SOCW 6060 Walden Week 6 Cognitive Behavior Theory Case Study Discussion

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Humanities

SOCW 6060

Walden University

SOCW

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This week, your theoretical orientation is cognitive behavior theory. You will use the same case study that you chose in Week 2 and have been analyzing in this course. Use the "Dissecting a Theory and Its Application to a Case Study” worksheet to help you dissect the theory. You do not need to submit this handout. It is a tool for you to use to dissect the theory and then you can employ the information in the table to complete your assignment.

In this Assignment, you prepare a 5-minute video script. It is common to present a case analysis in multidisciplinary team meetings or with your supervisor and colleagues.

To prepare:

Use the same case study that you chose in Week 2.

(Tiffani Bradley)

Read this article listed in the Learning Resources: González-Prendes, A. A., & Thomas, S. A. (2009). Culturally sensitive treatment of anger in African American women: A single case study. Clinical Case Studies, 8(5), 383–402. https://doi-org.ezp.waldenulibrary.org/10.1177/153...

This article provides a nice framework for how the authors’ cognitive-behavioral theoretical orientation shaped the conceptualization of the case and assessment and intervention.

In 1 to 2 sentences, identify and describe the presenting problem.

In 1 to 2 sentences, briefly define and conceptualize the problem from a cognitive-behavioral theoretical orientation.

Formulate 2 assessment questions that you will ask the client to better understand the client’s problem. Remember, the assessment questions should be guided by cognitive-behavioral theory.

In 1 to 2 sentences, identify two goals for treatment. Again, remember, the goals should be consistent with cognitive-behavioral theory.

In 1 to 2 sentences, describe the treatment plan from a cognitive-behavioral theoretical orientation. Remember, the treatment plan should align with the goal(s) for work.

Discuss one outcome you would measure, if you were to evaluate whether the intervention worked, and explain how this is consistent with cognitive behavior theory. Evaluate one merit and one limitation of cognitive behavior theory as it relates to the case study.

Evaluate the application of cognitive-behavioral theory in relation to a diversity issue pertinent to the case.

Be sure to:

Identify and correctly reference the case study you have chosen.

