Helana is a 20-year-old Hispanic female school student. She comes from a middle-class family, which is able to afford her education. She lives with her parents and two young siblings (aged 15 and 10 years) in an urban center where she attends school.
Two Chief Complaints
When asked to describe significant experiences that affect her life, Helana explains, “I have been unable to sleep, and I tremble when I hear loud sounds after witnessing an accident that killed one of my closest friends.”
History of the Current Two Problems
Helana reports that she visited her friend on the weekend to discuss class assignments. She asked her friend to escort her to the bus stop to find a cab and return home. She crossed the road first, but her friend was knocked down by an over-speeding white sedan driven by a middle-aged white man who appeared intoxicated. The friend’s body was so dismembered that she trembled as she tried to carry her to an ambulance that had arrived. She remembers seeing a white substance splattered at the accident scene, and she believes it was her friend’s brain since her skull was broken. She has been unable to sleep for about three weeks and panics when she hears abrupt loud sounds.
Family Emotional and Psychological History
Helana’s family members do not have a history of sleep problems or fear of loud sounds. Her 54-year-old mother, who works at a community health center, is psychologically healthy. She does not remember her mother complaining about a lack of sleep for a prolonged period. Her father, who retired from the teaching profession, is also leading a healthy life as he runs a family business. None of her siblings have experienced symptoms to those she has developed since the death of her friend.
After the accident, Helana went home and shared details of the tragedy with her family members. She cried uncontrollably as she narrated the events, and her mother kept consoling her. The following day, she did not attend school because she felt emotionally distressed. She stayed in her room the entire day, thinking about the death of her best friend. When her parents realized that she struggled to cope with the accident’s psychological effects, they bought her some prescription medications that helped her to sleep for a few hours. Without taking medication, she cannot sleep comfortably. She is also unable to overcome fear for loud sounds.
Mental and Emotional Personal Status Evaluation
From the onset of the initial interview, Helana looked distressed. Over the course of the assessment she could remain silent for several seconds before continuing with the description of her life experiences. She appeared to be experiencing emotional distress as she recalled the events of the accident. Helana was certain that her well-being continued to deteriorate due to the accident’s impact on her mental health status.
Helana’s two main problems identified in the session are sleep disturbances and fear of loud sounds, which she attributes to the death of her close friend in an accident.
Operationalization of Problem(s) Targeted for Intervention
Issue one: Fear/anxiety
One of the problems targeted for intervention is anxiety. During the assessment, the client avers, “I tremble when I hear loud sounds.” The identified problem is evidenced by her incapacity to overcome the fear of loud sounds since her friend’s accident. The client and I choose to target this problem first because it has detrimental effects on her overall well-being and school performance. Notably, due to the fear she experiences, the client is unable to attend school. Furthermore, fear is the primary cause of her distress.
Issue 2: Sleeplessness/ Post Traumatic Stress Disorder (PTSD)
The second problem targeted for intervention is sleeplessness. The client states, “I have been unable to sleep after witnessing an accident that killed my friend.” The identified problem is evidenced by her inability to sleep for three weeks since the accident, and significant dependency on sleeping pills to sleep comfortably. The client also adds that she can only sleep a few hours even after taking the pills.
The client and I reached a consensus to target this problem because of its detrimental effect on her physical well-being. Notably, the client only enjoys a few hours of sleep, which affects her ability to function effectively, especially in terms of attending school. The client also states that without prescription drugs, she cannot sleep comfortably.
A Feedback-Informed model of practice will be utilized to target the issue of sleeplessness, which is attributed to posttraumatic stress disorder (PTSD) and anxiety of loud sounds exhibited by the client.
Standardized scales/ measures
Problem One: Measures of Fear and Anxiety
Scale One. The first measure of anxiety is the Beck Anxiety Inventory (BAI). The BAI is a screening tool developed by Aaron Beck for use in measuring anxiety among psychiatric patients. The tool consists of 21 items with a Likert Scale ranging from 0-3 and raw scores ranging from 0-63, indicating the magnitude of fear, from mild to severe (Lennard et al., 2011). Prior studies indicate that the scale has a high internal consistency, which signifies its reliability in clinical and non-clinical samples, and constructs validity (Fydrich et al., 1992). The self-report scale takes 5-10 minutes to administer and less than 5 minutes to interpret (Oh et al., 2018). Furthermore, the tool is validated in several languages, including German, Spanish, and Nepal.
