social anxiety disorder case study

Interpretational Processing Biases in Emotional Psychopathology pp 301–321 Cite as

“I Don’t Want to Bother You” – A Case Study in Social Anxiety Disorder

• Katharine E. Daniel 3 &
• Bethany A. Teachman 3  
• First Online: 29 March 2023

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Part of the book series: CBT: Science Into Practice ((CBT))

Gi, a 34-year-old second-generation Korean American man, presented to treatment with pronounced and longstanding anxiety in many social situations, which significantly impaired his functioning (e.g., his perceived ability to run errands in crowded stores and care for his ill father). Gi engaged in cognitive behavior therapy (CBT) via telehealth during the COVID-19 pandemic. Key cognitions and biased cognitive processes that were maintaining his anxiety included a judgment that others frequently reject him, an assumption that if he expressed his own needs, then he would be unreasonably burdening others, and a core belief that he was incompetent, along with a pervasive tendency to make negative interpretations about his abilities in most social situations. He experienced marked functional improvements and reduced anxiety throughout his 17-session course of treatment. Gi’s case and treatment are detailed throughout this chapter to illustrate how individual CBT for social anxiety disorder can be implemented. Special discussion of how the clinician continuously and collaboratively modified her case conceptualization and intervention approaches with reference to aspects of Gi’s identities and in response to her own missteps are offered throughout.

• Social anxiety disorder
• Culturally informed treatment

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Anxiety & Depression Association of America. (1.12.2022). Social anxiety disorder. https://adaa.org/understanding-anxiety/social-anxiety-disorder .

Beck, J. S. (2020). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford Press.

Google Scholar  

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58 , 10–23. https://doi.org/10.1016/j.brat.2014.04.006

Article   PubMed   PubMed Central   Google Scholar  

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99 , 20–35. https://doi.org/10.1037/0033-2909.99.1.20

Article   PubMed   Google Scholar  

Gover, A. R., Harper, S. B., & Langton, L. (2020). Anti-Asian hate crime during the COVID-19 pandemic: Exploring the reproduction of inequality. American Journal of Criminal Justice , 1–21. https://doi.org/10.1007/s12103-020-09545-1

Harpole, J. K., Levinson, C. A., Woods, C. M., Rodebaugh, T. L., Weeks, J. W., Brown, P. J., Heimberg, R. G., Menatti, A. R., Blanco, C., Schneier, F., & Liebowitz, M. (2015). Assessing the straightforwardly-worded Brief Fear of Negative Evaluation scale for differential item functioning across gender and ethnicity. Journal of Psychopathology and Behavioral Assessment, 37 (2), 306–317. https://doi.org/10.1007/s10862-014-9455-9

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). The Guilford Press.

Leahy, R. L., Holland, S. J. F., & McGinn, L. K. (2012). Treatment plans and interventions for depression and anxiety disorders (2nd ed.). Guilford Press.

Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping patients change behavior (3rd ed.). Guilford Press.

Norton, P. J., & Weeks, J. W. (2019). A multi-ethnic examination of social evaluative fears. Journal of Anxiety Disorders, 23 , 904–908. https://doi.org/10.1016/j.janxdis.2009.05.008

Article   Google Scholar  

Piccirillo, M. L., Taylor Dryman, M., & Heimberg, R. G. (2016). Safety behaviors in adults with social anxiety: Review and future directions. Behavior Therapy, 47 (5), 675–687. https://doi.org/10.1016/j.beth.2015.11.00

Turner, S. M., Johnson, M. R., Beidel, D. C., Heiser, N. A., & Lydiard, R. B. (2003). The social thoughts and beliefs scale: A new inventory for assessing cognitions in social phobia. Psychological Assessment, 15 (3), 384–391. https://doi.org/10.1037/1040-3590.15.3.384

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Daniel, K.E., Teachman, B.A. (2023). “I Don’t Want to Bother You” – A Case Study in Social Anxiety Disorder. In: Woud, M.L. (eds) Interpretational Processing Biases in Emotional Psychopathology . CBT: Science Into Practice. Springer, Cham. https://doi.org/10.1007/978-3-031-23650-1_16

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• Social Phobia/Anxiety Case Study: Jim

Jim was a nice looking man in his mid-30’s.  He could trace his shyness to boyhood and his social anxiety to his teenage years.  He had married a girl he knew well from high school and had almost no other dating history.  He and his wife, Lesley, had three children, two girls and a boy.

