Problem The purpose of this paper is to present a case study completed in an effort to determine the best form of treatment for a young adult suffering from anxiety. Discussion will include information obtained via a literature review accomplished to help determine what intervention tools are the most effective to decrease anxiety symptoms in young adults. Details regarding assessment and tools utilized as well as a description of methods and the results of the process are presented.
Moreover, the research will help to prove the importance of treatment taking into account the compelling statement by Kasteenpohja et al. (2016) which identifies that “anxiety disorders have been shown to have a negative impact on the individuals who suffer from them (p. 2). In addition, a twelve year study of physician based psychiatric visits for youth ages two to twelve years old presented findings that showed an increase in the diagnosis of anxiety disorders from 45 in year one to 58% in year twelve (Rajakannan, Safer and Burcu, 2016, p. 289).
The discussion will intentionally leave out any identifying information to protect the client (Reamer, 2013, p. 167). Tam currently completing my second year MSW field placement at Quality Behavioral Health (QBH) in Warwick. It is a privately owned, for profit mental health agency. Assessment, diagnosis and treatment of behavioral disorders are delivered on an outpatient basis and are provided by psychotherapists, psychiatrists, neuropsychologists, psychiatric nurse practitioners, licensed mental health counselors and licensed social workers.
My role as a student intern includes providing clients with clinical telephone intake and assessment to determine need and identify an appropriate provider. In addition, I am also charged with completing clinical assessments during one face to face, forty-five minute session as well as providing individual therapy. The first step to begin working with a client is to complete an initial clinical evaluation or assessment. Initial clinical assessment is completed during the first office visit. This process takes place between the client and a therapist or clinician.
Student interns are allowed to complete assessments for patients that have Untied Health as their primary insurance via a contract the agency has with United. The assessment process is expected to take no more than forty five minutes utilizing the agencies Initial Evaluation Report forms, (see Appendix A). The form lists general topics to review and each section is meant as a guide for the clinician to ask open ended questions. The client is responsible for completing several other agency forms including a health history, privacy policies and consent to treatment.
It is the therapist responsibility to review the forms, seek clarification and to use them as part of the full assessment and diagnostic process. Each patient must receive a formal DSM-5 (2013) diagnosis at the end of the assessment appointment for billing purposes (American Psychiatric Association). If the symptoms do not clearly indicate a diagnosis, clinicians are required to select the diagnosis that is the closest match. Clara (name disguised to protect client) (Reamer, 2013, p. 167) is a seventeen year old high school student that was referred to the agency by her primary care provider for symptoms of anxiety.
Clara was described as having issues due to worries at home, school and work. The initial telephone assessment was completed by an intake specialist at QBH using information provided by Clara’s mother. I met Clara and her mother when they came for her initial assessment. Due to her age, QBH policy required Clara’s mother be present during the entire assessment interview. Clara reported that she was a single high school student who lives at after school.
My role as clinician is to complete a competency based initial clinical assessment and hen to provide individual therapy at intervals determined together with Clara according to her needs which have been identified during the formal assessment process (Gray & Zide, 2011, p. 21). Literature Review The process of reviewing literature is completed to inform treatment using evidence based interventions and methods for assessing symptom levels and to identify the most effective methods treat anxiety.
Anxiety is affects many individuals, according to Gray and Zide (2013) “anxiety disorders are the most common and frequently occurring mental disorders” (p. 55). According to Gray, McCullagh and Petros (2016) lifetime prevalence rates have been noted to be as high as 25-30% (p. 186). The literature that I reviewed indicated the followin treatment methods for anxiety disorders; Cognitive Behavioral Therapy (CBT), Mindfulness-Based Stress Reduction (MBSR), SelfAdministered Strategies and Pharmacological Treatments. Cognitive Behavioral Therapy is described by Kendall and Peterman (2015) as the first line of psychological treatment for adolescents suffering from anxiety symptoms (p. 20).
Cognitive behavioral therapy is based on the belief that an individual’s thought process can be maladaptive, this can play a role in affecting a person’s anxiety level and that by re-structuring the thought process, one can decrease anxiety levels (Bowler et al. , 2012, p. 1022). This type of re-structuring can be delivered in individual therapy sessions using a combination of interventions, exposure exercises and psychoeducation to challenge and change distorted thinking (Smits, Julian, Rosenfeld and Powers, 2012, p. 625).
Furthermore, study findings presented indicate 60-80% of youth show clinically significant improvement after CBT treatment and describe that those gains are maintained several years after treatment has been completed (Kendall et al. , 2015 p. 520). Additionally, CBT was proven to be the most cost effective form of treatment in a model based economic analysis presented by Mavranezouli et al. , (2015, p. 1). Mindfulness-Based Stress Reduction is described by Solar (2013) as a structured program used to reduce anxiety and stress, alleviate pain and increase relaxation through mindfulness techniques (p. 4).
Kallapatran et al. (2015) provides a meta-analysis comparison taking into consideration five studies of 659 participants which identified that MBSR was more effective than other treatments at improving stress (p. 184). Mindfulness emphasizes awareness of present-moment experiences and can be completed in almost any setting (Shepardson, Funderbunk and Weisburg, 2016, p. 116). To be mindful, an individual must pay attention to their thoughts, behaviors and feeling that they presently are experiencing (Biegel, Brown, Shapiro and Shubert, 2009, p. 855).
In a study of that was published in 2014, Mitchell and Heads determined that mindfulness can have a direct impact on emotional regulation which can be linked to feelings of anxiety (p. 897). Furthermore, mindfulness activities such as deep breathing can help to aid in relaxation and decrease the bodies stress response levels (Scotland-Coogan and Davis, 2016 p. 435). Self-administered strategies are considered another form of treatment and are also known as the self-help method.
These include the use of work books, worksheets and other self-identified supports that do not include working with a trained therapist (Mavranezouli et al. 015, p. 3). In the presentation of a meta-analysis of self-help treatment models Farrand and Woodford (2015) identified two forms of intervention, self-administered CBT interventions and undefined internet based programs noting that the overall effectiveness of both forms of treatment was low (p. 590).
Pharmacological treatment includes the use of psychotropic and psychoactive substances in a clinical setting to relieve the symptoms of emotional disturbances and emotional pain (Brandell, 2011, p. 63). Rajakannan, Burcu and Zito (2016) pointed out that past research cannot substantiate the effective treatment of NOS (not otherwise specified) psychiatric disorders using psychotropic medications (p. 293; American Psychiatric Association, 2013). There is evidence as presented by Palazzo, Dell Osso, Altamura, Stein and Baldwin (2014) that there is limited use of psychotropic medication in anxiety treatment because individuals want to avoid the potential side effects (p. 214).
It is the role of the clinician to assist clients in providing information about the use of pharmacological treatment and by keeping informed about current medications including advocating with medical providers on the client’s behalf as needed (Roberts, 2009, p. 688). QBH requires that all forms of therapy must include Cognitive Behavioral Therapy for medical billing purposes because it is evidenced based. Other forms of therapy can then be utilized at the discretion of the clinician. The use of any form of therapy must take into consideration the client’s needs which should be identified by the assessment process.
Using the requirements from the field placement as well as the information identified in the literature review, I have decided to use two forms of treatment. They are CBT and Mindfulness-Based Stress Reduction (MBSR) techniques and were chosen because they are both proven effective treatment models. CBT treatment will include the use of coping self-talk, identifying and challenging negative thoughts and helping the client to select and engage in enjoyable activities. MBSR will include the use of deep breathing exercises and grounding techniques which will be incorporated into the CBT treatment.
