Case Study Week 7: Amanda

Description of Client:
Amanda is a 9-year-old girl who lives with her biological mother, father, and little sister (age 6).
She enjoys swimming and playing with her friends, but also spends a lot of time on her own.
She is very creative and used to paint on a daily basis but lately has spent more time alone in
her room or in bed. She is currently in grade 5 and attending a new school this year.
Client Goal:
Amanda has been referred for therapy due to severe emotional stress about attending school
(anxiety, temper tantrums, somatic issues, and depression). The main goal is to have Amanda
return to school. The hope is that during therapy Amanda will learn to identify reasons why she
does not want to attend school and learn techniques to increase her coping skills.
Relevant Background Information:
Amanda has always had difficulty attending school, but with much coaxing and encouragement
she did attend until this past school year. Since then the problem worsened to the point of
complete school refusal. She begs to stay home from school and when her pleading does not
work she becomes oppositional, often barricading herself in her room and refusing to get
dressed. When asked why she does not want to go to school she indicates that school makes
her feel uncomfortable, sad, and sick. She is unable to identify anything or anyone at school
that makes her feel that way and insists that her teacher and classmates are all nice. The
school is becoming increasingly concerned with her absences.
When Amanda did attend school, she complained of stomach aches, headaches, and asked to
call home frequently. There were days when talking to her mother reassured her and she
returned to class. Other days, she ended up back in the office within the hour. Her mother or
father would resort to picking her up early approximately two times per week. At home, she
usually spent the time playing close to her Mom, reading, or watching TV.
Amandas teacher reports that she is a good student but that all of the absences are starting to
impact her grades. She indicates that Amanda is very well-behaved at school, unless she is
refused the opportunity to call home, at which time Amanda becomes very tearful, withdrawn,
and appears to shutdown.
Other Important Information
Amanda has not attended school at all for the past 4 weeks. She has stated that it is all too
much. She is on the waitlist to be assessed by a psychologist. Her parents have become
increasingly overwhelmed with Amandas refusal to attend school and have indicated that they
just cant fight with her about going to school everyday. It is beginning to affect their marriage
and the entire family. Amandas little sister is now stating that she does not want to go to
school.

Treatment Plan Using Cognitive Behaviour Therapy

Rationale for Using CBT to treat School Refusal:
All children experience a certain amount of anxiety and fear about school. However, some
children experience intense anxiety that results in the child refusing to go to school (King,
Tonge, Heyne & Ollendick, 2000). There are many reasons that a child may be refusing to go to
school including anxiety disorders and separation anxiety. CBT is an effective approach to treat
school refusal (Haarman, 2009). CBT teaches the client new skills that include challenging
inappropriate or unrealistic beliefs, identifying and monitoring negative self statements, and the
development of coping strategies. These new cognitions are then encouraged as a mantra to
help decrease the cognitive distortions leading to the clients anxiety (King et al., 2000;
Haarman, 2009).

Treatment Goals:
(Haarman, 2009; Beck & Weishaar, 2011)

Cognitive-Behavioral Therapy
1. Recognizing and identifying anxious feelings and somatic indicators
2. Clarifying unrealistic or negative expectations or anxious thoughts
3. Developing coping strategies (self-talk, breathing, relaxation,
distractions, etc.)
4. Evaluating coping behavior and self-reinforcement

Length of Treatment:
The length of treatment is dependent on the severity of the problem. Individuals with anxiety or
moderately to severe depression generally require two sessions per week for four to five weeks
and then one session per week for ten to fifteen weeks (Beck & Weishaar, 2011). Cognitive
therapy is present-centered, goal-oriented and time limited (Beck & Weishaar, 2011). In
Amandas case, treatment would end once she is able to return to school feeling confident and
brave. Her mother would be included in therapy sessions to review treatment goals and identify
ways to help support Amanda.

Overview of Treatment Plan:

Technique

Application

Psychoeducat
ion explaining the
basics of CBT

It is crucial for
Amanda to
understand the
basics of CBT for
her to eventually
understand how
her thoughts,
feelings and

Specific Tasks and Goals

1. Use pictures or visuals to teach Amanda how negative
thoughts, feelings, and behaviours can lead to anxiety.
2. Introduce the idea of helpful and unhelpful thoughts.
3. Use role play to help Amanda understand CBT.

behaviour are
affecting her
school
attendance.
Recognize
anxious
feelings

Goal: Amanda will be able to explain in her own words how

unhelpful thoughts can lead to unhelpful feelings that result in
unhelpful behaviour.