At our first meeting, Jim was very shy and averted his eyes from me, but he did shake hands, respond, and smile a genuine smile.  A few minutes into our session and Jim was noticeably more relaxed.  "I’ve suffered with this anxiety for as long as I can remember", he said.  "Even in school, I was backward and didn’t know what to say.  After I got married, my wife started taking over all of the daily, family responsibilities and I was more than glad to let her."

If there was an appointment to be made, Lesley made it.  If there was a parent-teacher conference to go to, Lesley went to it.  If Jim had something coming up, Lesley would make all the social arrangements.  Even when the family ordered takeout food, it was Lesley who made the call.  Jim was simply too afraid and shy.

Indeed, because of his wife, Jim was able to avoid almost all social responsibility -- except at his job.  It was his job and its responsibilities that brought Jim into treatment.

Years earlier, Jim had worked at a small, locally-owned record and tape store, where he knew the owner and felt a part of the family.  The business was slow and manageable and he never found himself on display in front of lines of people.  Several years previously, however, the owner had sold his business to a national record chain, and Jim found himself a lower mid-range manager in a national corporation, a position he did not enjoy.

"When I have to call people up to tell them that their order is in," he said, "I know my voice is going to be weak and break, and I will be unable to get my words out.  I’ll stumble around and choke up....then I’ll blurt out the rest of my message so fast I’m afraid they won’t understand me.  Sometimes I have to repeat myself and that is excruciatingly embarrassing........"

Jim felt great humiliation and embarrassment about this afterwards: he couldn’t even make a telephone call to a stranger without getting extremely anxious and giving himself away.  That was pretty bad!  Then he would beat himself up.  What was wrong with him?  Why was he so timid and scared?  No one else seemed to be like he was.  He simply must be crazy!  After a day full of this pressure, anxiety and negative thinking, Jim would leave work feeling fatigued, tired, and defeated.

Meanwhile, his wife, being naturally sociable and vocal, continually enabled Jim not to have to deal with any social situations.  In restaurants, his wife always ordered.  At home, she answered the telephone and made all the calls out.  He would tell her things that needed to be done and she would do them.

He had no friends of his own, except for the couples his wife knew from her work.  At times when he felt he simply had to go to these social events, Jim was very ill-at-ease, never knew what to say, and felt the silences that occurred in conversation were his fault for being so backward.  He knew he made everyone else uncomfortable and ill-at-ease.

Of course, the worst part of all was the anticipatory anxiety Jim felt ahead of time – when he knew he had to perform, do something in public, or even make phone calls from work.  The more time he had to worry and stew about these situations, the more anxious, fearful and uncomfortable he felt.

REMARKS: Jim presented a very typical case of generalized social phobia/social anxiety.  His strong anticipation and belief that he wouldn’t do well at social interactions and in social events became a self-fulfilling prophecy, and his belief came true: he didn’t do well.  The more nervous and anxious he got over a situation, and the more attention he paid to it, the more he could not perform well.  This was a very negative paradox or "vicious cycle" that all people with social anxiety get stuck in.  If your beliefs are strong that you will NOT do well, then it is likely you will not do well.  Therefore, thoughts, beliefs, and emotions need to be changed.

The depression (technically "dysthymia") that comes about after the anxious event continued to fuel the fire.  "I’ll never be able to deal with this," Jim would tell himself, thus constantly reinforcing the fact that he saw himself as a failure and a loser.

