Heriani

CASE REPORT 3. Avoidant Behavior using Behavior Modification to change Cognitions

1. SCREENING OR INTAKE PHASE

Name : Miss Lisa (not her real name)

Age : 17 years old
Education : high school student, 12th class
Address : Pasar Minggu

Social Situation:
 The patient came for the first time accompanied by her mother. Her mother was
concerned because she had been more and more withdrawn, could not concentrate on her
school work, had lost her spirit of learning and thereby her academic performances had been
getting worse recently (especially since going back to school after the year-end holiday) while
final examination was getting near.
 Her mother said that this was caused by some remarks someone at school made at her. She had
told her daughter to just ignore it but her daughter just couldn’t do that. She used to be a good
student, had many friends, and eager of going to school. Now her performances at school
declined, she had no friends because she thought that nobody wanted to play with her.
 Note 1: During the interview, even when the question was directed towards Lisa, her mother was
quick to response and didn’t give Lisa the chance to explain the situation herself. Lisa looked as if
she was going to cry, but kept quiet and looked down. Finally the therapist asked Lisa if she
wanted the interview to be done just by the two of us. She said yes, so the mother left the room.
 The patient said that this had been going on since she was in junior high school (the second
semester of 7th year). One day she was seated next to a boy, and he told her that she smelled.
She didn’t take this seriously, but the next day that boy had told several others in the class about
her being smelly. She still didn’t take this seriously until others from other classes had exclaimed
that she smelled, or covered their nose when she was around, or left her. This started to bother
her and she became self-conscious about her smell and started to avoid people because she was
afraid of people ridiculing her. At junior high she still coped quite well although she had turned
into a shy girl. She didn’t know why he did that.
 In senior high, that boy and some of the people who ridiculed her also went to the same school
as her. This stressed her more because she thought that they would surely tell others that she
smells. These people were the popular ones and they could influence other people not to
include her in their community. She didn’t know why, but she had become more and more afraid
of people looking at her and thus started to avoid looking at people, and she gradually became
more silent and withdrawn. Because she avoided looking at people, (she said that) they thought
that she was a weird person and they avoided her. So she didn’t have any friends at school and
this stressed her a lot. Lately she not only avoided people at school but also her neighbors and
her childhood friends as well. She was afraid of going to school. She often cried alone, but not
every day. She was happy when she was at home. She could enjoy life on holidays. It was when
she had to go back to school after a school holiday that she felt the worst. She said that when
people talked to her first, she liked it and actually wanted to have a conversation with them. She
never talked to people first because she was afraid that they would avoid or ridicule her or say
nasty comments on her.
 Note 2: Actually at first she told the therapist that people avoided her, but after probing further
and asked her in a “S  O  R  C” manner, she realized that actually it was she who had been
avoiding people because she had been afraid that people would ridicule her, said nasty things to
her, and avoided her. When asked whether there were people at school that were nice to her or
at least were neutral, at first she said none, but gradually said that her friend who shared the
desk with her had said that she shouldn’t take their remarks and comments to heart. And some
of her friends WERE nice to her but now they too didn’t talk to the patient anymore but maybe
it’s because the patient had been keeping silent.
 During the first interview, Lisa looked so distressed, tears ran down her cheeks, but she spoke
spontaneously and could systematically tell her story. Her mood was low, her affect was
appropriate with her thoughts. There were no psychotic symptoms, no suicidal ideas. Cognitive
function was good. Impulse control was good. Social judgment: good. Insight: intellectual insight.

Formulation of problem(s):
The patient had shown a progressive decline in her academic performances as the result of the
worsening of her social functioning.
It started with a comment a boy made, in junior high, about her being smelly that spread around the
school. She, who used to be a friendly person, became shy.
 This problem got worse when that boy went to the same senior high-school as she did. She was
afraid that he would do the same thing he did in junior high and that people would look down on her
and make nasty comments. She had been avoiding looking at people because she was more and
more afraid of people looking at her and ridiculed her or made comments on how smelly she was.
She gradually became more silent and withdrawn. Actually nobody had commented on that
anymore, so it was only in her belief system. Because she avoided looking at people, (she said that)
they thought that she was a weird person and they avoided her. Actually people didn’t talk to her
anymore because she avoided people.

