Social Phobia Jill Hutzel K W and L

Social Phobia Jill Hutzel, K. W. and L. K. Touro College Fall 2012

Background Information l Cathy is a pretty 12 -year-old girl who is presently in the 7 th grade. She has Attention Deficit Disorder: Attention Subtype but is managed very well with medication and is an above average student. Academically there appears to be no problems or struggles in any of Cathy’s classes. One of her teachers made a referral to the school psychologist because she noticed that Cathy is more of a loner and does not interact with her peers. She has no difficulty conversing with the teacher one to one but Cathy never raises her hand to answer questions or participate in class discussions.

Background Information Continued l One day the teacher was walking by the lunchroom and noticed that Cathy was eating by herself. The teacher is unsure of what is going on with Cathy but truly feels that her lack of social interaction and lack of participation for a smart girl her age is not within normal limits.

Cathy’s Home Life l At home Cathy and her two sisters (one age 14 and the other age 8) is being raised by their father. Their Aunt (father’s sister) lives upstairs with her two daughters. Cathy’s parents got divorced when she was eight years old because her mother was a severe alcoholic. She has very little interaction with her mother who is constantly in and out of rehab, and anytime that Cathy’s mother attempts to make contact with her, Cathy wants nothing to do with her. Also, at home Cathy does not have any issues interacting with her father or sisters. Cathy has one close friend, John, who she has known since the age of three.

Interview with Cathy’s Teacher l Cathy’s teacher said that when Cathy is able to pay attention (and take her medication), she performs well academically and gets good grades. She noticed that Cathy seems to be a loner, eats lunch alone and rarely (if at all) interacts with other students. When the teacher tries to speak alone with Cathy, she is able to converse with no difficulties. When in class, Cathy never raises her hand to answer a question, even if its obvious that she knows the answer. The teacher is concerned because even though Cathy is a smart and pretty girl, her social interaction and amount of participation is certainly not within normal limits.

Interview with Cathy’s Father l Cathy’s Father said that Cathy has no trouble at all interacting with himself or her sisters at home. Her one sister is 14 years old and the other is 8 years old. Her father went on to talk about her one close friend, John, that she has had since she was three. He said they hang out all the time and she seems to have no problems interacting with him. Cathy’s father said that since his divorce with Cathy’s mother, Cathy has very little interaction with her mother. Her father divorced Cathy’s mother when Cathy was 8 -yearsold because she was a severe alcoholic. Cathy’s mother attempts to make contact with Cathy, yet anytime she does, Cathy wants nothing to do with her.

Interview with Cathy’s Aunt l Cathy’s aunt is her father’s sister and she lives upstairs from Cathy’s aunt lives with her two daughters and is estranged from her daughter’s father. Cathy’s aunt agrees that Cathy does not seem to have any difficulty interacting with her sisters or her two cousins (Cathy’s aunt’s daughters). Cathy’s aunt does however, think that Cathy has low self-esteem. She does not seem depressed but she does not seem confident and is always second guessing herself. She seems fine at home and thought the self-esteem-thing was part of puberty…but she had no idea how unsocial she was at school.

Objective Tests l l Cathy was administered a Wechsler Intelligence Scale For Children. Fourth Edition (WISC-IV) which showed that Cathy is within the “Average” range for her I. Q. Cathy was also administered a Woodcock-Johnson III Test of Achievement in which she scored a Total Achievement score was also within the “Average” Range. (Cathy’s Average score put her within the “blue” range for this bell curve. The blue indicates her score is close to the mean compared with other kids her age).

Self-Report Measures l Cathy was given a Beck Anxiety Inventory (BAI) which showed that Cathy suffers from anxiety, mostly in social situations and she seems to be terrified of being embarrassed.

Cathy showed on her BYI-II Self-Rating Scale that she demonstrated difficulties with socialization and self-esteem but demonstrated no significant difficulties with happiness and interests in school.

Subjective Tests l On the Rotter Incomplete Sentence Blank a projective psychological test, she appeared to have a lot of negative answers when it came to sentences about being in groups, crowds, or speaking in public. For example: l I regret… “not being able to make more friends. ” l The earliest memory of my mother… “is her drinking and crying in our living room”. l I failed… “at being popular or just being noticed by others”. § A sample of this test follows…

Observations l When observing Cathy in one of her classes it was noticed that she never raised her hand. She often kept her head down and ruffled through papers trying to seem busy. It appeared her lack of eye contact and appearing busy was a way to avoid being called on. When the class broke into group work, Cathy hardly made eye contact with her peers and didn’t speak at all during the group work. When it was time for lunch, Cathy seemed to step back and wait for the crowd of kids to file into the cafeteria. She then went in and sat at the end of a lunch table by herself. She ate in silence while observing the other students as they interacted, laughed, and had a good time.