Unusual in this situation is that Jim’s wife remained loyal to him, understood his problem to some extent, and even seemed to enjoy her role as the family’s "social director".  The more and more she did for Jim, the more and more he could avoid.  It got so bad that Jim, who loved to listen to new albums and read new books -- could not even go to stores or to the library.  He would tell his wife what to buy and she would buy it.  She even kept track of when the library books were due and made sure she took them back on time.

This family situation is unusual because most people with social anxiety/social phobia have an extremely difficult time making and continuing personal relationships -- because of self-consciousness and the need for more privacy than most other people.  In fact, social phobia ranks among one of the highest psychological disorders when it comes to failed relationships, divorce, and living alone.

TREATMENT for Jim consisted of the normal course of cognitive strategies so that he would relearn and rethink what he was doing to himself.  He was cooperative from the beginning, and progressed nicely doing therapy.  He took each of the practice handouts and spent time each day practicing.  He made a "special time" for himself that his family respected and he used this place and time to practice the cognitive strategies his mind had to learn.

His biggest real-life fear, speaking to another person in public, was not really a speaking problem; it was an anxiety problem.  There was nothing wrong with Jim’s voice, his reading ability, or his speaking ability.  Jim was a bright man who had associated great anxiety around these social events in public situations.

The course of treatment here is NOT to practice!  In fact, practicing would just draw attention to what Jim perceived was the problem: his voice, his awkwardness, his perceived inability to speak to others.  Thus, it would reinforce the very behaviors we do not want to reinforce.

Instead, Jim worked on paradoxes.  We deliberately goofed-up.  We tried to make as many mistakes as possible.  We injected humor into the situation and found that when he exaggerated his fears, he thought this was funny.  Although more is involved than just this, the concept here is to de-stress the situation and enable the person to see it for what it is: NO BIG DEAL!  If you make a mistake, SO WHAT?  Everyone else does too!

Over the weeks, before group therapy began, Jim did a number of interesting things in public that began proving to him that he was NOT the center of attention, and it just didn’t matter if he made a mistake or two.  After all, he was human just like everyone else.  It’s this idea of perfectionism, of always having to "do your best" that must be broken down.  Jim was human; humans make mistakes; so what?  It was certainly nothing to get upset about.  In fact, as time went by, it become even more funny and humorous, rather than humiliating or embarrassing.

After completion of the behavioral group therapy, Jim had an opportunity for advancement in his company, which he now felt comfortable to take.  The promotion entailed holding weekly meetings in which he was in charge.  He would have to do some public speaking and respond to his employees’ questions.  By this time, Jim was feeling much more comfortable and much less anxious about the whole situation.  "I think I’ll deliberately goof up," he joked to me before the start of his new job.  "It would be interesting to see how everyone else responds."

To say that Jim did not have any anticipatory anxiety before taking this position or before making his weekly presentations would be inaccurate.  The difference was now they were manageable.  They were simply minor roadblocks that could be overcome.  Jim’s thinking about social events and activities had changed a great deal since the first day I saw him in therapy.

I talked to Jim a few months ago and everything was going well.  His responsibilities at work had increased slightly, but Jim now had the ability and beliefs to deal with them.  He was much more confident and had a feeling of being in control.  He was doing more around the house and his wife was a little surprised at his metamorphosis.  Luckily, this did not change the marriage dynamics adversely, and the last time I talked with him, Jim had become a father again: another little boy.

"He’s the last," Jim said, laughing over the phone, "I can’t get too distracted.  I’ve got too many speeches to give now."

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Home / Parenting, Kids & Teens / Could my child’s social challenges actually be signs of social anxiety disorder?

Could my child’s social challenges actually be signs of social anxiety disorder?

An excerpt from Anxiety Coach

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Anxiety Coach by Mayo Clinic child psychologist Stephen P. Whiteside, Ph.D, L.P, takes Mayo Clinic’s safe, rapid, effective Exposure Therapy program for children and teens suffering from anxiety disorders, OCD and phobias, and adapts it from a supervised clinical setting to the family home in an easy to follow self help guide for parents and kids. In the following excerpt from Anxiety Coach , Stephen Whiteside helps parents figure out if their child’s social challenges are actually signs of social anxiety disorder, what sets off social anxiety, why a child avoids triggering situations and finally presents a simple case study of a 16 year old girl with social anxiety disorder, who went on to be successfully treated with Exposure therapy.     