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Theory Into Practice: Four Social Work Case Studies In this course, you select one of the following four case studies and use it throughout the entire course. By doing this, you will have the opportunity to see how different theories guide your view of a client and that client’s presenting problem. Each time you return to the same case, you use a different theory, and your perspective of the problem changes—which then changes how you ask assessment questions and how you intervene. These case studies are based on the video- and web-based case studies you encounter in the MSW program. Table of Contents Tiffani Bradley ................................................................................................................. 2 Paula Cortez ................................................................................................................... 9 Jake Levey .................................................................................................................... 10 Helen Petrakis ............................................................................................................... 13 1 Tiffani Bradley Identifying Data: Tiffani Bradley is a 16-year-old Caucasian female. She was raised in a Christian family in Philadelphia, PA. She is of German descent. Tiffani’s family consists of her father, Robert, 38 years old; her mother, Shondra, 33 years old, and her sister, Diana, 13 years old. Tiffani currently resides in a group home, Teens First, a brand new, court-mandated teen counseling program for adolescent victims of sexual exploitation and human trafficking. Tiffani has been provided room and board in the residential treatment facility for the past 3 months. Tiffani describes herself as heterosexual. Presenting Problem: Tiffani has a history of running away. She has been arrested on three occasions for prostitution in the last 2 years. Tiffani has recently been court ordered to reside in a group home with counseling. She has a continued desire to be reunited with her pimp, Donald. After 3 months at Teens First, Tiffani said that she had a strong desire to see her sister and her mother. She had not seen either of them in over 2 years and missed them very much. Tiffani is confused about the path to follow. She is not sure if she wants to return to her family and sibling or go back to Donald. Family Dynamics: Tiffani indicates that her family worked well together until 8 years ago. She reports that around the age of 8, she remembered being awakened by music and laughter in the early hours of the morning. When she went downstairs to investigate, she saw her parents and her Uncle Nate passing a pipe back and forth between them. She remembered asking them what they were doing and her mother saying, “adult things” and putting her back in bed. Tiffani remembers this happening on several occasions. Tiffani also recalls significant changes in the home's appearance. The home, which was never fancy, was always neat and tidy. During this time, however, dust would gather around the house, dishes would pile up in the sink, dirt would remain on the floor, and clothes would go for long periods of time without being washed. Tiffani began cleaning her own clothes and making meals for herself and her sister. Often there was not enough food to feed everyone, and Tiffani and her sister would go to bed hungry. Tiffani believed she was responsible for helping her mom so that her mom did not get so overwhelmed. She thought that if she took care of the home and her sister, maybe that would help mom return to the person she was before. Sometimes Tiffani and her sister would come downstairs in the morning to find empty beer cans and liquor bottles on the kitchen table along with a crack pipe. Her parents would be in the bedroom, and Tiffani and her sister would leave the house and go to school by themselves. The music and noise downstairs continued for the next 6 years, which escalated to screams and shouting and sounds of people fighting. Tiffani remembers her mom one morning yelling at her dad to “get up and go to work.” Tiffani and Diana saw their dad come out of the bedroom and slap their mom so hard she was knocked down. Dad then went back into the bedroom. Tiffani 2 remembers thinking that her mom was not doing what she was supposed to do in the house, which is what probably angered her dad. Shondra and Robert have been separated for a little over a year and have started dating other people. Diana currently resides with her mother and Anthony, 31 years old, who is her mother’s new boyfriend. Educational History: Tiffani attends school at the group home, taking general education classes for her general education development (GED) credential. Diana attends Town Middle School and is in the 8th grade. Employment History: Tiffani reports that her father was employed as a welding apprentice and was waiting for the opportunity to join the union. Eight years ago, he was laid off due to financial constraints at the company. He would pick up odd jobs for the next 8 years but never had steady work after that. Her mother works as a home health aide. Her work is part-time, and she has been unable to secure full-time work. Social History: Over the past 2 years, Tiffani has had limited contact with her family members and has not been attending school. Tiffani did contact her sister Diana a few times over the 2-year period and stated that she missed her very much. Tiffani views Donald as her “husband” (although they were never married) and her only friend. Previously, Donald sold Tiffani to a pimp, “John T.” Tiffani reports that she was very upset Donald did this and that she wants to be reunited with him, missing him very much. Tiffani indicates that she knows she can be a better “wife” to him. She has tried to make contact with him by sending messages through other people, as John T. did not allow her access to a phone. It appears that over the last 2 years, Tiffani has had neither outside support nor interactions with anyone beyond Donald, John T., and some other young women who were prostituting. Mental Health History: On many occasions Tiffani recalls that when her mother was not around, Uncle Nate would ask her to sit on his lap. Her father would sometimes ask her to show them the dance that she had learned at school. When she danced, her father and Nate would laugh and offer her pocket change. Sometimes, their friend Jimmy joined them. One night, Tiffani was awakened by her uncle Nate and his friend Jimmy. Her parents were apparently out, and they were the only adults in the home. They asked her if she wanted to come downstairs and show them the new dances she learned at school. Once downstairs Nate and Jimmy put some music on and started to dance. They asked Tiffani to start dancing with them, which she did. While they were dancing, Jimmy spilled some beer on her. Nate said she had to go to the bathroom to clean up. Nate, Jimmy, and Tiffani all went to the bathroom. Nate asked Tiffani to take her clothes off and get in the bath. Tiffani hesitated to do this, but Nate insisted it was OK since he and Jimmy were family. Tiffani eventually relented and began to wash up. Nate would tell her that she missed a spot and would scrub the area with his hands. Incidents like this continued to occur with increasing levels of molestation each time. 3 The last time it happened, when Tiffani was 14, she pretended to be willing to dance for them, but when she got downstairs, she ran out the front door of the house. Tiffani vividly remembers the fear she felt the nights Nate and Jimmy touched her, and she was convinced they would have raped her if she stayed in the house. About halfway down the block, a car stopped. The man introduced himself as Donald, and he indicated that he would take care of her and keep her safe when these things happened. He then offered to be her boyfriend and took Tiffani to his apartment. Donald insisted Tiffani drink beer. When Tiffani was drunk, Donald began kissing her, and they had sex. Tiffani was also afraid that if she did not have sex, Donald would not let her stay— she had nowhere else to go. For the next 3 days, Donald brought her food and beer and had sex with her several more times. Donald told Tiffani that she was not allowed to do anything without his permission. This included watching TV, going to the bathroom, taking a shower, and eating and drinking. A few weeks later, Donald bought Tiffani a dress, explaining to her that she was going to “find a date” and get men to pay her to have sex. When Tiffani said she did not want to do that, Donald hit her several times. Donald explained that if she didn’t do it, he would get her sister Diana and make her do it instead. Out of fear for her sister, Tiffani relented and did what Donald told her to do. She thought at this point her only purpose in life was to be a sex object, listen, and obey—and then she would be able to keep the relationships and love she so desired. Legal History: Tiffani has been arrested three times for prostitution. Right before the most recent charge, a new state policy was enacted to protect youth 16 years and younger from prosecution and jail time for prostitution. The Safe Harbor for Exploited Children Act allows the state to define Tiffani as a sexually exploited youth, and therefore the state will not imprison her for prostitution. She was mandated to services at the Teens First agency, unlike her prior arrests when she had been sent to detention. Alcohol and Drug Use History: Tiffani’s parents were social drinkers until about 8 years ago. At that time Uncle Nate introduced them to crack cocaine. Tiffani reports using alcohol when Donald wanted her to since she wanted to please him, and she thought this was the way she would be a good “wife.” She denies any other drug use. Medical History: During intake, it was noted that Tiffani had multiple bruises and burn marks on her legs and arms. She reported that Donald had slapped her when he felt she did not behave and that John T. burned her with cigarettes. She had realized that she did some things that would make them mad, and she tried her hardest to keep them pleased even though she did not want to be with John T. Tiffani has been treated for several sexually transmitted infections (STIs) at local clinics and is currently on an antibiotic for a kidney infection. Although she was given condoms by Donald and John T. for her “dates,” there were several “Johns” who refused to use them. 4 Strengths: Tiffani is resilient in learning how to survive the negative relationships she has been involved with. She has as sense of protection for her sister and will sacrifice herself to keep her sister safe. Robert Bradley: father, 38 years old Shondra Bradley: mother, 33 years old Nate Bradley: uncle, 36 years old Tiffani Bradley: daughter, 16 years old Diana Bradley: daughter, 13 years old Donald: Tiffani’s self-described husband and her former pimp Anthony: Shondra’s live-in partner, 31 years old John T.: Tiffani’s most recent pimp 5 Paula Cortez Identifying Data: Paula Cortez is a 43-year-old Catholic Hispanic female residing in New York City, NY. Paula was born in Colombia. When she was 17 years old, Paula left Colombia and moved to New York where she met David, who later became her husband. Paula and David have one son, Miguel, 20 years old. They divorced after 5 years of marriage. Paula has a five-year-old daughter, Maria, from a different relationship. Presenting Problem: Paula has multiple medical issues, and there is concern about whether she will be able to continue to care for her youngest child, Maria. Paula has been overwhelmed, especially since she again stopped taking her medication. Paula is also concerned about the wellness of Maria. Family Dynamics: Paula comes from a moderately well-to-do family. Paula reports suffering physical and emotional abuse at the hands of both her parents, eventually fleeing to New York to get away from the abuse. Paula comes from an authoritarian family where her role was to be “seen and not heard.” Paula states that she did not feel valued by any of her family members and reports never receiving the attention she needed. As a teenager, she realized she felt “not good enough” in her family system, which led to her leaving for New York and looking for “someone to love me.” Her parents still reside in Colombia with Paula’s two siblings. Paula met David when she sought to purchase drugs. They married when Paula was 18 years old. The couple divorced after 5 years of marriage. Paula raised Miguel, mostly by herself, until he was 8 years old, at which time she was forced to relinquish custody due to her medical condition. Paula maintains a relationship with her son, Miguel, and her ex-husband, David. Miguel takes part in caring for his half-sister, Maria. Paula does believe her job as a mother is to take care of Maria but is finding that more and more challenging with her physical illnesses. Employment History: Paula worked for a clothing designer, but she realized that her true passion was painting. She has a collection of more than 100 drawings and paintings, many of which track the course of her personal and emotional journey. Paula held a fulltime job for a number of years before her health prevented her from working. She is now unemployed and receives Supplemental Security Disability Insurance (SSD) and Medicaid. Miguel does his best to help his mom but only works part time at a local supermarket delivering groceries. Paula currently uses federal and state services. Paula successfully applied for WIC, the federal Supplemental Nutrition Program for Women, Infants, and Children. Given Paula’s low income, health, and Medicaid status, Paula is able to receive in-home childcare assistance through New York’s public assistance program. 