Dbarclay_01-28-2024-Case Study Amara

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CASE STUDY: AMARA 1 Case Study: Amara Daniel Barclay School of Behavioral Sciences, Liberty University Author Note Daniel Barclay I have no known conflict of interest to disclose. Correspondence concerning this article should be addressed to Daniel Barclay Email: dsbarclay@liberty.edu

CASE STUDY: AMARA 2 Case Study: Amara Client Concerns Symptoms Behavior Stressors Anxiety Anxiousness Death of husband, retirement, and family conflict Insomnia Trouble sleeping and inconsistent sleep patterns Rumination and worry Worry/Rumination Constant fatalistic and negative thought patterns Family conflict and existential concerns Substance use Drinking alcohol has increased Anxiety Fatigue Tired throughout the day Insomnia Irritability Snapping at daughter Strained familial relationships (Amara Case Study Data, 2024) Assessment Amara is showing signs of family dysfunction due to her excessive worrying and inability to communicate her concerns effectively. The Family Assessment Device (FAD) is a self-administered survey designed to evaluate different aspects of family operation, such as communication, roles, affective responsiveness, affective involvement, behavior control, and overall functioning. It offers insights into dysfunctional areas and assists in directing therapeutic interventions. This would be more beneficial than a standard depression or anxiety inventory such as Beck’s depression or anxiety inventories due to many of the problems seemingly occurring because of familial dysfunction. Additionally, one study found the FAD to be effective in Malaysia, which has a culture that holds similar family values to that of Indian culture Cong et al., 2022). Diagnostic Impression Amara is exhibiting symptoms of Generalized Anxiety Disorder (GAD), the ICD-10 code of which is F41.1. The symptoms that Amara is exhibiting which align with the diagnoses of

CASE STUDY: AMARA 3 GAD are constant and excessive anxiety and worry about various aspects of her life such as her family, career, past decisions, and her perceived uselessness (American Psychological Association, 2022). Amara also self-reports that she has gone from feeling “high-strung” to excessively and uncontrollably worrying about everything. Additional symptoms that support the diagnosis of GAD are feelings of both fatigue and restlessness, irritability, muscle tension, and disordered sleep, all of which have been occurring longer than the required period of 6 months (American Psychological Association, 2022). Signs and Symptoms DSM-5-TR Diagnostic Criteria: Generalized Anxiety Disorder (GAD) (F41.1) Client’s Signs/Reported Symptoms: Criterion A: Uncontrollable anxiety/worry “absolutely uncontrollably anxious about everything.” Criterion B: Fatigue “…being fatigued happened two to three days a week.” Criterion C: Restlessness “…difficulty sitting still when she starts to worry and will often get up and walk around.” Criterion D: Irritability “…she and Amara have gotten into multiple fights over the last 12 months because of Amara's irritability.” Criterion E: Muscle tension “…over the past 24 months she has felt increasing tension in her body.” Criterion F: Disordered sleep “…she has struggled to get to sleep nightly.” (Amara Case Study Data, 2024) Other DSM-5-TR Conditions Considered Various diagnoses were considered while reviewing Amara's case, including mood disorders, eating disorders, and other cognitive disorders. The client reported some signs of social anxiety disorder such as increased concern with how others were perceiving her, but they

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CASE STUDY: AMARA 4 did not appear to be distinct from her already present excessive worrying. The client also reported three symptoms associated with major depressive disorder (MDD) (insomnia, fatigue, and sadness), but since a minimum of six symptoms is required for a diagnosis of MDD, the diagnosis was ruled out. Additionally, panic disorder was contemplated; however, as the client did not exhibit any symptoms of panic disorder such as avoiding situations and events that trigger panic, it was dismissed as a potential diagnosis. Developmental Theories and/or Systemic Factors The Erikson Psychosocial Development Theory would describe the life stage that Amara is in as the final stage or “integrity vs. despair.” Integrity pertains to one’s understanding of self and life satisfaction whereas despair concerns one’s feelings of wasted opportunities and chances (Wong et al., 2021). A recent study on older populations in Switzerland found that the density of conflict in a family system and the extent to which an individual is the central connector of their family are directly correlated to that individual’s quality of life and health-related issues (Widmer et al., 2017). Given the existence of so much dysfunction in Amara’s family system, it is not surprising that she is experiencing so many feelings of worry and existential despair. As a result of the loss of her husband and her choice to retire, Amara appears to be experiencing anxiety that is related to her inability to move from a place of despair to a place of equilibrium and integrity, which is in turn contributing to increasingly more dysfunction in her family system. Ultimately, this results in even more feelings of worry, anxiety, and uselessness.