What is social anxiety disorder ?

The term social anxiety disorder fits when children are overly nervous about interacting with other people, particularly peers. Kids with social anxiety are afraid they will make mistakes when talking or will say or do something that could lead other people to think of them negatively. Feeling nervous leads kids to avoid situations that involve talking with or hanging out with or even being around other kids. When children with social anxiety disorder consistently avoid social situations, it means they miss out on fun activities, like sports, or don’t do things they need to do, like give a class presentation. Over time, missing out on these important activities can cause other problems. Social anxiety disorder is one of the most common reasons families come to our clinic.

How do we know it’s social anxiety disorder?

Social anxiety disorder is different from typical shyness in the degree of anxiety that kids experience and how much their fears cause problems. There is nothing wrong with being shy or introverted; I myself was pretty shy as a child. Being nervous giving presentations at school or starting a new activity is also a very normal, common experience. As I mentioned earlier, it’s important not to unnecessarily label your child’s behavior as a problem. If they are content with the way they are living their life and they are doing the school and social activities they need to, that’s a solid sign that all is well. However, when fears of embarrassment are so upsetting that  they get in the way of living everyday life, that’s when we call it social anxiety disorder and recommend treatment. There are times in our clinic when kids and parents disagree on whether social anxiety is a problem. This usually happens in two scenarios. Since many social interactions for kids occur in school, without parents there to witness their child’s difficulties, parents have only the impression they get from seeing their child function in the family setting, whether that’s at home or in public. In these cases, parents may not realize how much their teens or kids are struggling socially. Other times, it’s the reverse, and kids are so upset by their social difficulties that they deny they are nervous and instead say they are simply not interested in spending time with other kids, and what is wrong with that conscious choice, if they are making it? In that and similar kinds of cases, we need to focus on the three jobs we expect from kids and teens—being successful in school, with friends, and at home—and if there are problems in those areas, we can explore how social anxiety might be getting in the way. In addition to situations and activities, for some kids social anxiety is set off by memories of awkward social situations or physical feelings of anxiety or embarrassment, like blushing or sweating, which lead to the same withdrawal and avoidance as social anxiety that relates to real-time, everyday scenarios.

What sets off my child’s social anxiety?

Social anxiety is typically set off by things in the world around us, most often situations in which kids need to talk to their peers or other people or when they may be observed by others. There are many different types of social situations and not all will give your child feelings of anxiety. Some children get more nervous in performance situations— reading aloud in class, acting in a school play, singing in a school musical, answering a question in class, competing in a basketball game, playing in a school concert, or giving a presentation in class. Others might get more nervous in unstructured social situations, like initiating conversations, meeting other kids at the start of a new school year, joining a club, finding people to sit with during lunch, or making small talk in the hallways between classes. And then there are kids whose anxiety is set off by talking to adults, especially in public situations such as the school principal, a teacher, or a sports coach. These children may also be nervous to order food at restaurants, ask questions of store clerks, or check out with you at the grocery store. Sometimes children feel nervous simply being in public where people may be watching and observing them. For many kids with social anxiety, all of the above may set off their anxiety.

