Assessment of Sarah’s Case Using the Five-Area Model

Assessment of Sarah’s Case Using the Five-Area Model

            Sarah’s main complaint is breathing difficulty and chest pains. However, the general practitioner (GP) does not think that the origin of Sarah’s condition is psychological as no physical causes are isolated. The problem Sarah is experiencing is recurrent, and based on her life, a five-area model can be used to present her problems and diagnose her condition.

Life situation

            The first time Sarah experienced breathlessness and chest pains was after she moved from Kosovo to the UK with her family. Having fled from a conflict area, the UK was supposed to provide safety for the family. However, Sarah must have felt that she was unable to cope with the new life situation. The first problem was the language barrier and then the bullying that this attracted. The new environment posed challenges that Sarah was not sure she could cope with. This indicates that she was suffering from anxiety. According to Schless et al. (1977), stressful events can cause mental illness, among which are anxiety and depression.

Sarah’s highly demanding work environment also triggers the current symptoms. She is a high performer in charge of a highly qualified team. This puts a lot of pressure on Sarah to be outstanding. When she experiences a crisis, she feels inadequate as a leader.

Altered Thinking

• Sarah experiences reduced self-esteem and self-confidence.
• She is feeling guilty for her team’s failure, and this affects her view of her self-worth.

Altered physical symptoms

• Difficulty in breathing
• Chest pains

Altered behavior

• She is limiting her social activities, reducing her work input and domestic activities.

Altered Mood or feeling

• She has a depressed mood due to the implications that she cannot manage her team effectively.

The changes in these five areas of Sarah’s life indicate that she could be suffering from anxiety and depression, which explains her symptoms (Schless et al., 1977).

Context

Predisposing Factors

            Predisposing factors are physiological states, pathological conditions, or habits associated with a higher rate of a disease occurrence (Kash et al., 2018). In Sarah’s case, several predisposing factors related to her habits can be identified. When she arrives in the UK as a young girl, Sarah is bullied, and this negative experience serves as a motivation for her to become the best in academics and sports to prove her worth and to gain a sense of power.  As a result, Sarah is becoming a perfectionist as she ties her worth to her achievement. Perfectionism is more than doing things perfectly. It is a personality trait that centers on extreme self-pressure to meet high standards always; this has a powerful influence on how one perceives themselves (Wade & Tiggemann, 2013). Therefore, perfectionists set high personal goals but also have evaluative concerns that make them avoid failure. They also react negatively when they fail or when they are criticized for their performance.

Sarah’s established herself as a popular member of her school, and her only guarantee for remaining popular was for her to perform. She carries this trait to the workplace, where she manages a high functioning team. She feels the pressure to deliver the best result, and when her team experiences failure, she is demoralized. She develops bad feelings and reduces her activities. According to Dr. Brene Brown, a research professor at the University of Houston, perfectionism can be harmful in an individual’s self-worth and productivity. She argues that it is because perfectionists are often attached to their achievements and explain that pursuit of excellence can be helpful if done right and unhelpful if done in strife for perfection (Brown, 2013).

Precipitating Factors

            A precipitating factor can be a stressful or traumatic experience that leads to mental or physical disorders (Kash et al., 2018). Sarah suffers stressful situations that make her feel out of control of the outcome. She is the manager of a team that is expected to produce high results. When a crisis in the team occurs, Sarah is stressed because the member of the team deflects the blame to her. It makes her feel uncertain of the outcome. Even though the issue is solved, Sarah feels inadequate. In a study to determine the role of stress in the precipitation of mental illness, patients were interviewed on the preceding events before they were admitted to the hospital. Two groups consisting of Medical and surgical patients and psychiatric patients were interviewed. The results showed that psychiatric patients reported more events compared to medical and surgical patients. The medical and surgical patients reported more events compared to the control group formed from the general population (Schless et al., 1977). The study established that stressful events were a precipitating factor in causing mental illness and also a factor that contributed to the escalation of other medical conditions.

Perpetuating factors

            Perpetuating factors are the factors that make a condition persist. That is, they make a condition severe, make compliance to medication options difficult, and leads to failure to resolve predisposition and precipitating factors (Henderson & Martin, 2014). Sarah has altered thinking, which affects her condition. She is feeling inadequate to complete her normal tasks of management at work. She has reduced self-esteem and self-confidence, and these put her in a vicious circle of reduced activity. Her stressful situation worsens and, as a result, feels chest pains and breathlessness.

Protective factors

            These include social support, community support, physical activities, and a functional family (Henderson & Martin, 2014). The first time Sarah experiences these symptoms, her risk factors included migration and being a minority. She had just settled in the UK and had a negative experience at school. However, academic achievement and intellectual development have served as protective factors for Sarah, both at school and in her career. While in school, academic excellence gives her high self-esteem, which made her popular.

