Bonnie, a 15 year old girl studying in grade 9, belonging to a middle class family; is a bright child with 2-3 friends of similar nature and quite well in studies but deals with anxiety to be at public places or gatherings and talk to different people. Any kind of interaction with the strangers or even her peers or teacher either face to face or even over phone calls makes her hesitant and leads to headaches and stomach aches in anticipated situations and full blown panic attack at some adverse situations.
From the symptoms and the conditions analyzed it can be implemented that Bonnie is experiencing Social Anxiety Disorder. Social Anxiety Disorder (SAD) also called Social Phobia can be referred to as a chronic mental health condition in which the person fears social and public setting and feels as he/ she will be negatively evaluated by others (9). This fear of getting embarrassed, humiliated, rejected or be negatively judged by people makes them avoid all form of social interactions and prefer state of isolation to avoid communication with the outer world. This is considered as the third most common disorder after substance use and depression and the commonest anxiety disorder (8). It is highly prevalent and if not treated can further lead to an increased risk of suicidal or depressive thought process. All these situations and symptoms of SAD are similar to that of Bonnie’s.
Cognitive Behavioral Approach
Figure 1: Cognitive Behavioural Therapy
Source: (2)
The Cognitive behavioral therapy (CBT) also known as talk therapy is a very common and widespread approach adopted for numerous psychological and mental health problems such as depression, anxiety, alcohol addiction ,drug abuse, and other mental or behavioral illnesses. It is a short term therapy approach that focuses on threating the patient’s maladaptive emotional responses by analyzing their thoughts and behaviors (7). The CBT approach focuses on identifying the pattern of the patient i.e. the thoughts they have that make them feel self-conscious in front of the crowd. Once the pattern is identified efforts are made to change the thinking patterns by reevaluating them to showcase the reality use different problem solving skills to cope up with difficult situations (1). The therapy session can be considered like a student-mentor relationship where the mentor talks to the student and guides him/her to lead a new path and the student follows the instructions of the mentor. The therapist trains and gives assignments and shows different perspectives to look at the crowd. For instance, it might guide the Bonnie to include one more friend among her old ones the next time she meets and in this way gradually expand her circle or might assign a home work to talk for 5 minutes to a shopkeeper and then examine how Bonnie performs in the assignment.
Exposure Therapy
Under the exposure therapy the patient is made to face the fear gradually, i.e. they are made habitual of their fear. This process is known as habituation. The patients are made to move out of their comfort zone or regular surrounding behavior. Relaxation training is given by gradually exposing the patient to the feared stimuli. Under this theory it is believed that the most effective way to remove a fear is to be familiar and deal with it (16). This theory is widely used to treat patients with SAD. In this approach, starting with very basic the therapist gradually increases the difficulty level until the fear to face public vanishes and then finally introduces the patient to the outer real life environment (14).
These two theories are selected because of their wide spread usage to deal with SAD. CBT is most widely used practice to deal with the Social Phobia. Also exposure therapy is very helpful as it provides strength to face the real world.
For Cognitive Behavioral Therapy (CBT)
i. Cognitive reframing or reconstructing: the therapist makes the patient discuss about the negative thought process associated with the situation and makes efforts to reconstruct the thought in to a positive approach. For this the patient when tells the therapist about the entire situation the therapist reanalysis it and tell about a different point of view to the patient which he or she is in initial denial to accept. It can also be thought as seeing a positive approach behind every reason. Hence the therapist uses this technique to turn the negative thoughts in to positive actions. The therapist can take in to account the technique of reconstructing for Bonnie to make her realize that the surroundings do not have a negative image about her.
ii. Self-monitoring: in this technique the client is asked to record their own thoughts or emotions. This can also be done by maintaining a diary on daily basis. This helps the patient to self-analyze their thoughts and clearly express their emotions. Recording their thoughts and every other scenario will help them to clearly identify the situation and gradually they will also learn to do it on a rational basis excluding their personal biasness. It is also easy for the therapist to record the observation of the client from their perspective of the situations that do not occur in front of them. As simple as it seems it is difficult for the clients to initiate it due to their fear to identify all the situations negatively. Recording about the situation will help them face the situation which they fear to avoid. The following things can be asked to record by the counselor: the events, emotions, thought process, memory, body sensation, attention span, overall behavior etc(18). Becoming aware of actually what is happening will improve their ability to better link the situations and thought process and the therapist will be able to better analyze. Hence it will help Bonnie by facing and analysis the situation rather than fearing it.
For Bonnie, it is suggested to implement the exposure therapy rather than cognitive behavioral therapy since it is more relatable and will help Bonnie to face many people and be comfortable around everyone in the natural real world environment and even encounter the possible negative situations instead of listening to a single instructor i.e. the therapist. It should be more effective to help Bonnie socialize and overcome her fear in all extreme scenarios.