Expectations that make social situations scary                                      

Once you’ve identified the situations that set off your child’s anxiety, the next thing to do is pinpoint the expectations that cause your child to feel nervous in these situations when most of their peers enjoy them or feel only somewhat uncomfortable. As we have learned, there are two main expectations that drive fear and worry— something bad will happen and I won’t be able to handle this —both apply to kids with social anxiety. A core component of social anxiety is the fear of being judged negatively. However, the type of feared judgment often differs based on the situation in which kids feel anxious. Kids who get nervous speaking in performance situations may have expectations that they will make mistakes, perform poorly, and be judged as not good enough, smart enough, or talented enough. Kids who are more nervous about talking to peers may be more afraid that they will do something embarrassing and everyone will think they’re uncool or unlikable. And when kids are nervous around authority figures they are typically concerned about getting in trouble, being a burden, or irritating others. For many children with social anxiety, expectations can occur in any combination of the above. Despite the importance of expecting negative judgment in social anxiety, it’s important to note that some kids don’t describe these specific worries. Younger kids especially are more likely to simply say that talking to others is scary and they don’t know why. Teens may add that they know it’s unlikely that people will laugh at them or be mean but that they still feel nervous. If this is the case, you might describe the child’s expectation as believing they can’t handle talking to people or they have to avoid being around people to feel okay.                                                   

Avoidance of social situations

Next, we need to identify what avoidance strategies your child uses to stay away from the situations they fear and in doing so, miss out on the opportunity to learn that these situations are not as bad as they expect them to be. The most common form of avoidance for kids with social anxiety disorder is partial physical avoidance, which is when kids can’t completely avoid a situation but try to avoid as much of it as possible when they are in the midst of it. For example, these kids can’t avoid going to class, but when in class, they are careful never to raise their hand to answer a question asked by a teacher. Or because of anxiety around playing on the school football team, a teen might arrive at practice at the last minute and rush home quickly afterward to avoid the banter and socializing among teammates in the locker room. Partial avoidance due to social anxiety can also include a child keeping their head down while walking in the hallways between classes at school, avoiding eye contact to make sure no one talks to them, or purposefully reading a book before class to put up a wall against being greeted by fellow classmates. As many parents of socially anxious children know, full avoidance of anxiety-provoking activities can also occur. Complete avoidance involves not signing up for sports, clubs, and other extracurricular activities. Or not attending school dances or sporting events. Or eating lunch in the library. It may grow to include staying home from school on days there is a presentation due or even transitioning to online school or homeschooling. Kids with social anxiety may also often rely on others to help avoid feared social interactions. As we saw earlier, parents may be asked to order food in restaurants or communicate with teachers.

Social anxiety disorder, a case study

Meet 16-year-old Maria, a smart, likable teenager and a successful figure skater. She and her parents agreed that she had always been shy, but it hadn’t been a problem because she’d maintained a core group of friends since kindergarten. In restaurants, she’d appear nervous, and her parents would order for her, but they weren’t overly concerned about it. None of this was a problem until she entered middle school. With that transition, she began to struggle. Her core friends connected with new faces and added new friends, while Maria stayed on the sidelines, feeling shy. She felt even more nervous in class when she didn’t yet know many of the other students and, with seven different classes a day, there wasn’t much of a chance to get to know her teachers. In this new environment, she came to dread presentations, yet was too nervous to ask for help. Under pressure across the board, some of her grades began to slip. When Maria began to complain that she felt too sick to go to school on days she had a class where there was always a lot of student participation, her parents brought her in to Mayo Clinic for help. During the initial assessment, Maria readily acknowledged that in social situations she was afraid she would say the wrong thing and look ridiculous in front of other kids who all seemed to be calm, outgoing, and happy to make new friends and expand their social circle. She had always felt comfortable with figure skating because so much of it involved working on her own without having to make conversation with the other skaters. However, now that they were getting older and spending more time chit chatting before and after practice, she was struggling with these interactions and feeling awkward. What she feared most was doing something foolish that would lead her peers to laugh at her and, as a result, see no value in being friends with her. Although she outright avoided some school activities and relied on her parents to order for her at restaurants, most of her avoidance strategies involved finding ways to dodge direct conversation when at school or during activities by looking busy, avoiding eye contact, or leaving early. It had reached a point where she felt left out and was considering quitting. After our clinical assessment, a diagnosis of social anxiety disorder was agreed upon and she went on to be rapidly and successfully treated with Exposure therapy. 

