Case Example

Thomas was a 68-year-old married man, diagnosed with Parkinson's disease four years previously. As a consequence of the disease he had become uncertain and fearful of others' reactions to him in professional and social situations and had increasingly avoided such situations. This had profoundly affected his self-concept; he was experiencing many features of depression.

A cognitive formulation of Thomas's presenting problems suggested that, at a core level, central to his sense of self, Thomas had assimilated the belief that his acceptability as a person was conditional on being respected and regarded as competent in all domains and at all times. His career as a carpenter and his retirement interests involved fine motor skills that had been essentially lost through the progression of the Parkinson's disease.

The onset and progression of the Parkinson's disease had activated Thomas's beliefs about his acceptability as a person as conditional on being respected and regarded as competent, because it had compromised his competence in what he believed were key areas. He had begun to doubt his self-worth and acceptability; as he put it, 'people will think I am at the end of the pier ["a lesser person"] if they know about the Parkinson's disease.' Because Thomas tried to 'camouflage' the disease and its impact on him from friends and family, he had started to avoid many social situations. This had in turn maintained the social fears and exacerbated his depression by disabling opportunities to establish whether his beliefs were true: whether people would in fact 'write him off'.

Thomas attended 16 therapy meetings over eight months. Initially meetings were weekly, but later meetings were biweekly and then monthly. The steps in cognitive therapy were:

(1) education about social anxiety, depression and the cognitive model to normalise Thomas's experience, (2) diary keeping of thoughts, feelings and behaviour across a range of upsetting situations to help Thomas further understand his beliefs and their role in his psychological difficulties, (3) reducing avoidance of feared situations in graded homework assignments and (4) testing and challenging hypothesised conditional and core beliefs.

In terms of his presenting problems, Thomas responded well to cognitive therapy's pragmatic 'here-and-now' approach. Thomas identified the following strategies from cognitive therapy as helpful in managing his social anxiety: (1) the solicitous use of self-disclosure,

(2) 'what-if' thinking (asking yourself 'What would be so terrible if the feared consequences really did happen?'), and (3) 'the head-on approach' (confronting fears head-on, in a shameless, bold manner). Armed with these strategies, Thomas attended a series of social engagements (giving a speech at a colleague's leaving party, visiting former colleagues, several Christmas parties) to test the basis of his beliefs in reality. On each occasion, his fear was not substantiated. In fact, on several occasions Thomas was taken aback by how warmly his friends and colleagues welcomed him. Thomas drew on a boxing metaphor and said that he felt 'better able to cope with difficult situations, because I can beat my negative thinking to the punch.' He stated that he no longer avoided social situations and, for the most part, depression featured less prominently. However, the progression of his Parkinson disease presented considerable challenges, and Thomas over several years attended 'booster sessions' to help him maintain his psychological health as best as possible while his physical health deteriorated.

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