6 Social History: Paula is bilingual, fluent in both Spanish and English. Although Paula identifies as Catholic, she does not consider religion to be a big part of her life. Paula lives with her daughter in an apartment in Queens, NY. Paula is socially isolated as she has limited contact with her family in Colombia and lacks a peer network of any kind in her neighborhood. Five (5) years ago Paula met a man (Jesus) at a flower shop. They spoke several times. He would visit her at her apartment to have sex. Since they had an active sex life, Paula thought he was a “stand-up guy” and really liked him. She believed he would take care of her. Soon everything changed. Paula began to suspect that he was using drugs, because he had started to become controlling and demanding. He showed up at her apartment at all times of the night demanding to be let in. He called her relentlessly, and when she did not pick up the phone, he left her mean and threatening messages. Paula was fearful for her safety and thought her past behavior with drugs and sex brought on bad relationships with men and that she did not deserve better. After a couple of months, Paula realized she was pregnant. Jesus stated he did not want anything to do with the “kid” and stopped coming over, but he continued to contact and threaten Paula by phone. Paula has no contact with Jesus at this point in time due to a restraining order. Mental Health History: Paula was diagnosed with bipolar disorder. She experiences periods of mania lasting for a couple of weeks then goes into a depressive state for months when not properly medicated. Paula has a tendency toward paranoia. Paula has a history of not complying with her psychiatric medication treatment because she does not like the way it makes her feel. She often discontinues it without telling her psychiatrist. Paula has had multiple psychiatric hospitalizations but has remained out of the hospital for the past 5 years. Paula accepts her bipolar diagnosis but demonstrates limited insight into the relationship between her symptoms and her medication. Paula reports that when she was pregnant, she was fearful for her safety due to the baby’s father’s anger about the pregnancy. Jesus’ relentless phone calls and voicemails rattled Paula. She believed she had nowhere to turn. At that time, she became scared, slept poorly, and her paranoia increased significantly. After completing a suicide assessment 5 years ago, it was noted that Paula was decompensating quickly and was at risk of harming herself and/or her baby. Paula was involuntarily admitted to the psychiatric unit of the hospital. Paula remained on the unit for 2 weeks. Educational History: Paula completed high school in Colombia. Paula had hoped to attend the Fashion Institute of Technology (FIT) in New York City, but getting divorced, then raising Miguel on her own interfered with her plans. Miguel attends college full time in New York City. Medical History: Paula was diagnosed as HIV positive 15 years ago. Paula acquired AIDS three years later when she was diagnosed with a severe brain infection and a Tcell count of less than 200. Paula’s brain infection left her completely paralyzed on the right side. She lost function in her right arm and hand as well as the ability to walk. After 7 a long stay in an acute care hospital in New York City, Paula was transferred to a skilled nursing facility (SNF) where she thought she would die. After being in the skilled nursing facility for more than a year, Paula regained the ability to walk, although she does so with a severe limp. She also regained some function in her right arm. Her right hand (her dominant hand) remains semi-paralyzed and limp. Over the course of several years, Paula taught herself to paint with her left hand and was able to return to her beloved art. Paula began treatment for her HIV/AIDS with highly active antiretroviral therapy (HAART). Since she ran away from the family home, married and divorced a drug user, then was in an abusive relationship, Paula thought she deserved what she got in life. She responded well to HAART and her HIV/AIDS was well controlled. In addition to her HIV/AIDS disease, Paula is diagnosed with Hepatitis C (Hep C). While this condition was controlled, it has reached a point where Paula’s doctor is recommending she begin a new treatment. Paula also has significant circulatory problems, which cause her severe pain in her lower extremities. She uses prescribed narcotic pain medication to control her symptoms. Paula’s circulatory problems have also led to chronic ulcers on her feet that will not heal. Treatment for her foot ulcers demands frequent visits to a wound care clinic. Paula’s pain paired with the foot ulcers make it difficult for her to ambulate and leave her home. Paula has a tendency not to comply with her medical treatment. She often disregards instructions from her doctors and resorts to holistic treatments like treating her ulcers with chamomile tea. When she stops her treatment, she deteriorates quickly. Maria was born HIV negative and received the appropriate HAART treatment after birth. She spent a week in the neonatal intensive care unit as she had to detox from the effects of the pain medication Paula took throughout her pregnancy. Legal History: Previously, Paula used the AIDS Law Project, a not-for-profit organization that helps individuals with HIV address legal issues, such as those related to the child’s father . At that time, Paula filed a police report in response to Jesus' escalating threats and successfully got a restraining order. Once the order was served, the phone calls and visits stopped, and Paula regained a temporary sense of control over her life. Paula completed the appropriate permanency planning paperwork with the assistance of the organization The Family Center. She named Miguel as her daughter’s guardian should something happen to her. Alcohol and Drug Use History: Paula became an intravenous drug user (IVDU), using cocaine and heroin, at age 17. David was one of Paula’s “drug buddies” and suppliers. Paula continued to use drugs in the United States for several years; however, she stopped when she got pregnant with Miguel. David continued to use drugs, which led to the failure of their marriage. Strengths: Paula has shown her resilience over the years. She has artistic skills and has found a way to utilize them. Paula has the foresight to seek social services to help her 8 and her children survive. Paula has no legal involvement. She has the ability to bounce back from her many physical and health challenges to continue to care for her child and maintain her household. David Cortez: father, 46 years old Paula Cortez: mother, 43 years old Miguel Cortez: son, 20 years old Jesus (unknown): Maria’s father, 44 years old Maria Cortez: daughter, 5 years old 9 Jake Levy Identifying Data: Jake Levy is a 31-year-old, married, Jewish Caucasian male. Jake’s wife, Sheri, is 28 years old. They have two sons, Myles (10) and Levi (8). The family resides in a two-bedroom condominium in a middle-class neighborhood in Rockville, MD. They have been married for 10 years. Presenting Problem: Jake, an Iraq War veteran, came to the Veterans Affairs Health Care Center (VA) for services because his wife has threatened to leave him if he does not get help. She is particularly concerned about his drinking and lack of involvement in their sons’ lives. She told him his drinking has gotten out of control and is making him mean and distant. Jake reports that he and his wife have been fighting a lot and that he drinks to take the edge off and to help him sleep. Jake expresses fear of losing his job and his family if he does not get help. Jake identifies as the primary provider for his family and believes that this is his responsibility as a husband and father. Jake realizes he may be putting that in jeopardy because of his drinking. He says he has never seen Sheri so angry before, and he saw she was at her limit with him and his behaviors. Family Dynamics: Jake was born in Alabama to a Caucasian, Eurocentric family system. He reports his time growing up to have been within a “normal” family system. However, he states that he was never emotionally close to either parent and viewed himself as fairly independent from a young age. His dad had previously been in the military and was raised with the understanding that his duty is to support his country. His family displayed traditional roles, with his dad supporting the family after he was discharged from military service. Jake was raised to believe that real men do not show weakness and must be the head of the household. Jake’s parents are deceased, and he has a sister who lives outside London. He and his sister are not very close but do talk twice a year. Sheri is an only child, and although her mother lives in the area, she offers little support. Her mother never approved of Sheri marrying Jake and thinks Sheri needs to deal with their problems on her own. Jake reports that he has not been engaged with his sons at all since his return from Iraq, and he keeps to himself when he is at home. Employment History: Jake is employed as a human resources assistant for the military. Jake works in an office with civilians and military personnel and mostly gets along with people in the office. Jake is having difficulty getting up in the morning to go to work, which increases the stress between Sheri and himself. Shari is a special education teacher in a local elementary school. Jake thinks it is his responsibility to provide for his family and is having stress over what is happening to him at home and work. He thinks he is failing as a provider. Social History: Jake and Sheri identify as Jewish and attend a local synagogue on major holidays. Jake tends to keep to himself and says he sometimes feels pressured to be more communicative and social. Jake believes he is socially inept 10 and not able to develop friendships. The couple has some friends, since Shari gets involved with the parents in their sons’ school. However, because of Jake’s recent behaviors, they have become socially isolated. He is very worried that Sheri will leave him due to the isolation. Mental Health History: Jake reports that since his return to civilian life 10 months ago, he has difficulty sleeping, frequent heart palpitations, and moodiness. Jake had seen Dr. Zoe, a psychiatrist at the VA, who diagnosed him with post-traumatic stress disorder (PTSD). Dr. Zoe prescribed Paxil to help reduce his symptoms of anxiety and depression and suggested that he also begin counseling. Jake says that he does not really understand what PTSD is but thought it meant that a person who had it was “going crazy,” which at times he thought was happening to him. He expresses concern that he will never feel “normal” again and says that when he drinks alcohol, his symptoms and the intensity of his emotions ease. Jake describes that he sometimes thinks he is back in Iraq, which makes him feel uneasy and watchful. He hates the experience and tries to numb it. He has difficulty sleeping and is irritable, so he isolates himself and soothes this with drinking. He talks about always feeling “ready to go.” He says he is exhausted from being always alert and looking for potential problems around him. Every sound seems to startle him. He shares that he often thinks about what happened “over there” but tries to push it out of his mind. Nighttime is the worst, as he has terrible recurring nightmares of one particular event. He says he wakes up shaking and sweating most nights. He adds that drinking is the one thing that seems to give him a little relief. Educational History: Sheri has a bachelor’s degree in special education from a local college. Jake has a high school diploma but wanted to attend college upon his return from the military. Military History: Jake is an Iraqi War veteran. He enlisted in the Marines at 21 years old when he and Shari got married due to Sheri being pregnant. The family was stationed in several states prior to Jake being deployed to Iraq. Jake left the service 10 months ago. Sheri and Jake had used military housing since his marriage, making it easier to support the family. On military bases, there was a lot of social support and both Jake and Sheri took full advantage of the social systems available to them during that time. Medical History: Jake is physically fit, but an injury he sustained in combat sometimes limits his ability to use his left hand. Jake reports sometimes feeling inadequate because of the reduction in the use of his hand and tries to push through because he worries how the injury will impact his responsibilities as a provider, husband, and father. Jake considers himself resilient enough to overcome this disadvantage and “be able to do the things I need to do.” Sheri is in good physical condition and has recently found out that she is pregnant with their third child. Legal History: Jake and Sheri deny having criminal histories. 