For Exposure Therapy
i. In-vivo social mishap exposure: The practice of in-vivo social mishap exposure might also implement in some cases if the fear is associated with a particular mishappening. This helps to face the fear that the patient is so determined not to face and volatile the perceived norms by the patient. Hence the negative consequences are also created purposefully for the patient for them to overcome their myth of the severity of the consequences (15). They would need to deal with post the conformance with the situation for example in case of SAD a purposeful scenario might be created for the patient where people might be taking bad or negative about the patient and let him/ her face the situation and give the people a proper answer. Bonnie will have to eventually attend all the public places and experience that will help her to overcome the fear.
ii. VRET (Virtual Reality Exposure Therapy): Now-a-days virtual reality is also used in exposure therapy. It is an alternative to in-vivo where the patient instead of facing the situation head on in the real world is made to experience virtually. However, long term practice of might not solely be considered an optimum treatment for SAD (17).This technique can be really beneficial for Bonnie as by looking into the world virtually she will reduce the fear as she will be prepared for the image in her head before facing it head on.
MindSpot.au
It is a non-for-profit digital clinic that provides mental health support for the Australians. Funded by the government, and contracted with the Department of Health the institute provides support to more than 150,000 Australians. It facilitates facilitate free counseling aid to patients dealing with diverse mental health issues such as depression, anxiety, bipolar disorders, stress, OCD etc. Besides form providing online services, it is located at Macquarie University’s eCentreClinic , Sydney (4) They are well known for their online treatment, and courses for wellbeing that teach adolescents and adults to manage stress and anxiety by using the Cognitive Behavioral Theory (CBT). It has proven to be a leading virtual mental health entity globally and records to have helped more than 20000 Australians every year. It provides trial teleplone therapy treatment, single session treatment, launches various education and learning programs via its academy. It has been very active to provide the services during the COVID phase since they have recorded a 90% increase for help via phone calls and websites. The procedure that the agency follows includes creating an online account, taking an assessment test, and filling the questionnaire to identify the symptoms, after which discussion is held over phone with the therapists, and then specialized courses for treatment by iCBT (Internet delivered CBT) are offered generally for a time period of 8 weeks that comprises of lessons and assignments (3) .They are updated via emails for their progress and offered alternative treatment options or face-to-face counseling assistance if the condition does not improve.
HelpingMinds
HelpingMinds, founded in 1976, is a registered provider of mental health services under the National Disability Insurance Scheme (NDIS). It provides person-centered care and supports in various specialized range including Anxiety, Bipolar Borderline, Personality Disorder, Depression, Psychosis, Schizophrenia etc. It provides psychosocial recovery coaching support for the patient and their families and frames a recovery plan for patients facing challenges in daily living. The services include counseling for youngsters and students aged 7-17, adults and their families as well as the careers over phone, in-school or face to face. They offer free and confidential support, after school workshops or school holiday programs, peer support, family LINK program, online forums and live chat, activities to rest and revive in the environment and advocate the people living in Western (6). To provide anxiety related support, such as for SAD, they have personalized programs and offer therapy sessions using treatments like CBT, prescribing right anti-depressant medications and relaxation therapies. It was widely active to extend its services digitally over the phone as well as online during COVID pandemic (5).
Both the organizations are well established and structured and are active in providing assistance for mental health issues especially anxiety. It will be more helpful for bonnie to select HelpingMinds since it provides wide range of programs for young children and adolescents and also offers special in-school program support. The face to face therapy assistance will also be more helpful for Bonnie.
Ethical Issues to Consider
Ethics is a system that contains moral principles concerned with individuals or society. It is the responsibility of the counseling practitioner to abide by the code of Ethics during his practice. To respond to Bonnie’s teacher, the following ethical issues would be needed to consider in account to give a proper reply:
Personal Information: The therapists must comply with the Australian Privacy Principles (APP) during their training session and must have an updated privacy policy about how they are going to manage the personal information. Only reasonable information relating to the treatment must be collected and recorded (11).
Consent for treatment: under the code of ethics the counselors and psychotherapists need to obtain proper written consent of the patient for the therapy. This involves informing about the therapy procedure, the time period, the cost of the total therapy sessions and the related risks associated with the therapy (10). The document containing this information must be easily readable and must also be duly explained. After informing about all of these details proper consent and proof of the consent must be availed from the patient and/or the guardian.
Confidentiality of the provided information: During the entire therapy session it is important that the personal information of the client is not disclosed with any of the third parties without their consent. The client is also allowed to attend the clinic under an anonymous identity. There might be ambiguity in defining the limits of confidentiality (10).
