Case Study: Supporting John’s Transition to Independent Living through a Positive Systems Approach and Teaching Coping Skills using more Traditional Types of Therapy
- drbobcarey
- Dec 3, 2024
- 7 min read
Introduction
John, a 20-year-old young man with borderline cognitive ability (IQ 70-80) and epilepsy, faced significant challenges during his first experience living independently. Though he demonstrated good language skills, his anxiety about managing daily life, particularly health concerns, became overwhelming. The agency supporting John had limited resources and could only provide minimal weekly support, exacerbating his anxiety. His situation escalated to frequent, unnecessary emergency calls, prompting the need for a comprehensive intervention.
Background
John's primary challenges included:
Anxiety and Health Concerns: John frequently experienced panic attacks, fearing heart attacks and seizures, despite medical evidence showing no physical cause.
Inadequate Support System: Limited support of only a few hours per week from the agency led to his reliance on emergency services for reassurance.
Behavioural Issues: His anxiety-driven calls to emergency services numbered over 20 per day, causing distress to local authorities and leading to police warnings.
Intervention Approach
A Positive Systems Approach was implemented which looked at a number of factors including the lack of sufficient supports, the suitability of his living arrangement, medical factors that contributed to his symptoms (i.e. – seizures, medication side effects), and addressing his lack of coping skills. This was done by having him participate in twice weekly psychotherapy sessions with a focus on:
Cognitive Behavioural Therapy – CBT
Cognitive Restructuring: Sessions aimed at altering John’s perception of stress, shifting from a catastrophic mindset to a more balanced outlook.
Cognitive restructuring is a core component of Cognitive Behavioural Therapy (CBT) aimed at identifying and challenging distorted thinking patterns that contribute to anxiety. For individuals like John, who experience persistent health anxiety without medical justification, cognitive restructuring helps replace catastrophic thoughts with more balanced, rational perspectives. In John’s case, this was done using the following steps:
Identifying Automatic Thoughts
Goal: Help the individual recognize anxious thoughts as they arise.
Example in John’s Case: John may think, “I’m having a heart attack,” every time he feels a minor chest discomfort.
Technique: Use thought logs or journals where John writes down his thoughts, associated emotions, and physical sensations during perceived health crises.
Evaluating the Accuracy of Thoughts
Goal: Challenge the evidence for and against the anxious thought.
Example: John would be guided to ask, “What evidence do I have that this is a heart attack?” or “Has this happened before, and what was the outcome?”
Technique: Socratic questioning, where the therapist asks probing questions like:
“What happened the last time you felt this way?”
“What would you say to a friend who had this same worry?”
Reframing the Thought
Goal: Replace the distorted thought with a more rational, balanced thought.
Example: Instead of “I’m going to die,” John could reframe it to “This discomfort is probably due to anxiety, not a heart attack, and it has passed before.”
Technique: Create alternative statements that are more realistic, such as “I’ve felt this way many times, and it always turns out to be nothing serious.”
Behavioural Experiments
Goal: Test the validity of anxious thoughts through experience.
Example: If John believes that sitting quietly when anxious will cause harm, he might be encouraged to sit and monitor what actually happens.
Technique: Track the outcome of situations where no action is taken (e.g., no emergency call), reinforcing that anxiety symptoms subside without dire consequences.
Reducing Catastrophic Thinking
Goal: Help the individual recognize and lessen the tendency to jump to worst-case scenarios.
Example: John may initially think, “I’m having a seizure,” but learns to adjust this thought to “This feels like anxiety, not a seizure.”
Technique: Use thought-challenging worksheets where John evaluates the likelihood of the worst outcome and considers more probable outcomes.
Reinforcing Positive Outcomes
Goal: Strengthen confidence in new, rational thought patterns.
Example: Celebrating each instance where John reframes his thought and avoids calling emergency services reinforces his progress.
Technique: Use positive reinforcement, like praise or a reward system (read on further to see how we used Behavioural Contracting), to acknowledge successful application of cognitive restructuring.
By challenging automatic thoughts, cognitive restructuring attempts with John were successful in interrupting the feedback loop of anxiety and physical symptoms. John learned to use evidence-based reasoning rather than emotional responses to perceived health issues. Over a period of several months, he learned that he could manage anxiety without external reassurance, fostering his independence. Cognitive restructuring transformed his health anxiety by replacing fear-driven thoughts with logical, calming self-talk, enabling John to regain control over his anxiety and reduce unnecessary distress.
Jacobsen Deep Muscle Relaxation:
This was introduced to help John manage physical manifestations of anxiety, such as muscle tension. A more detailed description of exactly how this was done with John will be outlined in next week’s Blog on drbobcarey.com.