Observation Continued l In between classes, Cathy walks with her head down, walking along side the wall. She is often the first person to get to each of her classes. Cathy is often the first person on the bus and sits by the window in the same seat as her older sister. They don’t seem to talk much on the bus, but once they get home it is a whole different story. Cathy still doesn’t make much eye contact at home but she is talkative. She interacts moderately with her sisters and cousins. She does seem to enjoy her alone time and gets all of her homework done because getting good grades seems to be important to Cathy.

Developmental Factors l Cathy had met all of her developmental milestones within the normal range. Her medical history seems to be unremarkable besides the fact that she has been diagnosed with Attention Deficit Hyperactivity Disorder: Attention Subtype. She has her ADHD managed fairly well with the help of medication. § /

Systematic Factors l Family: Her father is a highly supportive as well as her aunt, sisters and cousins. They let Cathy be aware that they are always there to help her out with any issues. l School: Her school psychologist, teachers, social workers, administrators and the girls in her new therapy group are all there to support her through any concerns she is having in school.

Risk Factors l Risk Factors: Family circumstances, emotional difficulties (stemming from mother) and interpersonal problems (social phobia). § § These risk factors are thought to increase Cathy’s risk of being unable, as an adult, to contribute to society, earn a living, and form healthy families

Protective Factors l Protective Factors: Good quality of school, school psychologist, teachers, good father that is very involved as well as having her aunt, sisters, cousins and John as a good support system. These protective factors serve as a buffer through interactions with risk factors § Disrupts the chain reaction from risk factors to disorder §

A. B. C’s l l l Antecedent: Social environments such as school, classroom and cafeteria. Having to work in a group or speak in front of class. Behavior: Stays quiet, keeps head down, leg shakes, stomach hurts, lack of eye contact, pretends to be busy. Consequence: Misses out on interpersonal relationships, friendships and develops a Social Phobia.

Diagnostic Impression l Social Phobia (Anxiety) -According to the DSM-IV, Social Phobia is defined as a persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating. l Attention Deficit Hyperactivity Disorder: Attention Subtype- In general, ADHD includes may include a combination of problems, such as difficulty sustaining attention, hyperactivity and impulsive behavior. Children with ADHD also may struggle with low self-esteem, troubled relationships and poor performance in school l Educational Classification: Other Health Impaired (OHI)- As a side note… under IDEA, a child who has an “other health impairment” is very likely to be eligible for special services to help the child address his or her educational, developmental, and functional needs resulting from the disability.

Working Hypothesis l Cathy may have developed the type of schema that she did because of her mother. Her mother left her life at the age of eight, when the father divorced her because she was a severe alcoholic. This leads to a lack of trust, commitment and a sense of abandonment. These internal feelings manifest and may cause Cathy to keep to herself and not let any new people into her life (Besides her only friend John who has been her friend since she was 3).

Three Short Term Goals 1 st Goal: Raise hand participate in class. 2 nd Goal: Sit with at least one other person at lunch. 3 rd Goal: Attempt to make at least one new friend. These goals will help to activate a sense of confidence within Cathy to hopefully accomplish her long-term goals

Three Long Term Goals l l l 1 st Goal: Be able to give a presentation in front of a class or crowd. 2 nd Goal: Be able to recognize others in a similar situation and be able to become a mentor for them. 3 rd Goal: Be able to maintain friendships. These goals will eventually help Cathy in real life situations. Hopefully she will be able to take on challenging events while being self -confident, motivated and successful.

Full Intervention Plan l School Based: Group Treatment for Adolescents with Anxiety Problems 15 Weeks l Cognitive-Behavioral Approach l Group Counseling l

Full Intervention Plan l The group consisted of 4 other girls that had different types of anxiety disorders, one also being Social Phobia. Another girl had Generalized Anxiety Disorder. One of the girls had Panic Anxiety Disorder. The other girl in the group had Obsessive Compulsive Anxiety Disorder.

Full Intervention Plan l First Session: The first session was all about building rapport among the girls, to introduce the girls to the program and to encourage all of them to participate. To encourage interaction the girls were able to color and decorate their folders and program workbooks and they made lists of rewards that they would like to earn throughout the program. The girls also played a game in which they listen to three facts and one lie about themselves and the other girls had to guess what they lie was. The game facilitated group interaction and aided in rapport building.

Full Intervention Plan l First Session: During the first session Cathy was somewhat quiet and spoke minimally. She laughed during the game and really enjoyed decorating all of her stuff. She did however seem to struggle with coming up with a list of rewards. Cathy was encouraged to think of tangibles (food, clothes, magazines), Social events (Bowling with the family), and Activities (Renting a movie).

Full Intervention Plan l Sessions 2 – 4: mainly focused on learning about their emotions and managing their somatic reactions to anxiety

Full Intervention Plan l Session Two: Discussed how different feelings are associated with different physical expressions. The therapist also created a “Feelings Thermometer. ” There was a rating from 0 to 8. This thermometer helped Cathy to realize what situations gave her more anxiety than others. Each girl also created a personal hierarchy of anxiety-provoking situations, rated from low to high.

