A Thesis Submitted to The University of Birmingham For the...

A Thesis Submitted to

The University of Birmingham

For the Degree of

Doctor of Clinical Psychology

Volume II

By Marc Desautels

School of Psychology

University of Birmingham

Septembre 2008

University of Birmingham Research Archive

e-theses repository This unpublished thesis/dissertation is copyright of the author and/or third parties. The intellectual property rights of the author or third parties in respect of this work are as defined by The Copyright Designs and Patents Act 1988 or as modified by any successor legislation. Any use made of information contained in this thesis/dissertation must be in accordance with that legislation and must be properly acknowledged. Further distribution or reproduction in any format is prohibited without the permission of the copyright holder.

Overview

This thesis is submitted in partial fulfilment of the requirement of the degree for

Doctor of Clinical Psychology at the School of Psychology, University of

Birmingham. The thesis consists of two volumes.

Volume I

This volume comprises of two parts. The first part is a review of the literature that

has contributed to the understanding of the role that siblings play in the development

of emotion regulation. The second part is an empirical study that investigates the

experience of growing up with a sibling who has a learning disability. The literature

review put forward the argument that siblings play a significant role in the

development of emotion regulation. This paper has been prepared for submission to

the journal Family Processes. The empirical study utilises qualitative methodology to

examine the experience of eight people who have a sibling who has a learning

disability and how this has impacted on their life, when they were children and now.

This paper has been prepared for submission to the British Journal of Developmental

Psychology. The Public Domain Briefing Paper is also submitted in this volume.

Volume II

Five Clinical Practice Reports (CPR) are presented in this volume. The first report

details the case of a man with a learning disability, presenting with challenging

behaviours, formulated from a psychodynamic and cognitive perspective. The second

report is a service evaluation of an anxiety management group for people with

learning disability. The third report details the treatment of a nine-year old girl with a

bird phobia. The fourth report is a case study on a seventy-two-year old man

presenting with cognitive difficulties, discussed from a systemic approach. The fifth

report was assessed orally and so the abstract is presented in this volume.

All names and identifying features have been changed to ensure confidentiality.

Acknowledgements

I wish to express my thanks to all my participants for giving me their time and sharing

their stories with me.

To my supervisors, Dr Gary U. Law and Dr Biza Kroese not only for their help and

guidance but also for their support and enthusiasm.

Thank you also for my partner Kevin, without his constant support and devotion, I

would not have got through this intact. Thank you to my parents for their faithful

encouragements and confidence in me. Finally, thank you also to my cat, Maurice,

for keeping journals open at the right place with his paws.

Contents of Volume I

Literature review paper: Page 1 What role do sibling relationships play in the development of emotional regulation? Introduction Page 2 Methodology Siblings and Emotion Regulation Page 13 Discussion Page 22 Clinical and Research Implications Page 26 Conclusion Page 29 References Page 31 Empirical research paper Page 35 The experience of growing up with a sibling who has a learning disability Introduction Page 36 Method Page 40 Reflexivity Page 44 Findings Page 45 Discussion Page 62 Conclusion Page 69 References Page 70 List of Tables Table 1 Page 8 Table 2 Page 42 List of Figures Figure 1 Page 23 Figure 2 Page 62 Public Domain Briefing Paper Page 75 Appendices Page 80

Contents of Volume II

Clinical Practice Report 1: Psychological Models Page 1

Martin

Clinical Practice Report 2 : Small Scale Service Related Project Page 31

Anxiety management group programme for people

with learning disabilities- the sum is larger than its parts.

Clinical Practice Report 3 Page 52

The treatment of a bird phobia with a nine-year old girl.

Clinical Practice Report 4 6

Psychological assessment of a 72-year old man

initially presenting with cognitive difficulties.


The assessment and formulation of a 49 year-old man

presenting with depression.


List of Tables


Table 1. Summary of session agendas. Page 38

Table 2- GAS raw scores Page 39


Table 3- SCAS scores Page 57


Table 4 Summary of Scores 3


List of Figures


Figure 1- Martin’s triangle of conflict Page 7

Figure 2- The triangle of the person Page 12

Figure 3- Perpetuating factors Page 21


Figure 4- Anxiety thermometer results Page 39


Figure 5- Hierarchy of fear Page 55

Figure 6- Formulation Page 58

Figure 7- Tricia’s ratings Page 65


Figure 8- Ron’s formulation in family situations 1

Appendices Page 97

Clinical Practice Report 1- Psychological Models Martin Abstract

This clinical practice report examines the case of Martin who is a resident of Iliad

House and has a learning disability. Martin was referred to the Psychology Service

because of a series of incidents in the community and at the home where he became

aggressive and at times physically violent. The problems presented by Martin are

examined through two formulations, a psychodynamic one and a cognitive-

behavioural one. The psychodynamic formulation explores Martin’s relationship

patterns and highlights the conflict between his anger at carers for not giving him the

care he feels he needs and his dependency on the same carers for receiving care. This

is done using Malan’s triangles (1995). The cognitive-behavioural formulation looks

at his thinking patterns and how he has developed a way of construing the world

where he believes that people cannot be trusted. This is done by using the model

suggested by Dudley & Kuyken (2006). The two formulations are discussed and

criticised. Their shortcomings, in terms of including the learning disability factor in

their formulation of the issues, are also considered.

1

Background to the case

Referral

Martin (not his real name) was referred to the Psychology Service by his Community

Nurse from the People with Learning Disability Service. In the referral letter, the

Community Nurse states that Martin has issues around his anger and finds it difficult

to control his aggression. He further reports, “There have been several incidents in

the local community where Martin felt he was being stared at and became abusive and

angry frightening several elderly women.” The letter also describes an incident where

Martin attacked a man at the local newsagents and the shopkeeper had to intervene

otherwise Martin could have been seriously hurt. Martin is now not allowed to go out

alone due to concerns about his behaviour. He has also become aggressive with staff

members.

Background information

The information gathering for the assessment was conducted over a period of several

weeks. I firstly interviewed the Community Nurse who referred him as well as the

Psychiatrist who follows him. Interviews were also conducted with the Home

manager, the care staff at Iliad House, the home where Martin resides, and with

Martin himself. I also read through the Psychiatrist’s file. It is important to note that

the information contained in Martin’s files is relatively recent. It would appear that

the Martin’s file from the hospital where he lived for many years was lost and

2

therefore a large part of Martin’s history, social and medical, is unknown. I also

observed Martin at Iliad House.

This is a summary of the information that was collected during the assessment.

Martin was born in 1970 and but not much is known about his family. The

information about his childhood is rather sparse and it appears that he was

institutionalised from his early teens. When the hospital where he was closed, he was

re-housed in a hostel where he stayed for a few years before moving to Iliad House

five years ago. Before I met Martin, the Community Nurse described him as very

‘institutionalised’ (meaning highly dependent, rigid in his routine, no sense of

initiative and a strongly suspected history of abuse) and the Psychiatrist concurred

adding that he was most afraid of ‘being locked up again’.

There are notes in the home file that suggest he still saw his mother and sister on a

regular basis but all visits stopped about four years ago when his sister accused him of

bullying their mother. The notes also report that Martin appeared to be afraid of his

family. Mother and sister lived together and after a move to a different address did

not inform Martin of their new contact details. According to the staff at Iliad House,

Martin does not have any contacts with his family. The staff at Iliad House have all

been employed by the housing association for less than three years and have never

met with either Martin’s mother or sister.

3

According to Martin’s psychiatric file, not only has he a diagnosis of moderate

learning disability but also one of schizophrenia. He was assessed for pervasive

development disorders but did not appear to be on the autistic spectrum.

Martin presents with a mild to moderate learning disability. He is rather sociable and

appears to enjoy meeting new people. He has good verbal abilities and can express

himself in a limited but effective way. His conversations are often one-sided and

amongst the favourite topics covered are the weather forecasts, cigarettes and bus

routes. It is rather difficult to assess whether Martin has a good memory or not; he

often claims to have forgotten what the previous week’s or day’s events were,

especially if there was an incident of aggression, but will sometimes tell things that

happened a few years ago. Martin does not appear keen on volunteering such

information and will often change the subject when questioned further. Martin

enjoys wearing trendy clothes and is concerned by his physical appearance; although

staff have mentioned to me that he often needs to be reminded to take a shower or

change his clothes. He enjoys smoking and going to the pub and appears especially

fond of doing these activities with his key worker.

The presenting issues

From my interviews with various staff and with Martin and my observation sessions,

it appears that he has the following difficulties:

Martin believes that people are staring at him with aggressive intentions and he feels

that people around him want to molest him. This makes him angry and he then feels

4

the need to retaliate. For example, he told me that some members of staff do not like

him and that they would hit him if they had a chance. He added that he must defend

himself against them otherwise he might get seriously hurt. The problem has also

occurred in the community but has not repeated itself since Martin has been escorted

on outings. Martin, indeed, told me that “it’s a dangerous world out there” and that he

needs to look after himself otherwise people will steal his money or cigarettes.

Care staff have also reported that there is an element of competition for attention

between him and two other residents of Iliad House (Jake and Marty); from my

observations, I noticed that when a member of staff is working individually with

another resident, Martin will often interrupt their sessions for what appears to be

trivial reasons (e.g. asking about weather forecast or who is on shift later today). I

noticed also, on fewer occasions, that individual sessions with Martin were also

interrupted by other residents.

Martin appears to have a very low threshold of frustration and as a consequence he

gets easily angered by other residents. Martin has also been caught bullying Jake and

Marty, repeating endlessly the only sentence Jake is capable of saying and asking

Marty, who suffers from double incontinence, if he has “shat in his pants, again.”

It has been reported by the home staff that Martin has the habit of wearing several

layers of clothing. For example, he will wear four or five pairs of underpants as well

as layers upon layers of t-shirts. This has been an area of friction between staff and

Martin as the former often feels it is not an appropriate way of dressing. Martin says

5

he does not want to get cold. The Community Nurse also mentioned that he wears his

belt so tightly that he has begun to develop pressure sores around his waist.

Martin appears motivated to change his behaviour. He told me that “this has to stop

because it makes me unhappy”. I used a non-standardised tool developed by an

assistant-psychologist (a collection of pictures cut out from magazines representing

various people with different facial expressions) with Martin. He was able to identify

most emotions depicted on the pictures. Martin also appears able to link feelings to

various events; we did a non-standardised cognitive mediation task where I discussed

simplified scenarios based on real-life events and Martin was able to tell me how he

would feel or how he had felt when these events occurred. His emotional vocabulary

is limited but adequate to express basic feelings.

I will firstly attempt to formulate Martin’s problem using a psychodynamic

perspective. This will then be followed by a cognitive-behavioural formulation. A

critical appraisal of the two formulations will conclude this assignment.

Psychodynamic formulation

The following formulation relies on the triangle of conflict and the triangle of the

person as described by Malan (1995). The triangle of conflict shows the interactions

between the defence mechanisms the client uses to protect his ego against the anxiety

generated by the hidden feelings. Malan states that the hidden feelings can be

directed at one or several points of the triangle of the person. This triangle shows the

various relationships of the client with his/her parents and siblings, other people and

6

the therapist. This latter relationship is also described as a transferential relationship

where feelings belonging to a previous relationship (usually the one between client

and parents/siblings) is transferred onto the therapist. This is also known as the

‘unreal’ relationship as the pattern of behaviour displayed does not take a full account

of the reality of this current relationship. (Gelso and Hayes, 1998).

Triangle of conflict

Hidden feelings: Fear of disintegration, fear of rejection, anger at being disabled, fear of being unwanted or unloved.

Anxiety: Not being cared for and fear of showing anger in case the level of care is even more reduced.

Defences Projection, projective identification, layers of clothing and secondary handicap.

Figure 1- Martin’s triangle of conflict

Defences

Martin appears to be using a variety of defence mechanisms in his interactions with

people. Some of these defences have however become maladaptive and are distorting

Martin’s perceptions.

Martin uses projection, which can be define as “attributing our more difficult and

unacceptable feelings to others” (Bateman, 1998, p. 46). Martin is projecting on other

people his unwanted aggressive impulses and feelings. As a consequence he feels

7

constantly persecuted and under attack. This seems to happen in various

circumstances and the belief that members of staff are persecuting him through their

requests is an illustration of this.

He also uses projective identification, which occurs when unwanted feelings are

projected and ‘deposited’ into another person and through their interactions, the

recipient of those feelings is made to feel, think or behave in a manner congruent to

these projected feelings (Thomas, 1996). This seems to happen in his interactions

with other residents. In lay terms, Martin often winds up Jake and Marty and makes

them attack him. Jake and Marty have been described by staff as rather placid and

friendly characters; the aggression they sometimes show towards Martin is described

as out of character.

The use of this latter defence mechanism is also illustrated in the belief that people are

staring at him. Both staff members and the community nurse have reported that

Martin actually stares at people when on outings. Martin seems to be making people

behave in a manner congruent to his phantasy.

Through the defences of projection and projective identification, Martin gets rid of his

unwanted feelings and impulses. He is not capable of containing them and tries to

evacuate them as quickly as possible. These projections are unfortunately not always

processed by people around Martin; they are not being contained or made more

manageable. In fact, recipients of Martin’s projections tend to act upon them, because

they are frightening, and the projection can go back full circle to Martin. Martin’s

distress is not alleviated but increased as the recipients have added their own fear and

8

aggression. Thus Martin is often being taught that his impulses are so dangerous and

frightening that they cannot be contained by other people.

Martin’s defences are helping him to protect himself by managing his anxiety but

have often made his situation worse.

I would suggest that the layers of clothing worn by Martin might be another defence

that could be linked to the previously discussed defences through Bion’s concept of

containment. Bion (1962) explains that babies will project their emotions onto their

mothers who will them ‘contain’ them and feed them back to the babies in a more

tolerable form. This enables babies to learn to ‘contain’ themselves as opposed to

developing a fear of disintegration from overwhelming emotions. Martin might be

using the layers of clothing to contain himself and prevent disintegration. He might

unconsciously feel that this is needed as people around him constantly fail to contain

his emotions.

Martin uses another defence mechanism known as secondary handicap, which was

originally described by Sinason (1992). This mechanism is used by the individual

when s/he exaggerates the learning disability in order to protect the self against the

painful feelings of being ‘different’. By pretending to have a more profound learning

disability, the individual avoids thinking about his or her circumstances. One of the

consequences of this defence mechanism is that it prevents Martin from thinking or

reflecting on current situations and gain knowledge or wisdom from them. The

anxiety here is a fear of thinking. Thinking, in Martin’s case, would mean

acknowledging the reality of his disability, the pain experienced throughout his life

9

and the difficulties of his current situation. These are, I would suggest, some of his

hidden feelings.

Hidden feelings

Based on my interviews with staff, my observations and my interactions with Martin,

I believe that the content of the hidden feelings revolves around anger and fear. I

would suggest that Martin fears his own feelings and impulses as they appear so

dangerous- they cannot be contain by other people- that they could annihilate or cause

him to disintegrate (hence the need to be physically ‘contained’ by layers of clothing).

This would link with the diagnosis of schizophrenia made by the psychiatrist.

Due to the lack of information contained in the file and the limited amount of material

Martin is able to provide, it is rather difficult to elaborate what the hidden feelings

might be. Leiper (2006) has suggested that a psychodynamic formulation should

always be hypothetical; the following elaboration on Martin’s feelings is even more

hypothetical than the previous discussion.

Martin’s hidden feeling might also be about a fear of rejection because of his

disability, which might find its origins in his relationship with his mother and family.

The arrival of a disabled baby has a massive impact on the parents and can make the

parent-infant relationship more difficult (Miller, 2004) and even lead to rejection. A

hostile relationship where people are rejecting towards his needs leaving him feeling

abandoned and uncontained, and angry to have to look after himself alone, might have

been internalised by Martin. This would have left Martin in a double bind that might

10

still be enacted today; he is still not supposed to express anger towards people he

depends on as they might give him even less care (which they sometimes do as a form

of punishment) and has therefore to evacuate his anger using an alternative method.

Anxiety

The anxiety that prompts the use of the defences would stems from this conflict where

Martin feels angry at staff (and past parental relationships) for not responding to his

needs and his dependency on them for care. At an unconscious level, Martin knows

he needs them but feels they are not looking after him properly and feels angry at

them as a result. This creates anxiety which he manages by the defences discussed

above.