11 Alcohol and Drug Use History: As teenagers, Jake and Sheri used marijuana and drank. Both deny current use of marijuana but report they still drink. Sheri drinks socially and has one or two drinks over the weekend. Jake reports that he has four to five drinks in the evenings during the week and eight to ten drinks on Saturdays and Sundays. Jake spends his evenings on the couch drinking beer and watching TV or playing video games. Shari reports that Jake drinks more than he realizes, doubling what Jake has reported. Strengths: Jake is cognizant of his limitations and has worked on overcoming his physical challenges. Jake is resilient. Jake did not have any disciplinary actions taken against him in the military. He is dedicated to his wife and family. Jake Levy: father, 31 years old Sheri Levy: mother, 28 years old Myles Levy: son, 10 years old Levi Levy: son, 8 years old 12 Helen Petrakis Identifying Data: Helen Petrakis is a 52-year-old, Caucasian female of Greek descent living in a four-bedroom house in Tarpon Springs, FL. Her family consists of her husband, John (60), son, Alec (27), daughter, Dmitra (23), and daughter Althima (18). John and Helen have been married for 30 years. They married in the Greek Orthodox Church and attend services weekly. Presenting Problem: Helen reports feeling overwhelmed and “blue.” She was referred by a close friend who thought Helen would benefit from having a person who would listen. Although she is uncomfortable talking about her life with a stranger, Helen says that she decided to come for therapy because she worries about burdening friends with her troubles. John has been expressing his displeasure with meals at home, as Helen has been cooking less often and brings home takeout. Helen thinks she is inadequate as a wife. She states that she feels defeated; she describes an incident in which her son, Alec, expressed disappointment in her because she could not provide him with clean laundry. Helen reports feeling overwhelmed by her responsibilities and believes she can’t handle being a wife, mother, and caretaker any longer. Family Dynamics: Helen describes her marriage as typical of a traditional Greek family. John, the breadwinner in the family, is successful in the souvenir shop in town. Helen voices a great deal of pride in her children. Dmitra is described as smart, beautiful, and hardworking. Althima is described as adorable and reliable. Helen shops, cooks, and cleans for the family, and John sees to yard care and maintaining the family’s cars. Helen believes the children are too busy to be expected to help around the house, knowing that is her role as wife and mother. John and Helen choose not to take money from their children for any room or board. The Petrakis family holds strong family bonds within a large and supportive Greek community. Helen is the primary caretaker for Magda (John’s 81-year-old widowed mother), who lives in an apartment 30 minutes away. Until recently, Magda was self-sufficient, coming for weekly family dinners and driving herself shopping and to church. Six months ago, she fell and broke her hip and was also recently diagnosed with early signs of dementia. Helen and John hired a reliable and trusted woman temporarily to check in on Magda a couple of days each week. Helen would go and see Magda on the other days, sometimes twice in one day, depending on Magda’s needs. Helen would go food shopping for Magda, clean her home, pay her bills, and keep track of Magda’s medications. Since Helen thought she was unable to continue caretaking for both Magda and her husband and kids, she wanted the helper to come in more often, but John said they could not afford it. The money they now pay to the helper is coming out of the couple’s vacation savings. Caring for Magda makes Helen think she is failing as a wife and mother because she no longer has time to spend with her husband and children. 13 Helen spoke to her husband, John (the family decision maker), and they agreed to have Alec (their son) move in with Magda (his grandmother) to help relieve Helen’s burden and stress. John decided to pay Alec the money typically given to Magda’s helper. This has not decreased the burden on Helen since she had to be at the apartment at least once daily to intervene with emergencies that Alec is unable to manage independently. Helen’s anxiety has increased since she noted some of Magda’s medications were missing, the cash box was empty, Magda’s checkbook had missing checks, and jewelry from Greece, which had been in the family for generations, was also gone. Helen comes from a close-knit Greek Orthodox family where women are responsible for maintaining the family system and making life easier for their husbands and children. She was raised in the community where she currently resides. Both her parents were born in Greece and came to the United States after their marriage to start a family and give them a better life. Helen has a younger brother and a younger sister. She was responsible for raising her siblings since both her parents worked in a fishery they owned. Helen feared her parents’ disappointment if she did not help raise her siblings. Helen was very attached to her parents and still mourns their loss. She idolized her mother and empathized with the struggles her mother endured raising her own family. Helen reports having that same fear of disappointment with her husband and children. Employment History: Helen has worked part time at a hospital in the billing department since graduating from high school. John Petrakis owns a Greek souvenir shop in town and earns the larger portion of the family income. Alec is currently unemployed, which Helen attributes to the poor economy. Dmitra works as a sales consultant for a major department store in the mall. Althima is an honors student at a local college and earns spending money as a hostess in a family friend’s restaurant. During town events, Dmitra and Althima help in the souvenir shop when they can. Social History: The Petrakis family live in a community centered on the activities of the Greek Orthodox Church. Helen has used her faith to help her through the more difficult challenges of not believing she is performing her “job” as a wife and mother. Helen reports that her children are religious but do not regularly go to church because they are very busy. Helen has stopped going shopping and out to eat with friends because she can no longer find the time since she became a caretaker for Magda. Mental Health History: Helen consistently appears well groomed. She speaks clearly and in moderate tones and seems to have linear thought progression—her memory seems intact. She claims no history of drug or alcohol abuse, and she does not identify a history of trauma. More recently, Helen is overwhelmed by thinking she is inadequate. She stopped socializing and finds no activity enjoyable. In some situations in her life, she is feeling powerless. 14 Educational History: Helen and John both have high school diplomas. Helen is proud of her children knowing she was the one responsible in helping them with their homework. Alec graduated high school and chose not to attend college. Dmitra attempted college but decided that was not the direction she wanted. Althima is an honors student at a local college. Medical History: Helen has chronic back pain from an old injury, which she manages with acetaminophen as needed. Helen reports having periods of tightness in her chest and a feeling that her heart was racing along with trouble breathing and thinking that she might pass out. One time, John brought her to the emergency room. The hospital ran tests but found no conclusive organic reason to explain Helen’s symptoms. She continues to experience shortness of breath, usually in the morning when she is getting ready to begin her day. She says she has trouble staying asleep, waking two to four times each night, and she feels tired during the day. Working is hard because she is more forgetful than she has ever been. Helen says that she feels like her body is one big tired knot. Legal History: The only member of the Petrakis family that has legal involvement is Alec. He was arrested about 2 years ago for possession of marijuana. He was required to attend an inpatient rehabilitation program (which he completed) and was sentenced to 2 years’ probation. Helen was devastated, believing John would be disappointed in her for not raising Alec properly. Alcohol and Drug Use History: Helen has no history of drug use and only drinks at community celebrations. Alec has struggled with drugs and alcohol since he was a teen. Helen wants to believe Alec is maintaining his sobriety and gives him the benefit of the doubt. Alec is currently on 2 years’ probation for possession and has recently completed an inpatient rehabilitation program. Helen feels responsible for his addiction and wonders what she did wrong as a mother. Strengths: Helen has a high school diploma and has been successful at raising her family. She has developed a social support system, not only in the community but also within her faith at the Greek Orthodox Church. Helen is committed to her family system and their success. Helen does have the ability to multitask, taking care of her immediate family as well as fulfilling her obligation to her mother-in-law. Even under the current stressful circumstances, Helen is assuming and carrying out her responsibilities. John Petrakis: father, 60 years old Helen Petrakis: mother, 52 years old Alec Petrakis: son, 27 years old Dmitra Petrakis: daughter, 23 years old Althima Petrakis: daughter, 18 years old Magda Petrakis: John’s mother, 81 years old 15 Culturally Sensitive Treatment of Anger in African American Women: A Single Case Study Clinical Case Studies 8(5) 383­–402 © The Author(s) 2009 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1534650109345004 http://ccs.sagepub.com A. Antonio González-Prendes and Shirley A. Thomas Abstract Culturally sensitive clinical practice challenges practitioners to recognize the cultural significance and importance of clients’ behaviors and belief systems. This article reports a case study of the treatment of anger in an African American woman. Presented within a framework of cognitivebehavioral theory, the case illuminates three important issues that influence experience and expression of anger in African American women: the influence of gender role socialization on the mode of anger expression; the experience of powerlessness, rooted in historical and contemporary discriminatory and oppressive realities; and culture-related messages that create unrealistic expectations of strength. The article addresses conceptualization, assessment, treatment processes, and clinical strategies, as well as limitations of a single case study, implications for practice and recommendations for future research. Keywords African American women, anger treatment, cultural sensitivity, cognitive-behavioral 1 Theoretical and Research Basis Culturally sensitive treatment approaches must be able to conceptualize, recognize, and evaluate the client’s belief system and behaviors within the context of the client’s gender, race and culture, among other factors. This is particularly important when working with individuals from minorities and other traditionally disempowered groups, whose beliefs and behaviors run the risk of being pathologized when taken out of the context of their cultures and measured against the standards of the dominant group. This article presents and discusses, within the framework of a case study, central elements of a culturally sensitive approach to the treatment of anger problems in an African American woman. The conceptual model for the treatment approach suggests that, if anger in African American women is to be understood accurately, it must be viewed through the twin prisms of gender and race (Thomas & González-Prendes, 2009). Previous studies have underscored the idea that, in order to develop an accurate understanding of the emotional experience of women of color, one must be able to integrate issues related to gender, culture, and race Wayne State University Corresponding Author: A. Antonio González-Prendes, Wayne State University, School of Social Work, 4756 Cass Avenue, Room #301, Detroit, MI 48202 Email: aa3232@wayne.edu 384 Clinical Case Studies 8(5) (King, 1988, 2005). More specifically, related to women’s anger, deMarraias and Tisdale (2002) emphasized that emotions are sensitive to the contexts in which such emotions are experienced. Therefore, we propose that if anger treatment in African American women is to be successful, it must address the contextual nature of that anger, as well as gender-role and cultural expectations that have engendered beliefs that affect the experience and expression of anger in those women. The model suggests that there are three central themes that underscore their experience and expression of anger: the influence of gender-role socialization messages that dictate to the woman “socially appropriate” ways to express her anger; culture-related messages translated into beliefs or self-imposed demands that set up unrealistic expectations of “strength” among African American women; and the experience of powerlessness often rooted in historical as well as present-day situations of discrimination and disempowerment. Limitations of Current Anger Research A review of current anger research literature reveals several critical limitations. As DiGiuseppe and Tafrate (2003) have noted, anger research has relied too heavily on college student populations. This focus makes it difficult, if not impossible, to generalize those findings to community-based samples of individuals with anger problems. Another significant limitation is the overwhelming use of samples that are either entirely or overwhelmingly male. GonzálezPrendes (2008) reviewed a series of meta-analytic studies addressing the effectiveness of anger research (Beck & Fernandez, 1998; DelVecchio & O’Leary, 2004; DiGiuseppe & Tafrate, 2003; Edmondson & Conger, 1996) and reported that, of a total of 148 studies in the meta-analyses, only two, both unpublished dissertations, focused exclusively on women. Furthermore, none of the available studies focused exclusively on women of color. The need for more research among racial and ethnic minorities has also been addressed in the United States Department of Health and Human Services Surgeon General’s report discussing the impact of culture, race and ethnicity on mental health (USDHHS, 2001). Yet, as clinical practice has emphasized the need for evidence-based practices, it is imperative to produce more clinical research that examines the effectiveness of clinical methods with minority populations. Although a single case study has intrinsic limitations discussed elsewhere in this article, it illuminates specific theoretical concepts, client variables, and practice concerns that could lead to larger empirical research studies. Adaptive-Healthy Versus Maladaptive-Unhealthy Anger When discussing anger, it is imperative to differentiate between healthy and unhealthy types. Anger is a normal and common human emotion that, in itself, is neither good nor bad; and indeed anger often may play a positive adaptive and functional role for the individual. Therefore, anger treatment does not focus on the total elimination of anger, but rather it focuses on enhancing the healthy expression of it. Healthy anger is experienced through the realistic and rational processing of information and environmental cues and with mild to moderate levels of internal physiological arousal. This type of anger allows the person to organize cognitive, physical, emotional, and behavioral capabilities in order to take prosocial constructive action to resolve a problem. This often includes the ability to express one’s angry feelings directly, openly, and appropriately in a way that facilitates healthy outcomes, while at the same time, respecting the rights and dignity of the other person or entity. However, anger becomes toxic for some individuals, when it becomes harmful and destructive to self and others. These individuals may experience internal