Behavioural Contracting
Behavioural contracting is a structured agreement between a therapist and a client that sets clear, measurable goals and defines rewards or consequences for specific behaviours. For someone like John, who made frequent emergency calls due to anxiety about perceived health crises, behavioural contracting provides a framework to gradually reduce this behaviour by promoting accountability and reinforcing positive change.
Key Components of Behavioural Contracting
1. Setting Clear, Achievable Goals
Goal: Establish a realistic target for reducing the number of daily emergency calls.
Example:
Week 1: Limit emergency calls to no more than 10 per day.
Week 2: Reduce to 5 calls per day.
Final Goal: Reach 0 emergency calls per day over several weeks.
Why It Works: Breaking the goal into manageable steps makes it less overwhelming and provides a sense of accomplishment at each milestone.
2. Defining the Contract
Content: The contract outlines the expectations, goals, and rewards for meeting each goal.
Example Contract Terms:
John agrees to reduce emergency calls by a set amount each week.
John will call his Independent Support Worker instead of emergency services when feeling anxious.
The therapist and John will review progress during therapy sessions.
Why It Works: A written contract formalizes the commitment, making it feel more concrete and binding.
3. Incorporating Rewards and Consequences
Rewards: Offer incentives for meeting goals, which can be simple and motivating.
Example: Earning extra leisure time, a favorite treat, or verbal praise for achieving a daily or weekly target.
Consequences: Ensure any consequences are reasonable and reinforce accountability without being punitive.
Example: If John exceeds the agreed number of calls, he must review what triggered the behaviour with his therapist.
Why It Works: Positive reinforcement strengthens the desired behaviour, while mild consequences encourage adherence to the contract.
4. Tracking and Monitoring Behaviour
Goal: Maintain a record of the number of calls made each day. Hospital and Emergency services also kept track of any calls and informed his supporting agency.
Example: John logs each call in a journal, noting the time, reason, and how he felt before and after the call.
Why It Works: Keeping a log increases self-awareness and helps identify patterns or triggers that can be addressed in therapy.
5. Adjusting the Contract as Needed
Goal: Ensure the contract remains achievable and realistic based on progress.
Example: If John struggled to meet the target, the reduction pace was slowed, or additional support provided. Conversely, if progress was faster than expected, goals were adjusted upward.
Why It Works: Flexibility ensures the contract remains motivating rather than discouraging.
Why Behavioural Contracting Works for Health Anxiety
Provides Structure and Accountability: The contract makes expectations clear, reducing impulsivity driven by anxiety.
Encourages Alternative Coping Mechanisms: By tying success to rewards, John is motivated to practice other anxiety-management strategies learned in therapy.
Gradual, Sustainable Change: The incremental reduction in calls ensures progress is manageable, preventing feelings of failure.
Builds Self-Efficacy: Each success reinforces John’s belief that he can manage his anxiety without external reassurance, fostering long-term independence.
In summary, behavioural contracting leverages goal-setting, rewards, and accountability to create a structured pathway for reducing anxiety-driven emergency calls, empowering individuals like John to regain control over their behaviour.
Problem-Solving Skills Development
John was taught to systematically identify problems, generate potential solutions, and evaluate outcomes. See a future Blog providing extensive detail on how we used Problem Solving skills training into John’s therapy sessions.
Homework assignments reinforced these skills, with follow-up discussions during sessions to provide feedback and guidance.
System Advocacy: Enhanced Support System
The agency successfully advocated for increased funding to enhance John’s support hours, expanding John’s weekly support fivefold.
John was provided a direct contact number for his Independent Support Worker, which was closely monitored to maintain appropriate usage.
Outcomes
Within two months, John’s emergency calls dropped to zero per week, demonstrating the effectiveness of CBT and behavioural interventions. He developed the ability to independently assess problems and implement solutions, reducing his reliance on external reassurance. The additional support hours provided John with the necessary assistance, ensuring he felt more secure without overburdening emergency services. His calls to his Support Worker were maintained at minimal levels, indicating a balance between support needs and independence.
This case highlights the success of a multi-faceted intervention using a Positive Systems Approach to support individuals with borderline cognitive ability and anxiety disorders. The combination of tailored psychotherapy, behavioural contracting, problem-solving skill development, and advocacy for increased support services allowed John to thrive in his independent living situation.
Key Takeaways:
A structured approach with measurable goals is essential in managing anxiety-driven behaviours.
Advocacy for increased resources can significantly enhance the quality of life for individuals with limited cognitive and emotional resilience.
Using more traditional therapy approaches (i.e. – modified CBT approaches, Relaxation Training) can be very effective in working with people who have developmental disabilities. Teaching practical problem-solving skills fosters long-term independence and reduces reliance on emergency services.
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