors.
In order to classify an individual as one who suffers from performance anxiety, one must look for specific behavioral and cognitive signs. First, the person must object to performance situations or social situations that would expose him or her to scrutiny. He or she also fears performance situations because they might lead to embarrassment or humiliation. Furthermore, such a person usually thinks that he or she will not meet the required standard and will fail. In this case, Joann has all these signs; she dreads tests, classroom participation, and group assignments because she fears exposure to scrutiny. Since she often downplays her achievements, then it may also be true that Joann expects to fail in the tests or classroom activities.
Secondly, a person with performance anxiety manifests intense level of anxiety when placed in that performance situations (American Psychological Association, 2000). Examples of such anxious behavior include freezing, crying, tantrums and many more. Joann’s teachers continually report that this adolescent is extremely anxious prior to classroom tests and other academic milestones. Her headaches, fainting spells and physical illness indicate this level of stress.
Thirdly, a person with performance anxiety needs to recognize that his or her fear is excessive. However, analysts say that children do not have the ability to do so. Joann is an adolescent, so she has adult-like characteristics and child-like traits. The case study notes do not mention whether Joann recognizes that her fear is excessive. Nonetheless, one may assume that this is true owing to the differences in behavior that exist between Joann and her classmates before tests or classroom tasks.
Fourthly, an individual with this problem may try to avoid the performance situation, or may go through it with intense distress. Joann falls in the latter category. She explicitly stated that she dislikes school and has no favorite subject. Because Joann has no choice but to attend school, she does it with immense distress. Her headaches and fainting spells also prove this.
Lastly, people with this condition tend to function abnormally in social or occupation activities because of the avoidance, anxiety and anticipation inherent in their disorder. Joann is distressed about her phobia because she keeps struggling in her academic work. This problem is so severe that her educational administrators decided to study her situation.
One should not consider test anxieties and other performance anxieties as recognizable DSM IV disorders, i.e. social phobias, unless they are long lasting and cause marked psychological effects. Joann’s case has been quite prolonged, and it has clear effects on her behavioral and cognitive functioning. Furthermore, the condition should have lasted for longer than six months; Joann has had her condition from the second grade. This individual is quite sensitive to negative evaluation or rejection.
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Joann manifests this symptom because tests and assessments are her main problem, yet people design tests to evaluate individuals. They may either result in positive or negative feedback; it is likely that Joann has a problem with negative comments from her instructors. If this problem persists, Joann’s academic performance may decrease substantially. In the long run, she may avoid other situations in her career that require her to take tests. This may hinder pursuance of jobs or promotions. She may settle for unsatisfying work because of the fear of evaluation of test taking in lucrative jobs.
This situation requires a multifaceted approach to the treatment of the problem, but all these components fall under cognitive behavior treatment. Psychologists assert that the most effective treatment for this psychological condition is cognitive-behavioral therapy (CBT). This method is not one-sided; it involves collaborative efforts between the therapist and the client. Joann and a therapist should each come up with ways of conquering her anxiety. The general goal in this choice of behavior is to transform the client into her own therapist; therefore, therapeutic sessions should last for a short time (Antony & Rowa, 2008). In this case, Joann should do 16 sessions only. This method of treatment also requires a focus on the present.
Although certain childhood experiences may have contributed to the problem, it is imperative to focus on behavioural patterns that exist presently, and perpetuate the client’s symptoms. The therapist should structure all the sessions in CBT. This means that the therapist will identify gaols for every single session. Joann will have to do ‘homework’, or unsupervised activities. The intention is to ascertain that she can experience real-life scenarios that necessitate a renewed manner of thinking. Lastly, research is the foundation for this proposed therapeutic method. Analysts have worked on clients with similar conditions and have found that CBT works (Hoffman & Otto, 2008).
The first step should involve psycho-education. One should learn about one’s problem in order to deal with test anxiety and performance anxiety. If a person recognizes that he or she has a psychological problem, then he or she can start working towards a solution. Joann needs to be educated about performance anxiety and social phobia in general. She should be told about its possible origins as well as its persistence in her since childhood. The individual should also learn that her performance anxiety – like all performance anxieties – is unique, so she should work hand in hand with the therapist in order to understand her conditions well (Hoffman & Otto, 2008).
Cognitive restructuring is another step that they should consider in treatment. The main cause of performance anxiety is holding negative beliefs about oneself and others. These beliefs often manifest as unhelpful thoughts in those performance situations. Cognitive restructuring will involve a joint effort between Joann, and her therapist to establish the negative thought patterns that cause her to have performance anxiety. The main point is to practice these thought patterns until Joann becomes skilled in detecting them.
That will allow her to come-up with strategies for looking at her experiences in different or harmless ways. Joann should keep saying positive things to herself whenever a stressful situation arises. For instance, when her teacher asks her to respond to a certain question, Joann might think “Oh my! I will give a silly answer, and everyone is going to think that I am stupid”. The therapist should teach her to say things such as “Everyone can give a wrong answer in class; it does not mean they are stupid” or “I am here to learn; no one expects me to have all the right answers”.
The therapist will need to write down these phrases and require Joann to memorize them. With time, the irrational thoughts that lead to her physical illnesses may start to subside. The same self-talk should go on when she receives compliments or reinforcements from her parents or peers. In the cognitive restructuring processes, the therapist should focus on teaching Joann how to believe in her own abilities as a student. Since she has above average grades, then she needs to realize that she can accomplish academic goals independently.
