|
Jonathan Singer
April 29, 1996
MSSW Colloquium
Dr. Cynthia Franklin
Modified Stress Inoculation Therapy
Treatment For An Anxious Client
With Multiple Diagnoses
Modified Stress Inoculation Therapy Treatment For An Anxious Client With Multiple Diagnoses
Abstract
Literature is reviewed addressing the concept of Co morbidity in diagnosis and treatment.
Treatment issues for a 12 year old white male, diagnosed with PTSD, ADHD and Dysthymic
Disorder are considered. A modified version of Stress Inoculation Therapy (SIT) is used over a 7
week single-subject design. Results indicate no correlation between intervention and outcome.
The study is critiqued for time-considerations, expectation of the subject, and method of data
collection.
LITERATURE REVIEW
Co morbidity
Children and adolescents in treatment are often diagnosed with more than one disorder
(Nottelman and Jensen, 1995). For example, common dual diagnoses are ADHD and Conduct
Disorder, and Anxiety and Depression (Hubbard et al, 1995; Bird, Gould, and
Staghezza, 1993;
Curry and Murphy, 1995). These diagnoses often have high Co morbidity, and there is debate in the
literature as to whether they are separate disorders or two different expressions of the same
underlying psychopathology (Boulenger and Boyer, 1994). Stark, Laslow, and Laurent (1993),
studied 59 children from grades 4-7 with three separate diagnosis groups and one nondisturbed
control group. The authors found that while there were significant differences on a number of
diagnostic scales between the diagnostic and experimental groups, there was no difference within
the experimental groups. There has been some attempt to account for high Co morbidity by authors
who distinguish between behavior that is undercontrolled (externalized) and overcontrolled
(internalized); these two basic types of behaviors manifest themselves in a number of different
disorders (Bird et al, 1994; Hollon and Beck, 1994; Kazdin, 1991). For example, aggression,
antisocial behavior and hyperactivity are externalized behaviors and fearfulness, anxiety, and
depression are internalized behaviors (Maag and Kotlash, 1994).
Lilienfeld, Waldman, and Israel (1994), argue that the plethora of comorbid diagnoses in
the literature reifies diagnostic categories because the diagnosis takes precedent over the
symptoms. The tendency for such reification is a reminder that categories used for diagnosis are
socially constructed; clients present symptoms and we look for categories within which to fit them.
The literature often discusses single or multiple treatments for a single diagnostic category. For
example, the literature is dominated by books of cognitive-behavioral treatments for single
diagnostic categories such as depression (Wilkes et al, 1994; Shafii and Shafii, 1992), trauma
(James, 1989), and impulsivity (Kendall and Braswell, 1993). The theory is the same, but the
interventions are diagnosis specific. The literature does not describe the effect of single or
multiple treatments on clients who have multiple diagnoses. Comorbid conditions are treated with
two different treatments, either concurrently or in succession. It would be important to know how
effective single treatments are on clients with multiple problems (Kazdin, 1994). The focus on
single diagnoses is problematic because therapy treats presenting symptoms, not diagnoses.
Symptomology
Diagnostic symptomology sometimes manifests itself differently in children and
adolescents than in adults. The different manifestations of anxiety in children can lead to a number
of different diagnoses. Children who exhibit anxiety through fidgeting and impulsivity can be
diagnosed with ADHD. Children who exhibit anxiety through hyper vigilance and poor sleeping
habits can be diagnosed with PTSD. Children for whom anxiety manifests itself as irritability and
inability to concentrate might meet criteria that would suggest a diagnosis of a Depressive
disorder. Those same symptoms in adults are less commonly diagnosed as Depressive disorder
and more commonly as Anxiety disorder (DSM-IV, 1994). In fact, comorbidity of
PTSD, anxiety
and depression among children is very high (Scott and Stradling, 1992). Regardless of the
diagnosis, both the therapist and the client are concerned with finding ways to reduce the
symptoms; the diagnosis can be used as a guide for treatment, but does not in itself produce change
in the client. Vitulano and Kraemer (1991) address this issue and argue that
the complexity of this symptom picture, coupled with the considerable
overlap between these and other symptoms of disorder in childhood and
adolescence, has led behavioral investigators to argue that the most
effective intervention for childhood [disorders] is to treat specific
symptoms of the disorder... (In Lewis, 1991, p. 820).