The dynamics between the three corners

At the level of hidden feelings, Martin fears rejection. He also feels unwanted and

unloved. There are also feelings of anger at this situation. This creates anxiety as

Martin does not feel that he gets the care (or acceptance/love) he should be getting but

knows unconsciously that if he were to show anger, the little amount of care he gets

could be jeopardised (see figure 1). Martin copes with this anxiety by using the

various defences detailed. This has a protective effect for himself as he projects and

deposits his anger and fear in other people. This was somehow demonstrated to me

when interviewing Martin as he said that he did not understand why he was being

punished when it is “all the other residents’ fault”. In Martin’s mind, the evacuation

of these difficult feelings leaves him with the conviction that he is a loveable but

victimised resident.

11

Some of the defences Martin uses are working well and shows a clear link between

the hidden feelings and the defences. For example, the secondary handicap defence is

protecting him against the anger at his disability.

Triangle of the person

Others Staff at Iliad House, people in community and other residents are all dangerous.

The Past: Older sister in control, maybe bullying. Mother or figures of authority unable to protect him. Institutionalisation where various forms of abuse might have occurred.

Therapist: Relates to me as a powerful character able to change many things for him. Positive transference.

Figure 2- The triangle of the person

The past

The information available on Martin’s family relationships is rather sparse. There is a

suggestion in the notes that Martin seems to fear his family. It also appears that his

sister played a significant part in managing Martin’s relationship with his family. She

seemed to have been in control of when the visits would occur. I would also include

in this corner of the triangle Martin’s long history of being institutionalised and the

suggestion that abuse might have occurred in this setting. This may have influenced

the way Martin experiences relationship with figures of authority.

12

I would suggest that the conflict Martin is experiencing in many of his current

relationships first occurred in this section. Martin might have felt that his non-

disabled sister got more care or love when they were both leaving at home, leaving

him feeling neglected and angered. Martin would have experienced the same anxiety

where expressing openly his angered would have jeopardised the care he was

receiving. Similarly, we could hypothesised that the same dynamic was repeated

when he was living in an institution where he might have felt that other residents were

getting more care than himself.

Other

Martin’s relationships with the Staff at Iliad House are often difficult. He often

appears to feel threatened by the requests made of him and feels the need to retaliate

in a verbally or physically aggressive manner. Similarly, when Martin is out in the

community, he often feels that people are staring at him with violent intentions.

Relationships with other residents at Iliad House are also difficult as Martin accuses

them of bullying him.

The same conflict and use of defences appear to be occurring here. Martin does not

feel cared for by the staff and feels that other residents might be getting more care

than he does. This makes him angry at an unconscious level and, again, he is afraid of

showing this anger in case in makes matters worse for him. The anger is projected on

and into care staff and Martin believes they are angry at him.

13

Therapist

I have only just completed the assessment phase with Martin and therefore our

relationship is still relatively new. Initially, Martin had difficulties understanding

what my role with him was. He appeared very early on to think that I was very

powerful and would be able to sort all sorts of things for him (for example, change his

medication, find him a social worker, move him to another home, make the other

residents ‘behave’, reprimand staff, etc.). The transference appears positive at the

moment and seems to revolve around a strong father figure.

In this relationship, Martin seems to be using mostly his secondary handicap defence.

I have been interviewing him on many aspects of his life and ask about his current

relationships with staff and family. I would suggest that Martin is exaggerating his

disability in order to prevent himself from thinking about the role he might be playing

in the conflicts that are occurring. The exaggerated disability might also be a way of

communicating to me at an unconscious level his needs for care and love; my

countertransference feelings have often been around the themes of feeling sorry for

him.

Combining the two triangles

The triangle of conflict can be transposed in each corner of the triangle of the person.

The same conflict between need for care and anger at not receiving it is, I would

suggest, replayed in each relationship Martin has. This pattern was originally

developed in the Past with his primary carer and family and then re-enacted with other

people. This might actually have been significantly reinforced when institutionalised

14

where the care might have been regimented and not tailored to Martin’s need. If there

was abuse of any type, this would have worsened Martin’s internal conflict as he

could have been abused by the very people who were supposed to give him care. In

the relationship with me, Martin is still very much at a stage where he believes I can

provide him with the care he needs. I would predict that he will also become angry

with me when he realises I cannot provide him with all the care he wants. I would

suggest that I am also likely to become a figure of persecution.

Cognitive behavioural theory formulation

The following formulation relies on the five ‘Ps’ model as described by Dudley and

Kuyken (2006). The five ‘Ps’ are Presenting issues, Precipitating factors,

Perpetuating factors, Predisposing factors and Protective factors. This formulation

model is based on various cognitive-behavioural theory (CBT) principles amongst

which are the fact that formulations are seen as working models and therefore always

provisional. They should also offer a framework for intervention by identifying the

cognitive and behavioural mechanism at the root of the problem (Dudley & Kuyken,

2006).

The first part of this formulation model, the presenting issues, requires the therapist to

establish a clear list of problematic issues with the client; once the intervention

completed this list can be used to evaluate the outcome of treatment. The

‘precipitating factors’ describe what the triggering events are in terms of proximal

internal and external factors. The ‘perpetuating factors’ are the elements that

maintain the current problems; they are represented in a cyclical model which is

15

constituted of situation, cognitions, behaviour, physiological response and feelings.

The ‘predisposing factors’ look at how the problems have developed through the

individual’s history. Finally, the ‘protective factors’ are concerned with the

individual’s own resources and sources of support that will help with recovery. This

type of formulation appears suitable for an individual with learning disability as it

highlights the range of strengths and limitations Martin has as well as the nature of the

presenting problems (Willner, 2006).

The amount of information Martin is able to provide about his own cognitions is

reasonable. He is verbal but this skill is limited. He however appears suitable for a

simplified version cognitive-behavioural therapy according to the factors described by

Joyce, Globe and Moody (2006) in that he has the language skills and basic emotional

vocabulary. He also appears motivated to change his behaviour and can link feelings

to events.

Martin finds it difficult at times to express his feelings and thoughts effectively and

therefore it is necessary to emphasise that the following formulation stands at a very

hypothetical level.

Presenting Issues

These can be defined as follow:

• Martin gets agitated when he goes on outing as he says people are staring at

him.

• Martin gets agitated when members of staff ask him to do something.

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• Martin gets upset when other residents are getting attention.

• Martin gets wound up when other residents are teasing him.

• Martin gets aggressive verbally and physically when he is agitated.

Precipitating factors

This section is concerned with Martin’s beliefs about the events that are triggering his

reactions. This follows an ABC model (activating event, beliefs and consequence).

The activating events are varied but share similarities. Events that have triggered

physically violent responses from Martin have often started when a member of staff

asked Martin to do something. For example, moving along on the sofa to make room

for another resident, take a shower, closing the back door, and many others. Other

events have occurred when other residents have teased Martin or when staff were

working one-to-one with someone else. Events that occurred in the community

happened when Martin was in the company of unknown people; for example, when

travelling by public transport or in a shop. In this latter case, Martin constantly

watches people to see whether they are looking at him. Requests from staff,

‘demands’ from other residents and proximity to unfamiliar people have all triggered

reactions from Martin.

Martin’s beliefs often appear revolve around the conviction that people are

threatening him. For example, when staff are asking him to do something, Martin

seems to think that they are being aggressive towards him and that they might even be

physically violent with him. Similarly, when other residents are teasing him, he also

17

appears to think that they are bullying him. In the community, Martin seems to

believe people are staring at him and that they might attack him.

I interviewed Martin on a few occasions when a violent incident had occurred with

members of staff. During those interviews, I used the method recommended by

Dagnan and Chadwick (1997) where the emotional consequence after the event was

clarified, then the antecedents were explored (I asked Martin what had happened) and

finally his beliefs about the situation were discussed. I then attempted to link the

latter with the consequences. On one such occasion, Martin was able to tell me that

he was angry because Linda (care staff) had told him off for leaving the door open.

He said he believed she was angry and was going to punish him, which made him feel

angry for being treated so unfairly. After asking the member of staff what had

happened, she told me she had simply ask Martin to close the back door when he goes

out for a cigarette. The attack, she said, came as a surprise.

On another occasion, Martin came to see me at the clinic by public transport. He was

accompanied by his key worker. When they arrived, he was clearly anxious; he then

told me that people on the bus were looking at him in a funny way. He told me he did

not feel safe and thought something might happen. When questioned further, he said

there were two ladies with tightly held umbrellas who were going to poke him with

them. The key worker commented to me later that Martin had been staring at two

women on the bus and had clearly intimidated them.

During interviews with staff and key workers, they gave me numerous other examples

of similar situations.

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The consequence of this belief system is that Martin not only becomes angry as he

believes that people are being aggressive towards him but also he appears to have

learnt to pre-empt the aggression by being violent himself, verbally or physically.

Martin appears to believe that people are bullying him or being aggressive towards

him. A simple and normal request from staff is seen as a personal attack upon his

person. The triggering events are in themselves rather innocuous but Martin’s

interpretation of these events explain his reaction.

Perpetuating factors

This part of the formulation looks at how the problems are being maintained by

examining the circular relationship between Martin’s various responses and how they

can spiral into a self-reinforcing schedule. To illustrate this part of the formulation, a

genuine incident which happened at Iliad House with Martin will be used (see figure 3

below).

Situation

This is the triggering event. In this case, a member of staff asks Martin if he had a

shower this morning. Martin says ‘yes’. The member of staff, whilst escorting

another resident to the bathroom, notices that the shower cubicle and tray are dry and

therefore have not been used recently. This member of staff goes back to Martin and

asks him to go and have a shower. This event occurred a few weeks I got involved

19

with Martin; we had a few sessions together following it where we looked in details at

what happened that morning.

Thoughts/Cognitions

Using the method suggested by Dagnan & Chadwick (1997) we initially discuss the

emotional consequence of the event and its antecedents. Martin said that he was

annoyed because he was going to be forced to take a shower, which he did not want to

do. His belief about this situation is that he is being threatened and might get

punished for lying.

Behaviour

Martin hits him.

Physiological

Martin is highly aroused and agitated. A stress response of fight or flight is activated.

Feelings

Martin told me he felt angry and cornered; he did not feel like showering on this cold

morning but he did not seem able to voice it to the member of staff. He also said he

was afraid that he might forced to have a cold shower as a punishment for lying and

not showering when told to do so.

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Thoughts They are

threatening me, they are going to

punish me unfairly.

Feelings Anger Fear

Physiological Aroused Agitated

Behaviours Hit them

Situation Staff asking

Martin if he had a shower this

morning.

Figure 3 Perpetuating factors

In this model, thoughts, feelings, physiological factors and behaviours are all

interconnected. The thoughts not only influence the feelings but also have an impact

on the behaviour and the physiological factors, which in turn also affect the thoughts.

The behaviours are also connected to the feelings; Martin hits the member of staff

because he is angry and vice-versa. The thoughts affect the physiological factors by

making Martin aroused and agitated which reinforces in turn his negative cognitions.

The role of the intervention is to break this cycle and stop the problem from

escalating. By working on the thoughts and challenging the negative cognitions, this

cycle can be broken and replaced by a more appropriate response. It aims to help

Martin link an event to its emotional response (Willner, 2006). For example, if

Martin did not construe this request as a threat he could simply say that he would

rather wait to have his shower as it is a rather cold morning.

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Predisposing factors

The previous section looked at how the problems are being maintained. This section

of the formulation is interested at looking at the onset of the situation. It suggests that

the precipitating factors trigger deep-seated beliefs (i.e. core beliefs) about oneself

that have been learnt through formative developmental experiences. These beliefs are

connected to a range of coping strategies, or rules for living or assumptions, that keep

the core beliefs system intact through the use of compensatory strategies. (Wills &

Sanders, 1997).

In Martin’s case, this is probably the most difficult section of the formulation to

complete due to the lack of information in the file and his limited verbal abilities.

What is discussed here is based on my interviews with Martin and with the staff. I

will, however, make many assumptions in an attempt to unify his experience

Martin’s development experience

Martin had a long history of institutionalisation, which, according to the community

nurse, meant that he was maintained in a highly dependent state with a rigid routine

and with any sense of initiative erased. There is also a suspected history of abuse.

This is likely to have shaped his core beliefs. For example, maybe when Martin was

institutionalised, demands from staff might have been abusive and led to punishment

or aggression. Martin might have come to believe that any request will be followed

by an unwanted or dangerous consequence.

22

Core beliefs

Institutionalisation might have conditioned Martin into believing that people around

him cannot be trusted and will abuse or molest you at the first opportunity. Based on

my various sessions with Martin, especially those that followed violent incidents, it

appears that his core belief revolves around feelings that he can never be safe.

Rules for living/assumptions

Martin appears to be functioning according to the rule: “If I strike first I can offer

myself better protection” or “if people are afraid of me, they will leave me alone”.

Compensatory strategies

Martin maintains himself in a constant state of high arousal ready to defend himself.

The hypothesis here is that the combination of these various factors have created the

situations he finds himself in. Indeed, Black, Cullen and Novaco (1997) found that

people who maintain themselves in such a high state of arousal perceive and select

certain situational cues to fit in their internal schemas cognitive dispositions. This is

another kind of vicious circle Martin is in as people’s reactions to his behaviours and

feelings only reinforce his core beliefs and rules for living. When Martin hits a

member of staff, the rule at Iliad House is that he is not allowed to go out on that day.

Martin is in effect punished. Because Martin believes he was going to be attacked, he

does not understand why he is being punished for defending himself and sees the

23

punishment as undeserved and unfair, which then confirms his core belief that he

cannot trust or rely on people.

Protecting factors

This part of the formulation aims to highlight the personal and environmental

strengths that are preventing the problems to get out of hand. They list the resources

that might be built on during the intervention.

In Martin’s case, there are fortunately a number of strengths available to him. The

following list is not exhaustive but gives examples of relevant resources:

• The staff at Iliad House knows him well and are used to dealing with him;

• The staff is well trained and receives regular supervision;

• Martin has two supportive long-term friends in the community;

• Martin is keen to improve his behaviour;

• The multi-disciplinary team meets regularly

• The community nurse has known Martin for a long time and has a good

relationship with him.

All of the above can be drawn upon in designing and applying the intervention plan

for Martin.

24

Critical appraisal

A formulation is a framework that enables the practitioner to describe and explain the

client’s difficulties by using psychological theories (Johnstone & Dallos, 2006). This

is what I have attempted to do in my two formulations.

The two formulations share common elements that could be synthesised in a more a-

theoretical formulation. In lay terms, it could be suggested that Martin’s relationships

have often been difficult. He appears to have learnt that people are not reliable and

could even be dangerous. From this evolved a need to protect himself and the belief

that people cannot be trusted. This need for self-protection is now so powerful that it

is having an impact on all his relationships and makes him difficult to manage.

There are also significant theoretical differences between the two formulations. The

psychodynamic formulation emphasises more the relationship patterns Martin has

developed over the years starting by assumptions made about the relationship with his

primary carer (mother or other). It shows how the relationship pattern is repeated

with people around him. In contrast, the cognitive-behavioural formulation is more

focused on the thinking patterns Martin displays. It shows that Martin has developed

a way of construing the world through his developmental experience and that this

colours the way he thinks. This latter point can be used however to bridge the gap

between the two formulations; indeed the concept of transference, which can be

explained as a form of conditioning, also explains that Martin will apply a pattern

developed through another relationship on a current relationship. The way he thinks

or construes a relationship is affected by the transferential conditioning.

25

One advantage the cognitive-behavioural formulation has is that it identifies strengths

or resources that are available to the client. These can be used directly in the

intervention and also gives a positive perspective to the formulating exercise.

The psychodynamic formulation, on the other hand, has the advantage that Martin’s

presenting problems can be integrated into the one formulation. For example, the

layers of clothes he wears fits into the theoretical explanation provided by the

formulation. The cognitive-behavioural formulation does not accommodate this issue

and would probably require another formulation to explain this idiosyncrasy.

In terms of weaknesses, I would suggest that the main problem with these two

formulations is that they do not take into account the learning disability Martin has.

The two models appear to have been elaborated with the needs of a non-learning

disabled population. For example, it was impossible for me to gather much

information about Martin’s past; the files were missing and Martin does not appear to

remember much of his past to give me the information I was looking for. Therefore

the perpetuating factors, especially the thoughts and feelings, and predisposing factors

in the cognitive-behavioural formulation and similarly the ‘past’ section of the

triangle of the person and the hidden feelings in the psychodynamic formulation all

have to remain at an even more hypothetical level than in a formulation for a non-

learning disabled individual. I have tried to use the little evidence I have to support

my assumptions but this remains a weak area of the formulations.