CASE STUDY: AMARA 5 Multicultural and/or Social Justice Considerations Asian Americans naturally experience life differently than many other groups in America, particularly in the ways that they develop and deal with mental pathologies. For example, caregivers for older adults in the Asian American community are typically older and experience poorer health compared to individuals who are not caregivers (Miyawaki et al., 2022). In the case of Amara, this has relevant implications regarding the caregiving role she has continued to play in her mother’s life amid an already tumultuous period. Although Amara did not explicitly discuss instances in her history of discrimination or marginalization linked to her religious identity, it is nonetheless still crucial to consider the potential adverse impacts of cultural bias or preconceptions on her mental well-being. Her cultural background could be a source of discrimination or microaggressions, contributing to underlying feelings of discomfort or distress. Treatment Recommendations Key Issues for Treatment  Persistent anxiety  Existential confusion  Dysfunctional family communication Recommendations for Individual Counseling One recommendation would be cognitive-behavioral therapy (CBT). CBT would be beneficial to Amara for several reasons. Firstly, cognitive behavioral therapy has the benefit of eliminating avoidant and safety-seeking behaviors (Nakao et al., 2021). Both safety-seeking and avoidance behaviors are symptoms of anxiety disorders like GAD (Petwal et al., 2023). CBT

CASE STUDY: AMARA 6 also frequently integrates mindfulness techniques to enhance individuals' awareness of the current moment. Mindfulness assists in observing thoughts without judgment, fostering a non- reactive and accepting approach to anxious thoughts and feelings. All these effects could be beneficial to Amara’s ability to resist excessive worry and rumination over imagined problems. Another type of therapy that could be helpful for Amara is existential therapy. Existential therapy is a philosophical and therapeutic approach rooted in existentialism, emphasizing a dynamic and concrete engagement with life's challenges, focusing on the inherent "givens" of human existence, such as death, freedom, isolation, and meaninglessness (Heidenreich et al., 2021). The existential approach in therapy promotes a collaborative exploration of life dilemmas, acknowledging the therapist and client as fellow travelers in the human experience. Amara could benefit from this therapy because it could help her process her feelings of uselessness and fears about her future. Additionally, taking a collaborative approach with elderly individuals helps them feel that they have a say in what happens to them. Ultimately, this collaborative approach to counseling will help Amara maintain a sense of dignity and control over what is happening to her, which is vital not only to aging individuals but also to their caregivers (Hung et al., 2023). Specific Considerations Amara expressed her Hindu faith and indicated a desire to incorporate the principles of her religion into the counseling process, so that should be considered for more than one reason. One recent study discovered that engagement in religious activities provided older adults with a means to manage stress, strengthen support networks, and maintain cognitive activity (Hosseini et al, 2021). Integrating her Hindu religion into counseling sessions could provide her with

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CASE STUDY: AMARA 7 comfort and guidance regarding her existential confusion. Additionally, there may be specific practices used by those in her religion that could assist her in dealing with many of these symptoms. Yoga, for example, is a practice that originated in India and is widely known for its potential to help in managing anxiety (Cramer et al., 2018). Medication Considerations Amara shared that she has been taking Paxil as prescribed by her doctor, but she has yet to feel any significant changes. She stated that she is aware that it may take time for the effects of the drugs to be noticeable. Ideally, Amara should follow through with this treatment until the effects of the drugs are either noticeable or the drug needs to be changed. However, Henssler and their colleagues (2019) reported in one study that it is best to gradually reduce the dosage of antidepressants like Paxil over a period exceeding four weeks if that time should arise so that negative side effects can be avoided. Another option for Amara would be a class of drugs called benzodiazepines. Benzodiazepines such as alprazolam are effective in clients suffering from generalized anxiety disorder (Bounds & Nelson, 2023). Benzodiazepines are also widely used for those suffering from sleep issues and have the added benefit of muscle relaxation, all of which Amara is dealing with. However, they do have the potential to become addictive, so it is typically advised to use the minimal effective dose necessary when utilizing them for that reason. Unique Client Considerations The role of cultural background is important in this case. Primarily because those who come from Asian cultures often feel a larger obligation to care for their older parents (Miyawaki