Cognitive Behavior Therapy
Cognitive-behavioral therapy (CBT) has been shown to be effective in treating many of the
symptoms associated with problems of children and adolescents (Kazdin, 1994; Kendall, 1985;
Meyers and Craighead, 1984). Zarb (1992) notes that social-learning theory is particularly well
suited for work with adolescents, for whom macro-environmental influences play a significant role
in development. Cognitive-behavioral therapies have been shown to be more effective than strict
behavioral therapies in generalizing outcomes outside of the treatment environment (Gross and
Drabham, 1982; Kanfer and Karoly, 1982; Kendall and Braswell, 1993). Kendall (1985) notes
that cognitive-behavioral models are concerned with "the cognitive activities that surround
behavioral events and seek to determine how anticipatory, concurrent, and post hoc cognitions
contribute to adaptive and maladaptive patterns of behavior" (p. 360). In other words, treatment
can be generalized because change occurs in the understanding of the behaviors, which can then be
applied (generalized) to different environments.
Maag and Kotlash (1994) identify several cognitive-behavioral intervention techniques
used in reducing anxiety including self-instruction training, self-management strategies, problem-solving training, attribution retraining, and relaxation training. Meichenbaum and Turk (1976)
developed Stress Inoculation Therapy (SIT) as a treatment approach for the management of
anxiety, anger, and pain. Novaco (1979) notes that SIT focuses on helping individuals develop
and employ a variety of skills that enable them to cope with a variety of stressful situations. Maag
and Kotlash (1994) explain that the three phases of stress inoculation training (SIT) are "a)
conceptualization, b) skills acquisition and rehearsal, and c) application and follow-through.
Foa, Rothbaum, Figgs, & Murdock (1991) compared the effectiveness of three different treatments for
PTSD; SIT, PE (prolonged exposure), and counseling. SIT and PE were found to be more
effective than counseling, and SIT was found to be the most effective treatment at termination.
The current study applies the cognitive behavioral technique of SIT to the presenting
symptoms of a client with multiple diagnoses: PTSD, ADHD, and Dysthymic Disorder. Mezey
(1992) notes "the most promising treatment strategies appear to be those that provide the [client]
with specific mechanisms and alternative responses to manage their anxiety" (p. 139). It appears
that SIT is a good framework for providing concrete approaches for the treatment of anxiety. This
study hypothesizes that the implementation of SIT will result in a lower level of client anxiety.
METHODS
Case Presentation
Sam is a twelve-year old Anglo male in the 6th grade. He lives with his mother (Ms. H)
and two house mates in a four bedroom house in a low-income neighborhood in Austin. Sam's
parents have been divorced for five years and he has limited contact with the father. He presents
as a highly intelligent and verbal pubescent adolescent.
Sam was diagnosed with Post Traumatic Stress Disorder at age four after the family
discovered he had been sexually abused by a family friend for a period of several months. He was
admitted to Charter Lane Hospital subsequent to the abuse when he became physically aggressive,
displayed oppositional behavior, began having nightmares and increased levels of anxiety. He
was hospitalized for six weeks and both Sam and his parents received group and individual
therapy. Sam was sexually abused a second time at age six by a group of three adolescent males in
a single incident. Sam received counseling at Child and Family Services from that time until one
year ago. He was diagnosed with ADHD at age 7 by MHMR and was taking Ritalin 3x/day for 4
years. He stopped taking Ritalin last year because he said it was making him depressed.