Full Intervention Plan l Session Three: The girl’s discussed how people experience various bodily reactions when they are feeling anxious. They then focused on normalizing their anxiety experiences. The girls were given information that they discussed the normal and adaptive nature of anxiety reactions. The therapist discussed situations that made her anxious. She then discussed how the steps of this program helped her to normalize her anxiety in those situations. The group was then taught relaxation techniques to help reduce their somatic responses to anxiety.

Full Intervention Plan l Session Four: Focused on helping the girls identify their thoughts and to understand that certain types of thoughts may increase their anxiety. Therapist showed the girls pictures of people with empty thought bubbles and the girls filled out what they thought the people were thinking, why and how they may possibly feel and react. They then showed alternative thoughts and reactions to similar situations. Then, the girls then did some role playing with one another. In this exercise the girls began to implement the first two steps of coping with Anxiety…

Full Intervention Plan l l l Example of the first 2 steps of coping with Anxiety: “F step”: Cathy had to ask herself if she was feeling anxious. If her body was sending her any clues (ex: sweaty palms, jittery leg, etc. ) that would help her to indicate if she was anxious. “E step”: Cathy had to ask herself if she was expecting anything bad to happen. § § If Cathy expected anything bad to happen-like being laughed at and other students thinking she was weird. Coping thoughts: “The girls in my group don’t think I’m weird or stupid, so maybe the students in my class won’t either. ” “Even if I get laughed at when saying a wrong answer, they may not think I’m weird because even the popular kids get laughed at. ” “Most kids probably won’t care how I answer the question. ”

Full Intervention Plan l Session Five: The girls learned about the third step in coping with Anxiety: Learning an approach to problem solving. The therapist proposed a mildly anxiety-provoking situation (Ex: Blemish in the morning before school). The girls then brain stormed many solutions both good and unhelpful (Ex: not go to school). After a long list was developed, the girls began to evaluate the solutions by weighing the pros and cons. The girls then decided, as a group, which solutions looked the most promising. The therapist then gave each girl a card that had an anxietyprovoking situation on it and they had to write down the first 3 steps of their coping plan about their situation.

Full Intervention Plan l Session Six: The girls learned about the fourth and final step in coping with Anxiety: Rating and Rewarding themselves for trying to cope. The girls discussed how people do things to receive rewards (Ex: chores for allowance) because people feel good when they receive a reward and when they reward themselves. The therapist discussed the importance of positive self-talk and that the girls should not only reward themselves when they have positive effort! The therapist used her own life examples in which she used rewards to help motivate herself and to do new things.

Full Intervention Plan l l l Session Seven: This session was dedicated to the group reviewing the entire four-step plan for coping with anxiety: Step 1: F: “Am I Feeling anxious? What does my body tell me? Step 2: E: “What am I Expecting to happen? What is my self-talk? ” Step 3: A: “What Actions & Attitudes can best help me in this situation? ” Step 4: R: “What self-Ratings & Rewards do I receive for trying to cope?

Full Intervention Plan l Session Seven (Continued): The girls brought up real life situations that have happened to them and they applied the “FEAR” plan to those situations.

Full Intervention Plan l 2 nd Half of Treatment: The girls practiced applying the newly acquired skills in a variety of graduated exposures to anxiety-eliciting situations. The cooperation of all of the girls was very important during this phase of treatment. l They began with imaginable exposures within the group and progressed to in vivo exposures involving the group as a whole, then to in vivo exposures involving individual group members.

Full Intervention Plan l 2 nd Half of Treatment Continued: l l The girls role played some real life anxiety-provoking situations and the girls all practiced the 4 -step plan on how to cope in these real life situations. The last phase involved each member doing in vivo exposures independently. For Cathy this meant tackling some of her short term goals of making a new friend at school, participating in class and doing class presentations. The other girls offered Cathy support and some creating ideas and congratulated her on her successful completion of the exercise. § The Support of one another and verbal praise helped the girls feel more confident. The girls created friendships with each other, didn’t feel so alone and knew they now had support from teachers, family members, therapists and now some peers

Cathy’s Results Although Cathy still feels anxiety from time to time, her improvements are noticeably obvious. Cathy is no longer too shy to participate in class discussions or sit alone during lunch time. She has become aware for herself that if she doesn’t at least try to be interactive, she might never know how people will respond to her. She has also taught herself to realize if people don’t like or understand her, it is O. K. She is now noticing how everyone is different, no one is perfect and that everyone goes through their own issues one way or another.

Cathy’s Results Continued… Some issues of unwanted anxiety will still emerge for Cathy such as becoming red in the face, stuttering over words and become fidgety. Cathy has become accustomed to the reality that this might happen but she is trying not to make it a big deal. She has learned not to dwell on the small things and to take life one day at a time. She has realized that by letting her disorder over take her, she will miss out on many exciting things in life. Cathy has grown to understand her mind all its worth. She has matured enough to know that her body is controlled by no one but herself and if feelings go beyond her control, she needs take a minute to get back to reality.