Article one. The first article for the BAI scale is “Validation of the Nepali version of beck anxiety inventory” by Kohrt et al. (2003). The study in the article consisted of an initial population of 406 individuals from an outpatient clinical population from Tribhuvan University Teaching Hospital in Maharajgunj (TUTH), community sample with psychiatric and no psychiatric illness from Jumla, and a community in Jumla that did not receive psychiatric diagnoses (Kohrt et al., 2003). Blind sampling was used to select the study participants, after which a sample of 340 individuals was used in the final research.
The alpha score for the scale was α=0.80. Besides, the specificity and sensitivity of the scale amounted to 0.89 and 0.90, respectively (Kohrt et al., 2003). The reliability of the psychiatric sample in the study was 0.80, while that of the full sample, comprising psychiatric and healthy individuals, was 0.89 (Kohrt et al., 2003). The mean for the anxiety group (23.1) was within the range of moderate to severe anxiety (19-29), while that of the healthy group (6.8) was (0-9) for non-anxious persons (Kohrt et al., 2003). Also, the reliability of the BAI was higher than that of the BDI.
Limitations. The study was exclusively conducted using a rural-Nepalese sample that had unique anxiety disorders. Therefore, it may not be generalizable in a large population. Furthermore, the kappa score was not provided.
Article two. The second article for the BAI measure is “Confirmatory factor analysis of the Beck Anxiety Inventory among Chinese postgraduates” by Zhou et al. (2018). The study by Zhou et al. (2018) consisted of a population of 600 postgraduate students from two universities in Nanjing. The researchers utilized a random sampling technique to select the sub-sample for study. Out of the 600 participants, a sample of n=531 was used in the final research (Zhou et al., 2018). 58.3% and 41.7% of the sample were men and women, respectively, between the age of 22 to 26 years (Zhou et al., 2018). Also, the sample was divided into two groups, CFA and EFA, constituting of 265 and 266 participants, respectively.
The Cronbach’s alpha score for the BAI was α=0.90 when an item in the scale was deleted, and ranging from 0.937-0.940 when all items were included (Zhou et al., 2018). Furthermore, the four-factor for a sub-sample EFA was (df=183). Furthermore, 50.3% of the population had a mean score of higher than 16 points, a sign of above-moderate anxiety (Zhou et al., 2018). Based on findings from the study, the mean for the BAI was higher than 25 points, an indication of severe anxiety symptoms in the population.
Limitations. While the sample size was randomly selected, the participants were discriminately chosen from universities in East China. The authors acknowledge that the region in East China is more economically advanced compared to the North and West areas of China (Zhou et al., 2018). Therefore, the results could not be generalized in a broader population. Furthermore, the kappa store for BAI was not provided.
Limitations of measure one. Literature suggests that BAI measures of anxiety overlap with depression. Therefore, the tool may not be entirely specific for assessing fear in a primary care population (Muntingh et al., 2011). Also, the Cronbach’s alpha for BAI is highly dependent on the number of items included in the scale. As noted, the alpha declines when an item from the scale is deleted (Zhou et al., 2018). Furthermore, the results of the scale may be client or provider-biased since it’s a self-administered measure.
Scale Two. The second measure of the targeted anxiety problem exhibited by the client is Depression, Anxiety, and Stress Scale (DASS-21). Lovibond developed the scale as a single measure to assess anxiety, depression, and stress (Gloster et al., 2008). Notably, DASS-21 is a 42 items scale comprising three scales of 14 items referring to a past week, and scores range from 0 (did not apply to me at all) to 4 (applied to me very much or most of the time) (Gloster et al., 2008). In the context of anxiety, the scale measures autonomic arousal, physiological hyperarousal, and subjective feeling of fear, which is of great interest in our client’s case (Gloster et al., 2008). Furthermore, it is argued that the validity and reliability of the DASS-21 have been replicated in both clinical and non-clinical adult samples (Le et al., 2017). All prior studies have ascertained the internal consistency of the DASS 42 and 21-item scale.