Ms. H contacted the Austin Child Guidance Center (ACGC) 10 weeks ago with the
presenting problems of behavior problems and academic problems. Their roommate said that she
had had enough of Sam's "lewd behavior and remarks." Similarly, the school had notified Ms. H
that Sam's classroom behavior had become increasingly disruptive in the last year. In the Initial
Screening at ACGC, Ms. H indicated that she felt that the combination of Sam going off
medication and going through puberty was making it difficult for him to behave properly and
perform well academically. During the first session, Sam appeared very anxious and fled the
room when we started discussing school. By the end of the session Sam had told us that he did not
like "bugging out" so much and wanted to stop. Based on information from Ms. H, Sam, and the
staff psychiatrist, Sam has been diagnosed with Dysthymic Disorder (DSM-IV, 1994).
Instruments
We used the Clinical Anxiety Scale (CAS) (Thyer, 1992) at the beginning of each session.
According to Fisher and Corcoran (1994), the purpose is to measure clinical anxiety. CAS is a 25
item scale that is focused on measuring the amount, degree or severity of clinical anxiety reported
by the respondent, with higher scores indicating higher amounts of anxiety. The CAS is simply
worded and easy to administer score and interpret. The items for the CAS were psychometrically
derived from a larger number of items based on a criteria for anxiety disorders from DSM-III. The
CAS has a clinical cutting score of 30 (plus or minus 5) and is designed to be scored and
administered in the same way as the scales of the WALMYR assessment scales.
The CAS asks clients to rate each item based on a 7-point Likert scale. It is important to
note that Computer Assisted Social Services (CASS) was used to score the results. In this
program the Clinical Anxiety Scale is a 7-point scale, not 5-point scale as it is printed on the
scales. Thyer (1995) explains that the scale was changed to a 7-point scale to improve validity
and reliability. Since the original scale was printed as a 5-point scale, the client was given a sheet
with the 7-point scale and instructed to answer from there. The CAS is manually scored in the
following way. The 7 items listed at the bottom of the page are reverse scored. To get the total
score (S), add up all the scores after reverse-scoring (Y), subtract the number of items completed
(N), multiply that by 100, and divide that number by the number of item completed (N) multiplied
by the largest possible value for an item response (in this case 7) minus 1. The formula presented
by Bloom, Fisher and Orme for this process is
S=(Sum [Y]-N)(100)
(N)(K-1)
According to Fisher and Corcoran (1994), the norms of the CAS are based on an initial
study of 41 women and 6 men (average age 40.9 years) from an agoraphobic support group, 51
men and 32 women from the US army who were attending courses in health sciences (average age
25.7 yrs) and 58 female and 15 male university students (average age 26.6 yrs). No other
demographic information was available nor were actual norms.
According to Fisher and Corcoran (1994), CAS has excellent internal consistency with a
coefficient alpha of .94. The standard error of measurement of 4.2 is relatively low, suggesting a
relatively low amount of measurement error. It has good stability with a 2 week test retest
correlation ranging from .64 to .74. CAS also has good known groups validity, discriminating
significantly between groups know to be suffering from anxiety and lower anxiety control groups.
Using the clinical cutting score of 30 the CAS had a very low error rate of 6.9% in distinguishing
between anxiety and control groups. No other validity information was available. Analysis of the
CAS in relation to demographic variables such as age, sex and education reveals that scores on the
CAS are not affected by those factors (ethnicity was not examined).
Anxious Behavior
Videotape was used to record in-session behaviors that Sam identified as being indicative
of his anxiety. (Note: The client did not use the word "anxiety" to describe his state. He
mentioned being "bugged out" and "on edge" in conjunction with the behaviors). The behavioral
observation followed steps outlined by Bloom, Fisher and Orme (1995).
We specified the following targets for intervention: "Interrupting," which we defined as
anytime the client spoke over what I was saying for more than 5 words. "Pacing," which we
defined as anytime the client got up from his chair to walk around the room. "Looking at the
camera," which we defined as anytime the client turned to the camera.