26

This might be remedied by doing a more thorough search through the archives of the

old hospital but it would be rather expensive in terms of time and costs. The end

result might also prove itself to be disappointing in what it might reveal. The remedy

to this shortcoming might be done at an institutional level where a consistent and

effective filing system could be put in place. This could also take the form of keeping

a ‘life history’ book, which would combine photo album, scrapbook and journal for

each person.

Another aspect of these two formulations related to the previous one is that they do

not take into account of how the individual’s deficits, in other words how the learning

disability in itself, impact on the presenting issues. There is no space in the

formulations to include a physiological elements or physiological limitations that

could contribute to the behaviour. It might not be within the remit of a psychological

formulation to include these factors but they might nonetheless have a direct link to

the presenting issues. A neuropsychological element to the formulations might

remedy this shortcoming.

In summary, the two formulations demonstrate that Martin has a difficulty in

deciphering people’s intentions when interacting with him. The psychodynamic

formulation tries to explain it in terms of relationship patterns whilst the cognitive-

behavioural formulation attempts to demonstrate that the problem lies in Martin’s

thinking patterns. Martin’s way of construing the world appears to be erroneous. The

two formulation models fail however to take into account Martin’s learning disability.

However, these formulations do not claim to provide the ultimate fully comprehensive

27

answer to Martin’s issues but endeavour to provide a constructive framework to base

a sound psychological intervention on.

28

References

Bateman, A. (1998). Defence mechanism: general and forensic aspects. In C. Cordess and M. Cox (Eds.) Forensic psychotherapy: crime, psychodynamics and the offender patient (pp. 41-51). London: Jessica Kingsley. Bion, W. (1962). Learning from experience. London: Heinemann. Black, L., Cullen, C., & Novaco, R.W. (1997). Anger assessment for people with mild learning disabilities in secure settings. In B. Stenfert-Kroese, D. Dagnan, & K. Loumidis (eds) Cognitive-behaviour therapy for people with learning disabilities (pp.33-52). London: Routledge. Dagnan, D., & Chadwick, P. (1997). Cognitive-behaviour therapy for people with learning disabilities: assessment and intervention. In B. Stenfert-Kroese, D. Dagnan, & K. Loumidis (eds) Cognitive-behaviour therapy for people with learning disabilities (pp. 110-123). London: Routledge. Dudley, R., & Kuyken, W. (2006). Formulation in cognitive-behavioural therapy: ‘there is nothing either good or bad, but thinking makes it so’. In L. Johnstone and R. Dallos (Eds.) Formulation in psychology and psychotherapy: making sense of other people’s problems (pp. 17-46). Hove: Routledge. Gelso, C.J., & Hayes, J.A. (1998). The psychotherapeutic relationship: theory, research and practice. New-York: John Wiley & Sons. Johnstone, L., & Dallos, R. (2006). Introduction to formulation. In L. Johnstone and R. Dallos (Eds.) Formulation in psychology and psychotherapy: making sense of other people’s problems (pp. 1-16). Hove: Routledge. Joyce, T., Globe, A., & Moody, C. (2006). Assessment of the component skills for cognitive therapy in adults with intellectual disability. Journal of applied research in intellectual disabilities, 19, 17-23. Leiper, R. (2006). Psychodynamic formulation: a prince betrayed and disinherited. In L. Johnstone and R. Dallos (Eds.) Formulation in psychology and psychotherapy: making sense of other people’s problems (pp. 47-71). Hove: Routledge. Malan, D.H. (1995). Individual psychotherapy and the science of psychodynamics (2nd edition). London: Arnold. Miller, L. (2004). Adolescents with learning disabilities: psychic structures that are not conductive to learning. In D. Simpson and L. Miller (Eds.) Unexpected gains: psychotherapy with people with learning disabilities (pp.83-97). London: Karnac. Sinason, V. (1992). Mental handicap and the human condition: new approaches from the Tavistock. London: Free Association Books.

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Thomas, K. (1996). The psychodynamics of relating. In D. Miell and R. Dallos (Eds.) Social interaction and personal relationships (pp.157-211). London: Sage and Open University. Willner, P. (2006). Readiness for cognitive therapy in people with intellectual disabilities. Journal of applied research in intellectual disabilities, 19, 5-16. Wills, F., & Sanders, D. (1997). Cognitive therapy: transforming the image. London: Sage.

30

Clinical Practice Report 2- Small Scale Service Related Project Anxiety management group programme for people with learning disabilities- the sum

is larger than its parts

Abstract

A group of four people with learning disabilities were recruited to take part in an

eight-week anxiety management psychoeducational programme. The programme

followed a cognitive-behavioural group approach and included elements of teaching,

relaxation, cognitive restructuring and problem solving. Progress was monitored

using the Glasgow Anxiety Scale (Mindham & Espie, 2003) and a non-standardised

‘anxiety thermometer’. Qualitative feedback was also obtained via a group evaluation

questionnaire. This report also discusses issues such as engagement and group

dynamics. Results from measures showed no changes in levels of anxiety but

participants reported benefiting from taking part in the group. It is argued that the

therapeutic experience of belonging to such a group should not be underestimated.

31

Introduction

According to the Office for National Statistics (ONS), one in six adults will

experience mental distress at any one time (as cited by Mind, 2006). Similarly, the

Mental Health Foundation estimates that 10 to 25% of the general population will

suffer from mental health disorders at some point in their life (Mental Health

Foundation, 1999). The ONS also suggest, according to their surveys, that anxiety is

one of the most common forms of mental distress in the general population.

Anxiety is also the most common forms of psychological distress in people with

learning disabilities (Deb, Thomas & Bright, 2001). Although there is a significant

body of literature on anxiety in the general population and on its treatment of choice,

cognitive-behavioural therapy (NICE, 2004), there is a surprising lack of published

studies on their applications to populations of people with learning disabilities

(Raghavan, 2004).

There are several possible reasons for this lack of research in anxiety in people with

learning disabilities; Lindsay, Neilson and Lawrenson (1997) identified three of them

as being: 1- people with learning disabilities are a devalued population and therefore

of limited interest to the clinical/research community; 2- because of their

impoverished cognitive abilities, it makes it difficult to measure whether

improvement, or lack of it, is directly linked to a psychological treatment; 3- a

potential assumption that the research findings obtained from the general population

are directly applicable to a population of people with learning disability and therefore

no need to do specific studies on this population.

32

There have been however a few studies that have shown promising results in treating

people with learning disability who are suffering from anxiety problems (see Dagnan

& Lindsay, 2004). Dagnan and Jahoda (2006) indeed suggest that there are good

reasons to recommend cognitive-behavioural therapy for people with a learning

disability in that “many of the cognitive processes that mediate psychological and

mental health problems in people without intellectual disabilities are also present in

people with intellectual disabilities” (p.92). Indeed, Joyce, Globe & Moody (2006)

have shown that people with learning disabilities who are able to label emotions, link

events and emotions and self-report can benefit from cognitive-behavioural therapy as

long as they get good support from the therapists.

Using those positive and optimistic trends and in the spirit of the white paper

“Valuing People” in providing accessible services, a group intervention for people

with learning disabilities and anxiety was designed. The group format was chosen not

only for financial reasons but also because group therapy is believed to benefit

individuals who have similar experiences and needs. Group participation offers hope,

feelings of belonging, and an opportunity to learn from the experience of others (

Yalom, 1985). There is also evidence that people with learning disabilities can

benefit from this treatment format (Mishna & Muskat, 2004).

A psychoeducational programme was designed using the main components, principles

and procedures of cognitive-behavioural therapy for the treatment of anxiety. It

roughly followed the programme designed by Kennerley (n.d.) but was revised and

adapted to be suitable for a group of participants with learning disabilities, as

suggested by Willner (2006). It included elements of education about the causes and

33

effects of anxiety and teaching on a variety of relaxation methods, as well as the

standard cognitive restructuring, problem solving, goal setting and assertiveness

training. The benefits of using a systemic approach are various; following a

structured programme enables the therapists to monitor what parts of it are

functioning well or less well and to change sections that need improving. A systemic

approach also allows easy replication by other therapists. The components of the

programme acknowledged that anxiety is a multidimensional problem and therefore

all levels (for example, physiological, social, occupational and behavioural) were

considered in the planning (Keable, 1997). The aims of the group were:

1. To enable individuals to monitor their levels of anxiety and to better manage

and cope with their anxiety symptoms;

2. To teach/advise/practice skills which can help with anxiety symptoms;

3. To make use of materials and resources for use in the group that are

‘understandable’ and ‘user friendly’; and

4. To allow individuals to share their experience of anxiety with others who

experience similar feelings.

This study aims to evaluate the effectiveness of such an intervention for people with

learning disabilities who are suffering from anxiety problems using a quantitative

approach and a more reflective approach on the processes involved in delivering such

a programme.

34

Method

Participants

Participants were recruited with the help of community nurses, psychiatrists and

clinical psychologists working in Learning Disability Services. Letters and

information sheets were sent to these professionals inviting them to refer any suitable

clients in the specified area. The inclusion criteria were simple in that clients had to

have: a mild to moderate learning disability, difficulties coping with anxiety, enough

verbal ability, in English, to participate in such a group and the ability to get to the

venue independently. The ‘mild to moderate’ criterion refers to a significant, but not

severe, impairment of intellectual functioning and intermittent or limited need for

assistance in terms of adaptive/social functioning (BPS, 2000).

Although recruitment letters were sent several weeks in advance, only four suitable

participants were recruited. An initial assessment was done with the referrer over the

telephone to assess the suitability of each participant. Once this was completed, an

invitation letter was sent to the participants.

The group consisted of four males aged between 21 and 35 years (mean age 27 years).

They all had a learning disability with varying degrees of ability. All participants had

anxiety issues such as difficulties leaving the house or panic attacks. One of the

group members dropped off after the first session due to medical issues. Two other

members attended regularly and the third one missed two sessions. Of the three

members who attended regularly, two were in part-time employment and the third one

was unemployed.

35

Measures

Several measures were used to monitor progress. The main measure to assess anxiety

was the Glasgow Anxiety Scale for people with intellectual disability (GAS-ID)

developed by Mindham & Espie (2003). This scale was specifically developed for

people with learning disability and showed to be psychometrically robust (Mindham

& Epsie, 2003). The GAS-ID was administered at session number one and at the final

session.

Participants were required to complete a weekly diary monitoring their anxiety levels.

A sheet with a box for each day of the week was distributed at each session and

participants were invited to record their daily anxiety level by sticking a coloured dot

(red for always, green for sometimes and blue for never) on each day box. The

principles behind this exercise was to check whether the participants found certain

days of the week more difficult than others and thus help them with appropriate

strategies and to monitor week by week the effects of the programme on their anxiety.

An ‘anxiety thermometer’ was also used at the first, fifth and eighth sessions to record

their general level of anxiety. This was a self-report non-standardised measure.

Finally, at the last session, an evaluation questionnaire combining quantitative and

qualitative items was used to assess the usefulness of the anxiety management group.

All measures are in Appendix three, Five and Six.

36

Group structure and content

The intervention consisted of eight sessions of two hours, with an available extra half

hour for debriefing when needed. A fifteen-minute break was also scheduled after the

first hour.

Two facilitators ran the group (a trainee clinical psychologist in year one of his

training and an assistant psychologist). Each facilitator took it in turn to lead the

group every other session, with the assistance of the other. One of the facilitators (the

assistant-psychologist) missed sessions six and seven for health reasons. Following

each group, a debriefing session was held for half an hour and notes were taken on the

morning of the following day. The facilitators received weekly supervision from a

qualified clinical psychologist.

The group intervention used a cognitive and behavioural approach in a group format.

The content of the intervention was based on published literature on group and

individual treatment of anxiety in clients with learning disability (Turk & Frances,

1990; Lindsay, Neilson and Lawrenson, 1997) and clients without learning disability

(Keable, 1997). This type of group had already been run by previous trainees and

assistants and their notes were also consulted to benefit from their experience and

advice.

Components of the intervention included psychoeducation about anxiety and group

discussions on experiences of anxiety (Keable, 1997), relaxation techniques

(Kennerley, n.d.), cognitive restructuration and lifestyle advice (Turk and Frances,

1990; Keable, 1997) and relapse prevention (Marlatt, 1982; Kennerley, n.d.). See

Table 1 for summary of session agendas and Appendix One for more details

37

Table 1. Summary of session agendas.

Session 1 Introduction, ground rules, structure, monitoring progress and measure (Glasgow Scale), brainstorm on words used to describe anxiety.

Session 2 What is anxiety? Definition and common myths; what makes you anxious and how is it affecting your life, introduction to relaxation.

Session 3 Body reactions to anxiety and how these contribute to anxiety, benefits of relaxation and relaxation session.

Session 4 What causes anxiety and what maintains it? Identification of personal behaviour of participants that contribute to maintaining their anxiety.

Session 5 The anxiety spiral and how to break it. Group exercise on positive thinking and alternative ways of thinking.

Session 6 How to stop being anxious. Distraction techniques and lifestyle issues.

Session 7 Relapse prevention. Planning of positive coping strategies for each participants.

Session 8

Course review, measure and feedback form, presentation of attendance certificates.

Participants were expected to complete a weekly diary monitoring their levels of

anxiety and had simple homework to complete.

Analysis of psychometric measures

An informal ‘thermometer of anxiety’ was used to measure levels of anxiety; this was

used on the first, fifth and last sessions. Figure 4 shows a graph of the results

obtained for the thermometers. Except for client a, there does not appear to be any

downward trends, which suggests that anxiety levels for the two other clients did not

change as a result of the group.

38

Graph of anxiety thermometre results

0102030405060708090

1 5 8

Sessions

Perc

enta

ges

of fe

lt an

xiet

y

Client aClient bClient c

Figure 4: Anxiety thermometer results

The Friedman test for related designs was administered on the anxiety thermometers

results. The ordinal data provided by the thermometers were also non-parametric.

Again, it was not significant (p>0.264, df=2), which suggests that the levels of anxiety

did not change during the group sessions.

The Glasgow Scale of Anxiety (GAS) (Mindham & Epsie, 2003) was the main

psychometric tool used during the anxiety management group. The GAS was

administered twice: at the first session and the last session. Table 2 shows the raw

scores obtained.

Table 2- GAS raw scores

First Session Last Session

Client A 13 11

Client B 30 21

Client C 43 40

39

The GAS is an ordinal scale that provides non-parametric data. The Wilcoxon test for

related design was performed on the GAS results for the group participants. The

result for the two-tailed test was not significant (p>0.109), which suggests that the

group did not have an impact on the participants’ anxiety.

The weekly diaries were unfortunately not useable for statistical analysis as the few

which had been completed were illegible.

Thoughts on the group

Engagement

One of the advantages of an anxiety management group is that it enables the

Psychology Service to provide an intervention for several people at a lower cost in

terms of staff and time. However, for the participants to benefit from such a format,

they need to be able to engage fully in the group activities.

Participants were carefully selected to ensure that they would have the ability to get

the most out of the group. Two of the inclusion criteria were specific in terms of

being able to engage with the group: a good enough verbal ability (in English) and the

capacity to get to the venue independently.

A first indicator of engagement is the attendance pattern displayed by the participants.

The group started with four people, Mahindra, Mohamed, Ashok and Faisal. Ashok

left the group after the first session; this was due to medical reasons. Of the three

40

remaining participants, only Mahindra attended every single session. The two others

missed one and two sessions.

The three participants had different levels of learning disability. Mohamed and Faisal

had a mild to moderate learning disability whilst Mahindra’s disability was more

moderate in that he needs more assistance in terms of adaptive/social functioning. It

became clear in the group and when reflecting in supervision that not every member

was able to get the same out of the group. Faisal had been in a similar group before

and was keen to make the most of it. He would often be ahead of the two others in

terms of grasping the material presented.

Mohamed, although suffering from anxiety, never acknowledged this in the group.

He was however probably the keenest member of the group as this was the only time

he went out of the family home during the week. He mentioned on several occasions

that Wednesday was his favourite day of the week because of the group. He showed

limited interest in the material presented but was keen to hear what the others had to

say and listen to their experience. His motivation was more about attending the group

as a social event rather than an opportunity to deal with his anxiety.