Article One. The first article of the DASS-21 scale is “Psychometric properties of the 21-item depression anxiety stress scale (DASS-21),” by Coker et al. (2018). The study, which was conducted to determine the internal consistency reliability estimates, convergent, and discriminant validities of the DASS-21, consisted of a population of 250 medical students from the second to the sixth year in Nigeria. Out of the 250 participants, 96% (240) between the age of 25 and 34 years participated in the study. Of the 240 participants, 120 were females, while the rest were male (Coker et al., 2018). However, the sampling technique was not provided, as participation was voluntary.
Based on statistical analysis, the Cronbach alpha for the three domains of the DASS-21 was α=0.91. This value showed that the DASS-21 had an excellent internal consistency as established in other studies. However, the alpha coefficients were lower in the independent domains; anxiety (α=0.89), stress (α=0.78), and depression(α=0.81) (Coker et al., 2018). Furthermore, the concurrent, convergent, and divergent validities of the subscales of the DASS-21 were found to be moderately strong (Coker et al., 2018). The anxiety subscale of the DASS-21 was positively and strongly correlated with the State-Trait Anxiety Inventory (STA1) (0.517) (Coker et al., 2018).
Limitations. The authors of the article acknowledged that one of the limitations of the study is that a homogenous sample was selected from a single university (Coker et al., 2018). Therefore, the results of the research cannot be generalized to all students in the population. Also, the study lacked a kappa score. Besides, the test-retest reliability of the scale was not investigated.
Article two. “The Depression Anxiety Stress Scale-21 in Chinese Hospital Workers” was a study conducted by Jiang et al. (2020) to test the reliability, latent structure, and measurement invariance of the DASS-21 across genders in the facility. The study population constituted of 1,575 medical personnel from three hospitals in China, out of which 1532 individuals between the age of 19-73 years volunteered to participate in the research (Jiang et al., 2020). Of the 1532 persons, 74.4% were women while the rest were male.
The alpha score for the total DASS-21 scale was α=0.95. This value was consistent with the Cronbach’s α for prior studies conducted using the scale, and it signified the consistency of the measure. The df for the total sample was 189 (Jiang et al., 2020). Additionally, the t-test showed that the depression subscale was significantly higher in men than in women (Jiang et al., 2020).
Limitations. One of the limitations of the study was the lack of a kappa score. Also, the test-retest reliability of the scale was not determined (Jiang et al., 2020). Furthermore, the authors acknowledged that the sample size was not equally representative of all genders, as half of the sample consisted of nurses, who were mostly females (Jiang et al., 2020). Furthermore, the self-assessment nature of the questionnaire limited clinical assessment to confirm levels of depression, anxiety, and stress in the study participants (Jiang et al., 2020).
Limitations of the Measure. Among the shortcomings of the DASS-21 is its limited items of measure. Notably, the scale does not assess further risk, such as suicide risks exhibited by a client. Furthermore, the self-report nature of the test can result in a biased response by the client and potential misinterpretation of the data by the social worker.
Problem two: Post Traumatic Stress Disorder
Scale one: PTSD checklist-civilian version (PCL-C)
The PTSD checklist-civilian version is a popular measure for detecting PTSD among patients. The self-reported questionnaire consists of 17 items that correspond to the symptom of PTSD in the DSM-IV (Gelaye et al., 2017). Prior studies ascertain that the Civilian version of PCL (PCL-C) is valid and reliable for general traumatic experience in both clinical and non-clinical settings (Gelaye et al., 2017).
Article one. The first validation study for the PTSD Checklist- Civilian Version (PCL-C) is “Validity of the posttraumatic stress disorders (PTSD) checklist in pregnant women” by Gelaye et al. (2017). The study population consisted of pregnant women undergoing prenatal care at the Instituto Nacional Materno Perinatal (INMP) in Lima, Peru (Gelaye et al., 2017). A sample size of 3289 participants was selected after diagnosing the population for PTSD within the past 12 months. Further, 641 women were randomly selected from the sample to complete the PCL-C, out of which eight were excluded due to missing information.
Statistical analysis of the data revealed excellent reliability of the scale. Notably, the Cronbach’s alpha of the PCL-C was α=0.90 (Gelaye et al., 2017). The cut-off score of 26 of the scale offered a sensitivity of 0.86 and specificity of 0.63 (Gelaye et al., 2017). Also, there existed a correlation between the 17 items of the scale (p-values<0.0001).