We focused on these three behaviors for a number of reasons. We wanted to identify the
behaviors that most often indicated that Sam was feeling anxious. We wanted to keep the number
low enough so that we could keep track of them during the session. We decided that it would be
difficult to keep track of them between sessions, but that it would be important to build awareness
of them. We also chose behaviors that were interpersonal, IE behaviors that would impact the
client's interactions with others. These would be more memorable because there would be an
external trigger (in the form of a reaction from those around the client) that could serve as a
reminder. Finally these behaviors were chosen because the client had reported getting in trouble
at school as a result of two of the three behaviors (interrupting and pacing). In the intervention we
externalized these behaviors in an attempt to help the client feel he had control over them.
We decided that both Sam and I would be responsible for noticing the behaviors during the
session, but that I would be responsible for recording data from the videotapes. We would
collect data only during the sessions for the following reasons: The client was already having
problems doing homework and we did not want to set him up for more failure. Sam also stipulated
that only I would be able to watch the video tapes, because he did not trust anyone else. In an
effort to build trust, the study has excluded the option of a second judge and decreased the
reliability of data afforded by a second judge.
ABBC Design
The ABBC design allowed us to track the primary intervention (anxiety reducing
exercises) and account for the introduction of medication after the 5th session. In the first phase
(A), we established a 2 week baseline from the CAS scores and the behavior rates. The second
phase (B), lasted for 3 weeks, in which Sam learned ways to reduce his anxiety. The third phase
(BC), continued the B phase and introduced Wellbutrin, an anti-depressant as the second
intervention.
Intervention (SIT)
This study used a modified version of Stress Inoculation Therapy (SIT) from the cognitive-behavioral literature (Maag and Kotlash, 1994). The first phase of SIT is used to educate clients
about the nature of their disorder. Following a more constructivist model, for the first two
sessions we reversed the roles and Sam educated me about his fears and anxieties. Specifically,
we used situations that Sam talked about from his everyday life and explored his fears and
anxieties. This approach worked well because Sam is hypersensitive and feels threatened easily,
as is common with people diagnosed with PTSD. The only anxiety reducing activity Sam could
self-generate was hitting the Bobo doll, a four-foot tall bottom heavy bag stuffed with punch-absorbent materials with a male figure painted on the front and back.
The first intervention occured at the end of the second session. Sam was recounting an
incident at school where his teacher was yelling at him for not doing his work. While recounting
the story, Sam's face got flush and he started pacing, a behavior he had previously identified as
indicative of anxiety. I used reflexive statements such as "It seems like your face is getting red and
you are pacing," to focus our attention on the physical manifestations of his anxiety. Then Sam
made a joke and said he always does that when he wants to change the subject. I suggested that the
next time he feels anxious, that he stop what he is doing and take a deep breath. He thought this
was silly, so I suggested we role play it. Role playing is part of the second phase of SIT. Sam
played the teacher and I played Sam and when I (as Sam) felt myself getting anxious, I stopped
pacing and took 5 deep breaths. Although Sam laughed, he tried it a few minutes before the end of
the session.
The following 5 sessions (3-7) were spent practicing relaxation techniques and punching
the Bobo doll. At the beginning of each session I would ask Sam to "help me out for my class and
take this interview" (the CAS). Once that was complete we would talk about his week. I
encouraged him to talk about anxious times. At a certain point he would take the Bobo doll and
start punching it. He usually did this for about 20 minutes. Each week, following the Bobo doll
pummeling, we did a deep breathing exercise. In the 7th session Sam had a major breakthrough
and closed his eyes during the relaxation exercise. He said it was because he was tired.
The third phase of SIT involves taking the treatment into the anxiety producing
environment. Sam has contracted to continue services through August, so I will be able to
continue tracking progress. It is my hope that we will be able to get to the third phase of SIT
before treatment terminates.