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Look closer ... I am not "just shy": recognizing social anxiety disorder: a case study

• PMID: 25417333
• DOI: 10.1177/1942602x14545481

Early recognition, assessment, and treatment of social anxiety disorder are criteria to prevent persistent functional impairment in educational and occupational settings and in relationships. Individuals who avoid social settings due to the fear of embarrassment miss out on activities, learning opportunities, and interactions with others. Those who work with children in schools or health care settings are in an ideal position to help those who often don't have a voice. The 2013 updated NICE guideline, Social Anxiety Disorder: Recognition, Assessment and Treatment, has been critically reviewed and applied to a case study. The guideline is intended to provide evidence-based best practice advice for providers on how to recognize, complete assessments of and treat social anxiety disorder.

Publication types

• Case Reports
• Anxiety Disorders / diagnosis*
• Anxiety Disorders / nursing*
• Evidence-Based Nursing / methods
• Practice Guidelines as Topic
• School Nursing / methods*
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8 Treatment of Social Anxiety Disorder: A Case Complicated by Panic Disorder

• Published: February 2013
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Chapter 8 covers the treatment of Social Anxiety Disorder (SAD), and includes information about the condition, epidemiological considerations, the case study, assessment strategy and case formulation, intervention model and course of treatment, strategies for handling homework non-compliance, handling poor attendance and relapse, relapse prevention, post-treatment assessment, basic science for this case/condition, alternative strategies to consider, ethical consideration, cultural factors, clinical implications, and avoiding common mistakes during treatment.

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Counselling Case Study: Social Anxiety

Sasha is a 60 year old woman who has recently retired from a career in teaching. Working for many years in a secondary school environment, Sasha was confident, motivated and dedicated to her work, but at the same time looking forward to retirement so she and her husband could travel and spend more time with their adult children who lived nearby.

However upon finishing work, Sasha found herself experiencing severe anxiety, particularly when around other people, and began not wanting to leave the house or invite people into the house. She also experienced bouts of crying when attempting to complete tasks such as housework and using the sewing machine. Sasha found her symptoms eased when she and her husband went on camping trips in national parks where they often did not see other people for days.

While working with Sasha, the Professional Counsellor adopts strategies from Cognitive Behavioural Therapy and Gestalt frameworks in order to address any irrational thoughts and behaviours which may be maintaining Sasha’s anxiety, and to complete any unfinished business which may have led to the development of her anxieties in the first place. For ease of writing, the Professional Counsellor is abbreviated to “C”.

Sasha was an unplanned baby, born after her older brother. Her parents did not want a second child but when they realised another was on the way, they hoped for another boy. As a child Sasha remembers always being in the background and her brother and father being the ‘important’ ones.

Sasha reported a vivid memory of coming home from school one day and finding no-one home. Sasha sat on the front porch and cried until her mother eventually came home and told her to stop being so silly. She described her mother as being more concerned with the state of the house than with her young daughter.

Sasha’s father died when she was very young, and she remembers her mother not coping well for a long time. During this time she (but not her brother) was often sent to her grandparents’ farm to give her mother a break. Here Sasha spent most days on her own. However she remembers these visits fondly, like ‘a lull in the storm’.

When her mother died, she left everything to Sasha’s brother, who was by then a well- paid solicitor with a young family. Sasha also had a young family but did not question her mother’s decision as she had been conditioned from childhood to believe males were more important.

Issues identified

Sasha’s symptoms appeared to be those of social anxiety disorder. They included:

• An extreme fear of situations where she may have to meet new people or be scrutinized by others.
• Social situations were either experienced with intense anxiety or avoided altogether.

When she did face these situations, she experienced physical symptoms such as sweating, shaking, tension, shaky voice, dry mouth and a pounding heart. The main symptom of this disorder involves feeling extreme anxiety in the presence of others. Sufferers often believe other people are very confident in public and that they are the only ones who aren’t.

Almost everyone experiences some social anxiety now and then; however social anxiety disorder severely limits the lifestyle of the sufferer, causing them to avoid making friends or miss important opportunities at work.