Limitations. One of the limitations of the study is the lack of test-retest reliability. Furthermore, the researchers used DSM-IV criteria, which is an outdated version of the DSM-5 criteria currently used. Also, the validity kappa for the measure was not provided.
Article 2. In their article, “Validation of the PTSD Checklist- Civilian version in survivors of bone marrow transplantation,” Smith et al. (1999) conducted a study to try and validate the PCL-C scale. The study population comprised of Bone Marrow Transplant (BMT) recipients at a cancer centre. A sample of 111 participants was selected, out of which 51% were male (Smith et al., 1999). Also, 77% of the study population were White, and the respondents’ mean age was 39.31 years (Smith et al., 1999). Four measures were used for the study, namely: the PCL-C, IES, BSI, and MOS SF-36.
Statistical findings showed a significant correlation between the individual scale items. Also, the alpha coefficient for the subscale was 0.74 for the intrusion subscale, 0.76 for the avoidance subscale, 0.78 for the arousal subscale, and 0.89 for the total scale (Smith et al., 1999).
Limitations. The kappa coefficient for the study was not provided. Also, test-retest reliability for the study participants was not conducted. Furthermore, it was not clear of the sampling technique used by the authors to select the sample size.
Limitations of Measure One. One of the limitations of PCL-C is the lack of a standard cut-off score for diagnosing PTSD within a study population (Ruggiero et al., 2003). Notably, some studies use a cut-off point of 44, 45, and 50, thus creating a variation in diagnosis during practice.
Scale two. PTSD Symptom Scale Interview (PSS-1)
The PSS-1 is a “27-item semi-structured interview that assesses PTSD DSM-5 diagnosis and symptom severity in the past month based on interviewer ratings” (Foa et al., 2018, p.40). Depending on the reported symptoms, the interviewer rates, and sums the items on the scale from 0 (not at all) to 4 (6 or more times a week/almost always. The PSS-1 provides subscale ratings for intrusion (items 1-5), avoidance (items 6-7), changes in cognition and mood (items8-14), and increased arousal and reactivity (items 15-20) (Foa et al., 2018).
Article one. The first article of focus is “Psychometrics of the child PTSD symptom scale for DSM-5 for trauma-exposed children and adolescents” by Foa et al. (2018). In their study, Foa et al. (2018) evaluated the psychometric properties of PSS-1 using a population of children and adolescents between the age of 8 to 18 years, who had experienced a DSM-5 criterion A trauma (Foa et al., 2018). A sample of 64 participants was involved in the study, out of whom 33 were female while 31 were male. Also, the responders belonged to different races, including Whites (19), African American (29), Hispanics (9), and biracial (6). The researchers used a random sampling technique whereby participants were randomly selected from clinics in Philadephia.
In this study, the internal consistency was found to be adequate α=0.76. Also, the test-retest reliability was relatively excellent (r=0.87). Furthermore, the interrater reliability on the PTSD diagnosis for the scale was good, k=1 (Foa et al., 2018). This kappa coefficient revealed a diagnosis agreement between CPSS-5-SR and CPSS-1. Additionally, the specificity and sensitivity of the scale were found to be 0.93 and 0.84, respectively (Foa et al., 2018).
Limitations. One of the shortcomings of the article was the use of a relatively small sample size, n=64. Therefore, the findings from the sample may not be adequate to be generalized in a larger population
Article 2. The second article of focus is “Validation of the Child PTSD Symptom Scale (CPSS) in Spanish adolescents” by Serrano-Ibanez et al. (2018). Notably, the article comprises a study conducted among high school students in Malaga, Spain, to test the validity of the PSS-1 scale. A sample size of 339 adolescents participated in the study, 172 and 167 of whom were boys and girls, respectively. An analysis of the article reveals that the sampling technique was not clearly highlighted.
The study established that the internal consistency of the scale was significant. Notably, Cronbach’s coefficient for the full sample was α=0.90. The internal consistency of the independent subscale symptoms factors was α=0.80 for intrusion subscale, α=0.70 for avoidance subscale, α=0.83 for the dysphoria subscale, and α=0.74 for arousal subscale (Serrano-Ibanez et al., 2018).