RESULTS
Figure 1: Sam's Clinical Anxiety Scale Scores
| |
Week 1 |
Week 2 |
Week 3 |
Week 4 |
Week 5 |
Week 6 |
Week 7 |
| Scores |
45 |
67 |
45 |
63 |
57 |
45 |
32 |
| Clinical Cutoff |
30 |
30 |
30 |
30 |
30 |
30 |
30 |
Clinical Anxiety Scale (CAS) (Figure 1)
The CAS scores do not indicate a correlation between the intervention and the level of
anxiety (Fig. 1). The initial score of 45 indicates that Sam had a significant problem with anxiety.
The second week his score went up to 67, which indicates a serious problem with anxiety. The
baseline phase ended after the second week. The third week Sam's score dropped to 45.
Although this is a 22 point drop in the score, and it occurred after the intervention, the third week
score is the same as the initial score, 45. The fourth week Sam's score rose again, this time to 63,
an 18 point increase in the level of anxiety. The fifth week Sam's score was 57, six points lower
than the previous week and 12 points higher than the initial score. The sixth week Sam's score
lowered to 45, 12 points lower than the previous week and the same score as the first and third
weeks. In the sixth week Sam started the second intervention, Wellbutrin, and anti-depressant.
The last week of the study, Sam's score dropped to 32, thirteen points lower than the previous
week, and his lowest score of the study. According to Thyer (1994), a score of 32 falls with in the
+/- 5-point range for clinical significance. Sam's score of 32 may or may not be clinically
significant. It is not possible to suggest a correlation between the last score and the Wellbutrin
intervention.
Table 1: Rate and Duration of Interruptions per Hour by Sam
| |
Number of
Interruptions |
Period
Covered |
Minutes
Interrupting |
Minutes per
Interruption |
Number of
Minutes
| Rate
per Minute |
| Week 1 |
23 |
7:10-8:00pm |
35 |
1.52 |
50 |
0.46 |
| Week 2 |
18 |
7:10-8:00pm |
40 |
2.22 |
50 |
0.36 |
| Week 3 |
13 |
730-8:00pm |
20 |
1.53 |
30 |
0.43 |
| Week 4 |
8 |
7:00-8:00pm |
35 |
4.37 |
60 |
0.13 |
| Week 5 |
6 |
7:10-8:00pm |
30 |
5.00 |
50 |
0.12 |
| Week 6 |
8 |
7:00-8:00pm |
30 |
3.75 |
60 |
0.13 |
| Week 7 |
5 |
7:10-8:10pm |
15 |
3.00 |
60 |
0.008 |
Rate and Duration of Interruptions by Sam (Table 1)
Sam identified "interrupting" as the first behavior he would like to change. We
operationalized interrupting as any time Sam talked over me for 5 words or more, and
hypothesized that a reduction in the rate of interruptions would indicate a reduction in the amount
of anxiety. The first week we were in session for 50 minutes and Sam interrupted 23 times for a
total of 35 minutes, an average of 1.52 minutes per interruption and an average interruption rate of
0.46 minutes. The second week we were in session for 50 minutes and Sam interrupted 18 times
for a total of 40 minutes with an average of 2.22 minutes per interruption and an average
interruption rate of .36 minutes. The baseline phase ended after the second week. The third week
we were in session for 30 minutes and Sam interrupted 13 times for a total of 20 minutes with an
average of 1.53 minutes per interruption and an average interruption rate of .43 minutes. The
scores from the first and third week are almost the same. The fourth week we were in session for
60 minutes and Sam interrupted 8 times for a total of 35 minutes with an average of 4.37 minutes
per interruption and an average interruption rate of .13 minutes. The fifth week we were in session
for 50 minutes and Sam interrupted 6 times for a total of 30 minutes with an average of 5 minutes
per interruption and an average interruption rate of .12 minutes. The sixth week we were in
session for 60 minutes and Sam interrupted 8 times for a total of 30 minutes with an average of
3.75 minutes per interruption and an average interruption rate of .13 minutes. Sam started taking
Wellbutrin this week, starting the third phase (BC) of the study. The seventh week we were in
session for 60 minutes and Sam interrupted 5 times for a total of 15 minutes with an average of 3
minutes per interruption and an average interruption rate of .08 minutes. Compared to the initial
week, the minutes per interruption increased 1.48 minutes, but the rate per minute decreased by .38
minutes (Table 1.1).
