Case Management of Anxiety and Stress
Leah is a 24 year old woman who was recently discharged from the Army on medical grounds. During her four years in the Army, Leah experienced high levels of stress and anxiety which she coped with by drinking heavily. When she presented for counselling, Leah had been sober for 55 days and was seeking strategies to cope with her anxiety that didn’t involve drinking.
While working with Leah, the Professional Counsellor adopts a case management model in order to assist her to build a network of supports within the community, enabling her to maintain her sobriety and prevent recurrence of the factors which contributed to her high levels of stress. For ease of writing, the Professional Counsellor is abbreviated to “C”.
Leah was an only child whose parents separated during her teen years. She felt isolated and was often bored at school. Her love of art was the only thing that gave her any enjoyment and she expressed this by covering the school buildings with graffiti after dark. Already in conflict with her mother due to her poor school performance, the involvement of the police after she was reported for vandalising public property further worsened their relationship. Her father had moved away and was no longer involved in Leah’s life.
Leah left school intending to train as an ambulance medic. On being told she lacked the life experience required for this work, Leah joined the Army on a four year contract hoping to address this requirement. However the Army turned out to be a repeat of the constrictive structure within which she had struggled both at school and at home.
Being obligated to complete the full four years, she began to feel increasingly trapped and was often anxious and depressed. She was introduced to alcohol by her fellow recruits and began using this as a means of deadening her overwhelmingly negative feelings about the course her life was taking. After three years in the Army, Leah was discharged on medical grounds, having become dependent on alcohol and unable to control her intake.
A case manager’s initial function is to develop an understanding of the client and help build a resource network that the client can later access on her own. In this role, C performed an examination of Leah’s environment, behaviour and immediate needs which identified the following issues:
- Career indecision – although still wanting to be an ambulance medic, Leah had lost confidence in her ability to achieve this or any other career goal.
- Unsuitable accommodation – Leah was sharing a flat with a young man who yelled at her if she smoked and often made unwelcome passes at her.
- High levels of stress and anxiety – Leah continually craved alcohol during her period of sobriety and began using valium to replace the role alcohol had played in deadening her feelings
- Large amounts of unstructured time – Leah had no other strategies in place to cope with her negative thoughts and feelings and, now she was no longer working, found herself with large amounts of time during which she had nothing else to do but think.
- Lack of a personal support network – Leah was estranged from both her parents, had no siblings, and felt unable to contact any of her former Army colleagues because she felt inadequate due to the manner in which she had been discharged.
Following an identification of issues needing attention, the case manager then coordinates a plan to enable the client to access needed assistance within her community. In this role, C worked with Leah to outline a plan which involved the following strategies:
- Schedule pleasurable activities
- Obtain suitable accommodation
- Increase support networks
- Contact a supported job training network
- Access Centrelink benefits
- Undertake a drug and alcohol rehabilitation program
- Cognitive restructuring
- Medication monitoring
- Ongoing support
This plan was designed to utilise Leah’s strengths and was later outlined in clear measurable terms that allowed for periodic evaluation of her progress. This is particularly important when the client is becoming disillusioned as it illustrates to her that while she may not yet have reached her goals, she has made significant progress towards them. Leah’s goals were developed with her input to encourage her to feel ownership of them, increasing her motivation.
The following barriers to the above plan were identified:
- Craving for alcohol – Leah had used alcohol as a way of coping with overwhelming feelings, consequently she had strong cravings whenever she was feeling particularly stressed and anxious
- “Doctor shopping” – Leah had discovered that Valium served a similar purpose to alcohol and when her GP refused to give her any further prescriptions, she simply went to another doctor.
- Misinterpreting anxiety and stress symptoms – Leah had become hypervigilant towards her physical symptoms of anxiety (breathlessness, increased heart rate, hot flushes, dizziness), interpreting them as medical problems resulting from her drinking, which further increased her stress and anxiety levels
- Pessimism – Leah exhibited this internal barrier through her belief that she was solely responsible for the things that had gone wrong in her life and that because of this, there was no way for things to change and nobody would be able to help her. This left Leah feeling helpless, overwhelmed and at times suicidal.