Limitations. The article lacked a kappa score. The measurement invariance tests were also not conducted (Serrano-Ibanez et al., 2018). Furthermore, the sample size was relatively small.
Limitations of the measure. Compared to other scales, the PSS-1 takes the longest time to complete.
Identification of Validated Measures
The BAI is selected for use with my client to target the issue of anxiety, as evidenced by her behavioral symptoms. I feel that this measure is superior because it enables the patient to provide their adequate views about the severity of anxiety. Furthermore, the literature review reveals that the scale is consistent, thus reliable for use.
Post Traumatic Stress Disorder
The PTSD Symptom scale interview is selected for use with my client to target the sleeplessness and PTSD symptoms. I feel that this measure is superior because it is designed for use with children aged 8-18 years (Serraro-Ibanez et al., 2018). While my client is 20 years old, I feel that the scale fits for use in the age bracket.
The rationale for the developed instrument
One of the reasons for using the developed measure in Appendix A is its effectiveness in facilitating behavioral observation. Notably, the scale will help me track the client’s behavior and assess the severity and most recurring symptoms. With such information, it will be easier to establish measures that will help the client overcome her problems.
Intervention and Model of Practice
A cognitive-behavioral therapy that targets PTSD and anxiety is selected for use with Helena.
Definition and Purpose
Fenn and Byrne (2013) define cognitive-behavioral therapy (CBT) as a “directive, time-limited structured approach” that helps alleviate distress by assisting patients in developing more adaptive cognitions and behaviors (p579). In other words, CBT is a psychotherapeutic method that facilitates the treatment of mental health disorders by helping patients change their perceptions of events, which in turn shapes positive emotions and behaviors.
The expected gains of using this intervention include helping Helena monitor her anxiety and mind-body relationship, and training her on some relaxation strategies that may help ease her fear, anxiety, and negative thoughts.
The intervention will be coupled with a Feedback-Informed model of practice. This model of practice involves the frequent solicitation of client’s feedback to help identify aspects of the therapy that may or may not be working. The use of a Feedback-Informed model of practice is expected to help improve the intervention to facilitate adequate achievement of the client’s needs.
The CBT handbook shows that there are about three components of the intervention. The first component is labeling and monitoring anxiety (Kandasamy et al., 2019). The therapist enlightens the client about the mental health issue and ways in which to identify and monitor the condition. The second component of the intervention is teaching on relaxation strategies (Kandasamy et al., 2019). The patient is trained on tactics of remaining calm during the onset of fear. Often, the therapist can suggest different relaxation strategies and allow the client to try those that work for them. After teaching, the therapist helps the patient apply the coping strategy and monitors progress during the subsequent sessions.
Evaluating and Tracking Outcome of each Target Problem
A single subject, A-B-A design, will be used to track the outcome of each of the two target problems. The selected design involves the repeated measurement of the target problem (Malboeuf-Hurtubise et al., 2017; Engel & Schutt, 2008). Measurements of the score in Appendix A will be gathered before and after the withdrawal of the intervention. Also, a session rating scale will be administered to the client each week to help track the status of the therapy in meeting the client’s needs. The design is selected for use in Helena’s case because it will help assess the efficiency of the established treatment in combating anxiety, fear, and PTSD in the patient.
A trained therapist will help to collect the baseline, treatment, and follow-up data. The use of a trained therapist will help ensure that accurate data is gathered during the intervention. Most notably, data on the scores of the two scales will be collected after each session for ten weeks. In total, the sessions will be held for twelve weeks, with each session taking place ones per week for one hour. This data will be gathered exclusively from the information filled by the client in the BAI, PTSD Symptom Scale, and session rating scale (SRS).
Presentation and Interpretation of Case Data
As noted, the data was collected from the three scales, and it was presented in a graph as shown in appendix C. The data showed a significant decline in levels of anxiety exhibited by the client after the introduction and withdrawal of the treatment intervention. Most notably, all the incidents of anxiety and fear recorded on the BAI scale decreased by 8. Also, there was a significant decline in incidents of PTSD, decreased by 10, and an increase in session ratings by 6.