Mahindra was the most disabled of the group. The community nurse who had

referred him to the group had stated that he was having problems travelling on his

own (unless it was to go to work and back) because of his anxiety. When asked about

this, Mahindra denied any problem travelling and claimed he went all over the city on

his own. This was then checked with his parents who confirm what the nurse had

41

reported. This meant that in the group sessions, Mahindra showed little interest in the

material presented. Similar to Mohamed, he enjoyed listening to the others.

On reflection, the participants all engaged well with the group process and its social

aspect but found it more difficult to connect with the material presented. Maybe this

was related to their unacknowledged anxiety problems.

Group dynamics

The attendance pattern an effect on the group dynamics; when the oldest member of

the group, Faisal, was absent, the younger two had more difficulties remaining

focused on the tasks. This was also due to the fact that Mahindra had a more severe

learning disability than the others and found it difficult to follow the group’s

activities. Faisal and Mohamed both had a very mild learning disability and could

therefore engage with the material more easily. When the group became a pair (with

Faisal missing) Mahindra would often be disruptive by changing the topic of

conversation or requesting breaks.

The dynamics were also affected when the female facilitator was absent. Two of the

participants commented that ‘it was cool to be all the boys together’.

Despite the low numbers of referrals and participants, it was decided that the group

would be run anyway. The initial target number was six. Running a group with half

of that number was not ideal. Although it enabled the facilitators to give more

42

individual attention, it also meant that the group dynamics were often reduced to

exchanges between one participant and the facilitators.

A sense of safety and security appear to have been established early on in the group.

Mohamed was well known in the learning disability services as someone who was

difficult to engage and who was not keen on professional help. This was not the case

in the group. Mohamed was the most talkative member and used the group well to

express frustrations and current issues affecting him, which went beyond the anxiety

problem. The group appears to have given him a safe place to talk.

Although Mahindra was not interested in the material presented, he always listened

carefully to what Mohamed was saying. He was very supportive towards Mohamed

and often made comments to demonstrate it. He did not follow Mohamed’s example

but when discussed in supervision, it was concluded that he might benefit more from

belonging to a group like this one rather than from its content.

The group’s initial aim was to help participants manage their own anxiety. Although

this might not have been achieved, the group provided the participants with a place

where they were able to talk and find social support. This ended after the course was

over but it appears to have given the participants a positive experience.

Group evaluation questionnaires

The group evaluation questionnaires were completed by only two participants as the

third one was absent when they were administered. They provided general feedback

on the venue, organisation and content.

43

Both participants felt that the accommodation was not ideal. The first few sessions

took place in the common room of a health centre and despite the notice on the doors,

the sessions were interrupted a few times.

The length of the sessions was deemed adequate although both participants would

have like more than eight sessions. They also thought that the number of participants

was about right and that the facilitators were accessible.

The content of session items got a mid-range score and both participants identified the

tea breaks as the most interesting part of the sessions. The question of what part of

the sessions they enjoyed least drew no response.

Both participants felt that coming to the group had helped them with their anxiety and

were keen to recommend it to other people.

Facilitators’ observations

The three participants clearly had various anxiety related issues but were at very

different levels in terms of their experience of it. Faisal was able to grasp the

concepts more quickly than the others and was also able to apply them to his own

situation. It became clear however during our sessions that Faisal actual living

conditions were a genuine source of anxiety and led us to refer him to an advocacy

service.

44

Although the aims of the group were explained in depth in the first meeting, Mahindra

never appeared to have understood what the group was about. He attended every

session. When he was questioned on his anxiety problems, he never acknowledged

them, which was at times frustrating for the facilitators.

Mohamed was similar in his attitude to anxiety problems in that he never directly

acknowledged his difficulties but never denied them. He often talked about things

that were concerning him and that shows he was being anxious. He was however

keen to keep a brave face and did not admit to being distressed by them.

This situation was discussed on many occasions in supervision. One of the thoughts

that were expressed was that maybe acknowledging the anxiety problem was deemed

too dangerous by the participants. If the denial is a defence, removing it without

replacing it with a more appropriate defence might be too overwhelming for them to

cope.

The material presented appeared to be a challenge to the members of the group.

Although it was adapted for a group with learning disability, some of the concepts,

such as linking thoughts and feelings, remained difficult to grasp. This required a lot

of energy and effort from the facilitators.

The weekly diaries were not successful. Only Faisal managed to complete his on a

regular basis. Mohamed often forgot to complete them or claimed to have left it at

home despite regular prompting. Mahindra found it difficult to understand how to

complete it although it was explained to him every week.

45

Discussion and conclusion

The conclusion that can be reached from the statistical analyses of the measures given

to participants is rather limited due to the very small size of the group. The two

measures show clearly that the anxiety management programme did not have an effect

on the participants. This might have happened for several reasons.

Although the participants were carefully selected, there were significant discrepancies

in terms of individual abilities in the group. Some of the participants were able to

follow more easily than others who needed more input from the group facilitators.

This meant that some of the group discussions we had were more limited as only one

or two members were able to participate. It may be that these difficulties would have

been evened out in a larger group but it seems that in a smaller group, it would be

better to have participants with similar level of abilities. The assessment procedure

might benefit from assessing the participants directly instead of relying on the

referrers.

Another factor which is likely to have affected the outcome of the programme was the

reliance of the facilitators on the materials that had been used in earlier groups. The

programme was not manualised as such but the previous facilitators had left detailed

notes of the plan they followed in their group. It became clear after a few sessions

that the material needed to be customised to this particular group and that it was a

mistake to rely on content that had been prepared for another group. For example, the

previous group had been very keen on learning relaxation techniques whilst our group

46

was not enthusiastic about it. We had to change the teaching format of our sessions

on relaxation to make it more accessible to our group.

The concept of anxiety was a difficult one to grasp for our group. Although we spent

the second session talking about what is anxiety and what other words are used to

describe it (for example: stressed out, worked up, worried, etc.) and the third session

on body reactions to anxiety, the participants still found it difficult to understand what

anxiety is. The material used was simplified and thought to be adequate for the group

but on the whole it appears to have been insufficient. More time should have been

spent on talking about the participants’ experience of anxiety in order to ground their

understanding in their own experience.

The limited understanding of anxiety shown by the group participants was probably

related to the fact that two of the participants said they were not suffering from

anxiety despite what had been said by the referrers and evidence provided by the

carers. It might be that, as mentioned previously, acknowledging the anxiety

problems or showing an understanding of what is anxiety might have exacerbated the

current situations.

There were several advantages in using a set of comprehensive measures in evaluating

the outcomes of the group. The GAS-ID provided the facilitators with an objective

measure that not only described the anxiety symptoms but also quantified them

objectively. By contrast, the anxiety thermometers, being a subjective measure, gave

an indication of how the participants perceived their levels of anxiety and also

enabled them to say how they felt they were doing with the programme. The

47

evaluation questionnaires completed the measurement exercise by asking the

participants their views on taking part to the group and identify what they felt had

been the most useful parts.

The statistical analyses of the objective (GAS-ID) and subjective (anxiety

thermometers) measures did not show any changes on the levels of anxiety in the

group but the evaluation questionnaires suggest that the participants found the group

to be beneficial. Indeed, the participants seemed to have appreciated having a forum

where they were able to talk about their difficulties openly and be taken seriously.

Mohamed, for example, talked about his difficult relationships with neighbours and

the fights he regularly get involved in. Faisal talked about his difficult living

conditions and his marital problems.

As mentioned in a previous section, Mohamed was known in the Learning Disability

Directorate as someone difficult to engage and not keen on professional intervention.

This was not our experience of Mohamed in the group as he used it extensively to

express his frustrations and difficulties. Faisal used the group in a similar manner and

Mahindra always appeared interested in what the others had to say. He showed good

listening skills and compassion. This suggests that the programme content was less

significant than the experience of belonging to the group. There clearly was a social

aspect to the event, that the participants thoroughly enjoyed, but there also seemed to

be a therapeutic element to it. This was unfortunately not considered when the group

was set up and therefore no measurements were taken. The evidence, gathered from

verbal feedback expressed by the participants, remains anecdotal but suggests there

was a positive therapeutic outcome to the group. Indeed, the participants reported

48

reduced feelings of isolation, increased confidence in group situations and a general

feeling of increased optimism with their difficulties.

The evaluation questionnaires reported that the tea breaks were the most interesting

part of the sessions. This is partly explained by the point made in the previous

paragraph but it might also be a reflection on the paucity of social activities available

to people with learning disabilities. Being able to meet with other people of more or

less the same age and background in the context of a specific activity was clearly

valued by the participants. In this sense, the group had a positive outcome in breaking

the social isolation felt by the three group members.

The use of a group intervention with people with learning disability who are suffering

from anxiety should not be underestimated in its potential positive outcome.

Although the statistical analyses from this review showed no improvement in the

participants’ level of anxiety, most of them reported benefiting from attending the

sessions. The therapeutic aspect of belonging to a group should be taken into

consideration when planning for such a programme. With materials suitably adapted

to the group members and robust preparation by the facilitators, an anxiety

management programme is more than likely to have a beneficial impact on its

members.

49

References

British Psychological Society (2000). Learning Disability: Definitions and Contexts. Leicester: British Psychological Society. Dagnan, D., & Jahoda, A. (2006). Cogntive-behavioural intervention for people with intellectual disability and anxiety disorders. Journal of Applied Research in Intellectual Disabilities, 19, 91-97. Dagnan, D., & Lindsay, W. (2004). Cognitive therapy with people with learning disabilities. In E. Emerson, C. Hatton, T. Parmenter, & T. Thompson (eds.) International Handbook of Research and Evaluation in Intellectual Disabilities pp. 517-530. Chichester: Wiley. Deb, S., Thomas, M., & Bright, C. (2001). Mental disorder in adult with intellectual disability. 1: Prevalence of functional psychiatric illness among a community-based population aged between 16-64 years. Journal of Intellectual Disability Research, 45, 495-505. Joyce, T., Globe, A., & Moody, C. (2006). Assessment of the component skills for cognitive therapy in adults with intellectual disability. Journal of Applied Research in Intellectual Disabilities, 19, 17-23. Keable, D. (1997). The Management of Anxiety: A Guide for Therapists. New York: Churchill Livingstone. Kennerley, H. (n.d.). Managing Anxiety: A User’s Manual. Oxford: Waneford Hospital. Lindsay, W., Neilson, C., & Lawrenson, H. (1997). Cognitive-behaviour therapy for anxiety in people with learning disabilities. In B. Stenfert-Kroese, D. Dagnan, & K. Loumidis (eds) Cognitive-Behaviour Therapy for People with Learning Disabilities (pp. 124-140). London: Routledge. Marlatt, G.A. (1982). Relapse prevention: a self-control program for the treatment of addictive behaviours. In R.B. Stuart (Ed.), Adherence, Compliance and Generalization in Behavioural Medicine (pp. 329-378). New-York: Brunner/Mazel. Mental Health Foundation (1999). The Fundamental Facts. London: Mental Health Foundation. Mind (2006). Statistic 1: How Common is Mental Distress. http://www.mind.org.uk/Information/Factsheets/Statistics/Statistics+1.htm (accessed on 04/09/2006). Mindham, J., & Espie, C.A. (2003). Glasgow Anxiety Scale for people with an Intellectual Disability (GAS-ID): development and psychometric properties of a new measure for use with people with mild intellectual disability. Journal of Intellectual Disability Research, 47(1), 22-30.

50

http://www.mind.org.uk/Information/Factsheets/Statistics/Statistics+1.htm

Mishna, F., & Muskat, B. (2004). "I'm not the only one!" Group therapy with older children and adolescents who have learning disabilities. International Journal of Group Psychotherapy, 54(4), 455-476. NICE (2004). Anxiety: Management of Anxiety in Adults in Primary, Secondary and Community Care. Clinical Guidelines 22. London: National Institute for Clinical Evidence. Raghavan, R. (2004). Learning disability and mental health: reflections and future trends. Journal of Learning Disabilities, 8(1), 5-11. Turk, V., & Frances, E. (1990). An anxiety management group: strengths and pitfalls. Mental Handicap, 18, 78-81. Willner, P. (2006). Readiness for cognitive therapy in people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 19, 5-16. Yalom, I.D. (1985). The Theory and Practice of Group Psychotherapy. New-York: Basic books.

51

Clinical Practice Report 3- Single Case Experimental Design

The treatment of a bird phobia with a nine-year old girl

Abstract

This single case experimental design report presents the case of a nine-year old girl

named Tricia who was suffering from a bird phobia. She was referred to the Child

and Adolescent Mental Health Service by her GP. An assessment was conducted

using various psychometric questionnaires and a hierarchy of fear was built with

Tricia. This hierarchy and the problem formulation were used to design an

intervention based on behavioural principles. Measurements were taken before the

intervention and at each session. Relaxation techniques and self talk were taught and

practiced at each session. A gradual exposure to birds was introduced. The

evaluation was conducted using the measurements taken as well as self report, parent

observations and therapist observations. These showed that Tricia made progress in

tackling her anxiety. A discussion on the strengths and weaknesses of the formulation

and intervention follows.

52

Referral

Tricia was referred by her local GP who simply stated in her letter that she had a

severe bird phobia. Tricia is nine years of age and is from an Afro-Caribbean

background.

Initial interview

The aim of what is called in the service an ‘initial meeting’ is to collect more

information about the case and ensure that it is suitable for the Child and Adolescent

Mental Health Service (CAMHS). Enough information is usually collected to make a

preliminary formulation.

Tricia came to the Initial Meeting accompanied by her mother, Irene. They were met

by a clinical psychologist who later passed on the case to me. Irene described the

problem as having started two or three years ago. She said she could not think of a

precipitating event and admitted that the whole problem is a mystery to her. Tricia

could not say how it all started. Tricia is afraid of birds and this has affected the

family life. When there are birds around, Tricia will panic and runs away in any

direction. Irene said that this kind of behaviour worries her as Tricia will not pay any

attention to where she is going when she is running away. She said that Tricia has run

in the middle of busy roads and there is a safety concern here. The phobia has also

prevented the family from doing many leisure outings as they have to choose

activities that take place in an area where there are no birds.

53

Tricia’s mother also disclosed that she is not keen on birds herself although does not

fear them. She describes them as flying vermin.

Beside the bird phobia, the psychologist noted that Tricia appears well adjusted with

no signs of depression or other anxieties. She is doing very well at school where she

also has many friends. Tricia appears to be a popular child. Family life is stable and

the parents are together; Irene and Tom have been married for over fifteen years.

Tricia has a younger sister, Tina, who is seven years old and Irene reported that they

usually get along well.

The family has been coping with Tricia’s phobia by avoiding places where there

might be birds and, when they encounter some, Tom and Tina will shoo the birds

away whilst Irene holds on tightly to Tricia. Although Irene is clearly concerned

about this difficulty, she admits feeling rather impatient at times with Tricia and not

able to understand what is wrong with her.

First Meeting

Tricia’s case was unfortunately on the waiting list for over five months. She was

referred to me soon after the beginning of my child placement. Tricia came to our

first meetings accompanied by her mother and her sister. My supervisor was also

present for this first session.

Irene reported that nothing had changed since the Initial meeting; Tricia still had her

bird phobia.

54

Tricia’s cognitions with regards to birds were explored and she reported being afraid

that a bird might ‘poo’ or land on her head and also said she felt they were looking at

her. Her fears seem to revolve around being attacked by them. She said also that she

is afraid of feathers and claws. She does not like it when they flap their wings. This

led nicely to building a hierarchy of fear (see Figure 5).

Treatment goals were discussed with the family and were kept simple. Irene and

Tricia simply want the latter to be able to go into town, to the Central Library or the

markets, without being disturbed by the birds. They were both aware that Tricia

would probably never become a great bird lover, but they merely want her to be able

to go about town and get on with activities without any problem.