Diagnosis DSM IV:

 Axis I : Adjustment disorder with mixed anxiety and depressed symptoms
 Axis II : No diagnosis (she was not 18 years old yet, but she showed some avoidant personality
traits which may be the symptoms of her condition)
 Axis III : No diagnosis
 Axis IV : A group of people at school who keep ridiculing her about her smell (although the
original stressor happened five years ago, it is still going on)
 Axis V : Current GAF – 51 (moderate difficulty in social and school functioning)
HLPY GAF – 60 (moderate difficulty in social functioning, but generally functioning
quite well in school)

For what problem does the patient seek help?

 Her mother brought her to treatment because: she was concerned about her daughter’s
deterioration in academic performances at the time when National Examination was getting
near. She was also concerned about her daughter’s decreasing social life.
 The patient agreed to take treatment because: she wants to be able to feel confident again and
being able to make friends easily.

2. BASELINE PHASE

Describe the problem or handicap in precise behavior terms;

1. Excessive anxiety: about how people might think about her.

2. Avoidant behavior: avoided looking and talking to people.
3. Cognitive errors:
 Generalization:
- Nobody wants to be friends with me (because I smell),
- Everybody avoids me (because I smell),
- Everybody knows that I smell
- Everybody thinks that I smell and will insult me (like that boy and his friends did)
 Magnifying:
- This boy belongs to a popular gang  he will tell his friends  his friends will tell their
friends  the whole school will know that I smell  as they have friends outside the
school, people from outside the school will know that I smell.
- As he ridiculed me, the whole school will ridicule me as well  people outside school
will ridicule me (so I might as well avoid interacting with people).
 Mindreading/arbitrary inference:
- When somebody looks at me, it means that he/she thinks that I smell bad  he/she will
avoid me or ridicule me (so it’s better if I avoid looking at them, or talk to them)

Cognitive error Excessive anxiety Avoidant behavior

Consequences:
People stopped approaching her

Confirmed cognitive errors

Select an appropriate baseline procedure that will enable you to:
a. Monitor the problem behavior
b. Identify its current stimulus control
c. Identify the maintaining consequence
d. Make a functional analysis of the problem behavior

To monitor the problem behavior, to identify its current stimulus control and maintaining
consequences in order to make a functional analysis, we used Self Monitoring, which also served
as the first step towards behavioral change.

The first ‘self-monitoring’ took place in the second meeting, together with the therapist. That
was when she realized that actually it was she who avoided people and not the other way
around. So this baseline procedure also served as the beginning of the therapeutic sessions.
After she understood what she had to do, she did the Self-Monitoring task herself.

Stimulus Cognitive Emotion Response Consequences

Going to school “They are going to Fearful Can’t concentrate Internal (+):
ridicule me” By avoiding
Couldn’t look at the
looking at
teacher
people and
Didn’t pay any talking to
attention to class people, her
anxiety of
being
ridiculed
decreased
Internal (-):
Sad, because
she has no
friends
External (-):
People
avoided her
Grade
worsened
 People looking “I smell bad” Fearful Avoid looking at People think
at her “They will ridicule them she is weird.
Avoid talking to People don’t
me”
people approach her
anymore,
stopped
talking to her.
She has no
friends.

“I’m weird” Sad Withdrew herself People avoid

her more
“Nobody likes me”
Note: this is
when she
realized that
it was she
who avoided
people first
and people
avoided her
because of
her behavior,
not the other
way around.

Going to school (NS), which once was a nice occasion, was paired with being ridiculed by the popular
gang (US) that resulted in feeling fearful (UR).

Going to school became a CS  fearful in anticipation of going to school (CR)

By avoiding talking to people and looking at people (R)  Fear of being ridiculed, decreased; people
don’t ridicule her (maintaining consequences, positive reinforcement)

But the long-term consequences were bad grades (as the result of avoiding to look at the teacher and
what they were teaching, and didn’t answer their questions), and bad social life. These long-term
consequences were used to motivate the patient to make a change.