Amanda needs to 1. Help Amanda identify what it feels like in her body (racing heart,
be able to identify sweaty palms, headache, stomach ache) when she wants to leave
school. Imagining exposure might help Amanda identify how she
when she is
feeling anxious feels at school.
and what her
body feels like. 2. Introduce Chester the Cat Feels Anxious (Anxiety BC). Have

Amanda draw an outline of a body and write what happens in

each part of her body when she feels scared or worried similar to
Chester the Cat.
Goal: Amanda will be able to identify her physical triggers when
she is feeling anxious.
Homework: Assignment 1

Cognitive
RestructuringChallenging
irrational
thoughts

It is important to
ensure that
Amanda is not
catastrophizing
events and to
teach her how to
challenge her
unhelpful
thoughts.

1. Teach Amanda how to identify unhelpful thoughts and challenge

unhelpful thoughts (through cognitive restructuring). What are her
thoughts when she wants to leave school?
2. Teach Amanda to replace negative, anxious thinking with
realistic thinking by helping her understand self-talk, identify
thoughts that lead her to feelings of anxiety and ways to challenge
negative thinking.

Homework: Role play examples/non-examples of challenging

negative thinking
Self-talk: There are a variety of techniques that could be used
such as creating a visual to help Amanda identify how the same
situation can lead to positive or negative self talk, that results in
positive or negative feelings.
Identifying thoughts: Teach Amanda to pay attention to thoughts
that make her feel anxious. Amanda may have to self-track or
journal.
Homework: Cartoon drawing to identify self-talk
Challenge negative thoughts: Help teach Amanda that thinking
about something does not mean that it will happen or is true;

thoughts are often guesses. Amanda could be taught about

thinking traps which are overly negative ways of seeing things.
Teach her to ask herself, what is the worst thing that could
happen?
To help reinforce, teach Amanda the FEAR acronym from the
Coping Cat program.
Feeling frightened?; Expecting bad things to happen?; Actions and Attitudes that
can help?; Results and Rewards.

Goal: Amanda will be able to identify and restructure negative or

anxious thoughts.
Homework: FEAR Thought Diary
Teach
relaxation and
calming
strategies

It is important
that Amanda
learns ways to
relax and calm
her body when
she is feeling
anxious.

1. Teach Amanda calm breathing and progressive muscle

relaxation techniques.
Calm breathing: This is to help Amanda take slow and gentle
breaths when she is feeling anxious. She can be taught 6-in-60,
or 6 breaths in 60 seconds by breathing in through the nose,
pausing, and then out through her mouth.
Muscle Relaxation: Amanda will be taught how to relax her body
by tensing muscles and then relaxing them to lower her overall
tension and stress.

Goal: Amanda will learn relaxation and calming strategies to help

reduce feelings of anxiety.
Homework: Calm breathing and muscle relaxation and continue
FEAR thought diary
Amanda would
Teach
coping skills benefit from

having tools that

she can use
when she is
experiencing
anxious thoughts.

1. Amanda can create coping cards listing strategies that she

can use when she is feeling like she does not want to go to
school or when she wants to leave school.
An example of a coping card for Amanda:
Anxiety is not dangerous. It is just trying to bully me.
I can control my thoughts! They are not the boss of me.
Are my thoughts helping me right now?
If I have a headache and stomach ache it is just my
anxiety. It doesnt mean that I am in danger and it doesnt
mean that I need to go home.
I could do some deep breathing or muscle relaxation.
Everyone is okay, everything will be okay. I can do this.

The coping card could also list strategies from the FEAR acronym.
Homework

Throughout
treatment

see specific counselling task

Specific Counselling Task: Homework

Introduction

Homework is an important and effective component of cognitive therapy. Cognitive therapy

homework provides clients with an opportunity to integrate new skills and concepts learned
between therapy sessions (Beck & Weishaar, 2011). Examples of homework assignments are
self observation and self-monitoring, new skill practice such as challenging automatic thoughts,
reading literature related to anxiety, role playing, and behavioral rehearsal (Cully & Teten, 2008).
Using Homework with Amanda
Homework will be utilized with Amanda throughout treatment. The nature and frequency of
homework will be relevant to treatment sessions and appropriate for her age and developmental
level. The activities are meant to be simple yet engaging. Amandas parents will be
encouraged to be involved by being supportive and at times participating in Amandas
homework, but should not direct or critique her work. Before each homework assignment a
clear description of the objectives and reason why it has been assigned will be shared with
Amanda. For example, We have been working on.. this week I would like you to
practice by completing this activity at home. Before each assignment, the therapist will
complete an example(s) with Amanda. At the session following an assignment, homework will
be reviewed together and Amanda will be asked what she found challenging or useful, as well
as any new learning or things she would change about the activity. Gradually as treatment
progresses, involving Amanda in generating ideas for homework activities will support her as
she transitions out of treatment (Cully & Teten, 2008).
Assignment 1
Wilma-Jean the Worry Machine by Julia Cook
Objective: Identify thoughts and feelings that lead to anxiety
After reading the story with her parents or on her own, Amanda will identify the anxious thoughts
and feelings of the character Wilma-Jean and compare and contrast them to her own feelings
using a Venn Diagram.
https://www.lucidchart.com/publicSegments/view/525df278-a27c-484e-a44e-5ce60a009ec6