10 Extremely scary Bird on my head Crows 9.5 Going to markets Seagulls

(aka Pigeonland) 9 Going to Central Library 8 Walking near birds 7 Seeing a bird in a tree Ducks 6 Photos of birds Magpies/budgies 5 Feathers on pavement 4 Drawing of birds 3 Drawing birds 2 Talking about birds 1 Birds in cartoons on telly Robins 0 not scary at all When there are no birds around

Figure 5- Hierarchy of fear

55

Fear and anxiety surveys

During the first meeting, two anxiety scales were completed by Irene and Tricia. The

Spence Children’s Anxiety Scale (SCAS) (Spence, 1994), which provides an overall

anxiety measure, and the Fear Survey Schedule for Children- Revised (FSSC-R, 97-

item version) (Ollendick & Yule, 1983), which assesses a variety of fears that

children might experience, were administered. Tricia’s mother also completed the

Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997), which is routinely

administered to all parents in this service. This questionnaire is a brief behavioural

screening tool which comprises the following subscales: emotional distress, conduct

problems, hyperactivity/inattention, peer relationship problems, and prosocial

behaviour. The extended version of the SDQ used here also asks whether the

respondent thinks the young person has a problem, and if so, enquires about the

distress and social impairment of the problem on the child and provides an impact

score.

The results of the FSSC-R were surprising. Tricia scored 42 on the FSSC-R which is

well below the mean score for girls of her age (75.15 with a standard deviation of

29.41). On the SCAS, all her scores were well within the standard deviation for each

sub-scale for a girl of her age (see Table 3 below). Tricia’s total score is 31 which is

also below the mean score for clinically anxious children which is 42.

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Table 3- SCAS scores Panic

attacks

Separation

Anxiety

Phys.

injury

fears

Social

phobias

Obsessive

compulsive

General

Anxiety

Total

Tricia’s

scores

5 5 4 7 4 6 31

Raw

means

4.93 5.85 4.14 7.39 6.33 7.09

Standard

deviation

4.81 3.80 2.95 3.92 3.71 3.68

The results on the SDQ showed an abnormal score for the emotional distress scale and

abnormal score on the Impact of any difficulties on the child’s life scale. All the other

scales showed normal scores.

These results indicate that Tricia is a rather calm child with generally low anxiety.

This suggests that she is suffering from a very specific phobia that has quite an impact

on her life and the life of her family. According to the DSM-IV (APA, 1994),

Tricia’s problem could be identified as a ‘specific phobia’. The technical name for

bird phobia is ornitophobia (Csotti, 2003).

Problem formulation

Information was gathered from the initial interview and first meeting. The difficulty

Tricia is experiencing was formulated following a behavioural model which uses a

combination of classical and operant conditioning principles. These principles

explain the development and maintenance of Tricia’s phobia. Evaluative conditioning

theory (EC) suggests that a phobia will develop through the pairing of neutral material

with a negative stimulus resulting in a change in the emotional charge of the neutral

57

stimulus associated with the negative stimulus (Martin & Levey, 1987). The result is

a strong personal response that can be described as a ‘gut reaction’ which will then

modulate a person’s avoidance behaviours. Various studies have shown that EC is

relevant in the aetiology of many anxiety disorders (e.g. Lascelles, Field & Davey,

2003; Olantunji, 2006; Olantunji, Lohr, Sawchuck & Westendorf, 2005;).

It became clear during the assessment that Tricia and her family maintained the

phobia through avoidance behaviours, such as avoiding areas where there are birds,

shooing them away when they are too close or Tricia running away from them. This

had the consequence of stopping a natural extinction of the behaviour by preventing

Evaluative conditioning Neutral stimulus (NS) Neutral response Birds � no problem Unconditioned Stimulus Uncond. response Bird flying off � Anxiety Loss mum and birds flying

Neutral stim. + Uncond. Stim. Uncond. response Birds+ loosing mum � Anxiety

When Tricia sees birds or thinks there are birds, she gets very anxious.

Conditioned Stimulus Conditioned resp. Birds → Anxiety

Negative reinforcement People shoo birds away for Tricia. Family avoids going places where there are too many birds. Tricia runs away.

No opportunity to unlearn the conditioned fear.

Avoidance behaviour

Anxiety: Unpleasant physiological arousal, increased heart rate, increased breathing, sweating, unpleasant thoughts.

They are going to poo on my head. The birds are going to attack me. Cognitions

Figure 6- Formulation

the un-pairing of the two stimuli (birds and fear) (Malloy & Levis, 1988).

58

It is not clear how this bird phobia may have developed. There might have been

several small incidents where Tricia got frightened when there were birds around. It

may be that the fear Tricia experienced in those occasions was paired with birds.

These incidents may have been individually unnoticeable but the combination of them

might have been sufficient to create the bird phobia (Martin & Pear, 1999). This

could be the reason why both Tricia and her mother cannot remember a single

incident that would explain the phobia. The small incidents could be, for example,

Tricia, when aged six, having lost, momentarily, sight of her mother and being

surrounded by pigeons taking off. This example is fictitious and is used to illustrate

the process of conditioning that might have affected Tricia.

Rationale for Intervention

There is ample research literature to support a cognitive behavioural intervention,

such as exposure or desensitisation, in the treatment of children’s phobias (Moore &

Carr, 2000; Gros & Anthony, 2006).

Behavioural treatments of phobia share the same objective of ‘unlearning’ the

association between the conditioned stimulus (such as birds, in Tricia’s case) and the

conditioned response (fear and physiological arousal). Most techniques involve

gradual exposure to the conditioned stimulus until a certain habituation occurs in the

client. The exposure should be gradual, repeated and prolonged to optimise treatment

outcomes (Carr, 1999). During the assessment, a hierarchy is built with the client to

establish a list, from least scary to most scary, of phobic situations (Carr, 1999). At

the bottom of the list, the client identifies all the situations she or he avoids because

59

they trigger an anxiety response. These are then ordered in a hierarchical order of

easy to difficult where the most difficult should include contact with the conditioned

stimulus (see Figure 5 on page 46). The client will initially be exposed to a situation

identified at the bottom of the list, which should be a situation that triggers anxiety but

that they can tolerate. Repeated exposure is done until the client’s anxiety level has

decreased to a low level. The same procedure is the repeated with the other situations

on the list leading the client to confront gradually their fears, tolerate an acceptable

level of anxiety and be exposed to the phobic stimulus.

There is sufficient evidence in the literature to support cognitive behavioural therapy

(CBT) for treating childhood psychological problems (Carr, 2000; Kendall &

Treadwell, 1996; Silverman, Kurtines, Ginsburg, Weems, Rabian, & Serafini, 1999).

There is evidence that cognitive distortions are associated to with psychological

difficulties in children, but their role in the aetiology and maintenance of these

problems is not clear (Stallard, 2002). Most models of intervention have been based

on research conducted on adult populations and the interventions have simply been

transferred onto children without researching their appropriateness for that age group

(Stallard, 2002). This needs to be taken into consideration when formulating a child’s

problem from a CBT perspective. It is also important to consider whether the child

treated has acquired sufficient cognitive abilities to use CBT effectively; research has

indeed suggested that, although CBT is more effective than a waiting list condition, it

produces better outcomes for children aged eleven and above (Durlak, Furnhan &

Lampman, 1991; Stallard, 2002).

60

Tricia’s treatment had a strong emphasis on the behavioural exposure aspect (gradual

desensitisation) with elements of CBT in the use of statement of self-competence

(self-talk). This is a stress inoculation procedure which has been shown to help

reduce fear in anxiety provoking situations by blocking the frightening thoughts the

child usually has (Graziano & Mooney, 1982).

Planned Intervention

Based on the formulation and our first meetings, the CBT approach was selected and

explained to Tricia and her mother. A programme of gradual exposure was derived

from the hierarchy built in the first meeting. It was agreed that the aim of the

treatment was not to turn Tricia into a bird lover but simply to enable her to function

normally when she is in an environment where there are birds.

Each session was planned to focus on one aspect of the hierarchy (see Figure 5

above). It was decided not to set a specific number of sessions in order to keep some

leeway. As the intervention was also delivered during the summer holiday, it was

thought that there might be last minute cancellations and therefore flexibility might be

needed.

Each session also had an element of relaxation, as recommended for the treatment of

phobia (Carr, 1999). This was also set as a regular homework. Time was spent in

each session looking at the self-talk Tricia was using when thinking about birds and

suggestions of alternative positive self-talk statements were generated in a

collaborative manner (Silverman et al. 1999). Because Tricia’s mother felt that she

61

was used to seeing cartoons with birds on television and also as they often talked

about birds at home, we all agreed that we should start the intervention with the third

point in the hierarchy, as this would be slightly more challenging than usual.

At the beginning of each session, three subjective measurements of distress were

taken (subjective unit of distress- SUD). The three questions used for these were

based on Tricia’s potential proximity to birds; the window referred to in question 2

was three metres away from Tricia’s chair. Using a scale of nought to ten (nought

being not scared at all and ten being extremely scared), Tricia had to answer the

following questions:

1- How do you feel about talking about birds?

2- How would you feel if a bird was to land outside the window?

3- How would you feel if a bird was to land a meter away from you?

These three questions were asked initially over a period of five weeks before the

intervention started in order to establish a baseline measure.

Using the same scale, SUDs were taken during the exposure to each situation. A first

measurement was taken at the first stage (for example, feather three metres away from

Tricia) and the measurement was taken again after relaxation and self-talk. When the

score obtained was below six, the stimulus was brought closer.

62

Intervention

The duration of each session was planned for around one hour. However as the

sessions all took place at the end of the day, which fitted better with their school

commitments and other activities, it was agreed that some of them would be longer

than an hour to allow for the prolonged nature of exposure. Here is a brief summary

of the sessions:

Session One: This session focused on introducing relaxation, and Tricia and therapist

to draw a variety of birds. The aim of the session was to start developing a good

therapeutic alliance.

Session Two: A booklet with drawings of birds had been prepared. Each page had

two pictures of bird. Relaxation exercises were done in between pages to reduce

anxiety.

Session Three: A feather was placed at the far end of the room and gradually brought

closer to Tricia. Tricia was able to hold the feather in her hand at the end of the

session. Relaxation exercises were done at each step.

Session Four: A booklet with photographs of birds was prepared. Each page had

various photographs of birds. Relaxation exercises were done between pages to

reduce anxiety.

63

Session Five: An outing on the clinic’s grounds was done (the clinic is surrounded by

a park and has a large green). Birds were observed from a distance and then Tricia

went closer to them. 100 metres was achieved. Relaxation exercises and self-talk

were used.

Session Six: The outing on the clinic grounds was repeated. 50 metres was achieved.

Session Seven: The outing on the clinic grounds was repeated. We were not able to

get closer than 20 metres. Tricia however appeared significantly less anxious as she

laughed on many occasions.

Outcome

The case was based on a time series A-B design and the outcome was evaluated using

the following methods:

1. Visual inspection of the anxiety ratings collected at each session;

2. Statistical analysis of the weekly SUDs collected during the baseline period

prior to the intervention and during the intervention;

3. Self and parental reports;

4. Therapist’s observations.

Visual inspection

Figure 7 shows a graphical representation of Tricia’s Subjective Units of Distress over

the twelve weeks of contact (1-5 = assessment; 6- 12 intervention).

64

The three lines show that there was a high level of anxiety for all three conditions and

that these remain stable for most of the baseline period (intervention started at week

six). The anxiety was most severe for the situation where a bird would land within a

meter of Tricia.

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9 10 11 12Week

SUDTalkingWindowOne Meter

Figure 7- Tricia’s ratings

The question about talking about birds was the first one to change during the

intervention. Tricia was anxious about simply discussing birds in general. As she

explained herself, she knew that we would not merely be talking about birds in our

sessions but that these discussions would lead to something scarier. Therefore, she

felt apprehensive about coming to the clinic and chatting about birds with the

therapist. As her confidence and trust began to build and a therapeutic relationship

developed, she felt more relaxed about talking about birds and this led to what looks

like a significant decrease in SUD ratings.

65

The question about having a bird land within three meters of Tricia (bird landing

outside the window) was stable during the baseline period and in the early stages of

the intervention. The ratings obtained for these first eight weeks were consistently

eight out of ten. This began to change at intervention session five (week nine) when

we went out on the clinic’s grounds and Tricia got within 100 metres of the birds. The

question was asked before doing the task and Tricia was aware of what was planned

for the session that day. This might explained why she gave a higher than usual score

for that session. Approaching the birds seemed however to lower her fear and a

decrease in the ratings was then observed in subsequent sessions.

The question about having a bird land within one meter was the most anxiety

provoking condition for Tricia. The ratings obtained during the baseline period were

scored ten out of ten for all of the baseline period and for the first four weeks of the

intervention. They only began to change, and only slightly, at session nine, following

the outing on the clinic’s grounds. This suggests that her anxiety levels are still very

high but that they are beginning to decrease.

Statistical analysis of the weekly SUDs

Advice on the analysis of the data obtained was sought from the Trust’s statistician.

Testing for autocorrelation was not recommended. Davies (2007) argues that testing

for autocorrelation with only one participant will not produce adequate results as more

participants are needed to distinguish between autocorrelation and trend. Davies

(2007) suggests instead the use of the Runs test which checks the randomness

hypothesis of a data sequence, such as the one collected during this assessment and

intervention.

66

The Runs test performed to the three sequences of data showed that the scores

obtained were not randomly distributed. For the question of talking about birds, the

randomness hypothesis was not significant (p= 0.134, two-tailed). Similarly, the

question about a bird landing outside the window, the randomness hypothesis was

also not significant (p= 0.009, two-tailed). Finally, the question about a bird landing

within one metre of Tricia, the randomness hypothesis was not significant either (p=

0.009, two-tailed). (See Appendix Seven for SPSS output). This suggests that the

scores obtained are not the result of random ratings on Tricia’s part and may reflect a

change in her anxiety levels.

As suggested by Davies (2007), a nonparametric test for related samples was

administered to examine further the differences in anxiety scores and during

intervention. Davies (2007) asserted that such a test is reasonable to use as the

autocorrelation of the data cannot be established since there is only one participant.

Wilcoxon test for related samples did not show any significant difference between the

two conditions (assessment and intervention) for two of the questions and showed a

significant difference for one.

The question on talking about birds did show a significant difference between

baseline and intervention, Z= -2.032, N- Ties= 0, p= 0.042, two-tailed. The question

about having a bird land within three meters of Tricia did not show any significant

difference between the baseline measures and the intervention ones, Z= <0.001, N-

Ties= 3, p= 1.000, two-tailed. The question about having a bird land within one meter

67

did not show any significant difference either between baseline and intervention, Z= -

1.000, N- Ties= 4, p=.317, two-tailed. (See SPSS output in Appendix Seven).

This suggests that the intervention used on Tricia was partially successful in making a

difference to her level of anxiety.

Self and parental reports

Although significant changes cannot be concluded from all the statistical analyses,

Tricia’s mother, Irene, and Tricia herself reported noticeable changes in her

behaviour.

The session we had following intervention session five, where we went on the clinic’s

grounds, Irene reported that Tricia had gone with her cousin to the Central Library

without any difficulties, despite the fact that there were hundreds of pigeons around.

This was one of our treatment goals. Tricia said that she did notice the birds, but kept

her mind busy talking with her cousin. This distraction technique seemed to work

well for her. She was very proud of herself and was even more keen to carry on with

the intervention. Irene also reported that Tricia appeared more relaxed generally and

believed that this has had a positive impact on the family as the two daughters, who

generally get on well, had not be arguing for a while.

Therapist’s observations

Although Tricia’s ratings remained very much the same, she did appear more and

more relaxed as the sessions went on. She always appeared tensed, especially in the

sessions where we went on the clinic’s grounds. After a few minutes of relaxation

68

and self-talk, she would do the task I requested her to do without too many

difficulties. I managed to develop a good relationship with her and use her sense of

fun to make the activities more pleasant. The anxiety remained, but the immediate

fear of bird seemed to diminish. For example, she was initially reluctant to

accompany me when I went away to put slices of bread down to attract the birds. She

came with me to help after the first time and I took a very long time to accomplish my

part of the job. Tricia knew that I was doing it on purpose and began to laugh and

waited for me without any difficulties. Once the bread was down and I was done, she

retreated from the spot quickly but was still laughing. During sessions six and seven,

once we had been in the grounds for about twenty minutes and the birds were eating

the bread, Tricia announced that she would walk towards the birds and asked me to

stay behind. She walked closer to the birds (about twenty meters away from them)

and was clearly determined to achieve her goals. This was a new and positive

development.

Discussion

The end of this child placement came before the rest of the intervention was

completed. Although Tricia and her family had been regular attenders, the school

holidays, normal family life events and problems with room availability at the clinic

prevented her from coming to her appointments on a weekly basis. This meant that

the number of sessions used for the intervention was limited and it felt at times like

the momentum was lost. Indeed, Tricia’s parents reported towards the later sessions

that they were hoping for faster improvements and disclosed that they were feeling a

bit frustrated with Tricia and the Service.