hyperarousal and find themselves either “stuffing” their angry feelings, using aggression, or diverting their anger to González-Prendes and Thomas 385 other psychopathologies such as substance abuse (Gilbert, Gilbert, & Schultz, 1998; Larimer, Palmer, & Marlatt, 1999; DeMoja & Spielberger, 1997), self-cutting (Abu-Madini & Rahim, 2001; Harris, 2000; Matsumoto et al., 2004), and bulimia (Meyer et al., 2005). Toxic anger is a significant internal stressor that increases the risk of health problems such as: hypertension (Webb & Beckstead, 2005), coronary heart disease (Bongard, al’Absi & Lovallo, 1997; WarrenFindlow, 2006), cancer (Andersen, Farrar, & Golden-Kreutz, 1998); and obesity (Robert & Reither, 2004; Wamala, Wolk, & Orth-Gomer, 1997). As Thomas (1995) has suggested these are conditions that disproportionately impact the health of African Americans. Cognitive Theory and Anger A detailed discussion of cognitive theory is beyond the scope of this article. However, it is important to underscore that cognitive theory rests on key fundamental assumptions which suggest that cognitive activity affects emotions and behaviors; that the content and process of such activity can be monitored and changed; and that, by restructuring cognitions in a more rational and balanced direction, one can achieve behavioral and emotional changes and reduce symptoms (Dobson & Dobson, 2009; Dobson & Dozois, 2001). Cognitive therapy approaches (Beck, 1976; Ellis, 1962) have been used extensively to address a number of emotional and behavioral problems including, as indicated earlier, the treatment of anger. From a cognitive-theory perspective, the experienced of anger has been associated with cognitive processes such as: the threat to or perception of loss of a valued object in one’s life (Beck, 1999); external attributions of blame that lay responsibility for one’s loss on an identified “transgressor” (Averill, 1982; Beck; DiGiuseppe, 1995; Hareli & Weiner, 2002); rigid demands (Eckhardt & Jamison, 2002; Deffenbacher, 1999; Ellis, 2003; Ellis & Tafrate, 1997); attributions of intentionality or personalization (Epps & Kendall, 1995; González-Prendes & Jozefowicz-Simbeni, 2009; Girodo, 1998); and condemnation or denigration of the identified transgressor (Beck; Eckhardt & Kassinove, 1998; Ellis & Tafrate). In defining the experience of anger, Kassinove and Sukhodolsky (1995) suggest that anger is: A negative phenomenological (or internal) feeling state associated with specific cognitive and perceptual distortions and deficiencies (e.g. misappraisals, errors, attributions of blame, injustice, preventability, intentionality), subjective labeling, physiological changes, and action tendencies to engage in socially constructed and reinforced organized behavioral scripts (p. 7). Anger and African American Women The experience of anger in African American women must take into account factors such as gender-role and culture-bound messages, as well as the realities of powerlessness. Addressing the issue of gender-role socialization, several authors (Cox, Stabb, & Bruckner, 1999; Cox, Van Velsor, & Hulgus, 2004; Hatch & Forgays, 2001; Munhall, 1993; Sharkin, 1993) have suggested that cultural expectations and gender-role socialization messages shape the manner in which anger is experienced and expressed by women. Such messages, reinforced from an early age, discourage women from expressing anger directly and promote the view that such direct expression threatens the stability of their relationships. The outcome of these dynamics, according to Cox and colleagues, is that women often find themselves diverting or rerouting their anger expression in four ways: containment (e.g., a conscious attempt to avoid expressing anger, often accompanied by prolonged physical responses); internalization (e.g., suppression); segmentation 386 Clinical Case Studies 8(5) (e.g., dissociation from angry feelings, with little or no awareness of them); and externalization (e.g., use of aggression or projection of blame for one’s uncomfortable feelings). Besides the socialization process that African American women are exposed to as a function of their gender, they also may be influenced by culture-bound expectations of strength. Beaubeouf-Lafontant (2007) argued that the concept of the strong African American woman is grounded on problematic assumptions that create unrealistic characterization, demands and expectations that tyrannize African American women and, paradoxically, increases their risk of depression and other emotional distress. Similarly, Harris (1995) suggested that this notion of “strength” may often cut both ways: in one way it can be seen as a virtue needed to overcome adversity; on the other hand, it may create the false image of a “superwoman,” who sees it as her duty to help others, while ignoring her own distress. Harris (1995) goes on to state “this thing called strength, this thing we applaud so much in Black women, could also be a disease” (p. 1). As Thompkins (2004) asserted, too often the ideal of the strong back woman compels the woman to assume the role of caregiver, engaging in self-sacrifice and self-denial to attend to the needs of others. The woman may then find herself caught in a double-bind: on the one hand she may experience anger and resentment related to the lack of control over her own life and the lack of attention to her own needs, and on the other hand she may feel that expressing anger and dissatisfaction is nothing more than complaining, and therefore a sign of weakness. It might then follow that legitimate anger feelings are left in silence or diverted into other forms of anger expression (Cox et al., 1999; Cox et al., 2004). Another significant factor that influences anger in women is powerlessness (Fields et al., 1998; Thomas, 1995; Thomas & González-Prendes, 2009). Although the experience of powerlessness seems to be more common among African-American women, who are more likely to suffer from disparities related to income, education, employment, and poverty, the disempowering experience also affects middle-class African American women, even those who have achieved relative professional success (Fields et al., 1998; Richie et al., 1997). It could be argued that a feeling of powerlessness in African Americans is not only a function of socioeconomic disparities but also could be paradoxically influenced by the same culture-bound messages of strength that create unrealistic expectations for African American women. By emphasizing the importance of caregiving, self-denial and enduring adversities against all costs, paradoxically the woman may be left feeling less control over her own life. Perceived control and optimism have been associated with less emotional distress (i.e., depression and anger) among women experiencing a high number of exposures to acute and chronic stressors (Grote, Bledsoe, Larkin, Lemay, & Brown, 2007). Mabry and Kiecolt (2005) have proposed that a sense of control, the idea that one controls one’s outcomes, mediates the experience of anger more for African Americans than for Whites. 2 Case Introduction Karen is a 51-year-old, single, African American woman with one adult daughter and two grandchildren. She has a master’s degree in education and has completed all the course work for a doctoral degree in counseling. She has been a public school teacher for nearly 30 years. She is well-liked and well-respected by her students and colleagues. Karen, the oldest of three siblings, comes from a family in which women were viewed as strong, determined, self-reliable, and striving to improve their lives by working to achieve the top of their potential. That path had been established for generations, and was most evident in the example set by Karen’s mother, a single mother who, while living in a low-income housing project in St. Louis, Missouri, had worked full-time to support her family. She also attended law school in the evenings, and eventually graduated. González-Prendes and Thomas 387 3 Presenting Complaints Karen initially went to see her primary-care physician, complaining of physical symptoms, including headaches, high blood pressure, poor sleep, and feelings of tenseness and fatigue. In addition, Karen had related that over the past year she had struggled with on-and-off depressed mood, crying spells, social isolation, irritability, and anger bouts. Her anger bouts, although often felt in silence, were at times punctuated by verbal outbursts directed at an individual or entity. Karen tended to feel the episodic bouts of depression following her anger episodes. Upon examining her, the physician recognized that Karen’s symptoms were likely related to multiple personal and occupational stressors that Karen was facing and for which she had not allowed herself the time to process and find a healthy resolution. The physician suggested that Karen seek professional counseling to help her address some of those stressors. 4 History During her initial visit, Karen related how, in the past year and half she had experienced a number of significant losses in her life including the deaths of her brother, sister, and father. At about the time that Karen sought treatment, her oldest daughter had been diagnosed with terminal cancer and her step-father, the man she thought of as her father, had been diagnosed with a malignant brain tumor. Since Karen’s mother was advancing in years and struggling with her own health issues, Karen had assumed the role of major caregiver; this while still handling her full-time employment responsibilities as a teacher, as well as other personal responsibilities. Karen also related how over the past 2 years she had witnessed the steady deterioration of the educational atmosphere at the public school where she taught and the administration’s apparent unwillingness to address important issues. Teaching was Karen’s passion. She was extremely dedicated to her students and strived to provide them with the best learning experience, in the face of increasing difficulties in the urban school in an area of the city populated by low-income people. During the past year, there had been an increased in gang activity and the level of violence had increased both inside the school and in the surrounding area. On a number of occasions, the school had gone on “lockdown,” while the police swept the building to search for gang members and weapons. Teachers often felt that they worked in an unsafe environment, with a lack of supplies adequate to perform their duties. Karen, along with other teachers, also felt that the school administration did not care about improving the educational environment. The increasingly chaotic work environment prompted Karen to start questioning whether to continue teaching. This created a great deal of consternation because she found deep meaning and sense of personal satisfaction in her teaching, particularly to disadvantaged, disempowered, and underprivileged students. Karen’s frustration grew as her effort for advocacy and action appeared to fall on deaf ears. Although initially she did not recognize it or acknowledge it overtly, Karen often felt a profound sense of powerlessness in the face of such personal and professional stressors. In the face of that powerlessness Karen would find herself alternatively blaming others (i.e., the school administration, society, etc.) and experiencing intense anger, or blaming herself as being “weak” and “not strong enough” and feeling depressed. Reacting to these multiple losses and issues in her life, Karen projected a cynical view of the world. She saw the world as a “cold and calloused place” and people as “uncaring.” At times she questioned if she were doing a disservice to her students by trying to inject them with hope, when she “knew” they would be mistreated by the “unfair and uncertain” future that her students were about to face in life. Nonetheless, Karen presented with a number of significant strengths that would be considered throughout the course of treatment. Internally, Karen was an intelligent, insightful, and creative 388 Clinical Case Studies 8(5) woman with a particular aptitude for music and writing poetry. Although she was not a religious person, she saw herself as highly spiritual. Throughout her life she had been an activist, fighting for women’s issues as well as confronting racism, sexism, and other forms of discrimination and oppression of disempowered populations. Externally, Karen seemed to have a healthy support network made up of family and friends. She belonged to various civic groups. However, when in need, she felt hesitant and reluctant to use that support as she did not want to “burden others with my problems.” On the contrary, she was the one that others came to when they needed support or advice. Her narrative seemed punctuated by a prevailing theme: the need to be “strong” in the face of adversity. She recognized that that often meant that she could not allow herself to appear vulnerable to others. Others viewed her as the one who “kept it together.” Often she found herself attending to others’ needs and striving to make things better for them, even when she felt overburdened by doing so. That need to be “strong” was passed on to Karen in overt and covert messages and actions by her mother. Her mother’s stoic determination made a significant impact on Karen’s view of self, others and the world; the fact that her mother had raised her family as a single parent while going to law school and becoming an attorney and a judge, without much complaining, created a challenging role model for Karen. 