Formulation

In the first session, Sasha described her current physical symptoms and her feelings of hopelessness that she would never have the lifestyle she had dreamed of having in retirement. She was very tearful and her voice was quite high and shaky. She stuttered occasionally and her hands moved constantly, tearing the tissue she was holding to pieces.

She described trying to sew curtains and being overtaken by an uncontrollable fit of crying. She could not explain why this had made her so upset. She had also avoided inviting former work colleagues to her house for fear it would not be ‘good enough’. Her main concern was her daughter’s wedding, coming up in three months. She became more tearful talking about this, saying she did not know how the bride’s mother was supposed to look or act.

C then took a history of Sasha’s family background and noted that she had always been relegated to the background, leading to the core belief that she was unimportant. Sasha then described her work history which seemed to be in sharp contrast to her family experiences. C took some time to explore this with Sasha.

Sasha described being in the classroom as ‘being in control’. She felt that she had a good rapport with students and was good at her job. She often took on more than she could handle at work but somehow managed to get through it and was praised by her colleagues when she did this. It appeared that the only time Sasha had ever felt important was in the workplace.

However while she got along with other staff, she had made no real friends and had never had any friends throughout her life. C asked her why this was. Sasha became tearful again and said that she just wanted to go and live somewhere she wouldn’t have to see anyone except her husband and her children. She described her camping trips with her husband as being relaxed because she didn’t have to talk to other people. She experienced particular anxiety when her husband’s family visited as she felt pressure to be a perfect wife and housekeeper in their eyes.

Sasha mentioned that while she was working in the Education Department, she had been given a personality test to complete which had told her she was an extrovert. She was puzzled by this because she did not like people and clearly stated that it was not her goal in counselling to change this.

At this stage, C shared with Sasha her impression that Sasha appeared to have developed the belief that her authentic self was unacceptable and had created a false self to present to the world. This created intense anxiety because she was never quite sure who people wanted her to be from one situation to the next, requiring her to constantly scan her environment for clues as to how to feel and behave. Consequently it was easier to think about going away to a place where she would not have to see anyone, as she had done as a child at her grandparents’ farm. Only when she was away from people was she able to relax and feel in control.

Also, because she had married an introverted man who indulged her need to avoid social situations, she had learned to suppress her extroverted nature still further. It was no surprise that retirement was causing her such distress, since the only time she had ever felt important and comfortable around people had been in the work environment.

Session Content

Empty chair.

C decided to explore the unexpressed extroverted side of Sasha’s personality first. She asked Sasha what she did that was fun. Sasha could only list one item, the morning walk she took with her husband in the hills. Even this caused her concern however, because she felt she should be walking faster and further than she was.

Using the Gestalt technique known as Empty Chair, C placed a chair opposite Sasha and asked her if she would speak to the extroverted side of herself. Sasha found it difficult to stay in the first person and avoided this by talking directly to C. C guided her attention back to the empty chair and suggested she ask this part of herself what it would do if it could take over for a day.

When Sasha had done this, C asked her to move to the empty chair and reply as her extroverted self. Once seated in the other chair, Sasha began to relax and freely spoke about wanting to go to Dreamworld and wanting to make a quilt. When she returned to her original seat, C asked Sasha how she felt about allowing this side of her to have some fun. Sasha appeared reluctant but agreed to ask her husband if he would go to Dreamworld with her.

In the following session, Sasha reported she had not only gone to Dreamworld, but that they had purchased season tickets. Throughout the course of the counselling sessions, Sasha and her husband began visiting the theme park for half a day every week. She also started several creative projects, including hand quilting and scrap booking. She found these activities extremely difficult at first, but utilising cognitive-behavioural strategies to challenge her core beliefs, she was able to continue to the point where she was able to enjoy herself for the first time in years.