CASE STUDY: AMARA 8 et al., 2022). Amara could somewhat be expecting this felt sense of obligation from her children who could quite possibly not share that cultural sentiment. It would be wise to gather additional information from her regarding which traditional values typically found in Asian cultures she feels connected to so that they can be addressed and implemented into the sessions with her counselor. As a Christian, I may not see eye to eye with her Hindu-based belief system. Extra effort should be made on my part to learn about this religion which I may not know enough about to integrate into counseling sessions with her. Additionally, supervision and talking with peers may assist me in dealing with the differences in both age and cultural background.

CASE STUDY: AMARA 9 References American Psychiatric Association. (2022). Anxiety Disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787.x05_Anxiety_Disorders Bounds, C., & Nelson, V. (2023). Benzodiazepines . National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK470159/ Cong, C. W., Tan, S. A., Nainee, S., & Tan, C. S. (2022 ). Psychometric Qualities of the McMaster Family Assessment Device-General Functioning Subscale for Malaysian Samples. International journal of environmental research and public health, 19(4), 2440. https://doi.org/10.3390/ijerph19042440 Heidenreich, T., Noyon, A., Worrell, M., & Menzies, R. (2021). Existential approaches and cognitive behavior therapy: Challenges and potential. International Journal of Cognitive Therapy , 14 (1), 209–234. https://doi.org/10.1007/s41811-020-00096-1 Henssler, J., Heinz, A., Brandt, L., & Bschor, T. (2019). Antidepressant withdrawal and rebound phenomena. Deutsches Ärzteblatt International . https://doi.org/10.3238/arztebl.2019.0355 Hosseini, S., Meyer, S. B., & Oremus, M. (2021). Is your religious involvement helping your mind? the link between religious involvement and cognitive function from the perspectives of Christian pastors and parishioners. Journal of Religion, Spirituality & Aging , 34 (3), 208–225. https://doi.org/10.1080/15528030.2021.1938342 Hung, H. Y., Azman, A., & Jamir Singh, P. S. (2023). The impact of counseling on the dignity of older people: Protocol for a mixed methods study. JMIR Research Protocols , 12 . https://doi.org/10.2196/45557

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CASE STUDY: AMARA 10 Miyawaki, C. E., Bouldin, E. D., Taylor, C. A., McGuire, L. C., & Markides, K. S. (2022). Characteristics of Asian American family caregivers of older adults compared to caregivers of other racial/ethnic groups: Behavioral Risk Factor Surveillance System 2015–2020. Journal of Applied Gerontology , 42 (5), 1101–1107. https://doi.org/10.1177/07334648221146257 Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive–behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. BioPsychoSocial Medicine , 15 (1). https://doi.org/10.1186/s13030-021- 00219-w Petwal, P., Sudhir, P. M., & Mehrotra, S. (2023). The role of rumination in anxiety disorders. Journal of Rational-Emotive & Cognitive-Behavior Therapy , 41 (4), 950–966. https://doi.org/10.1007/s10942-023-00513-2 Widmer, E. D., Girardin, M., & Ludwig, C. (2017). Conflict structures in family networks of older adults and their relationship with health-related quality of life. Journal of Family Issues , 39 (6), 1573–1597. https://doi.org/10.1177/0192513x17714507 Wong, D., Hall, K. R., & Hernandez, L. W. (2021). Counseling individuals through the lifespan . SAGE.

Dbarclay_01-28-2024-Case Study Amara

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