Table 2: Rate and Duration of Pacing per Hour by Sam
| |
Number of
Pacings |
Period
Covered |
Minutes
Pacing |
Minutes per
Pace |
Number of
Minutes
| Rate
per Minute |
| Week 1 |
12 |
7:10-8:00pm |
44 |
3.67 |
50 |
0.88 |
| Week 2 |
10 |
7:10-8:00pm |
36 |
3.60 |
50 |
0.72 |
| Week 3 |
5 |
730-8:00pm |
10 |
2.00 |
30 |
0.33 |
| Week 4 |
8 |
7:00-8:00pm |
12 |
1.50 |
60 |
0.20 |
| Week 5 |
7 |
7:10-8:00pm |
6 |
0.86 |
50 |
0.12 |
| Week 6 |
8 |
7:00-8:00pm |
6 |
0.75 |
60 |
0.10 |
| Week 7 |
6 |
7:10-8:10pm |
2 |
0.33 |
60 |
0.03 |
Rate and Duration of Pacing per Hour by Sam (Table 2)
Sam identified "pacing" as the second behavior he would like to change. We
operationalized pacing as any time Sam left his chair and took more than 3 steps, and hypothesized
that a reduction in the rate of pacing would indicate a reduction in the amount of anxiety. The first
week we were in session 50 minutes and Sam paced 12 times for a total of 44 minutes with an
average of 3.67 minutes per pace and an average rate of 0.88 minutes. The second week we were
in session 50 minutes and Sam paced 10 times for a total of 36 minutes with an average of 3.6
minutes per pace and an average rate of 0.33 minutes. The baseline phase ended after the second
week. The third week we were in session 30 minutes and Sam paced 5 times for a total of 10
minutes with an average of 2 minutes per pace and an average rate of 0.33 minutes. The fourth
week we were in session 60 minutes and Sam paced 8 times for a total of 12 minutes with an
average of 1.5 minutes per pace and an average rate of 0.2 minutes. The fifth week we were in
session 50 minutes and Sam paced 7 times for a total of 6 minutes with an average of .86 minutes
per pace and an average rate of 0.12 minutes. The sixth week we were in session 60 minutes and
Sam paced 8 times for a total of 6 minutes with an average of 0.75 minutes per pace and an
average rate of 0.1 minutes. Sam started taking Wellbutrin this week, starting the second phase
(BC) of the study. The seventh week we were in session 60 minutes and Sam paced 6 times for a
total of 2 minutes with an average of 0.33 minutes per pace and an average rate of 0.03 minutes.
All indicators of the identified behavior decreased over 7 weeks. The minute per pace dropped
3.03 minutes from and initial duration of 3.67 minutes and the rate per minute dropped 0.85
minutes from an initial rate of 0.88 minutes (Table 2.1).