69

The choice of questions to evaluate the intervention is questionable. Although it

could be argued that they provide an accurate picture of what the client is actually

feeling, in Tricia’s case they often reflected more a general state of anxiety as

opposed to a truthful and well considered answer to each specific question. As

discussed above, Tricia more or less consistently gave a high score to the question

that referred to talking about birds because she knew it meant something else was

coming; she was actually not anxious talking about birds but rather was anxious about

the rest of the session. The validity of this measure is questionable. A different

question that explores the general feeling of anxiety, for example “how do you feel

about coming here today to work on your phobia” might have been a more valid one.

Another difficulty with the use of such subjective questions to measure change was

that they might have reflected more a ‘learnt’ anxiety response rather than an actual

behaviour. I often asked Tricia how she was feeling about going in the clinic’s

grounds before going out there (this was not one of the evaluative questions) and she

often answered she was terrified simply to go out. However, once out there, she

would rate her anxiety on a scale of nought to ten as five or six and did not appear

terrified in the way she had initially predicted. Although we did not go to the end of

the intervention together, this led me to question the validity of the distance questions

used. She might have gone closer to the birds with a tolerable level of anxiety but

when asked at a later stage how she would feel about doing this, she might have

resorted to a learnt anxiety response and rate it as a highly distressing experience.

There often seem to be a discrepancy between the subjective anxiety rating and the

70

actual behaviour. However, it could also be argued that the questions remain valid

and would be an accurate measure of cognitive shift for Tricia.

Choosing a CBT intervention also had limitations. Research has shown that it works

better with children aged eleven and older as they have more developed cognitive

abilities ( Durlak, Furnhan & Lampman, 1991; Stallard, 2002). Tricia was nine years

old during the intervention and her ability to access her cognitions was limited. When

asked about her thoughts on birds, these were restricted to “pooing on her head” or

“attacking me”. It was not possible to go any further than this with her at this stage.

The cognitive part of the intervention was therefore limited. Self talk was used as

well as self observation, but the effectiveness of these is difficult to assess.

The limited amount of data gathered made it difficult to reach any conclusion when

using statistics to test the intervention. Needless to say that more data would have

made the statistical testing more robust and the conclusions derived from this clearer.

This was however not possible because of the length of the placement and the

difficulty of meeting Tricia for weekly appointments.

The qualitative part of the evaluation has certainly been more useful in this case.

Observations made by Tricia’s mother as well as those made by the therapist show

that the intervention had an effect. Tricia’s confidence in the intervention visibly

increased at every session and this helped in reducing her levels of anxiety. Although

her mother expressed some frustrations at times, she also noticed that something was

happening with her daughter. This kind of outcome is not noticeable in the statistical

analysis but began to make a difference in the everyday life of the family.

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One of the limitations of the constructed formulation used for this intervention is that

it does not take a broad view of the family’s dynamics and wider environment. The

intervention focused very much on the immediate phobic behaviour and its related

cognitions, but did not explore what role this phobia might play in the family context.

Tricia appeared to be a well adjusted child and for this reason, looking at the role of

the phobia was not deemed a priority. This is not something the family appeared

willing to explore either. This is something that might need to be addressed

depending on the outcome of the intervention. Nevertheless, the role of the family

should have been included in the formulation, as it has been showed that children who

suffer from anxiety are likely to have parents with similar difficulties (Ginsburg,

Silverman & Kurtines, 1995) as was potentially the case with Tricia’s mother who

acknowledged not liking birds and being terrified of spiders. The formulation and

intervention should have also considered how the family interactions might contribute

to the maintenance of the phobia. Although avoidance behaviours were included, the

intervention did not take these into account. This could have been a significant area

to address as Shortt, Barrett, Dadds & Fox (2001) have demonstrated that children

might experience some situations as more threatening because of their parents’

reactions to the perceived threat. Therefore the intervention could have been designed

to involve the whole family at each step and a better look at the parents’ cognitions

and behaviours with regards to Tricia’s phobia.

Tricia was not able to complete the intervention with me and will carry on with the

help of my supervisor.

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References American Psychological Association (1994). Diagnostic and statistical manual of mental disorders (4th Edition). Washington: APA. Carr, A. (1999). The Handbook of child and adolescent clinical psychology. London: Routledge. Csotti, M. (2003). School phobia, panic attacks, and anxiety in children. Philadelphia: Jessica Kingsley. Davies, P. (2007) Personal communication, 11 September 2007, Institute of Child Health, Birmingham Children’s Hospital Trust, Birmingham. Durlak, J.A., Furnham, T., & Lampman, C. (1991). Effectiveness of cognitive-behaviour therapy for maladapting children: a meta-analysis. Psychological bulletin, 110, 201-214. Ginsburg, G.S., Silverman, W.K., & Kurtines, W.K. (1995). Family involvement in treating children with phobic and anxiety disorders: a look ahead. Clinical Psychology Review, 15(5), 457-473. Graziano, A.M., & Mooney, K.C. (1982). Behavioral treatment of night fears in children: maintenance of improvements at 2.5 to 3-year follow-up. Journal of Consulting and Clinical Psychology, 50, 598-599. Gros, D.F., & Anthony, M.M. (2006). The assessment and treatment of specific phobias: a review. Current Psychiatry Reports, 8(4), 298-303. Kendall, P., & Treadwell, K. (1996). Cognitive behavioural treatment for childhood anxiety disorders. In E. Hibbs and P. Jensen (Eds) Psychosocial treatments for child and adolescent disorders: empirically based strategies for clinical practice (pp. 23-42). Washington, DC: American Psychiatric Association. Lascelles, K.R.R., Field, A.P., & Davey, G.C.L. (2003). Using foods as CSs and body shapes as UCSs: a putative role of associative learning in the development of eating disorders. Behavior Therapy, 34, 312-335. Malloy, P., & Levis, D.J. (1988). A laboratory demonstration of persistent human avoidance. Behavior Therapy, 19, 229-241. Martin, I., & Levey, A.B. (1987). Learning what will happen next: conditioning, evaluation and cognitive process. In G.Davey (Ed.) Cognitive Processes and Pavlovian Conditioning in Humans (pp. 57-81). Chichester: John Wiley & Sons. Martin, G., & Pear, J. (1999). Behavior Modification: what it is and how to do it. Upper Saddle River, New Jersey: Prentice Hall.

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Moore, M., & Carr, A. (2000). Anxiety disorders. In A. Carr (Ed) What works with children and adolescents: a critical review of psychological interventions with children, adolescents and their families (pp.178-202). London: Routledge. Olatunji, B.O. (2006). Evaluative learning and emotional responding to fearful and disgusting stimuli in spider phobia. Anxiety Disorders, 20, 858-876. Olatunji, B.O., Lohr, J.M., Sawchuk, C.N., & Westendorf, D.H. (2005). Anxiety Disorders, 19, 539-555. Ollendick, T.H., & Yule, W. (1983). Fear Survey Schedule for Children Revised. In I. Sclare (Ed.)(1997) Child Psychology Portfolio: Anxiety, Depression and Post-Traumatic Stress in Childhood (pp. 19-34). Windsor: NFER-Nelson. Shortt, A.L., Barrett, P.M., Dadds, M.R., & Fox, T.L. (2001). The influence of family and experimental context on cognition in anxious children. Journal of Abnormal Child Psychology, 29(6), 585-596. Silverman, W.K., Kurtines, W.M., Ginsburg, G.S., Weems, C.F., Rabian, B., & Serafini, L.T. (1999). Contingency management, self-control, and education support in the treatment of childhood phobic disorders: a randomized controlled trial. Journal of consulting and clinical psychology, 67(5), 675-687. Spence, S.H. (1994). Spence Children’s Anxiety Scale. In I. Sclare (Ed.)(1997) Child Psychology Portfolio: Anxiety, Depression and Post-Traumatic Stress in Childhood (pp. 4-18). Windsor: NFER-Nelson. Stallard, P. (2002). Think good- feel good: a cognitive behavioural therapy workbook for children and young people. Chichester: John Wiley and sons.

Clinical Practice Report 4- Case Study Psychological assessment of a 72-year old man initially presenting with cognitive difficulties

Abstract

This paper considers the case of Ronald Rowling (not his real name), a 72-year old man who

initially presented with word finding difficulties. He was referred by his general practitioner

to the psychiatrist for the elderly who then referred him to the psychology service. A first

battery of neuropsychological tests was administered and, after a four-month break, some of

the tests were repeated and a new one was administered. Background information and

history were gathered during those sessions. Although referred for a memory test, the main

issues appeared to be about anxiety and low mood rather than cognitive impairment. The

details of these assessments are described along with the outcome. A formulation of his

current difficulties is offered. The paper concludes by reflecting on the learning experience

of undertaking such an assessment.

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Referral

Mr Ronald Rowling (not his real name) is a 72-year old man who was referred to the

Psychology Service by the Consultant Psychiatrist for the Elderly following an initial referral

by Ron’s GP. The Psychiatrist has requested a memory test for this patient. The presenting

issue was described as difficulties finding words or names and using the wrong nouns to

describe familiar objects (for example, he would call a toaster a dustbin). The GP’s referral

letter states that a full physical examination had been performed and beside scarring on his

brain (see discussion below), which might explained his word finding difficulties, and a

previously reported potassium deficiency, she could not explain his current difficulties.

Clinical Interview

The initial clinical interview was done less than six months ago by another psychologist who

has since left the service. The information gathered in this section was collated from the

reports written by this psychologist and from my own clinical interviews and testing with

Ron.

Background history

Mr Rowling was born in the Wolverhampton area where he has spent most of his life. He

describes his family as a hard working working-class family. He is one of six children, three

brothers and two sisters (see genogram in Appendix Nine). He was the fourth child. Ron

says both his parents worked and all the children had to be independent from an early age.

He says his parents cared for him but not much time was spent being ‘a happy family’. He

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adds that they all had to work as soon as they could, doing paper rounds and odd jobs for

neighbours and local shops.

When Ron was in his early teens, he was recruited by the local vicar to join the boxing club.

Ron said he enjoyed this very much and it brought a much-needed sense of pride to the

family as he did very well competing at a local, national and, later on, international level.

Ron was an international boxer for around 20 years and also trained other boxers when he

retired from competing. Towards the end of his boxing career, he was knocked unconscious

during a match. A few years later, he was experiencing recurrent headaches and word

finding difficulties. He had appointments with a private neurologist who told him he had

bruising or scarring on the brain and that nothing could be done to repair the damage. The

word ‘dysphasia’ (word finding difficulties) was also mentioned during those consultations.

This seemed to leave a strong impression on him as he said he has been constantly ‘keeping

an eye’ on himself ever since.

He joined the Army to do his national service when he was in his early twenties and remained

in the forces until he was thirty years old. During this time, he had the opportunity to train as

a chiropractor. When he left the Army, he set up his own private chiropractic clinic and

gained an excellent reputation as a practitioner. He worked full-time until very recently but

following pressures from his wife, he has now reduced the number of hours he spends

working.

Ron describes himself as a ‘no nonsense type of chap’ who is highly successful. He is very

proud of what he describes as his ‘modest origins’ and subsequent thriving career. He says

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he is a good provider and both his sons went to university. They are both married and have

children of their own; Ron talks about his grand children with glowing satisfaction. His wife

relies heavily on him for managing the finances and being ‘her strong man’. He confided in

me that he now feels like he is letting her down at times and that he does not want to talk to

her about it in case it makes things worse. He sees himself as a fighter who is still more than

capable of teaching a thing or two to younger people. Ron says he has never been sick or

missed a day of work in his life.

Presenting problem

Ron says his memory troubles have been present for at least 25 years. He adds that he was

never too worried about them, as his quality of life was not affected. However, in May 2006,

whilst on holiday, he lost consciousness whilst standing in line at the evening buffet. He was

seen by the resort GP who attributed the fall to a potassium deficiency. Ron added that his

wife did not show much sympathy and, in fact, appeared rather cross with him for spoiling

their holiday. He says his memory difficulties seemed to have got worse since that incident.

He says he often feels like his head is filled with cotton wool or sawdust and sometimes feels

like he is in a far away place, as if he were separated from people around him. This has led to

four fainting episodes over a period of six months. He also reports being more forgetful and

more difficulties with word finding (dysphasia). He says he easily looses his train of thought

but this was not apparent in our meetings. Ron did not have word finding difficulties in our

sessions and did not loose his train of thought.

During the interview, Ron revealed that these difficulties occur mostly when he is at home

with his wife. Ron added that his wife gets rather impatient with him when he can’t find a

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word or when he uses the wrong noun to describe something. He says his levels of anxiety

surge up when this happens. It became apparent during the interviews that the main problem

was not a cognitive impairment but rather an anxiety and low mood issue, one he is

especially experiencing when his wife is around.

Ron, although he describes himself as semi-retired, actually works full-time seeing over 75

patients per week. When asked about his performance at work, he says that nothing has

changed there. He says he has no difficulties in remembering new patients’ names and has

not lost any confidence in his capacity to work effectively and provide his patients with a

professional level of care. He says that he often discusses cases with his practice partner,

Roger, and although Roger is not aware of his cognitive difficulties, he has expressed no

worries with regards to Ron’s work. In fact, Ron added that he never experiences cognitive

problems at work.

Ron added that he had two patients who he saw for years for back problems and they both

had some form of dementia. He said that as he saw them regularly every three months, he

was able to witness the devastating effect of the illness on these two men. This appears to

have a significant impact on Ron.

He says that his mood is sometimes low and he feels anxious at times, especially in family

gatherings or social events, which he usually attends with his wife. This was apparent,

especially in our first meeting. Ron seems very sad and appeared rather fatalistic; he told me

he felt doomed and felt like giving up on life at times. When I asked more specific questions,

he said he was not suicidal but felt that his interest in life was diminishing as it felt “a bit too

much” (sic) at times.

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Assessment

Ron came to the Psychology Service for a total of six appointments; four weekly

appointments were given followed by a four-month gap. Although the most significant

difficulties did not seem to be neuropsychological in nature, routine neuropsychological tests

were administered. Two more appointments were then attended over a period of three weeks.

This ensured that the neuropsychological tests were done in close temporal proximity but

with enough time between them to avoid fatigue (Lezak, 1995). The tests used on Ron are

listed below according to the area of function that each examines:

Psychiatric symptomatology

Hospital Anxiety and Depression Scale (HADS) (Snaith & Zigmond, 1994)

Tests for dementia

Cambridge Cognitive Examination Revised (CAMCOG-R) (Roth, Huppert, Mountjoy, &

Tym, 1998).

Mini Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975).

Test for memory

Wechsler Memory Scale- 3rd Edition (WMS-III) (Wechsler, 1998).

Test of general intelligence

National Adult Reading Test- 2nd Edition (NART) (Nelson & Willison, 1991).

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The last two tests were administered by the psychologist who has since left the service. The

CAMCOG-R was administered twice, the first time by her and the second time by myself.

Outcome

Ron completed the HADS, which is a self reported measure that examines anxiety and

depression. He obtained a score of 6/21 on the anxiety scale and 3/21 on the depression

scale. Both scores fall into the non-clinical range (between 0 and 7).

The NART, which was administered by the previous psychologist, is designed to estimate

pre-morbid intelligence levels in adults presenting with cognitive difficulties. Ron made 21

reading errors, which suggests the following IQ scores, all within the average range:

Predicted Verbal IQ: 103

Predicted Performance IQ: 105

Predicted Full Scale IQ: 105

These results might however underestimate Ron’s IQ if he is in the early stages of dementia.

Patterson, Graham and Hodges (1994) found in their study that the NART tended to

underestimate premorbid IQ by one standard deviation or fifteen IQ points. Similar

conclusions were also obtained by Taylor (1999). At the time of the interview, the other

psychologist who administered this test noted that Ron appeared to function at a level

consistent with the NART findings. If Ron is in the early stages of dementia, this could mean

that his premorbid IQ might be higher and therefore the deterioration in his cognitive abilities

might not be noticeable for people who do not know him well as he is still functioning at an

average level.

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The WMS-III was also administered by the previous psychologist. The results below were

the only ones included in Ron’s files; I could not find any of the test sheets. The WMS-III

provides a profile of immediate, delayed and working memory skills. These scores can be

compared to the estimated IQ to assess for significant differences. Ron’s overall scores on

this assessment are within the average range, between the 32nd and 39th percentile. This

means that between 61 and 68% of people the same age would achieve a higher score. These

percentile scores are lower than the estimated IQ score, which is at the 50% percentile.