3. TREATMENT PHASE
Define goals / target behavior for treatment

She is able to think more rationally when she is faced with anxiety provoking stimulus and this could be
reached by making intermediate goals  to be able to:
 Look at people again,
 Talk to people again,

starting with people who are closest to her, like her desk mate at school, her best friends at home, and
then enlarge the circle bit by bit.

By changing the avoidant behavior, we hoped to change her negative automotive thoughts and
maladaptive assumptions (by un-proving her beliefs), and thus lessened her excessive anxiety. This way,
we will reach the other goals which were their reasons to seek treatment: being confident and make
friends easily, and get better grades in school.

Develop a treatment program/strategy/procedure

When the therapist asked Lisa, what could she do to reach her goal? Surprisingly she said “Change the
way I think”. I think at that time she had realized that it was she who has been avoiding people and that
people were only reacting to her behavior which was the result of her misinterpretation of a situation.

During the interview, Lisa was asked to think of the percentage of people who are actually nasty to her
and the people who are nice or neutral to her. I drew a circle and asked her to draw the proportion. She
said about 25% percent nasty people (“but they are like the popular guys in school!”). I colored that
section black. Then I told her that the black part is the nasty people, which make up of only a quarter of
the population at school, and the white bigger part is the people who are nice to her. By asking her
questions, she realized that all this time she had been focusing on the small part and never
acknowledged the bigger part. Then I asked her to rip the black part and tear it to small pieces, then
throw it to the trash basket. I told her that as we have thrown away the trash to the trash basket where it
belongs, we don’t think of them anymore and asked her to focus on the nice people. And as the ‘trash’
has never given her any benefit, so Lisa will start to reach her goal by befriending the nice people and
just ignore the ‘trash’, and that she should focus on the positives and not the negatives. (Note: Thinking
back, I’m not sure now whether it’s right to relate the nasty people as ‘trash’).

At the end of the interview which is also served as the beginning of the treatment phase, she looked
‘relieved’, stopped crying, and started to smile.
Then we decided on small target behavior to reach her goal for every week to come (graded exposure
program):
 Week 1: Tell her closest friends why she had been avoiding her; hopefully they will understand.
 Week 2: Look at the people she meets, plus a nod and a smile if she is brave enough already.
 Week 3: Start to say short greetings to people she meets.
 Week 4: Start a conversation with people, starting with the ones closest to her and gradually to
others.

She was also to make a daily record (self-monitoring task) and come to sessions every week to ensure
her commitment to her program.

When she asked what to do when the nasty people ridicule her again, the therapist reminded her that
we have agreed to focus on the ‘bigger white’.

No medication was prescribed.

Make steps to increase the clients commitment to accomplish the treatment goals

Self-Monitoring of graded exposure tasks and making a record of the result of the new behavior (how
people react to that and how she thinks and feels afterwards).

Carry out the treatment program

Session 2:

Self-monitoring task:

Time Stimulus Cognitive Emotion Response Consequences

Day At school Telling her (+):
friends and
1-3 At home Friends and family
family why
she has been members
understand, even
acting that
way said that she
shouldn’t mind to
what the others
said to her, just
ignore them.
 They were happy
that she talked to
them again and
opened up to them.

“They don’t ridicule Talked more Even someone from

me and actually the popular gang
understand me” Relieved Talk to more talked to her and
friends and
Happy sympathized with
family her (surprise,
surprise!)

More
relieved
“Not ALL of them are
nasty!” More
confident

Day Coming to Anxious Looked and Most people nod

school nod at people back though they
4–6 she met looked surprised,
some just looked
surprised, but
nobody made any
nasty comments.

“Hmm.. it’s not as Anxiety Nod and smile People smiled back
bad as I thought” decreased, to more and some even
felt more people greeted her.
confident

She greeted
back to them

Lessons learned of the week:

What she feared didn’t happen. Not ALL people are nasty to her. There are nice people who actually care
for her (her family, her close friends at home), kind to her (some students in her class, the teachers).
She was still concerned about what the ‘popular gang’ might react to her change. I reminded her to
focus on the people who were nice to her.

