Counselling Report On Client
Sam was referred for counseling by the Transitioning.org – a support site for the unemployed – to help him cope with the anxiety problem in social environment.
CLIENT’S PRESENTING PROBLEMS
Sam has been feeling very uneasy in social environment. He has little confidence to engage in conversion with people new and is often overwhelmed by anxiety. He felt that he is being watched and judged by others. He felt a tic at the left corner of his lip whenever anxiety sets in, which makes talking difficult.
KEY INFORMATION PROVIDED DURING COUNSELING SESSIONS
Sam said since young when he was living with his aunt’s family, his aunt family, particularly his cousin, would monitor and interfere on everything he or his sister did. During that time, he said his cousin was always keeping a watchful eye on him and was monitoring his every activity. This made him felt very miserable until, upon his mother’s consent, he and his sister secretly moved out on his grandmother’s house to live in the current flat. Today his cousin still is not aware of their moving out. To avoid unnecessary problem, Vincent’s mother did not disclose their XXXXX home address to the aunt.
Sam said he first experienced the unexplainable feelings of anxiety when he was about 10 years old, at Primary 4. He said he got anxious whenever his teacher called him up to read to the class and sometimes the feeling of anxiety got so overwhelming that he had difficulty uttering sentences from the text. He said over time, he realized that has developed a facial nervous tic on his lip whenever he tried to smile.
Sam said there was once his teacher teased him in front of the class of his shyness and anxious behaviour. The effects of which have caused him to feel very humiliated that he refused attend school the next day until his mother had to accompany him to school.
Sam said his facial nervous tic has deeply impaired his confidence to socialize.
When in secondary school, Sam said he did not socialize much with his schoolmate due to fear of his anxiety problem. He said that whenever he tried to socialize with his schoolmate, he became very anxious and that his mouth would start to tremble and make talking difficult. Sam felt that his schoolmates did not want to socialize with him because of his weird behaviour. He did not make many friends in school.
According to him, he felt that his schoolmates were always watching him and he must try all might to cover up his anxiety problem so that they would not perceive him as weak. He said the needs to be on a lookout exacerbated his feeling of insecurity and anxiety, which, he believed, had affected his academic performance.
Sam had attained 5 GCE ‘O’ Level pass and was posted to XXXXX. He said his anxiety problem had affected his learning abilities and study performance that he did not complete his courses there.
Sam said his anxiety problem has become so devastating that he needed much courage to carry out simple tasks such as paying at the casher counter or making orders at the restaurant.
Sam said when in public places such as shopping centers, in the MRT or buses, food count etc, he felt that he is being watched by people around and they are secretly judging him. He said he is afraid that his body language would unconsciously give away his true feelings and so he needs to be cautious of his posture and body movement. He fears being judged negatively.
Sam said that his anxiety problem and sense of insecurity have, through the years, cost his self-confidence and self-esteem.
Sam said he often seeks asylum in his house whenever he encountered an awkward situation and, for this reason, he seldom travels far from the neighborhood unless being accompanied by family members.
Comparing himself to his sister, Vincent said she is smarter and is more confident in doing anything. He felt that he could not measure up to his sister’s abilities.
Sam said he had sought treatment at IMH for anxiety problem and depression once but has since discontinued the treatment there as, according to him, he was concerned of the side-effects of medication and that he preferred no medication ways of treatment, such as by psychotherapy approaches.
Sam said he is fully aware that his social anxiety problem is affecting his daily functioning.
Sam has expressed determination to overcome his anxiety problems. He has sought the counselor’s help to guide him along to resolve his anxiety problems.
Sam has taken up evening jogging which he said has helped him to better control his anxiety problems.
KEY BEHAVIOURAL OBSERVATION
Sam was able to relate his thoughts well and articulate his feeling clearly. He has good command of both English language and Mandarin.
Most of the times during the counseling session, there was generally good eye contact. However, it was noticed that whenever somebody passed too close to our table, his eye contact would become erratic and his attention readily distracted.
Sam manifested little self-confidence and the feeling that he is incapable and his adequacy did not measure up to other people. He was also very sensitive on how others see or perceive him.
Sam held the belief that people are quietly judging him and was in constant worry of being judged negatively. Sam was very conscious of his bodily posture as he feared that his body languages would be perceived as weird and gave others the impression that he is abnormal.
His self-consciousness in others’ opinion about him and his self-perceived deficits has impacted his self-esteem. As such, a benign glance from someone would make him feel uneasy and anxious. At times, Vincent was observed to quiver when talking during our discussion.
ASSESSMENT METHOD AND PROCEDURE
Cognitive Behaviour Therapy (CBT) was adapted to assess Sam’s problem situations to derive the appropriate therapeutic intervention plan to help Sam.
Sam was mentally constrained when young while living in his grandmother’s house as his mentally disabled cousin tracked and interfered in his every activity such the he often needed to do his chores – for example doing his school works – secretly. While living with his cousin, he was deprived to self-experience and freedom that most children his age has. On top of that, Sam is an introverted person and tends to keep things within him.
Belief and Assumptions
Sam could have held on to a irrational belief that we should be thoroughly competent, intelligent, and achieving in all possible respects.
Sam manifested these irrational beliefs, such as: in believing that he is not measured up to others in the ways they are able to present themselves; he felt that people should be good at everything they do in order to gain respect and acceptance from others. Sam developed a set of “rules of livings” based on his irrational beliefs. And when he could not fulfill the expectations defined in the “rules of livings”, he began to doubt his abilities and lose confident in himself; his self-esteem. He feared that others might see his shortcomings and judge him as inadequate. This has brought about a lot of anxiety in him in social environments.