Leah’s goals were written in specific behavioural terms as follows:
- Schedule enjoyable activities – C asked Leah to make a list of five activities that had either given her pleasure in the past or were things she would like to try in the future. She listed jogging, calligraphy, painting, reading and walking on the beach. C asked Leah to carry out at least one of these activities every day.
- Obtain suitable accommodation – C asked Leah to contact a former Army colleague who had always been very caring towards Leah and who had previously invited her to share her home. Leah did this and, upon moving in, she and her new flatmate bought a new puppy, providing Leah with further enjoyable activity on a daily basis.
- Supported employment / job training – C accompanied Leah to an appointment with a supported employment service run by the state government. This service aimed to support Leah in regaining her confidence in returning to the workforce, providing her with vocational counselling to guide her career choices and ongoing support when searching for and commencing employment. They were also able to provide funding for retraining.
- Centrelink benefits – C helped Leah obtain and lodge necessary forms to help her transition to Newstart Allowance once her Army benefits had run out.
- Rehabilitation – C connected Leah with appropriate contacts to commence drug and alcohol counselling and to undergo residential rehabilitation if needed.
- Cognitive restructuring – C provided short-term intervention aimed at identifying Leah’s irrational thought processes and replacing these with a more functional belief system. Here C took on the counselling function of the case management role and centred the work around Leah’s belief that she was a failure and would never get her life together. This process utilised Rational Emotive techniques such as Examine the Evidence and Thinking in Shades of Grey (Ellis as cited in Dryden & Golden, 1986).
- The Gestalt technique ’empty chair’ (Perls as cited in Patterson, 1986) and aspects of Dialetical Behaviour Therapy (Linehan, 1993) were also used to address Leah’s unresolved feelings towards her parents and to teach her to tolerate distress without having to escape through the use of drugs or alcohol.
- Medication monitoring – C arranged for Leah to be seen regularly by a psychiatrist in addition to her local GP to ensure she was receiving the correct medication and to facilitate hospital admission should the need arise. She was also educated about the fight or flight response that was leading to her physical symptoms.
- Ongoing support – C provided Leah with contact names and numbers for local chapters of Alcoholics Anonymous and, following successful completion of her immediate goals, C referred Leah to her local community health clinic for ongoing monitoring and medical follow-up.
C has provided a combination of case management and counselling functions while working with Leah. As counsellor, C has used Cognitive Behaviour Therapy, Dialectical Behaviour Therapy and Gestalt Therapy techniques to facilitate achievement of the client’s goals.
In reducing her high levels of anxiety and stress, Leah was able to address her more practical needs, for example challenging her beliefs about what her former colleagues thought of her enabled her to contact one of them to follow up on the offer of accommodation. While C provided education and support in this regard, Leah carried out most of the practical tasks herself, thereby building on her strengths and further increasing her confidence levels and reducing her pessimism.
This process occurred over a three month period, during which two progress reviews took place between C, Leah and her psychiatrist. At this time, Leah was able to see the progress she was making and was also able to draw attention to any areas with which she was experiencing difficulty or concern.
Upon completion of the above plan for meeting Leah’s immediate needs, C has referred her to services able to provide her with ongoing but less intensive support. With Leah’s written permission, C provided the community health centre with a referral form outlining Leah’s history, medication regime, and a summary of the work undertaken with C, which C had documented following each session with Leah.
C maintained contact with Leah on a weekly basis during the transition to the new service and while she became comfortable in her local AA support group. In taking this step, C has ensured Leah has acquired the necessary skills for maintaining progress on her own, with assistance available to her as needed.
Author: Leanne Chapman
- Dryden, W. and Golden, W.L. (Eds). (1986). Cognitive-behavioural approaches to psychotherapy. London: Harper and Row Publishers.
- Linehan, M.M. (1993). Cognitive-behavioural treatment of borderline personality disorder. USA: The Guilford Press.
- Patterson, C.H. (1986). Theories of counselling and psychotherapy. New York: Harper and Row Publishers.