Please see table 4 for summary of scores.

Table 4 Summary of Scores Index Score (mean= 100) Percentile

Wechsler Memory Scale

Immediate memory 93 32

Delayed memory 96 39

Working memory 93 32

Despite the difference between his scores, it is difficult to separate the effects of memory

difficulties from language difficulties caused by his long standing dysphasia, as language is

used to access memory.

The CAMCOG-R is one subtest taken from the Cambridge Examination for Mental Disorder

in the Elderly (CAMDEX-R). It is a neuropsychological test sensitive to the effects of

dementia. It measures a broad range of cognitive functions. The test was administered twice

with a four-month gap in between. Ron scored 87/105 the first time the test was

administered. The cut-off point for an indication of dementing illness is at 81 points. The

psychologist who administered the test wrote in her note that Ron was very anxious during

the administration of the test and suggested that it should be re-administered at a later stage as

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she felt that his performance might not reflect his current cognitive abilities. The second time

the test was administered, Ron scored 92/105. Ron’s dysphasia might have also affected the

results of the CAMCOG-R. However, the expressive language scales of the CAMCOG-R

are not the most sensitive in detecting potential dementia (Williams, Huppert, Matthews,

Nickson, & MRC CFAS, 2003) as other subscales such as memory and attention (on which

Ron performed adequately). The CAMCOG-R does not take into consideration any previous

impairments and Ron’s scores are still within the norms (Williams et al., 2003) for someone

his age and level of education. Both results clearly indicate that his cognitive functioning

operates within the normal range for somebody his age. There is clearly an issue with the test

re-test procedure here but no literature appears to be available on this question. Detailed

results of both tests are in Appendix Eight.

The MMSE is a brief screening tool for dementia and tests a limited set of cognitive

functions. All the items of the MMSE are included in the CAMCOG-R so when this test is

administered, a score for the MMSE is also obtained. The first score Ron obtained on the

MMSE was 24/30, which according to the NICE and SCIE guidelines (2006) indicates the

possibility of mild dementia. However, the second time the test was administered, four

months later, Ron scored 29/30, which suggests no cognitive impairments.

The tests suggest that Ron is functioning according to what is expected for someone his age.

The psychologist who administered the first CAMCOG-R reported in her notes that Ron had

appeared anxious during the test; his wife was present in the room at the time. This was also

not long after he lost consciousness for the first time whilst on holiday. As he mentioned that

he had been rather shaken by that event, it is not unreasonable to assume that he was still

‘mentally recovering’ from this incident. He also reported during the second meeting that

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having his wife beside him gave him a sort of ‘performance anxiety’(sic). These two factors

might explain why the score he obtained for the second CAMCOG-R, which was

administered without his wife in the room, was higher than the first one.

As mentioned above, his results on the WMS-III were slightly below what was expected but

this could be explained by his word finding difficulties as opposed to memory impairments.

A career in boxing might have put Ron more at risk of developing neurological deficiencies;

Reiter and Deprospo (2003) reported that multiple concussions might put amateur and

professional boxers more at risk of developing what is known as dementia pugilistica; the

symptoms of this condition includes tremors, lack of co-ordination, unsteady gait and

inappropriate behaviours. Ron did not display any of these and said that he suffered from

concussion on only one occasion.

In summary, the tests show that Ron is not experiencing any significant cognitive

impairment. This seems to disappoint Ron. I re-emphasised that his word finding difficulties

might be the result of the scarring on his brain identified by the private neurologist but that

based on the test results and the information he gave me in our meetings, his current

difficulties appeared to be more the result of anxiety and low mood than anything else. I

explained that he is going through many transitions and that he seems to find these

challenging and difficult to accept. He is not as capable as he used to be but finds it difficult

to reconcile himself with this and as a result tries to work harder to compensate what he sees

as weaknesses. This does not always work and has the effect of making him feel more

anxious and sometimes defeated. I told him that this anxiety might aggravate what he feels to

be symptoms of dementia (his perceived memory difficulties) as a way of confirming to him

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and others that there is something wrong with him. I offered him the opportunity of one-to-

one sessions to discuss his current difficulties and the anxiety it creates and also suggested a

referral to the family therapy service. Ron declined both offers. He was re-referred back to

the Psychiatrist for further tests, which will investigate the physical side of his symptoms.

Formulation

A formulation was created based on the material obtained in the interviews and what the test

results suggested. As it was concluded earlier on that his main difficulties were around

anxiety and low mood, the formulation was constructed around these difficulties and includes

their potential impact on his cognitive problems.

Pearce (2002) suggests that a capacity for change is required when circumstances change and

that stress often occurs when families are moving from one stage of the life cycle to the next.

Symptoms are likely to occur when there is disruption in this capacity for change or where

there is more than one transition happening at the same time. Ron appears to be experiencing

such stress as he is facing some challenging transitions. His symptoms, such as memory

difficulties when his wife is around, seemed to have become more present, or more felt, since

he experienced his loss of consciousness during his holiday. Perhaps being confronted with

physical symptoms which he cannot explain was suggestive of his own ‘newly acquired’

vulnerability or mortality, a realisation that would be anxiety provoking for both him and his

wife. Although not discussed in the interviews with Ron, the relational problem they seemed

to be experiencing, such as not sharing fears and worries and frustrations at changing roles,

appear to support this hypothesis that the couple is going through a difficult transition period.

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Montgomery (1995) suggests that “cognitions associated with anger, anxiety, depression, or

other negative moods or states will compete for attention and thus interfere with the orderly

processing of information, learning, and competent performance.” (p.459). This appears to be

a significant problem for Ron.

Ron’s personal beliefs are affecting his levels of anxiety. From an early age, he learnt that he

needed to be self-resilient and needed to work hard to be valued in the family. He also learnt

that he had to look out for himself as no one else was there to do that for him. His experience

as a boxer, which was very successful and important to him, made him feel powerful and

valued. His family pride in him boosted his self-confidence and the adversity he encountered

throughout his life was always dealt satisfactorily, in his opinion. Thus, at a certain level,

Ron believes he should be invincible.

This was also experienced in his career as a chiropractor. When Ron opened his practice, he

was very well connected with the world of professional sports because of his own boxing

career and built up a very successful practice in no time because of his good reputation.

From the material gathered in the interviews, he appears to have been an excellent

chiropractor who was able to treat successfully many difficult conditions. He says he felt in

control and very capable. He added that his clients come from all over the country and

sometimes from abroad to see him specifically. Again, this reinforced his personal belief of

being a powerful and capable problem-solver. His sense of self-worth appears to have

become linked, not surprisingly, to his therapeutic successes.

Having never been unwell in his life, the fainting episodes are a new experience to him.

These are clashing with his beliefs of invincibility and are increasing his anxiety levels. He

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has witnessed the damages dementia can do to otherwise healthy individuals and this has

frightened him significantly. These new experiences do not fit with his belief of being in

control and being invincible. Furthermore, as a chiropractor, he is used to examining,

diagnosing and treating his patients; this makes his current situation even more frustrating as

he says that no one has been able to give him a straight answer as to what is happening to

him. He said many times during the interviews that he wants to know what is going on with

him and what he needs to do to have it fixed.

Ron’s world is gradually changing as he is getting older. He is not the man he once was and

works hard at trying to regain some of his past capacities. This does not always work and as

a result, Ron is left feeling defeated and depressed.

In terms of family context, it seems that the roles assigned to Ron and his wife are rather

traditional and rigid. Ron worked hard all his life and still does to provide a comfortable

lifestyle to his family. He saw himself very much as the head of the family and the one who

is supposed to look after his wife and children. He had to be strong and showing weaknesses

or vulnerability was not an option. The beliefs are still powerful as he mentioned that his

sons regularly come to him for his help in all sorts of matters. There is another belief about

how one should get on with life and be able to cope whatever happens. This was suggested

when Ron mentioned that his wife was getting impatient with him for not getting his problem

sorted quickly; Ron interpreted this as evidence that he was not coping as well as he used to.

As Pearce (2002) mentions, the physical effects of ageing and its associated illnesses raise the

potential thought of reliance on others and can bring the threat of changes in autonomy.

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Ron is indeed facing many changes that are contributing to his low mood and anxiety. He is

72 years old and although he has always been extremely fit, the ageing process now appears

to be catching up and is challenging his personal beliefs and family situation. His work is a

significant source of self-esteem for him which also gives him a strong sense of purpose. As

he said himself, until very recently, he still did the same amount of work he did thirty years

ago, almost suggesting that he has not aged at a professional level. He is aware that he will

not be able to carry on at the same pace for much longer as complete retirement looms ahead.

Although he has reduced the number of patients he sees in a week (from 100 to 75) he finds it

difficult to fill the two afternoons a week he now has at his disposal. Being a pensioner with

no money-earning activities is not appealing to Ron. It is a significant change and one that he

finds depressing.

The society and culture in which we live also provide its influence and Ron seems to be

feeling its effect. Curtis and Dixon (2005) suggest that there has been a shift in perceptions

of old age since the Second World War. Medical progress, compulsory retirement (although

recent anti-ageist legislation might slowly change this) and the welfare system have

contributed to a redefinition of old age as a period of leisure, not productivity, and a period of

decline and decrepitude rather than a period of contemplative wisdom. Old age has become

associated with burden and unproductiveness, which is reflected in Ron’s own attitude. As

Rayner (2005) suggests, Ron faces quiet threats from two different directions: first, there is

the potential deterioration in his bodily functions, especially the brain and his memory.

Second, there are the social expectations that he is useless because of his age, irrespective of

his current abilities.

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Although Ron has some mild cognitive impairments diagnosed several years ago, the

neuropsychological tests that were administered failed to show any other significant or new

impairments. Ron clearly is experiencing some kind of physical difficulties which

manifested themselves through the fainting episodes he had. These have clashed with the

various beliefs affecting Ron’s life. He seems to feel unable to come to terms with the

transitions he is going through. His wife does not appear very sympathetic to his current

predicament and also appears unable to cope with the changes they are facing.

Montgomery’s (1995) suggests that cognitions of a negative nature will affect the

individual’s capacity for information processing by dividing his attention from the task. In

Ron’s case (see figure 8), the beliefs he holds with regard to himself and to his family, which

are shared by his wife, is creating anxiety and low mood as they clash with his current

circumstances. This appears to be mostly manifested in situations where his wife is present

as she can have a modulating effect on Ron’s perceptions of his abilities. Ron already has

some cognitive impairments that were caused by what the private neurologist identified as

scarring on the brain and these impairments are worsened by the anxiety he is experiencing.

When there is no anxiety around, for example in work situations, Ron is able to function

normally and without any cognitive difficulties.

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Societal beliefs

• Physical Symptoms

• Ageing process

Anxiety Low mood

• Personal beliefs

• Family scripts

Ron’s wife

• Fear of dementia

• Beliefs about ageing

(word finding difficulties)

Cognitive Dysfunction

Figure 8. Ron’s formulation in family situations

Recommendations

In reporting back to the Psychiatrist who had referred him, a number of recommendations

were made. Firstly, it was suggested that the Ron meets with the Psychiatrist to discuss his

physical difficulties in the light of the outcome of the neuropsychological tests. Secondly, I

suggested that he comes back to the psychology service in twelve months for another

neuropsychological assessment, in order to monitor any changes in his cognitive abilities.

Thirdly, I reported that Ron had been offered the opportunity for some psychotherapeutic

input in the form of either one-to-one sessions with me or a referral to the family therapy

service. Both offers were declined by Ron who did not see the need for such interventions. I

wrote to the Psychiatrist that these offers were still open to Ron and his family should he

reconsider his decisions following his meetings with him.

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Reflective Practice

The experience of undertaking such an assessment was a new one to me. Ron was one of my

first clients in this placement and I felt rather anxious when I was given the task of assessing

him. Although it was something I wanted to do and furthermore something I had identified

as one of my main placement goals, it was not something I especially felt interested in; this

goal was the product of an identified gap in the list of competencies I need to achieve in order

to pass the course. Neuropsychology always appeared to me as very clinical or biological

and something that would ignore the phenomenological experience of human life- I am

definitely more interested in one-to-one psychotherapy than questionnaires and psychometric

tools.

Although I read relevant instruction manuals on the various neuropsychological tools I used

and textbooks on assessing cognitive abilities in older adults, I felt a lack of confidence in my

own abilities to do the assessment. I was very well prepared intellectually and had quite a

good understanding of dementia at a very theoretical level. The bridge between theory and

practice was the one I now needed to cross. I did tell Ron I was a trainee clinical

psychologist as I did not want him to believe I was a fully qualified expert in the field. Ron

did not seem to mind; in fact, he seemed so wrapped up in his issues that I do not believe he

paid any attention to that part of my introduction.

I was also very well aware that Ron had seen another psychologist the first time he came to

our service. I did wonder how he would feel about being seen by someone else and thus

having to re-explain all his concerns from the beginning. I asked Ron the question during the

first meeting and he explained that he did not mind and actually felt freer this time to discuss

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his issues as his wife was not around and he said he also felt that a man would be more able

to understand him (the first psychologist he saw was a woman).

The main difficulty I experienced in this assessment with Ron was that he wanted to have

clear answers. I did explain to him that the tests would give us some indications but that we

would not get a clear and precise diagnosis, which I think, with hindsight, is what he wanted

to have. I believe this showed how anxious he was about his current experience and although

I did administer an anxiety test (the HADS) I feel I could have spent more time discussing his

worries with him. This was especially significant as all the test results suggested there were

no cognitive difficulties; it did not give him something tangible to justify his ‘condition’. I

think that this might have made matters slightly worse for him as he would not have a clear

explanation that he could give to his wife. It is only later in supervision that I realised I

should have spent more time talking about his anxiety and maybe approach it from a different

angle, such as discussing the relationship with his wife.

This has been a valuable lesson for me in terms of assessment work, which was the topic of

discussion in many supervision sessions. I have learnt from this experience that there is an

emotional side to this type of work; it is not just about measuring cognitive abilities but also

about feeding back results tactfully and monitoring reactions in clients. Ron was an anxious

man who was looking for answers and maybe for a way to get sympathy from his wife;

although I provided him with what the psychiatrist had asked me to do, I could have been

more sensitive to his motivations to undertake such testing. I am left wondering whether he

would have accepted the offer of extra psychotherapeutic help if I had been more receptive to

his needs.

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References

Cronen, V., & Pearce, B. (1985). Towards an explanation of how the Milan method works: an invitation to a systemic epistemology and the evolution of family systems. In D. Campbell, & R. Draper (Eds.) Applications of systemic family therapy: the Milan approach. London: Grune & Stratton. Curtis, E.A., & Dixon, M.S. (2005). Family therapy and systemic practice with older people: where are we now? Journal of Family Therapy, 27, 43-64. Lezak, M.D. (1995). Neuropsychological assessment (Third edition). Oxford: Oxford University Press. Montgomery, G.K. (1995). A multi-factor account of disability after brain injury: implications for neuropsychological counselling. Brain Injury, 9(5), 453-469.

National Institute for Health and Clinical Excellence, & Social Care Institute for Excellence (2006). Dementia: Supporting people with dementia and their carers in health and social care. London: NICE and SCIE.

Nelson, H.E., & Willison, J.R. (1991). National adult reading test. Windsor: NFER Nelson. Patterson, K.E., Graham, N., & Hodges, J.R. (1994). Reading in Dementia of the Alzheimer Type : A Preserved Ability? Neuropsychology, 8(3), 395-407. Pearce, J. (2002). Systemic therapy. In J. Hepple, J. Pearce, & P. Wilkinson (eds.) Psychological therapies with older people: developing treatments for effective practice (pp. 76-102). Hove: Brunner-Routledge. Rayner, E. (2005). Old age. In E. Rayner, A. Joyce, J. Rose, M. Twyman, & C. Clulow (Eds.) Human Development: an introduction to the psychodynamics of growth, maturity and ageing. (pp. 275-286). Hove: Routledge. Reiter, H.H., & Deprospo, L. (2003). Neuropsychological aspects of boxing. International Journal of Sport Psychology, 34(4), 340-343. Roth, M., Huppert, F.A., Mountjoy, C.Q., & Tym, E. (1998). The Cambridge examination for mental disorders of the elderly- revised. Cambridge: Cambridge University Press. Snaith, R.P., & Zigmond, A.S. (1994). Hospital Anxiety and Depression Scale. Windsor: NFER Nelson. Taylor, R. (1999). National Adult Reading Test performance in established dementia. Archives of Gerontology and Geriatrics, 29(3), 291-296. Wechsler, D. (1998). Wechsler Memory Scale (3rd Edition, UK version). London: The Psychological Corporation.