Session 3:

Self-monitoring task:

Stimulus Cognitive Emotion Response Consequences

At home Call friends, They came and had
ask them to a nice chat
meet

Happy Kept doing it Friendship resumed

At school Anxious Looked and Most people

nod and greet greeted back
people she
met

”There ARE nice Anxiety Nod and smile People smiled and
people at school” decreased, and greet greeted her back.
felt more more people
confident

Try to make People responses

short by talking to her
conversations
(like ice
breaker
things)

Relieved
Happy
More
confident

This week’s discussion:

Although she now believed that there are actually nice people at school and that her old friends and
family do care for her, she was still concerned about what the ‘popular gang’ might react to her. Here is a
part of the dialogue we had.
The therapist (T) asked: “Why it is so important to you about what these people think?”

She said (L): “Because they are the popular ones.”

T: “So..?”

L: “Mmm…. They can influence other people’s opinion about someone, who to ‘play’ with and who is
not.”

T: “Okay. From what you have experienced these past few weeks, does this have any evidence?”

L: “No.. Hmm…, I guess doc, it’s because I want to be one of them.”

T: “Hmm…”

L: “Doc, I think I’m the one who have been rude to the nice people! I have been focusing so much on
being accepted by the popular crowd that I neglected and ignored the other persons who were nice to
me.”

T: “And..?”

L: “And by doing that, I have lost potential friends. I was the snob, not them! ”

T: “Well, now you have changed, and people reacted to you nicely. That’s good, isn’t it?”

L: “Yes” (she smiled).

T: “What about the popular crowd?”

L: “I guess I cannot have it all. If they accept me, fine. If they don’t, at least I still have my friends.”

T: “What if they ridicule you again?”

L: “So far, they haven’t. But if they did….., I don’t know. I guess I just have to ignore them, and focus on
my friends, right? It doesn’t mean that I’m a bad person.”

T: “Yes. By the way, why do you think they haven’t ridiculed you?”

L: “Mmmm…., maybe because I do NOT smell (smile). Or maybe because they have other things to do
than paying attention to me.”

T: “How do you think about that?”

L: “Well, you can’t win them all. But I think by starting to make friends, and hopefully get better grades,
they will be nice to me in the end. Or at least, I will have my own crowd.”

The therapist thought that it was important for her to be accepted at school and feel pretty, so we talked
about other things like doing a make-over, how to enhance her appearance
(Question: Is it okay to do this? It seemed to me to be important to her and that it will boost her ego and
confidence, but I may be projecting/externalizing my own feelings here, the way I thought about myself
when I was in high-school).

Session 4-5:

During the week she had tried to have more conversations with the people she had been comfortable
with, and tried to start conversations with new people. She felt happier and more confident now and not
thinking about how to be accepted by the popular crowd anymore, and that way, not too concerned
about being ridiculed by them.

Session 6:

This was the last session. We talked more on what she was going to do after she graduated.
The therapist congratulated her for having conquered her fear and her accomplishment so far. I gave her
a small token (a self-made ‘certificate’ and a pin) as a reminder of what she had achieved. Hopefully, next
time she is faced with low self-esteem or other anxiety provoking situations, these will remind her of the
lessons she had learned in the sessions, and she could do a self- CBT.

4. EVALUATION OF YOUR TREATMENT PROGRAM/STRATEGY

Describe the results in behavioral terms:

Doing the things she avoided to do had the purpose of giving the evidence that her maladaptive
assumptions had no evidence. If people were actually responding well to her, it would be a positive
reinforcement for doing the new behavior again and again, as well as changing her negative automatic
thoughts. It would also give her a sense of accomplishment that would increase her confidence
gradually. When her fear has gone (by the process of extinction), her concentration got better, and her
grades eventually improved.

Did your treatment have a satisfactory effect?

 Yes, I think so. The patient had conquered her fear and avoidant behavior, and adopted a
new and more adaptive behavior. By doing that, she had accomplished what she and her
mother came to therapy for: feeling confident and being able to make friends easily, and
improving her grades and being able to study well for the National Examination.