Theory

Cognitive Behavioural Therapy Model

CBT is a type of talking therapy that can be useful in the treatment of a wide range of mental health problems. The CBT is based on cognition, emotion, and behavior, that is, how people think, how they feel, and how they act (McLeod, 2019).  The theory argues that what one thinks determines their feelings and behaviors. This means that when a person has unrealistic and negative thoughts, it can lead to stress and consequently create problems for them. Problems develop because psychological distress leads to skewed judgment and interpretation of situations, and as a result, this affects the actions one takes in a given situation. This therapy aims at helping people to be aware of the negative interpretations they make, and the behavioral patterns, which support misleading thinking. Through CBT, patients can develop alternative ways of thinking and behaviors that reduce psychological stress.

The main assumptions of the CBT include:

• Mental illness results from faulty cognition concerning the world around the individual and others. The fault can develop from a lack of planning that causes deficiencies in cognition and from inaccurate information processing that leads to distortions in cognition (McLeod, 2019).
• The faulty cognitions lead to distortion in the way people see things either through irrational thinking or through cognitive triad.
• A person’s mental representation of the world determines how he or she interacts with it (McLeod, 2019). Disordered behavior, therefore, becomes a result of inadequate reasoning or inaccurate representations, which inform a person’s emotions and behaviors.

Sarah’s case can be explained using the CBT theory because Sarah’s view of the world around her, other people, and herself is faulty. When Sarah and her family migrate to the UK, she finds it difficult to adjust, and she develops a belief that she had to prove herself to earn popularity. This cognition serves as her guiding principle and affects the way she views herself as well. She pursues academic success, not because it is the right thing to do but because she feels that she must do it to be good enough. Her way of reasoning when it comes to success is faulty because she seeks perfection, and she doubts herself when she fails to reach perfection. The result is disordered emotions and behavior. She experiences reduced self-esteem and self-worth and reduces her activities due to a lack of motivation.

Psychodynamic Theory

The psychodynamic theory is an approach that represents all theories that emphasize unconscious motivations as the primary drive for humans and that adult relationships and personalities often stem from childhood experiences (Colarusso & Nemiroff, 2013). This theory was developed from Sigmund Freud’s psychoanalysis, but the approach has come to involve all the theories that have been brought forward in this area based on this idea. Psychodynamic therapy is used in the treatment of anxiety and depression-related disorders.

The main assumptions of the psychodynamic theory include:

• The unconscious mind includes mental processes that are not accessible to the conscious mind but still influences judgment, behavior, and feelings (Colarusso & Nemiroff, 2013).
• Freud argued that the unconscious mind is the fundamental source of human behavior. He compared human behavior to an iceberg that has its most significant part underwater. The most important part of the mind is the part that cannot be seen (Colarusso & Nemiroff, 2013).
• Feelings, decisions, and motives are influenced by past experiences, usually stored in the unconscious mind.

The basic argument of the theory is that childhood events have a significant impact on adult life, and they often shape adult personalities. This is possible because the occurrences of the childhood period are stored in the subconscious, and they can create problems later in adult life. Personality is a product of the modifications of drives caused by the various conflicts that occur at different times during childhood or psychosexual development. The theory puts forward that no behavior is accidental; all behaviors have a cause because they are determined. A person has no control over the unconscious factors that determine behavior.

Based on this theory, Sarah’s perfectionism is a trait that developed due to her childhood experiences.  Sarah is competitive, and even after school, she still plays Tennis and runs Marathons, which are behaviors that provide her with the parameters to evaluate her worth. She has excellent academic qualifications that have landed her a good job in the city and given her a managerial position. However, her personality as an adult has developed from her drives that stem from her unconscious mind. Her childhood experiences in school in a foreign country made her resort to hard work as a way to raise her status and compensate for immigrant minority status. She also had learned English quickly to avoid looking odd at school, and she succeeded. As an adult, Sarah does not deal well with failure; it leads her into anxiety and depression, which causes her chest pain and breathlessness.

Both CBT and psychodynamic theories support the idea that human behaviors stem from within them. The CBT theory argues that cognitions affect how a person sees things and, consequently, how he or she behaves. On the other hand, the psychodynamic theorists believe that all behaviors are caused by unconscious factors that an individual has no control over. Therefore, in either theory, the external environment of an individual has little to do with how they behave. From a CBT perspective, when an individual faces an unfamiliar situation, then their response depends on their cognition of the situation. From a psychoanalytic perspective, an individual reacts to situations based on their personality, which is determined by drives that are developed during childhood.