Sam is inherently a shy and an introverted person. He does not interact much with people. Sam was once felt deeply humiliated in front of the class by his teacher who teased him for his shyness and anxious behaviour. As he did not interact much with others in school, he was often isolated by his schoolmates.
Cognitive Sam developed negative thoughts which cognitively labeled his own self as insufficient and feared of being looked down upon. Such negative senses have formed his negative core beliefs which caused him to trap within his own mental block. The interaction of his negative core beliefs and the environment was in has led him to assume a set of “Rules for Living” largely based on his dysfunctional assumptions.
Emotions Sam’s negative predictions have caused him to assume a fear of rejection. The negative assumptions have reined his wanting to communicate with others. The challenges of making social initiation and the overwhelming anxiety along with these challenges have impeded him in making social progression.
His low self-acceptance and fear of not being accepted by others have exacerbated his dispirited feelings and confusion. His fear of being put on a spot in a “humiliated” situation has made him very sensitive to others opine about him.
- Behaviour Sam got anxious easily. At times, he would behave in a nervously and has difficulty talking. Sam relied a lot on his family member, especially his mother, sense of security. Sam’s negative predictions had led him to develop a range of maladaptive behaviors, such as: self-fulfilling prophesies, emotional reasoning and mental filtering.
Physiology Physically, Sam appeared healthy. He exercises regularly.
A few modifier factors were believed to have attributed to Vincent maintaining his problems going, such as: black or white thinking; mental filtering; mind reading; fortune telling and unfair comparison. These cognitive biases have served as maintainer of his negative core beliefs.
To avoid being put in a spot in an embarrassing social situation, he chose to hide himself his house. His behaviour has drastically reduced his opportunity to interact with other person, which subsequently reduces his social circle and interactions. The outcome of which further confirm his negative core beliefs.
It is crucial to assess the maintenance patterns that kept Sam’s problem going. These maintenance patterns are vicious cycles need to be disrupted in order for the therapeutic resolutions derived to be effective.
“Self-fulfilling prophesies”, “Performance anxiety” and “Perfectionism” are the maintenance processes identified to have been keeping Vincent’s problems going.
Sam perceived that the people judging him for his lack of confidence and competencies. This led him to change his perception and responses toward people. If they responded to him in ways that are not in congruent with his core negative beliefs, it confirmed his negative cognition of “self-fulfilling prophesies” and the vicious circle continue.
Sam developed a desire to prove his worthiness and capability; as a result he set unrealistic objectives and when he could not consistently accomplish them, he receded to his sense of worthlessness. Hence, maintaining the vicious circle of “Perfectionalism”.
In the process, he developed the anxiety of “fear to fail” which sets in to disrupt his ability to accomplish a task. This further confirmed his perception that he is a true failure. This erroneous thought maintained the vicious circle of “Performance anxiety”.
COUNSELLOR CONCEPTUATION OF THE PRESENTING PROBLEM
It is hypothesized that Sam might not good childhood experience as he was under constant watched and behavioral constraint by this older cousin, who is mentally disabled. He had little freedom to experience things himself which are important for nurturing self-confidence. According to Sam, he often had do things in a stealthily – to be on his toes – to avoid arousing his cousin suspicion.
His lack of opportunity for nurturing self-confidence would probably be attributed to his overly reliance on parental protection.
It is assessed Sam could be suffering from social anxiety disorder. During the series of counseling sessions, Sam has manifested consistent believe that he is being watched by the people in social environment. He is very conscious of how others see or perceive of him. He concocted the assumption that other people will be judging him negatively and he must put up a defensive front to avoid being harmed.
Sam fears being put on the spot in a perceived humiliating situation, which exacerbates his anxiety problem. To avoid encountering such situation, he seldom goes out of his house; this drastically diminished his opportunity for socializing.
Sam perceived a “rules of livings” based on sets of irrational beliefs. And when he could not fulfill the expectations defined in the “rules of livings”, he began the loss confident in his ability and on himself. The overcome of which has deeply affected his self-esteem to engage in social environments.
RECOMMENDATION AND INTERVENTION PLAN
The primary objectives of the treatment plan are to help Sam to realize and be able to dispute his irrational thoughts and to encourage reframing to elicit rational ones and, lastly, to disrupt the maintenance processes that keep his problems going. The secondary objectives are to impart CBT skills and to encourage self-empowerment in Sam to handle future challenges and relapses.
It should be noted that the treatment plan is based on assumptions and information gathered from Sam’s account of his problems during the counseling sessions and my observatory assessments.
Problem: Social Anxiety Disorder
1. Developed irrational assumptions and negative automatic about himself.
2. Deficit of encouragement, motivation and self-acceptance.
3. Developed over reacting fear and anxiety that impede his confidence his establish his social circle and interaction.
1. Elicit positive automatic thoughts, identity underlying irrational beliefs and replacing them with suitable alternatives.
2. Teach scaling technique to grade his irrational assumptions.
3. Eventual eradication of self-doubt, self-criticism and unfair comparison.
4. Improve social interaction.
5. Teach Sam to use CBT skills to achieve self-empowerment.
EVALUATION OF INTERVENTION OF OUTCOME AND OVERVIEW
Though our follow on assessments and email correspondence, Sam is able to understand that feeling, behaviour and physiological well-being are derived from his thoughts. He has learned to identify his irrational thoughts and uses reframing to replace them with rational one. He will continue to apply the skill learned to dispute his negative thoughts and through reframing to elicit positive ones. Sam is set a determined resolution to overcome his anxiety problems even though the process may be strenuous and slow. He understood that through continuous hard work, he would be able to overcome the mental block and to resume a normal life. My last correspondent with him, Sam has showed remarkable improvement.
Recorded by: K. Mong (volunteer counsellor)
20 July 2010
NB: Permission was sought to present the above counselling report from the client – Gilbert