5 Assessment The initial assessment consisted of a structured biopsychosocial assessment interview and completion of the Brief Symptom Inventory, (Derogatis, 1993) on which she had elevated scores in the depression (52), anxiety (45), and hostility (62) categories. In addition, Karen was asked to subjectively rate the frequency (how many times per week) and intensity (how strong each episode) of her anger episodes for the 4 weeks prior to coming to treatment. She did so by using a 0 to 10 subjective units of distress measure (Wolpe, 1990) and maintaining a log of such data (0 = no anger and 10 = enraged) for the duration of treatment. At pretreatment Karen indicated that she experienced 2-3 anger episodes weekly with an average intensity of 8-9. Her mode of anger expression seemed to divert such expression into a form of anger containment as defined by Cox et al. (1999) and Cox et al. (2004). In this form anger diversion, the woman “holds her tongue” and contains her anger, which remains active but covert, and leads to physical symptoms (Cox, Bruckner, & Stabb, 2003). Following the assessment process, Karen and the therapist reviewed the information and developed a list of concerns. Three main concerns emerged: (a) unhealthy experience and expression of her anger, (b) episodic bouts of depression that seemed to follow her anger outbursts, and (c) unresolved grief issues related to the multiple losses in her life. After reviewing this data, Karen acknowledged that she often experienced feelings of anger and also described her difficulties in processing and expressing such angry feelings. She described a cycle in which she would experience a setback or adversity, followed by the experience of anger. She would hang on to her anger silently, for fear of hurting other people’s feelings. Meanwhile she would suffer headaches, tension, restlessness, poor sleep and rumination as to how she “should” have handled the situation. At times, days or weeks later, she would just “explode” verbally at either the original object of her anger or some other unsuspecting target. Following this “outburst” Karen would feel guilty and depressed, fueled by self-condemnation for having “lost control.” She indicated that she had been experiencing these episodes for approximately 2 years and decided on her anger as the main focus of therapy. The goal of her treatment, as expressed by Karen herself, was to be able to manage her angry feelings in a healthier manner. A key aspect of the success of cognitive-behavioral therapy centers on the client’s and therapist’s ability to define the target problem in behavior-specific terms. Therefore, Karen was asked to describe what “managing her anger in a healthier González-Prendes and Thomas 389 manner” meant to her, and how she envisioned herself behaving, feeling and, most important, thinking differently, once that she had successfully completed therapy. Karen agreed that, as a homework assignment, she would work on defining what she wanted to get out of treatment. Three main objectives emerged. Behaviorally, Karen wanted to be able to verbally express her feelings of anger assertively and appropriately and she wanted to do so without the guilt and depression that she often experienced following her maladaptive forms of anger expression. Second, she wanted to be able to set healthy, reasonable limits as to how much she would take on or how much she would help others and she wanted to learn “how to relax.” Third, from a cognitive perspective, Karen wanted to be able think that it was okay to not always be available to others, and to think that it was okay to take care of herself without feeling guilty for doing so. 6 Case Conceptualization Karen’s anger was conceptualized, using a cognitive-behavioral conceptualization model outlined by Beck (1995) which identifies various levels of cognitions and their impact on the individual. Equally important, to increase the cultural relevancy of the conceptualization process, the schemas that supported her anger were framed within significant gender-role and culturally relevant factors that affected her mode of anger expression. Karen’s references to depression were conceptualized as the result of engaging in strong and persistent selfcondemnation and self-blame, usually following her anger outbursts and her perceived “loss of control.” Beyond those incidents, Karen did not present with any symptoms of depression, nor did she have any significant history of depression; therefore, we agreed that anger was the primary problem. Karen’s core beliefs related to how she viewed herself and the world/others. Her views of the self were underscored by these beliefs such as: “I am competent,” “I am strong,” and “I am a helper.” She saw the world as “hostile,” “cold,” and “uncaring.” Out of these central beliefs, Karen had developed important rules which she used to guide and measure her behavior, as well as the actions of others. Some of these rules were: “I should be able to help those in need,” “I should stand against the uncaring world that oppresses disempowered people,” “I should endure without complaint,” and “If I fail to help others, then I am a failure.” These beliefs and rules had translated into strategies that Karen used throughout her life. These strategies emphasized selfdenial and attention to others’ needs. In addition, Karen often felt that others should recognize that she was overworked and therefore should stop being so demanding of her time. Yet, she was unable to verbalize such wishes to others. When others continued to demand her time, Karen concluded that they were insensitive and just did not care. This type of blame was seen as a pivotal factor that fueled both her anger and depression. Whenever she felt frustrated in her attempts to achieve certain outcomes, she blamed others and her emotional response was anger directed, although unstated, at the perceived transgressor. Conversely, on those occasions when she blamed and belittled herself for not being “strong” and “losing control” by acting angrily, she experienced depression and guilt. A critical aspect of working with clients with anger problems is the establishment of a therapeutic alliance. This is particularly true when working with angry clients, whose view of the world is punctuated by suspiciousness and mistrust (DiGiuseppe, 1995; González-Prendes & Jozefowicz-Simbeni, 2009). In these situations, it is imperative that the client be engaged and actively included in every aspect and step of the treatment process. In Karen’s case, from the first interaction of the assessment process, it was imperative that she felt a sense of ownership of the treatment process. In cognitive behavior therapy, one strives to establish a collaborative empirical alliance (Beck, 1995) that empowers the client by getting her involved in the 390 Clinical Case Studies 8(5) decision-making process, from the identification of the problems, to the establishment of the goals, the formulation of homework assignments, the design of behavioral experiments and other strategies. Cognitive-behavioral therapy has been described as an empowering approach because it acknowledges the client’s expertise about herself and her ability to control and change her thinking; engendering changes in her emotional and behavioral responses (Hays, 1995). 7 Course of Treatment and Assessment of Progress Karen’s treatment took place more than 20 individual therapy sessions of 50 minutes in length. The first 12 sessions were weekly, followed by 6 every-other-week sessions. The last two sessions were follow-ups at a 3-month and 6-month point after the initial 18 sessions were completed. Treatment followed a cognitive-behavioral model that acknowledges the primary role of cognitions (i.e., judgments, meaning, attributions, etc.) in determining how one responds, emotionally and behaviorally, to life situations (Beck, 1976; Ellis, 1962). We employed a person-in-environment perspective to frame Karen’s beliefs within important sociocultural perspectives that gave special meaning to her actions. The overall cognitive-behavioral treatment occurred within a three-stage framework as outlined by Meichenbaum (1985, 1996). The goal of the first stage was to help Karen understand her anger. This entailed helping her to understand how her idiosyncratic thoughts and internalized messages impacted on her emotions and behaviors. Equally important was to help Karen understand her anger within the context of her gender and race. The focus here was to help her become aware of and connect with the various underlying gender and sociocultural schemas that shaped her anger expression. The second stage focused on skills development. To help her manage her anger effectively, the therapist introduced Karen to specific cognitive and behavioral skills. We presented and discussed these skills in therapy session; we then used role-play and behavioral experiments to promote practice of the learned skills. The third stage focused on applying the new insight and skills to specific life situations. Karen would bring these specific situations to therapy during which they were reviewed to reinforce successes and troubleshoot setbacks. The process of treatment ebbed and flowed among these three components. The specific treatment approach for treating anger in women has been presented elsewhere (González-Prendes, 2008). Treatment includes specific processes such as: helping clients increase awareness of the impact of their thinking on their moods and behaviors; identifying idiosyncratic thoughts that fuel anger and learning to assess the validity and functionality of those thoughts; restructuring cognitions to reflect a more balanced and rational view of self, the world and others; recognizing physical, emotional, and mental cues that signal the onset of unhealthy anger; implementing strategies to self-monitor so as to increase the client’s sense of responsibility for and control over her emotions; learning relaxation strategies; and building skills for assertive communication and conflict resolution. We introduced and reinforced these techniques through the use of therapeutic discussions, the application of a “Thought Record” (Greenberg & Padesky, 1995), role-plays, behavioral experiments, imaginal exposure and homework assignments. The theoretical foundation of this treatment approach to anger in African American women rests on the following hypothetical assumptions: treatment must help the woman become aware of how gender and culture messages shape her expression of anger; it must also empower the woman to rewrite the script of those messages in a more balanced, rational, and realistic manner; and treatment should introduce prosocial corrective measures to increase the client’s ability to express anger in an appropriately assertive way, set healthy boundaries and, overall, to cope effectively with setbacks and adversity. González-Prendes and Thomas 391 Helping Karen Make Sense of her Anger The first stage of treatment assisted Karen in developing a conceptual understanding of her anger. This involved helping Karen increase awareness of specific cognitive processes that influence the experience of anger, (i.e., externalization of blame, rigid demands, attributions of intentionality/personalization, etc.) as well as gender-role and cultural messages that impacted on how she expressed her angry feelings. Karen engaged in a process of exploration and discovery about the ways she had been socialized to express feelings of anger. She eagerly agreed to capture in a journal her early memories and thoughts about such messages. The prevailing theme that emerged was that, from an early, age Karen was encouraged to be in control of her emotions and that the expression of anger was seen as “losing control.” Since Karen’s mother was alive, she was able to ask her mother about how she had learned to express anger and how she had passed those messages to her children, including Karen. Interestingly, Karen learned from her mother that “getting angry and fussing” were not acceptable options for the women in her family. Karen could not recall one single event in which she saw her mother “lose control” and get angry. However, the men were not held to the same standards and their expression of anger, although not violent, was seen as a form of determination, strength, and forcefulness. Karen recalled that, even though she was never told directly that expressing anger openly was “unfeminine” or “unladylike,” the message was clear that “you just don’t do it.” The women in her family were expected to endure adversity with stoicism; giving in to emotions such as anger and depression was not acceptable. If anything, the women were expected to rely on their personal and religious strength to endure and cope with adversities. Besides becoming more aware of the variations of anger expression for men and women within her family, and the relative level of acceptance or lack thereof, Karen also began to explore the attitudes of society at large toward anger expression in women. Karen identified specific examples of how female public figures in politics and popular culture had at times, openly expressed anger, only to be faced with public scorn and criticism and saddled with derogatory labels, even by other women. Slowly, Karen began to tease out messages, often covert and subtle, but at times direct and open, that influenced the way she processed and expressed angry feelings. Using a model of anger diversion in women, (Cox & St. Clair, 2005; Cox et al., 1999; Cox et al., 2004) the therapist helped Karen to recognize ways in which she often diverted her angry feelings and to also discover the emotional and physical consequences that resulted. These consequences included physiological symptoms such as increased shallow respiration, accelerated heart rate, increased blood pressure and muscle tension, among others. These were all symptoms that had originally brought Karen to her primary-care physician. In addition Karen engaged in an exploration of the paradoxical juxtaposition of strength and powerlessness, a condition that creates unique aspect of anger in African American women (Thomas & González-Prendes, 2009). The challenge was for Karen to identify such issues in her. As Karen became aware of the specific and idiosyncratic messages that had shaped her style of anger expression, she began to systematically evaluate their validity and functionality. At this point Karen began using a thought-record form (Greenberger & Padesky, 1995) that methodically allowed her to challenge and reconstruct those messages. The thought record allowed her to focus on specific situations connected with anger episodes; identify the specific thoughts connected to those events and recognize how they contributed to her behavioral and emotional distress (i.e., anger); identify and assess evidence for or against the identified thoughts; and to formulate more balanced and healthy perspectives in order to engender healthier emotional and behavioral responses to upsetting situations. Karen, perhaps