Boundaries in therapeutic relationship: As therapists, it is important to maintain a patient-career relationship for healthy environment during the session. It is essential to keep the right amount of balance between the personal and professional boundaries to avoid indulgence in any form of dual relationship. Under the APA guidelines it is clearly stated that the therapists must restrain from disclosing the personal information on social networking sites. Boundaries must be maintained both during the sessions to not indulge any personal relationship as well as in the cyberspace for instance not including clients as friends on social media (12).
In-discriminatory services: the professional must ensure non-judgmental, in-discriminatory service free of personal bias and be responsive to the needs of the client to provide a healthy and supportive environment (13).
References
American Psychological Association. What is Cognitive Behavioral Therapy? [Internet]. 2017. Available from: https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral.pdf
Anxiety & Depression Association of America. CBT Strategies to Overcome Social Anxiety [Internet]. National Social Anxiety Center. 2017 [cited 2022 Mar 10]. Available from: https://nationalsocialanxietycenter.com/cognitive-behavioral-therapy/social-anxiety-strategies/#:~:text=Learning%20to%20identify%20your%20hot
Titov N, Dear BF, Staples LG, Bennett-Levy J, Klein B, Rapee RM, et al. MindSpot Clinic: An Accessible, Efficient, and Effective Online Treatment Service for Anxiety and Depression. Psychiatric Services. 2015 Oct;66(10):1043–50.
Schofield C, Titov N, Staples L, Dear BF, Nielssen O. A comparison of Indigenous and non-Indigenous users of MindSpot: an Australian digital mental health service. Australasian Psychiatry. 2018 Jul 30;27(4):352–7.
HelpingMinds. COVID-19 Emotional Support Services | Mental Health [Internet]. HelpingMinds. 2022 [cited 2022 Mar 11]. Available from: https://helpingminds.org.au/covid-19/
HelpingMinds. Mental Health Carer Support | List of Support Services [Internet]. HelpingMinds. 2022. Available from: https://helpingminds.org.au/services/
Kaczkurkin A, Foa E. Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Anxiety. 2015 Sep;17(3):337–46.
Rose GM, Tadi P. Social Anxiety Disorder [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2020 [cited 2020 Aug 25]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555890/
Mohammadi MR, Salehi M, Khaleghi A, Hooshyari Z, Mostafavi SA, Ahmadi N, et al. Social Anxiety Disorder among Children and Adolescents: A Nationwide Survey of Prevalence, Socio-demographic Characteristics, Risk Factors and Co-morbidities. Journal of Affective Disorders. 2019 Dec;263:450–7.
Lamont-Mills A, Christensen S, Moses L. Confidentiality and informed consent in counselling and psychotherapy: a systematic review [Internet]. 2018. Available from: https://www.pacfa.org.au/common/Uploaded%20files/PCFA/Documents/Research/Confidentiality-and-informed-consent-in-counselling-and-psychotherapy-a-systematic-review.pdf
Allied Health Professions Australia. Private Practice Privacy Guide 2020 [Internet]. 2020. Available from:
https://www.pacfa.org.au/common/Uploaded%20files/PCFA/Documents/Member%20Resources/AHPA-Private-Practice-Privacy-Guide_Final-Aug-2020.pdf
Bolton J. The Ethical Issues which must be addressed in online counselling. Australian Counselling Research Journal [Internet]. 2017;11(1):1–15. Available from: https://www.acrjournal.com.au/resources/assets/journals/Volume-11-Issue-1-2017/Volume-11-Issue-1-2017-FULL.pdfAustralian
Counselling Association. Code Of Ethics and Practice of the Association for Counsellors in Australia [Internet]. Australian Counselling Association. 2019. Available from: https://www.theaca.net.au/documents/ACA%20Code%20of%20Ethics%20and%20Practice%20Ver15.pdf
Cuncic A. 7 Types of Social Fears and the Best Way to Overcome Them [Internet]. Verywell Mind. 2020. Available from: https://www.verywellmind.com/practice-social-anxiety-disorder-exposure-therapy-3024845
Fang A, Sawyer AT, Asnaani A, Hofmann SG. Social Mishap Exposures for Social Anxiety Disorder: An Important Treatment Ingredient. Cognitive and Behavioral Practice. 2013 May;20(2):213–20.
Scheurich JA, Beidel DC, Vanryckeghem M. Exposure therapy for social anxiety disorder in people who stutter: An exploratory multiple baseline design. Journal of Fluency Disorders. 2019 Mar;59:21–32.
Horigome T, Kurokawa S, Sawada K, Kudo S, Shiga K, Mimura M, et al. Virtual reality exposure therapy for social anxiety disorder: a systematic review and meta-analysis. Psychological Medicine. 2020 Oct 19;1–11.
Farmer RF, Chapman AL. Behavioral interventions in cognitive behavior therapy: Practical guidance for putting theory into action (2nd ed.). Washington: American Psychological Association; 2016.
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