Table 3: Rate and Duration of Looks at the Camera per Hour by Sam
| |
Number
of Looks |
Period
Covered |
Minutes
Looking |
Minutes
per Look |
Number
of Minutes
| Rate
per Minute |
| Week 1 |
9 |
7:10-8:00pm |
15.0 |
1.67 |
50 |
0.30 |
| Week 2 |
8 |
7:10-8:00pm |
15.0 |
1.87 |
50 |
0.30 |
| Week 3 |
4 |
730-8:00pm |
3.0 |
0.75 |
30 |
0.10 |
| Week 4 |
0 |
7:00-8:00pm |
0.0 |
0.00 |
60 |
0.00 |
| Week 5 |
4 |
7:10-8:00pm |
3.0 |
0.75 |
50 |
0.06 |
| Week 6 |
1 |
7:00-8:00pm |
0.45 |
0.45 |
60 |
0.008 |
| Week 7 |
1 |
7:10-8:10pm |
0.30 |
0.30 |
60 |
0.005 |
Rate and Duration of Looks at the Camera per Hour by Sam (Table 3)
Sam identified "looking at the camera" as the third behavior he would like to change. We
operationalized looking at the camera as any length of time that Sam looked into the camera, and
hypothesized that a reduction in the rate of looking into the camera would indicate a reduction in
the amount of anxiety. The first week we were in session 50 minutes and Sam looked into the
camera 9 times for a total of 15 minutes with an average of 1.67 minutes per look and an average
rate of 0.3 minutes. The second week we were in session 50 minutes and Sam looked into the
camera 8 times for a total of 15 minutes with an average of 1.87 minutes per look and an average
rate of 0.3 minutes. The baseline phase ended after the second week. The third week we were
in session 30 minutes and Sam looked into the camera 4 times for a total of 3 minutes with an
average of 0.75 minutes per look and an average rate of .01 minutes. The fourth week we were in
session 60 minutes and Sam looked into the camera 0 times for a total of 0 minutes with an average
of 0 minutes per look and an average rate of 0 minutes. The fifth week we were in session 50
minutes and Sam looked into the camera 4 times for a total of 3 minutes with an average of 0.75
minutes per look and an average rate of 0.06 minutes. The sixth week we were in session 60
minutes and Sam looked into the camera 1 time for a total of 0.45 minutes with an average of 0.45
minutes per look and an average rate of 0.008 minutes. Sam started taking Wellbutrin this week,
starting the third phase (BC) of the study. The seventh week we were in session 60 minutes and
Sam looked into the camera 1 time for a total of 0.30 minutes with an average of 0.3 minutes per
look and an average rate of 0.005 minutes. All indicators of the identified behavior decreased
over 7 weeks. The minute per look dropped 14.70 minutes from and initial duration of 15 minutes
and the rate per minute dropped 0.295 minutes from an initial rate of 0.3 minutes (Table 3.1).
Medication
Sam did not indicate any change in his behavior outside of the session after one week on
Wellbutrin. None of the results correlate with the second intervention. At the seventh week, there
is not no indication that Wellbutrin has affected Sam's functioning.
DISCUSSION
This paper reviewed literature relevant to the treatment of a client with multiple diagnoses.
The prevalence of comorbid diagnoses in children poses a challenge in identifying specific
literature to support clinical interventions. The issues of single treatment for multiple diagnoses
was discussed earlier in the paper. It was found that a small portion of the literature supports the
concept that diagnosis based treatment is less relevant to children than it might be for adults. This
is not surprising, since until recently most therapies have tended to treat children as little adults
(Kazdin, 1994). One of the therapies that has recently focused attention on children and
adolescents is cognitive-behavioral therapies. The developmental focus, incorporating social
learning theory and Piagetian developmental theory, provides a solid basis for considering
developmental needs that are specific to children and adolescents. For those reasons, it appeared
that SIT would be a successful intervention. However, the intervention has yet to be successful.
CAS
Although Sam's CAS scores decrease during the last 3 weeks of treatment, his mean score
for the 7 weeks (50.6) is actually higher than his initial score was (45). After getting Sam's
scores back on the third week (45) I was hopeful that this intervention was working. However, the
fourth week's scores were almost as high as the second week's scores (63 and 67). There were
three weeks when Sam's score was 45. It might be helpful to know what was different about those
days; a longer study might show a pattern where CAS scores of 45 are Sam's good/average days.
Since that data is unknown, it is difficult to hypothesize as to the significance of the scores.
Clearly, though, the seventh week CAS score of 32, is remarkably low for Sam. With the +/- 5
points, we can say that Sam had one day without a clinically significant amount of anxiety. There
is not enough data to support the possibility that the medication (Wellbutrin) was starting to work.