due to her background as an 392 Clinical Case Studies 8(5) educator, responded well to the systematic and organized approach the thought record provided. It became an important tool throughout the treatment process. Confronting Unrealistic Expectations of Strength Harris (1995) and Martin (2002) have suggested that cultural expectations in African-American women may create unrealistic demands of strength that increase stress. Therefore, it was important for Karen to recognize how the experience of her mother and other women in her family and community had contributed to her internalizing these unrealistic expectations. Karen enthusiastically began to revisit the history of her family. An instance that illustrates how Karen first began to confront long-standing messages that underscored her own expectations of the strong African American woman came early in therapy. Karen related how her mother had raised her three children on her own, while living in the housing projects in St. Louis. Her mother, a highly accomplished and respected woman, completed her college education, became a teacher, worked a full-time job and attended law school in the evenings. Eventually, she moved her family out of the housing project, became an attorney and ultimately a judge. Karen later recalled that, despite the immense sacrifices she made and the hardships her mother faced, she could not remember any time when her mother complained; felt depressed or dwelt on self-pity. Rather, Karen’s memories of her mother were of a woman of stoic resolve to succeed and provide for her family, supported by her faith and religious convictions. Karen recalled how her mother was one of a long line of “strong” women who had strived to better their families, first in Mississippi and then in St. Louis, against a background of a hostile society, rampant with oppression and discrimination. The overt and covert messages that Karen received from an early age were that she had to be strong, be available to help others, and endure hardship with uncomplaining determination. For Karen these views had been functional at various points in her life. They helped her to achieve her own levels of success academically and professionally. However, such belief also drove her to blur boundaries of control; to take on more responsibilities than she could possibly handle; and to deny her own well-being and desires. Nonetheless, Karen saw herself as a “strong” African American woman, a member of a lineage of strong women in her family, and, as such, she had bought into the notion that she should be able to handle any challenge without complaint. The result, however, was that Karen often felt an undercurrent of resentment and anger at what she saw as a lack of consideration from others. She expected others to recognize her predicaments and not impose on her. However, she failed to realize how often it was she, who reflexively volunteered to tackle those challenges and failed to set healthy limits. Using the Thought Record to Address Unrealistic Expectations of Strength The Thought Record (Greenberger & Padesky, 1995) helps clients to deliberately and systematically assess and evaluate evidence for or against maladaptive thoughts or beliefs and eventually formulate more adaptive and functional views. An example of its use came early in the treatment process when Karen came in one day complaining of having experienced heightened anger and depression for the 2 weeks prior to the visit. Karen indicated that she had been struggling with pressures from work as well as with demands place upon her by her mother who daily was requesting Karen’s help to care for her ailing step-father. This despite the long hours she put in at her regular job in the high school. She also needed to attend to her own personal responsibilities outside work. As she struggled balancing these escalating demands on her time and energy, Karen began to grow increasingly angry and resentful at such requests. Yet she was constantly confronted by her desire to attend to her own needs, and on the other hand her internal beliefs that “I must be strong,” “I should be available to help those in need,” and “I should endure González-Prendes and Thomas 393 without complaining.” Even the fact that she struggled with such demands was “evidence” for Karen to see herself as “weak” and “not strong.” These self-condemnatory and negative evaluations of the self would feed a depressed mood. Simultaneously, she felt anger toward others who imposed upon her, and whom she often deemed as inconsiderate, because she believed they should have been more attuned to her predicaments. Yet, Karen could not bring herself to express her anger directly and openly; set healthy limits to protect her time and energy; or ask for help. For Karen those options were akin to complaining, and, as such, were viewed by her as a sign of weakness. The challenge for the therapist was to help Karen confront and challenge her unrealistic beliefs of strength so as to engender healthier emotional and behavioral responses, while at the same time preserving the historical and cultural significance of such belief. The therapist suggested that Karen begin using the Thought Record (Greenberg & Padesky, 1995) as a means of working through the anger and depression. When the client and therapist are able to identify and focus on a specific, well-defined issue, the use of a thought record is more effective. Karen’s working long hours and her caring for her ailing father, although fed by the same rigid beliefs of strength, were seen as two separate issues. Therefore, Karen agreed that first she wanted to work on addressing her mother’s daily demands for help. The first step in the use of the thought record is to specifically define the problematic situation. As Greenberg and Padesky (1995) indicated, this involves defining who? what? when? and where? In this instance the problematic situation was defined as: after working long hours at her job in the school and often feeling physically tired and emotionally exhausted, Karen would receive a phone call from her mother asking her to come over for the evening to help with the care of her ailing step-father. The next step in the process was for the Karen to identify the moods and behaviors connected with the situation. Her immediate emotion response following her mother’s call was anger, followed by feelings of resentment, guilt and, later on, depression. Yet, Karen would not say “no” and instead she would go and help her mother. Often, after Karen went home late at night she would feel tense, experience headaches, and have difficulties sleeping. The third step was for Karen was to identify the automatic thoughts that had crossed her mind at the time of or following the identified event. Karen was asked to focus on what had she told herself, relative to the situation, that sparked her emotional and behavioral responses. In some cases, due to the passage of time, the client might have some difficulty identifying the specific thoughts that she had at the time of the event. When that happens, the use of imaginal exposure may help the client to remember those thoughts. In this process the client is asked, while in session, to relive the identified situation, closing her eyes and, as specifically as possible, using the present tense and the “I” pronoun, recount in detail what transpired during the identified event. As the client relates the story, the therapist, in the least intrusive manner possible, asks the client to relate specific thoughts going through her mind at that moment, as well as the ensuing emotional reactions. During the exercise Karen was able to relive both the anger and guilt that she had experienced. The automatic thoughts that she described included “she (mother) should not be asking me to come over”; “she should know that I work long hours and that I am tired and exhausted”; “she should be more considerate”; “I must be strong and provide help as needed”; “If I say no to my mother then I am a weak and bad person.” Following identification of the automatic thoughts, the client, with the help of the therapist, engages in a systematic process of discovering evidence for or against the identified beliefs. At that point it is not unusual for clients readily to come up with extensive evidence that supports their irrational negative beliefs (i.e., “If I say no to my mother then I am weak and a bad person,” “I must be strong and provide help as needed”). On the other hand it is equally common for the client to have difficulty identifying evidence that refutes the validity of those irrational beliefs. 394 Clinical Case Studies 8(5) In the case of Karen, her thoughts relative to what it meant to be a strong Black woman (e.g., self-sacrifice, self-denial, always ready to help others, etc.) seemed to have more influence on her emotional and behavioral responses than other thoughts. These beliefs were deeply rooted in the history and culture of her family. She referred to the implicit and explicit messages related by her mother who had sacrificed to better herself and provide opportunities for her family. In challenging and restructuring such beliefs, it was imperative to tease out and nurture their healthy, cultural and historical aspects, separating those from the irrational and rigid demands that Karen put on herself and that tyrannized her and fueled her anger and depression. The work went on for several sessions and Karen painstakingly wrote in her thought record identifying “evidence” against the idea that she was “weak” and “not strong.” She would bring this information to therapy, during which she would further process and synthesize important aspects of it. Gradually, the use of the thought record forced Karen to look at her life in a more deliberate manner; stopping to recognize the importance and significance of many actions that, in the past, she had simply overlooked or taken for granted. She began to systematically detail her many accomplishments: her ability to endure multiple personal losses; her caring for her family; the long hours she spent helping her students succeed against seemingly insurmountable odds; her creativity and ability to write prose and poetry and the positive feedback she had received from friends or even strangers during her participation in local “poetry nights” and her social and political activism on behalf of a number of causes. Every time Karen returned to therapy with new evidence, she was asked to reflect on what she would make of such information, vis-à-vis her belief that, if she did not help others at all times and endure without complaining, that meant that she was a weak person. For the first time she began to seriously question the validity of that belief. Armed with that new evidence, the challenge for Karen was to create a more balanced perspective of herself that recognized and acknowledged her strength and the legacy of strong women in her family who survived, persevered and thrived often against a backdrop of racism and sexism. At the same time Karen began to separate those positive aspects of strength from the unrealistic expectations and demands that she had created for herself and the burden associated with them. Subsequently, Karen began to raise this issue with some of her African American female friends. This led her to realize how some of these other women had similar experiences, accompanied by similar beliefs and emotions. The fact that she never saw these women as “weak” further forced Karen to reassess her own negative self-evaluations. Furthermore, she began to see how her internalized sense of strength often prevented her from giving a voice to her burden and sense of powerlessness; expressing her frustration in a healthy manner; and setting clear boundaries for what she could and could not do for others. She became more cognizant of how, in her view, voicing her anger had not been compatible with her self-image of being a “strong” Black woman; it did not fit with the messages that she had internalized as she grew up in her family. Gradually she began to rewrite the scripts of those messages in a healthier, more balanced and rational manner. The new scripts were rooted in her strength and passion for helping others and reinforced the notion that she could be a better helper if she learned to pick her battles more selectively, and that doing so did not mean that she was “weak.” On the contrary, she began to see that the ability to set healthy boundaries was strength, in the sense that it allowed her become a more effective helper and advocate, while reducing and eventually eliminating the adverse effects of her unhealthy anger. Powerlessness Although the need to attend to others, while denying her own wishes, often left Karen feeling a lack of control over her life and a sense of powerlessness, she did not voice such feelings. Doing so, in Karen’s mind, was also akin to being weak. The unrealistic expectations of strength led her González-Prendes and Thomas 395 to endure and “bite her tongue.” The women in her family had used their strength to fight and overcome severe disempowering conditions in society. Therefore, in Karen’s family the notion of powerlessness was not openly considered or acknowledged. Yet, a sense of powerlessness surely fueled her anger and frustration. Karen’s feeling of powerlessness also manifested itself in her many attempts to help others. It was difficult for Karen to accept her relative lack of control over other people or situations. She had a difficult time recognizing and accepting the boundaries of her control. The culturally sensitive therapist needs to be aware that, for the African American woman with high expectations of strength, the acknowledgment of powerlessness can be difficult. Yet, the practitioner must help these women to give a voice to and acknowledge such powerlessness. One way of doing so is to help normalize the experience of anger by framing it within the larger societal system that has often created oppressive, limiting and disempowering conditions that disproportionately effect upon gender, racial and ethnic minorities. For Karen this led her to identify specific events when this had happened in her personal and professional lives. She recognized how she often left work meetings feeling angry because others would