In my view, the significant change in the level of the target problems was as a result of the selected intervention, which enabled the client to learn, understand and monitor the problem, and develop skills that helped her cope with her condition. Most notably, the CBT helped Helena label and monitor her anxiety each time it arose. Afterward, the client could apply the relaxation strategies taught during the sessions, such as taking slow and regular breaths at least ten times until the anxiety lessened. Controlling her level of anxiety could also have helped Helena to sleep more comfortably without the need for sleeping pills.
Similar results, as in Helena’s case, have been recorded in studies that implemented CBT as an intervention for childhood anxiety disorders. Most notably, in qualitative research conducted by Kandasamy et al., (2019) among children with anxiety disorders, 30 of the participants noted that cognitive interventions helped them overcome anxiety. These findings solidify the idea that the reduction in levels of anxiety and PTSD symptoms in the client are attributable to the CBT intervention.
Critique of the Evaluation
One of the primary strengths of the evaluation method is the ability to solicit the overall feedback of the sessions. As observed by Giatrelis (2017), the SRS has the potential to provide feedback on both outcomes (outside of sessions) and working alliance (within sessions). Therefore, the therapist was able to have a better insight into the quality of the service from the client’s perspective. This aspect influenced subsequent treatment approaches used with the patient.
Furthermore, the information generated from the evaluation process helped motivate the client as it became clear that the intervention was effective in lowering her levels of anxiety. Due to the positive outcomes of the evaluation process, the patient felt motivated to continue attending the sessions to achieve better results.
Among the significant limitations of the evaluation process was potential bias. Most notably, data on feedback about the sessions was inherently based on a self-report by the client, which could have been subject to bias (Duncan et al., 2003). As such, I believe that feedback should have been solicited from external sources too to enhance the effectiveness of the approach. Most notably, input from the client’s parents may have provided a better picture of the patient’s behavior outside the sessions and guided further treatment decisions.
Broader Implications for Social Work
Based on the results obtained, I would highly recommend my fellow practitioners to utilize the CBT intervention when dealing with patients that exhibit anxiety, fear, and PTSD symptoms. Some of the benefits associated with the technique include the ability to tailor treatment based on the patient’s characteristics. Most notably, if a client exhibits anxiety disorder, the practitioner can tailor relaxation strategies that may help lessen anxiety.
Merits of the Intervention
Level of Effort
The intervention has significant outcomes, yet it requires the least level of effort. The practitioner would only spend minimum time on gathering data from the three scales and interpreting it to tailor a treatment for the client.
The intervention also has merits based on effectiveness. Most notably, the majority of the studies reviewed during the coursework proved the effectiveness of the intervention in decreasing anxiety and PTSD symptoms among patients.
Client Focused and Centered
The intervention is both client-focused and centered. Most notably, treatment is instituted through a working alliance between the therapist and patient to formulate strategies that work best for the patient.
Efficiency of the Treatment Approach
The positive results of the approach can be recorded within 12-16 weeks. As such, the therapist has ample time to teach and facilitate the application of the cognitive and behavioral techniques acquired by the client to manage anxiety.
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The following scale will be used to target problem one.
Instructions: Please rate on a scale of 0-3 how often these things have happened to you in the last one week. The questionnaire should take less than five minutes to complete.
(0= none, 3 =all the time)
- I panicked due to loud sounds
- I was worried that the noises outside the house might cause me to panic, so I avoided it
- I did not feel comfortable leaving the house
- I preferred total silence in my room
The following scale will be used to target problem two.
Instructions: Please rate on a scale of 0-3 how you felt with regards to the highlighted problems in the past one week. Completing the scale should take less than five minutes.
(0=none, 3=all the time)
- I was able to sleep comfortably
- I was able to sleep without taking the prescription pills
- I had nightmares about my friend’s accident
- I got enough sleep
Session Rating Scale (SRS)
(Ages 13 to Adult)
Name Age (Yrs): Session #: Date:
Help us understand your feelings about today’s session by placing a line to the description that best fits your experience.
We did not work on the We worked on the most essential issues most essential issue
I did not feel understood I felt understood
I wish the therapist could The therapist’s approach is a good fit for me
change his approach
Something was missing in Overall, today’s session was alright for me
Appendices C and D