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 didnt 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.
BACKGROUND
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 Leahs 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.
RELATIONSHIP BUILDING
Leah decided to take professional help after she realized life was not taking its
right path and when things were getting bad to worse. On her first visit to the
counsellor she was reluctant to disclose all her feelings and anxieties. The
counsellor however with her gentle behaviour gave Leah the head start and
slowly she opened up to her. To reach up to this stage of confidence it took her
many sessions.
PROBLEM ASSESSMENT
The counsellor performed an examination of Leahs 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.
GOAL SETTING
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, counsellor 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 Centre link benefits

Undertake a drug and alcohol rehabilitation program

Cognitive restructuring

Medication monitoring

Ongoing support.
This plan was designed to utilise Leahs 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. Leahs goals were developed with her input to encourage
her to feel ownership of them, increasing her motivation.
Barriers
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.
COUNSELLING INTERVENTION
Leahs goals were written in specific behavioural terms as follows:
Schedule enjoyable activities Counsellor 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. Counsellor asked Leah to carry out at least one of these
activities every day.
Obtain suitable accommodation Counsellor 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 Counsellor 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 Counsellor helped Leah obtain and lodge necessary
forms to help her transition to New start Allowance once her Army benefits had
run out.
Rehabilitation Counsellor connected Leah with appropriate contacts to
commence drug and alcohol counselling and to undergo residential rehabilitation
if needed.
Cognitive restructuring Counsellor provided short-term intervention aimed
at identifying Leahs irrational thought processes and replacing these with a
more functional belief system. Here Counsellor took on the counselling function
of the case management role and centred the work on Leahs 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 Dialectical Behaviour Therapy (Linehan, 1993) were also used to
address Leahs 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 Counsellor 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 Counsellor provided Leah with contact names and numbers
for local chapters of Alcoholics Anonymous and, following successful completion
of her immediate goals, Counsellor referred Leah to her local community health
clinic for ongoing monitoring and medical follow-up.
EVALUATION
Counsellor has provided a combination of case management and counselling
functions while working with Leah. The counsellor has used Cognitive Behaviour
Therapy, Dialectic Behaviour Therapy and Gestalt Therapy techniques to
facilitate achievement of the clients 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 Counsellor 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 Counsellor, 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 Leahs immediate needs,
Counsellor has referred her to services able to provide her with ongoing but less
intensive support. With Leahs written permission, Counsellor provided the
community health centre with a referral form outlining Leahs history, medication
regime, and a summary of the work undertaken with Counsellor, which had been
documented following each session with Leah.
The counsellor 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, the counsellor has ensured Leah has acquired
the necessary skills for maintaining progress on her own, with assistance
available to her as needed.