not concur with her ideas or be ready to take immediate action to solve problems as she saw it fit. Karen began to acknowledge that in those situations there was a side of her anger that was justifiably fueled by her perception of the unfairness and limitations faced by her students. However, she also was able to see how another side of her anger, fueled by her demands that others and the world must follow her advice, was not healthy. She began to realize that, if she could use her anger prosocially to correct a wrong and attain successful outcomes, rather than internalizing it and “exploding” at some later point, she could be more effective in her endeavors. Through this process she began to realize that anger is a common emotion that in itself is neither good nor bad. This notion challenged her previously held fundamental beliefs about her anger. Karen began to see her anger as a normal human emotion that seemed justified when viewed against the backdrop of the oppression and sometimes discrimination that often thwarted her attempts to help others. Cognitively, she was able to challenge the notion that experiencing anger somehow made her inconsiderate, weak or a “bad” person. This revelation allowed her to view her feelings of anger more objectively, and to acknowledge more realistic boundaries of her power and control. She had started to understand that the only thing she could change for sure was herself and in doing so she was able to accept her powerlessness to change others. To Karen accepting her powerlessness did not mean becoming passive or giving up her passion for fighting injustice. Rather it meant she was learning to use her power and strength in a more effective manner and, consequently, becoming less subject to bouts of maladaptive anger and more successful in her endeavors. Paradoxically, by accepting the limits of her power and control, Karen began to feel more empowered. Karen’s View of her Anger Through the Prisms of Gender and Race Through therapy, Karen began to understand her anger within the context of her gender and race. As a woman, she had assimilated the notion that our society looks unfavorably on an “angry woman” and, as an African American woman, she also internalized unrealistic expectations of strength that, when confronted with the disempowering conditions within herself and in society, fanned the flames of her anger. Although Karen was a highly educated and accomplished woman, she had never really given much thought to the confluence of these factors and how they contributed to the way that she experienced and expressed anger. In therapy she began to see the link. Thomas and González-Prendes (2009) suggested that the challenge for the therapist working with African American women who are struggling with unhealthy or maladaptive anger entails helping these clients to: 396 Clinical Case Studies 8(5) rewrite the script of the old messages in a way that promotes a more balanced and realistic view of themselves as African American women; to nurture the cultural tradition of strength in a more self-empowering manner; and also to help these women build a healthier and more functional sense of personal responsibility for their anger. Once those messages are changed, the woman can begin to develop an assertive style of expression, underscored by the open, direct, and socially appropriate communication of her anger (p. 108). For Karen, the break-through in therapy came as she began to integrate the legacy of strength within her family with her new-found rational sense of boundaries and control. She was able to appreciate and nurture the history of strength among the women in her family as well as other African American women. She revisited the lives of historical Black women, such as Sojourner Truth and Harriet Tubman. She integrated her new-found perspectives in a way that led her to conclude that being “strong” did not mean that she had to be responsible for others’ emotional or physical well-being; nor did it mean that she had to stoically swallow her discomfort; nor did it mean that she had to stand passively by or stay inactive when confronted by injustice, coupled with her desire to help others. She could take action to help others while, at the same time, accepting that her actions might not always yield the results she anticipated. Introducing Relaxation and Other Strategies As treatment went on, Karen began to identify cognitive and somatic anger cues and became more aware of how they signaled an escalation to an unhealthy level of anger. The cognitive cues were demanding thoughts or mental images of specific situations in which her wishes had been frustrated. These thoughts and images would often intrude into her conscious awareness, fanning the flames of anger and frustration. As these demanding cognitions persisted, she would begin to experience somatic sensations such as muscle tenseness, accelerated heart rate, faster and shallower breathing and headaches. Karen learned to use these cues as alarms, alerting her to the need to take action to reduce their intensity. To help Karen slow her mind and body on those occasions, therapy built upon Karen’s personal interest in spirituality and meditation to incorporate strategies that increased her ability to relax in stressful situations. The strategies, although not a “solution” to anger, often help the client reduce the escalation of angry feelings and momentarily eliminate the internal discomfort and physiological symptoms that accompany unhealthy expressions. The expectation was that, in doing so, Karen would be in a better position to take healthy steps to address the source of anger. By incorporating the use of imagery, mindfulness, and diaphragmatic breathing, Karen learned to calm herself down whenever she began to notice a raising level of anger. At a particular session, she came to therapy in an agitated internal state, which she attributed to her school’s unwillingness to provide needed assistance to some of her students. On that occasion she was carrying a portable sphygmomanometer that she used to monitor her borderline hypertension. As an experiment to test the effectiveness of the relaxation strategies, Karen measured her blood pressure at onset of the session which read 147/99. The 50-minute session focused on rehearsing breathing relaxation steps while engaging in imagery and mindfulness exercises. By the end of the session Karen indicated that she felt rather relaxed and rechecked her blood pressure, it read 122/78. From that moment on, she was convinced of the usefulness of such strategies and began using them regularly in her daily life, not just when feeling upset. Therapy also helped Karen reinforce her assertive communication skills (Alberti & Emmons, 1990). She used “I-messages” to express feelings and wishes in a direct, clear, and unambiguous manner, while respecting others’ feelings and avoiding personal verbal attacks. Through insession role-play and reverse role-play, Karen engaged in various challenging scenarios that González-Prendes and Thomas 397 simulated work and personal situations, allowing her to rehearse and practice how to communicate her feelings and wishes assertively. The therapist also introduced Karen to the use of the Upsetness Scale and she found it to be particularly helpful (González-Prendes, 2007). This is a subjective instrument consisting of 10 increasing levels of upsetness intensity, ranging from mild disappointment (1) to enraged (10). The client uses it to measure the relative intensity of her upsetness in any given situation. This strategy helps the client to recognize alternative responses, other than anger, to unpleasant or upsetting situations. As González-Prendes indicated, the use of the term “upsetness” instead of “anger” is a deliberate attempt to reinforce the notion that a wider range of emotional responses to upsetting circumstances are available, besides anger. The therapist used the Upsetness Scale in combination with imaginal exposure to upsetting events to allow Karen to use coping selfstatements to actively dampen anger-inducing thoughts and thus maintaining a visual representation of the Upsetness Scale deliberately work to reduce the intensity of her reactions. These exercises employed a systematic approach in which: (a) Karen imagined specific upsetting situation that she had recently experienced. (b) Karen would allow her level of upsetness to raise to the maximum level associated with that event. (c) She then used self-statements and breathing relaxation while actively holding a mental image of her upsetness dropping in the scale. By employing the Upsetness Scale Karen was able to reinforce her ability to use coping, rational self-statements to control and manage her anger more effectively. Combined with her continued daily charting of her anger episodes, Karen was also able to increase her capacity to self-monitor her anger, as well as to take appropriate action to address it effectively. In addition to the daily charting and her work with the thought record, Karen and the therapist designed other written and experiential homework assignments. The aim of these activities was to help reinforce gains made through therapy; identify, challenge and reframe anger inducing beliefs; try out newly acquired skills (e.g., assertiveness); and test out newly formed beliefs about herself, other persons or the world-at-large. Karen’s log of anger episodes and thought record were reviewed at the beginning of each session and provided an ongoing means of measuring progress. The outcomes revealed Karen’s increased ability to identify, evaluate and reframe cognitions that fueled her maladaptive anger; the effective use and implementation of relaxation and communication skills to manage her mood and express herself more effectively; and the increased ability to gradually reduce the frequency and intensity of her anger episodes. At the end of the first 18 sessions, Karen felt more confident in her skills to manage her anger. Her behavior supported that confidence. Although her depression and grief issues had not been directly targeted during treatment, Karen was able to use the cognitive and behavioral skills she gained in therapy to help her with those issues as well. 8 Complicating Factors Although Karen’s cognitive-behavior therapy allowed her to implement significant positive cognitive, behavioral, and emotional changes in her life, she recognized that her work on the targeted issues would continue beyond the end of treatment. Karen knew that she was dealing with longstanding core beliefs that had formed the philosophy through which she had interpreted life for many years. These beliefs would not just disappear at the end of 18 weeks. She recognized that the same old messages were bound to resurface, particularly in time of stress or adversity, and if she did not stay alert to these, she could find herself struggling with the same old issues. The difference now however, was that Karen had increased awareness and knowledge of the old maladaptive beliefs and behaviors, but also had actively engaged in creating a new set of healthy and balanced cognitions and behaviors to help her cope effectively. She had integrated specific 398 Clinical Case Studies 8(5) skills that she could use daily to help her keep a rational perspective of self and others and thus avoid the perils of relapse. 9 Managed-Care Considerations The essential managed-care consideration was that Karen used her health benefits as a means of paying for treatment. Her insurance company, a health maintenance organization (HMO), allowed Karen 25 visits per calendar year for mental health treatment. We discussed this at the onset of treatment and spaced the therapy sessions to make maximum use of the available time. Including follow-up sessions, the therapist saw Karen for a total of 20 sessions. Of those 20 visits, two were used for a psychiatric evaluation and follow-up to evaluate Karen’s complaint of depression. Although the psychiatrist suggested a regimen of a low dose of antidepressant, Karen chose not to take the medication. Instead she decided to allow therapy to work. Cognitive therapy, with its rather short-term treatment approach and use of homework assignments, is effective within the managed-care constraints. Homework assignments reinforced the therapeutic gains Karen made in session, and this approach allowed extending the overall length of treatment by eliminating the need to meet weekly. 10 Follow-up At the end of the first 18 sessions, Karen agreed to return for follow-up or “booster” sessions at the 3-month and 6-month post-therapy periods. After the first 18 sessions were completed, Karen again completed the BSI (Derogatis, 1993). At that po...
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Running head: COGNITIVE BEHAVIOR THEORY: VIDEO SCRIPT

Cognitive Behavior Theory
Student
Institutional affiliation

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COGNITIVE BEHAVIOR THEORY: VIDEO SCRIPT

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The presenting problem
Tiffani, a 16-year-old with a background characterized by fleeing due to sexual and
physical abuse at home, was arrested for prostitution, be that as it may, Tiffani has been a
survivor of human sex trafficking. Her low esteem has been due to the several men who have
mistreated her, making her lack the perception of self-worth. Since she has severally been
mistreated, she likely has PTSD symptoms.
The cognitive-behavioural theoretical orientation
The hypothesized direction that I have chosen to use in Tiffani Bradley's case is Trauma
Focused-CBT. The approach is an evidence-based treatment to enable teenagers to recoup after
being traumatized. I have picked this since I have confidence that this is a treatment model
Tiffani will genuinely benefit from. Tiffani still can't seem to recuperate from her first
experience of being a survivor of sexual maltreatment.
Assessment Questions
To better contemplate on the patient’s problems, I will ask questions such as:
a) How do you feel when you think about John T and all other men who treated you
badly?
b) What moments made you happy when you were with your family?
Goal treatment
TFCBT is a remedial methodology that gives a guide to recuper...


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