Treatment should also entail in vivo exposure. Joann will discuss with her therapist the situations that cause her to manifest the performance anxiety. Some of these situations are question-answering and group discussions. Joan will gradually enter those scenarios without fighting the anxiety; she will allow it to dissipate naturally. It is likely that Joann will find this as one of the most difficult components of therapy. Therefore, the therapist should pay a lot of attention. Exposure must be done gradually, and both parties should plan for it. The difference between Joann’s exposure in the present and Joan’s exposure in the past is that this time the therapist will be beside her when confronting that situation. He will give her support and ascertain that she learns valuable lessons from her experiences (Hoffman & Otto, 2008).
In this case study, no details are available regarding the existence of interoceptive situations. However, there is a serious possibility that this might be a problem for Joann. Some clients tend to fear anxiety-related physical symptoms that accompany the actual performance situation such as shivering, sweating and many others. Interoceptive exposure should be another method of dealing with Joann’s problems. Since she has physical symptoms such as headaches, she may have anxiety about dealing with that symptom when in pressure-filled situations; that may intensify her condition. The therapist should expose this adolescent to situations that can cause some mild physical symptoms. Familiarizing Joann with the performance-related ailments is likely to minimize anxiety.
Lastly, the treatment process should also involve social skills training and academic training. When in the middle of an academic-related performance situation, Joann feels like she does not have the necessary academic or social skills needed to meet expectations. Extreme self consciousness and negative self talk have created this scenario.
However, Joann would probably find it helpful to learn new skills like how to: have conversations, do effective listening, be assertive, and many more. She will probably appreciate some tips on classroom etiquette as well as improvement of her academic performance. Since her problem also revolves around tests, Joann could benefit from study tips on early test preparation and the like. She needs to prepare for the tests and read ahead. The latter step will assist her in dealing with the tensions that relate to poor performance (Antony & Rowa, 2008).
The session should also involve prevention of the physical illnesses in the performance situation; this specifically centers on the tests as well as the classroom discussions. Joann should learn about relaxation techniques in order to achieve this. Research shows that relaxation techniques play a tremendous role in coping with performance situations. One way of achieving this is through controlled breathing. The technique involves carrying out slow, regulated breathing. Joann should concentrate on the process of exhaling and inhaling.
To do this effectively, she will need to close her eyes so as to seal off other interfering factors. She can then take-in one breath, hold it for a while and exhale. Joann must then start counting the periods between her breaths. She can take in a deep breath and hold it for 5 seconds then exhale and hold it for five seconds. When she feels confident about the process, she can then count to ten when exhaling and inhaling. She may do this in class when the performance situation arises. Another method of relaxation is positive self talk.
This therapy session will involve self efficacy as the major goal. Self efficacy is a person’s ability to believe in his or her performance capability. The actions under consideration ought to relate to a desired outcome. Joan believes that one requires certain actions to sit for tests or to participate in group assignments. She also possesses those skills, but lacks the belief in her ability to execute them when in that situation. The client’s classmates may think that she has the right skills, but her subjective appraisal differs from this belief.
Therefore, working on this subjective belief can improve her outcomes. Other smaller goals (that will facilitate achievement of self efficacy) include verbal persuasion, performance accomplishment, and emotional or physiological arousal. When used out of context, verbal persuasion is the least successful method for handling performance anxiety. The therapist will only use this in relation to anxiety management. However, Joann will use verbal persuasion as explained in cognitive restructuring (Hoffman & Otto, 2008). Another treatment goal is performance accomplishment. The therapist will assist Joann to approach her fears rather than run away from them. Role playing and grading of tasks should help her.
It is likely that Joann will achieve self efficacy when she has mastered this situation. The therapist should avoid interruptions during role plays so as to allow Joann to commit to the condition. She must give feedback about her performance too. Lastly, the treatment will entail the mastery of physiological or emotional arousal. When excessive physiological arousal takes place, it tends to hinder performance. Joann’s headaches and fainting spells are a manifestation of this. Reducing this arousal is one of the goals of treatment. Joann will achieve this through relaxation techniques such as breathing and internal verbalizations like “I am packing my body with peaceful energy”.
Questions to the supervisor regarding assessment, treatment or goal issues of the client.
“Does Joann’s stress increase when she thinks about the accompanying symptoms?”: In one of the treatment approaches, the therapist should induce situations that mirror the performance situation so as to physiologically arouse Joann. If the physical illnesses do not bother Joann, then this may not be an effective intervention strategy.
“Do Joann’s parents have the financial resources for therapy?”: The methods suggested in this paper require regular sessions for at least four months; Joann will meet the therapist four times in a week for sixteen sessions. If her parents cannot afford these sessions, then this may undermine the method’s effectiveness.
“Is Joann motivated enough to solve this problem?”: Cognitive behavior therapy does not solve a client’s problems overnight. It takes a lot of patience and perseverance from the parties involved. Joann should have a deep desire to deal with her psychological challenges; otherwise, the method may not work.
“Is it ethical to induce some of the physiological symptoms of stress?”: Joann may be afraid of these symptoms, and these may add to her anxiety. It may be necessary to expose her to those situations to allay these fears. However, it may be unethical to cause the client too much discomfort.
“What happens when CBT fails?” It is necessary to know whether Joann be put on drugs.
American Psychological Association (2000). Diagnostic and Statistical manual of mental disorders. Washington DC: APA.
Antony, M. & Rowa, K. (2008). Social anxiety disorder: physiological approaches to assessment and treatment. Gottingen, Germany: Hogrefe Press.
Hoffman, S. & Otto, M. (2008). Cognitive behavior therapy for social anxiety disorder. Evidence based and disorder specific treatment techniques. NY: Routledge.