Therefore, the two theories are equally applicable in Sarah’s case. Academic and sports excellence made Sarah self-confident and boosted her self-esteem. It served as a protective factor. That childhood experience affected Sarah’s adult personality but also affected her cognition of the concepts of success and failure. Her childhood experiences make her averse to failure and, at the same time, it makes her a perfectionist. The two cases drawn from the two theories suggest that Sarah is suffering from anxiety and depression.

Intervention

Sarah needs psychodynamic therapy (PDT). She needs to be guided for her to become aware of her subconscious to be able to gain insight into her behaviors that cause her to be depressed and anxious. She will also be able to create connections between her childhood traumatic experiences and her adult personality. The goal of this therapy is to provide insights that can help the patient to see the patterns in their behavior (Colarusso & Nemiroff, 2013). Since Sarah’s problem is recurring, this hint that her problem may have past connections. By making her aware of her subconscious, she can avoid being controlled by it.

The psychodynamic theory emphasizes the importance of the unconscious mind in influencing actions, feelings, relationships, and a person’s endeavors. As a result, conflicts in the unconscious mind lead to anxiety, depressive thoughts, moodiness, and disturbing personality traits (Colarusso & Nemiroff, 2013). The problems Sarah is experiencing that have led to difficulty in breathing and chest pains go beyond the crisis she experienced at work. The problem has its roots in past experiences she had as a child.

The therapy requires that Sara should meet with a psychoanalyst at least three times a week. The intensive schedule will establish the meeting location as a safe place where the patient can associate freely. The frequent meetings will also develop a bond between the analyst and the patient. They will help in revealing the patient’s full range of behavior patterns and personality traits, which enhances the process of self-understanding. The patient can lie down during the session to help them focus their thoughts inwardly and feel free to associate, although some people might find it helpful to sit up facing the psychoanalyst.

The intervention is a collaborative effort between the patient and the analyst. As the patient associates freely, the analyst must listen carefully and help her to understand the underlying subconscious sources of problems. The analyst then interprets the patterns evident in the patient’s narration, and this interpretation will serve as a basis to encourage the patient’s awareness by allowing her to reject, supplement or amend the interpretation (Colarusso & Nemiroff, 2013). Therefore, in Sarah’s case, she will associate freely with the analyst and tell him or her about her experiences, and the analyst will identify the patterns in her behavior. By providing interpretations of Sarah’s situation, Sarah will get a chance to reject or supplement them and, by so doing, gain an understanding of their behavior patterns. Sarah will have the opportunity to relive the experiences she lived in the past. For instance, the analyst will note that Sarah focuses her strength and time on achievements for her to feel self-confident and to boost her self-esteem. This is something she picked as a defense mechanism against the negative childhood experience, but it developed into an adult trait. Sarah still pursues academic excellence as a means to gain the confidence to in herself. When her team fails, and she is depressed, she is not reacting based on the current situation, but her response is reflecting drives shaped by her childhood experiences.

By understanding how her unconscious mind affects her present reaction to failure, Sarah will be able to prevent her unconscious from controlling her. She will gain insight into the unconscious factors and conflicts within her that make her depressed. Once this understanding has been established, some actions will be prescribed on how to prevent those disruptive patterns from making her unhappy and depressed.

References

Colarusso, C.A., and Nemiroff, R.A., 2013. Adult development: A new dimension in psychodynamic theory and practice. Springer Science & Business Media.

Dr Brené Brown, 2013. Why Brené Brown Says, Perfectionism Is a 20-Ton Shield | Oprah’s Lifeclass | Oprah Winfrey Network. Available at https://www.youtube.com/watch?v=o7yYFHyvweE [Accessed on 1st April 2020].

Henderson, S.W. and Martin, A., 2014. Case formulation and integration of information in child and adolescent mental health. IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions.

Kash, B.A., McKahan, M., Tomaszewski, L. and McMaughan, D., 2018. The four Ps of patient experience: A new strategic framework informed by theory and practice. Health marketing quarterly, 35(4), pp.313-325.

McLeod, S., 2019. Cognitive Behavioural Therapy. Available at https://www.simplypsychology.org/cognitive-therapy.html. [Accessed 1^st April 2020].

Schless, A.P., Teichman, A., Mendels, J. and DiGiacomo, JN, 1977. The role of stress as a precipitating factor of psychiatric illness. The British Journal of Psychiatry, 130(1), pp.19-22.

Wade, T.D. and Tiggemann, M., 2013. The role of perfectionism in body dissatisfaction. Journal of Eating Disorders, 1(1), p.2.

Wright, B., Williams, C. and Garland, A., 2002. Using the Five Areas cognitive–behavioural therapy model with psychiatric patients. Advances in Psychiatric Treatment, 8(4), pp.307-315.