Assignment 2
Role Play
Objective: Develop increased awareness of negative thinking patterns and how to consciously
think positive thoughts.
Behavioral rehearsal and roleplay of examples and non-examples of challenging negative
thinking with her parents. Amanda and her parents can take turns role playing either negative or
positive thinking related to a variety of situations. Suggested examples are below but Amanda
will be encouraged to personalize them by creating her own.
1.
2.
3.
4.

I am feeling worried and sad at school and I want to call home.

I called home from school and told my dad I dont feel well, but he said he wants me to stay.
I woke up in the morning and I have a tummy-ache when I think about going to school.
Im worried something bad will happen to my family when Im at school.

Assignment 3
Cartoon Drawing of Self-Talk
Objective: Increase awareness of anxious self-talk in order to generate positive messages

With the support of the therapist, Amanda will identify 2-3 situations or settings where she has
experienced anxious thoughts or feelings. Amanda will draw a simple cartoon character (or use
a cartoon generating website) illustrating both negative and positive self talk messages for each
setting.
Assignment 4
FEAR Thought Diary
Objective: To continue to develop Amandas self-reflection regarding anxious thoughts and
feelings and to reflect upon coping thoughts and rewarding herself for efforts and hard work.
Amanda will monitor her anxious feelings or experiences throughout the week by tracking them
in a table such as the one below.
Amandas Thought Diary

Feeling Frightened

Expecting Bad Things

to Happen

Attitudes and Actions

Where I was/What my
body was feeling

What I was worried would

happen

My coping thoughts and self How I solved my

talk
problem/Nice things I said to
myself

Results and Rewards

Assignment 5
Teaching Calm Breathing and Muscle Relaxation to parents and continue FEAR Thought Diary
Objective: Continued practice recognizing somatic cues of anxiety and practice use of relaxation
techniques
Amanda will model, teach, and practice the calm breathing and muscle relaxation techniques
with her parents. Amanda will try to practice a relaxation strategy once a day and continue
tracking of anxious thoughts and coping strategies using the FEAR diary.
Assignment 6
Culminating Activity near the end of treatment
Objective: Review of concepts and strategies learned in therapy and reinforcement of treatment
goals.
With the therapists support, Amanda will plan and create a format (video commercial, brochure,
pamphlet, poster) to share what she has learned that could be used to share with other children
about how to manage their anxiety.

References

AnxietyBC (2012). Retrieved October 16, 2013 from http://www.anxietybc.com/

Beck, A. T., & Weishaar, M. E. (2011). Cognitive therapy. In R. J. Corsini, & D. Wedding (Eds.),
Current psychotherapies (9th ed., pp. 276-309). Belmont, CA: Thomson Brooks/Cole.
Cook, J. (2011). Wilma-jean the worry machine. Chattanooga, TN: National Center for Youth
Issues.
Cully, J.A., & Teten, A.L. (2008). A therapists guide to brief cognitive behavioral therapy.
Houston, TX: Department of Veterans Affairs South Central MIRECC.
Friends in Canada (n.d.) Friends for life: Preventing and treating anxiety in children. Retrieved
from http://www.friendsinfo.net/ca.htm
Haarman, G. B. (2009). School refusal behavior: Effective techniques to help children who
cant or wont go to school. Addictive Behaviors, 31, 149-154.
King, N., Tonge, B. J., Heyne, D., & Ollendick, T. H. (2000). Research on the cognitivebehavioral treatment of school refusal: A review and recommendations. Clinical
Psychology Review, 20(4), 495-507.
Podell, J. L., Mychailyszyn, M., Edmunds, J., Puleo, C. M., & Kendall, P. C. (2010). The coping
cat program for anxious youth: The FEAR plan comes to life. Cognitive and Behavioral
Practice, 17(2), 132-141. doi:10.1016/j.cbpra.2009.11.001