Figure 1: Sam's Clinical Anxiety Scale Scores
| |
Week 1 |
Week 2 |
Week 3 |
Week 4 |
Week 5 |
Week 6 |
Week 7 |
| Scores |
45 |
67 |
45 |
63 |
57 |
45 |
32 |
| Clinical Cutoff |
30 |
30 |
30 |
30 |
30 |
30 |
30 |
Rate and Duration of Interruptions by Sam per Hour
With the exception of "minutes per interruption,"(Table 1.1), all other identified
symptoms have decreased. It is possible that as the relationship developed more trust Sam felt
like he could interrupt less, but when he did it was very important, so he would take his time to
finish. According to Sam's teacher at school, there has been no significant change in his
interruptions. One of the ways that Sam controls the situation is by determining who gets to say
what; if he is always talking, then no one can insult him or hurt him. It would appear that a
different intervention is necessary to impact the quality of interruptions.
Table 1.1: Rate and Duration Interruptions per Hour by Sam
| |
Week 1 |
Week 2 |
Week 3 |
Week 4 |
Week 5 |
Week 6 |
Week 7 |
| Minutes per
Interruption |
1.52 |
2.22 |
1.53 |
4.37 |
5.00 |
3.75 |
3.00 |
| Rate per
Minute |
0.46 |
0.36 |
0.43 |
0.13 |
0.12 |
0.13 |
0.08 |
Rate and Duration Pacing per Hour by Sam
The data suggest that Sam paced around the room less often as the seven weeks went by.
This might have been a significant finding had it correlated with any other finding. According to
Sam's teacher, Sam has not shown any improvement in staying in his seat since therapy started. It
appears that this behavioral change cannot be generalized. It is possible that generalizing will take
longer.
Table 2.1 Rate and Duration Pacing per Hour by Sam
| |
Week 1 |
Week 2 |
Week 3 |
Week 4 |
Week 5 |
Week 6 |
Week 7 |
| Minutes
Per Pace |
3.67 |
3.60 |
2.00 |
1.50 |
0.86 |
0.75 |
0.33 |
| Rate per
Minute |
0.88 |
0.72 |
0.33 |
0.20 |
0.12 |
0.10 |
0.03 |
Rate and Duration Looks at Camera per Hour by Sam
Although the most significant decrease was in the rate and duration of looks to the camera
(Table 3.1), it is possible that this is merely a result of getting used to the camera. Sam's behavior
did not change significantly in other ways, so there is a big question as to the importance of this
behavior. Another criticism of this measure is that it is not directly generalizable outside of the
treatment room. One possible way to generalize this is by making the camera symbolic of people
in Sam's life that he feels are always, but do not have any control over his life.
Table 3.1 Rate and Duration Looks to Camera per Hour by Sam
| |
Week 1 |
Week 2 |
Week 3 |
Week 4 |
Week 5 |
Week 6 |
Week 7 |
| Minutes per
Look |
1.67 |
1.87 |
0.75 |
0.00 |
0.75 |
0.45 |
0.30 |
| Rate per
Minute |
0.30 |
0.30 |
0.20 |
0.00 |
0.06 |
0.008 |
0.005 |
Implications for Future Research
The most significant pattern that has emerged is that the changes in the identified behaviors
do not correlate with the changes in the CAS scores. This would indicate a poor internal-consistency
reliability between measures. Both measures did however strongly suggest that there
was no significant improvement in Sam's anxiety. One of the difficulties of this case is that the
client has a known history of sexual abuse and trauma, but he has yet to present it. As a result,
much of the literature that addresses PTSD is not currently relevant to our treatment; much of the
PTSD treatment literature focuses on revisiting the trauma, systematic desensitization, corrective
emotional experiences, and other techniques that require the client to not only share the trauma, but
be willing to deal with it. Currently, Sam is working at his own pace; we are slowly building up
trust and he let me know last week that he had something important that he was wanting to tell me
in the next couple of weeks. It appears that a longer time frame would be important in doing a
research design with Sam, unless the focus of the research is the trusting relationship.
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