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Williams, J.G., Huppert, F.A., Matthews, F.E., Nickson, J., & MRC CFAS (2003). Performance and normative values of a concise neuropsychological test (CAMCOG) in an elderly population sample. International Journal of Geriatric Psychiatry, 18, 631-644.

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Clinical Practice Report 5- Oral Presentation The assessment and formulation of a 49 year-old man presenting with depression

Abstract

This presentation considers the case of Nick, a 49 year-old man referred by the psychiatrist to

the Psychology Service for chronic depression. Nick was initially referred by his GP and had

received cognitive-behavioural therapy from a specialist therapist five years before. Nick

does not remember much of the content of the sessions but recall that they were not helpful.

He reports having felt depressed for as long as he can remember and believes that there are

childhood issues at the root of his problem. At the time of the first appointment, Nick was

going through separation with his wife and was drinking heavily. A full assessment was

completed and schema therapy was deemed to be the appropriate treatment. Three schemas

were identified: Mistrust/abuse, emotional deprivation and defectiveness. A formulation was

developed. Nick’s early experience of his parents were not ‘loving’ and were characterised

by distance and feeling like he was a disappointment. Schemas are activated in his current

life through his relationship with his wife and also people at work. They are maintained by

the pattern of his relationships and often opting for solitary activities. This, in turn, reinforces

Nick’s core beliefs, which revolve around feeling like a fraud and that people cannot be

trusted. Coping styles used by Nick are also discussed as part of the formulation as well as

what the treatment would have consisted of. The presentation ends with a critical self

appraisal of the Trainee’s performance with this client.

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Appendices Appendix I – Summary of sessions Session One: Introduction to the anxiety management group Welcome and introductions. Do you know why we are here? This is an anxiety management group. We will be talking about anxiety, how it makes us feel and how to cope with it. Group plan: 8 weeks, 2-4pm, optional half hour breaks

2. What is Anxiety What makes you anxious?

3. What happens to your body when you get anxious Relaxation exercises

4. Understanding anxiety Why do I get anxious

5. The anxiety spiral Thoughts and behaviour that make us anxious

6. How to stop feeling anxious How to be assertive

7. How to prevent anxiety starting Developing coping skills

8. Review of the group What did you learn from the group Ground rules: You will be encouraged to participate in the group as far as you feel

comfortable You may leave the room if you need a break, but please return

You don’t have to discuss things that make you uncomfortable Try to do your homework every week, as they will help you to cope with anxiety

Confidentiality and video-recording Brainstorm of words associated with anxiety. Please give an example of a situation that makes you anxious. Looking at pictures of emotions and cutting from magazines. BREAK Completion of Glasgow scale and Anxiety thermometer. Introduce daily/weekly diary and colour stickers. Identify someone who can help you with your homework and relaxation exercises. Homework: What makes you anxious? (Drawing or writing). Weekly diary. Summary of next session. Questions and Debrief.

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Session Two: What is anxiety? Review of last session. Collection of weekly diary. Summary of today’s session. Teaching: What is anxiety? Anxiety is very common (1 in 10 people)

It’s a natural way of coping with a threat, danger or worry A little bit of anxiety can be helpful You can learn to cope with anxiety

Misconstrues about anxiety (not a disease, not madness) Feedback from homework task: What makes you anxious? BREAK Exercise: What makes you anxious? Feelings and thoughts (e.g. frightened, sad, can’t cope) Bodily sensations (e.g. heartbeat, faint, sick) Consequences (e.g. bad sleep, eat too much/little, anger) How has anxiety changed your life? How do you cope with anxiety at the moment? Stressful situations, life events, worries. Relaxation exercise: Tense and relaxed. Summary of today’s session: Everyone feels anxious sometimes. It’s ok to have these feelings. Homework: How does your body feel when you are anxious? (Body outline). Weekly diary. Summary of next session. Questions and Debrief.

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Session Three: Body reactions to anxiety and relaxation Review of last session. Collection of weekly diary. Summary of today’s session. Group exercise: How does our body feel when we are anxious? Large body outline on flipchart. Feedback from homework. Teaching: How bodily sensations can make us anxious. BREAK Teaching: Why is relaxation helpful? Helps us feel less tense Can be used in a stressful situation You need to practice everyday 3 exercises to try: Tensing and relaxing muscles Behavioural relaxation training Relaxation exercise: Breathing exercise and guided relaxation.

Quiet place, time, comfortable position Body, head, mouth, throat, shoulders, hands, feet, eyes, breathing How do you feel? Do you feel relaxed?

Summary of today’s session. Homework: Practice relaxation everyday. Weekly diary. Summary of next session. Questions and Debrief.

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Session Four: What causes anxiety and what maintains it? Review of last session. Collection of weekly diary. Summary of today’s session. Feedback from homework: Did you practice relaxation? How was it? Teaching and Practice: Why do I get anxious?

Bodily sensations Learned behaviour

Lots of worries or life event

Teaching: Why do I still feel anxious (maintaining factors)? Avoidance and triggers and unhelpful behaviours? Pictorial illustration of avoidant behaviour. BREAK Exercise: What do you avoid doing?

What triggers your anxiety? Unhelpful things you might do (before, during and after).

The wrong type of help (e.g. eating, drinking, smoking). Summary of today’s session. Homework: Continue to practice relaxation. Weekly diary. Summary of next session. Questions and Debrief.

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Session Five: the anxiety spiral and how to break it Review of last session: Why do we get anxious and how it’s maintained? Collection of weekly diary. Completion of anxiety thermometer. Feedback on homework task: Did you practice relaxation? Group exercise: Difference between thoughts and feelings List of words and sentences – Identify thoughts and feelings Examples on flipchart – Going shopping

Walking by someone in the street Seeing a dog

Break Teaching and practice: Discuss how thoughts affect our feelings and behaviour Individual experiences – Identify thoughts, feelings and behaviour Group exercise: Positive ways of thinking Alternative thoughts Homework: Practice relaxation and positive ways of thinking. Summary of next session Questions and Debrief

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Session Six: How to stop being anxious Review of last session: “The Anxiety Spiral and Positive Ways of Thinking” Collection of weekly diary. Feedback on homework task: Did you use positive thoughts when feeling anxious? Distraction techniques – Go for a walk Do some exercise Listen to some music Talk to someone Physical and Mental Relaxation Slow breathing More specific – Mental games: take attention away (e.g. recite a poem, sing a song,

count forwards or backwards) Environmental focus: focus on things around you (e.g. count number of red cars, guess what people do for a living)

Bridging object: happy thought (object, souvenir or photo) Break Lifestyle: Water, caffeine, alcohol (effects on the body) Sleeping Regular exercise Balanced diet Smoking Group exercise: What do you do that is not helpful when you are anxious? Homework: Decide which distraction technique you like the most and use it this week when you begin to feel anxious. Summary of next session. Questions and Debrief

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Session 7: Relapse prevention. Review of last session: “How to stop feeling anxious” Collect weekly diary. Feedback on homework task: Using distraction techniques when feeling anxious Devise an individual plan of positive coping strategies for each person, including: • What makes you anxious? • Thoughts, feelings, behaviours and bodily symptoms associated with particular anxiety-provoking situations • Positive ways of thinking • Physical/mental relaxation and slow breathing techniques • Other positive coping skills – Distraction techniques and positive lifestyle goals Break Complete individual coping plans Summary of next session. Questions and Debrief

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Session Eight: Review and ending. Review of last session: “Relapse Prevention” Collect weekly diary. Presentation of completed “Individual Plans for managing and coping with anxiety” Completion of Glasgow scale and Anxiety thermometer. Review of group program Break Group discussion – What has been most useful? What was not so useful? Completion of individual feedback questionnaires Presentation of “Certificates of Attendance” Questions and Comments

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Appendix II Group Evaluation We would like to find out what you thought about coming to the anxiety management group.

We would be pleased if you would answer some of the questions below. It is really important

that you are honest about your feelings. What you tell us can help to make changes and make

things better for the next group.

1. What did you feel about the room?

1 2 3 4 5 6 7 8 9 10 2. Each session lasted from 2 o’clock to 4 o’clock. What do you think of the

length of each session?

1 2 3 4 5 6 7 8 9 10 Would you have preferred them to be shorter or longer?

Less Time

The Same

More Time

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3. We met for 8 weeks. Was this a good number of sessions?

1 2 3 4 5 6 7 8 9 10 Would you have preferred to meet for more sessions or less?

THE SAME MORE LESS

4. There were 4 group members – xxxxxxxxx. Do you think this was a good

number of people?

1 2 3 4 5 6 7 8 9 10 5. How easy was it to speak to the group facilitators - Marc and Brinder?

1 2 3 4 5 6 7 8 9 10

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6. How useful was:

A. Learning about how anxiety affects us?

1 2 3 4 5 6 7 8 9 10

B. Learning about relaxation?

1 2 3 4 5 6 7 8 9 10

C. Learning about how our thoughts, feelings, and actions affect each other?

1 2 3 4 5 6 7 8 9 10

D. Learning about how to stop having anxious feelings?

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1 2 3 4 5 6 7 8 9 10

E. The homework tasks?

1 2 3 4 5 6 7 8 9 10 7. Which bits did you enjoy the most?

• Hearing information about anxiety • Drawing • Role play • Learning about relaxation • Group discussion • Tea breaks • Homework • Filling out questions • Other

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8. Which bits did you least enjoy?

• Hearing information about anxiety • Drawing • Role play • Learning about relaxation • Group discussion • Tea breaks • Homework • Filling out questions • Other

9. How easy was the information to understand? Easy Difficult 10. Has coming to the group helped you with your anxiety (panic, stress, worry, worked-up)?

1 2 3 4 5 6 7 8 9 10

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11. What have you learnt that has been useful in helping with anxiety (feeling stressed, worried, worked-up)? 12.If your friends had similar problems with anxiety (stress, worry, panic, worked-up), would you tell them to come to a group like this one? YES Maybe No 13. Would you like to make any other comments?

Thank you for completing this questionnaire.

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Appendix III Anxiety Management Group Invitation Letter Dear Colleague We are writing to inform you of a new anxiety management group to start in early February 2006 for service users in the XXX area. The group will be run for approximately 8 weeks from Wednesday 15th February 2006 at the Somewhere Heath Health Centre. Each session will last approximately two hours with breaks and an optional half hour debrief session. It is important that any clients you are thinking of referring possess reasonably good verbal skills. If you feel any of your clients may benefit from attending or would like to discuss the group further, please complete a referral form or contact John Smith or Jane Doe at the XXXXXXX, Tel: XXXXXXXXX. All referrals must be received by Tuesday 31st of January. We look forward to hearing from you. Yours sincerely John Smith Jane Doe

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Appendix IV Referral Form Referral to Anxiety Management Group Name of Referrer: ……………………………………………………………………………………………. Base: ………………………………………………………………… Tel: …………………………………………. Name of client to be referred: ……………………………………………………………………….. Address: ………………………………………………………………………………………………………………….. Tel: ……………………………………………………………………………………………………………………………. Date of Birth: Age: Gender: M / F GP: Ethnic group: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Clients living situation: Independent living Residential Home Lives with carer Other (please specify) Level of disability: borderline mild moderate Other diagnoses? Eg. Autism, Down’s Syndrome Any physical disabilities? (Please detail) Mobility issues? Language Skills: Please describe your client’s language abilities: Written skills: Is your client able to write and read and at what level? (Please give details)

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Transportation: Is your client able to travel or organise transport to the allocated venue? How does your client behave in social situations? Eg. Passive, sociable, shy but enjoys being in company. Client’s anxiety: What is the type of anxiety they are experiencing? How long has this been a problem? Are there particular triggers for their anxiety? What is the frequency of their anxiety? How long do these feelings tend to last? Have interventions been tried previously? What are their current coping strategies?

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Does your client have any weekly commitments that would interfere with attendance to the group? Eg. Employment, professional appointments, college, day centre. How do you see your client benefiting from the group? Have you discussed this referral with your client? Yes No If Yes, how does your client feel about the referral? Any additional information you feel is important for us to know? Please send completed referrals forms to: John Smith & Jane Doe

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Appendix V Anxiety Thermometer Name: Date:

ANXIETY THERMOMETER Self Report: High Anxiety

Low Anxiety Place a cross on the thermometer indicating how anxious you feel

Appendix VI Anxiety Management Weekly Diary

Name: Week:

Thursday Friday Saturday Sunday Monday Tuesday Wednesday

KEY: = NEVER = SOMETIMES = ALWAYS

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Appendix VII Single Case Experimental Design SPSS Output

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Appendix VIII Case Study CAMCOG-R Output

First CAMCOG-R administered in 2006 1. MMSE : 24 (out of 30), 0 missed (out of 19 items) 2. Blessed scores Abbreviated Mental Test : 8 (out of 10), 2 missed (out of 10 items) Dementia Scale : 0 (out of 17), 11 missed (out of 11 items) 3. CAMCOG scores CAMCOG : 87 (out of 105), 0 missed (out of 59 items) - orientation : 8 (out of 10) - comprehension : 8 (out of 9) - expression : 17 (out of 21) - remote memory : 5 (out of 6) - recent memory : 4 (out of 4) - new learning : 12 (out of 17) - attention/calculation: 7 (out of 9) - praxis : 11 (out of 12) - abstract thinking : 6 (out of 8) - perception : 9 (out of 9) Executive Function : 17 (out of 28), 0 missed (out of 7 items) All missing items are recoded to 0 (i.e. incorrect) producing a conservative estimate of performance. CAMCOG-R Profile ---------------- | % of maximum Sub-section |0 20 40 60 80 100 -------------------------|-------|-------|-------|-------|-------| CAMCOG-R overall |********************************* ( 87/105) orientation |******************************** ( 8/ 10) comprehension |************************************ ( 8/ 9) expression |******************************** ( 17/ 21) remote memory |********************************* ( 5/ 6) recent memory |**************************************** ( 4/ 4) new learning |**************************** ( 12/ 17) attention/calculation |******************************* ( 7/ 9) praxis |************************************* ( 11/ 12) abstract thinking |****************************** ( 6/ 8) perception |**************************************** ( 9/ 9) Executive function |************************ ( 17/ 28) Second CAMCOG-R administered in 2007 1. MMSE : 29 (out of 30), 0 missed (out of 19 items) 2. Blessed scores Abbreviated Mental Test : 6 (out of 10), 3 missed (out of 10 items) Dementia Scale : 0 (out of 17), 11 missed (out of 11 items) 3. CAMCOG scores CAMCOG : 92 (out of 105), 1 missed (out of 59 items) - orientation : 10 (out of 10) - comprehension : 9 (out of 9) - expression : 17 (out of 21) - remote memory : 5 (out of 6) - recent memory : 4 (out of 4) - new learning : 13 (out of 17) - attention/calculation: 8 (out of 9) - praxis : 12 (out of 12) - abstract thinking : 6 (out of 8) - perception : 8 (out of 9) Executive Function : 17 (out of 28), 0 missed (out of 7 items) All missing items are recoded to 0 (i.e. incorrect) producing a conservative estimate of performance.

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CAMCOG-R Profile ---------------- | % of maximum Sub-section |0 20 40 60 80 100 -------------------------|-------|-------|-------|-------|-------| CAMCOG-R overall |*********************************** ( 92/105) orientation |**************************************** ( 10/ 10) comprehension |**************************************** ( 9/ 9) expression |******************************** ( 17/ 21) remote memory |********************************* ( 5/ 6) recent memory |**************************************** ( 4/ 4) new learning |******************************* ( 13/ 17) attention/calculation |************************************ ( 8/ 9) praxis |**************************************** ( 12/ 12) abstract thinking |****************************** ( 6/ 8) perception |************************************ ( 8/ 9) Executive function |************************ ( 17/ 28)

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Appendix IX- A simple genogram of Ron’s relationships (Case study)

Died 1998 Age 92

Died 1977 Age 77

Died 2001 Age 74

Ron

Elder brother died of lung cancer.

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