Cognitive Restructuring

Challenging and modifying a client’s faulty thought processes is the basis of Cognitive Behavioural Therapy (CBT). After Sasha had outlined several situations that were causing her anxiety, C helped her identify her beliefs about these situations. Sasha was shown that it was her beliefs about these situations which led to her bad feelings, and was encouraged to find more realistic alternative beliefs. Some of these processes included:

Activating event (A) = sewing

Belief (B) = I can’t do it well enough, I might as well give up

Consequence (C) = crying, giving up, bored and depressed

Dispute (D) = I’ll do my best and focus on enjoying myself rather than focusing on the outcome

A = husband’s family staying

B = they’ll see the state of my house and be horrified

D = I’ve got better things to do than clean the house and if they don’t like it, it doesn’t mean I’m a bad wife

A = attending daughter’s wedding

B = I’ll let her down and embarrass the whole family by saying or doing something wrong

D = people will be focusing on the bride, not me, so I’ll focus on her too

In this manner, Sasha was asked to practice disputing her thoughts for homework.

C then asked Sasha to use the Empty Chair technique to complete unfinished business with her mother, addressing her feelings about coming home to an empty house and then being told she was ‘silly’ for crying. Sasha had always believed her mother had treated her as insignificant because she had been such an inadequate child. Playing both roles, Sasha was able to see that her mother had her own agenda which made it difficult for her to have time for her daughter. After Sasha told her mother via the Empty Chair technique how she had felt in this situation, she realised the beliefs she had developed about herself were not necessarily accurate or helpful and could therefore be challenged.

Again reverting to CBT techniques, C asked Sasha to look for disconfirming evidence for the belief that she was inadequate. She was able to find many examples of this, chiefly in her work and as a mother to her own children. Sasha was asked to continue noticing examples like this on a daily basis. She was also asked to be aware of herself in the present moment as much as possible, rather than focusing on the past or the future. This allowed her to enjoy what she was doing, rather than focusing on previous failures and criticisms, or future ‘what ifs’.

Session Summary

Sasha’s counselling sessions focused on a number of issues:

• Integrating repressed parts of herself that were ‘unacceptable’
• Allowing her extroverted side to be expressed so she could take part in and enjoy pleasurable activities which lifted her depression
• Completing unfinished business with her mother
• Challenging her thoughts and behaviours – the belief that she was unimportant and the need to compensate by being perfect
• Learning to be present in the here and now, allowing her to focus on the activity at hand and enjoy it, rather than worrying about the outcome Experimenting with relaxing her perfectionist standards, which showed her that nobody else even noticed.
• Her daughter’s wedding – Sasha discovered that by distracting her thoughts about being around so many other people in such an important role at her daughter’s wedding, and instead focusing on the needs of her daughter and guests, her anxiety was no longer present.

Sasha’s experiments reinforced the fact that her thoughts were producing her anxiety, not other people. She realised that when she wasn’t focused on herself, her anxiety was no longer there. When she couldn’t distract her thoughts, she learned to modify them to something more realistic. By challenging her irrational belief that if she wasn’t perfect she was inadequate, she began to enjoy everyday activities and became much more relaxed. This was noticeable even in her voice, which lowered in tone, and in her generally more relaxed nonverbal behaviour.

As a result of implementing these strategies, Sasha found it a lot easier to be around other people. By learning to accept herself as she was, she no longer felt the need to guess what other people wanted from her, and began to feel comfortable presenting her authentic self to the world.

Author: Leanne Chapman is a Psychologist who has worked in community clinics and hospital settings with both children and adults. She has also conducted group therapy for patients with anxiety, depression and eating disorders at New Farm Clinic. In addition to her work with AIPC, Leanne operates a successful private practice.

• February 11, 2008
• Anxiety , Case Study , CBT , Gestalt , Stress
• Case Studies , Clinical Mental Health , Stress Management

Comments: 1

I found this article useful especially as it illustrates how effective forms of CBT can be in regard to treating anxiety. I thought the model used (ABC of Emotional Disturbance) was Albert Ellis’ Rational Emotive Behaviour Therapy. I think CBT and the ABC of Emotional Disturbance is sometimes attributed to the work of Beck and others. I have always understood that this was Ellis’ creation.

Thanks again for a very helpful article.

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