Avoidance

Rehab with members who avoid situations because of the discomfort they experience in them. Their social skills may be adequate, but they choose to stay away from places where they'll have to interact with other people, especially groups of people they aren't well-acquainted with. Sometimes situations are avoided because they bring up bad memories or cause feelings of panic.

 

These are examples of G & I sections only, not the entire note.

G:  Janelle is a 31 y/o single African American female. Due to paranoia and fear of being negatively judged, Janelle experiences high levels of anxiety in public places and isolates in her home as a result. I met with her today to work on her #1 objective of increasing the number of minutes she is able to spend in a crowded room (or small area) without experiencing significant emotional distress, from a baseline of zero minutes to a target of 30 minutes.

I: Educated Janelle on the role stress can play in the severity of someone’s symptoms, particularly for people diagnosed with a thought disorder. Helped her identify unnecessary sources of stress in her life that she might be able to reduce or eliminate, as these could be making her voices louder and more frequent, and her paranoia more pronounced. These are the symptoms that contribute to Janelle’s reluctance to go places where lots of people will be around her, especially strangers. Reviewed 3 anxiety reduction techniques she can use before she goes out -- listening to soothing music, using positive mental imagery, and doing progressive muscle relaxation.

G:  Janelle is a 31 y/o single African American female. Due to paranoia and fear of being negatively judged, Janelle experiences severe anxiety in public/social situations and avoids them as a result. I met with her today to continue working on her #1 objective of increasing the number of minutes she is able to spend in a crowded room without experiencing significant emotional distress.

I: Reviewed the 3 relaxation techniques I demonstrated for Janelle at the end of our last session. I then introduced her to techniques she could use in the presence of others without drawing unwanted attention to herself (i.e., things she could do once she was already sitting in a crowded room). Modeled deep breathing for her and explained that I was trying to focus only on the physical sensations of breathing, how it felt, and keep my mind clear of other thoughts. I invited her to do it with me and talked her though it was we did it together. Explained the technique of using calming mental imagery (imagining herself in a relaxing location) and positive affirmations (reassuring things she can repeat to herself), pointing out that she can use these almost anywhere, whenever she feels the need to relax and center herself, without anyone noticing. I introduced the idea of carrying something with her, like a small round stone, that represented being calm and in control. Suggested she hold it firmly in her hand in situations that caused her to feel anxious, maintaining an awareness of its texture and shape, and what it represented.

G: Janelle is a 31 y/o single African American female. Due to paranoia and fear of being negatively judged, Janelle experiences high levels of anxiety in public places and isolates in her home as a result. I met with Janelle today to continue working with her on her current objective of increasing the number of minutes she is able to spend in a crowded room (or small area) without experiencing significant emotional distress.

I: I asked Janelle to hold her "calming stone" in her hand, then coached her through a series of deep-breathing and progressive relaxation exercises which she learned to do in prior sessions. I then asked her to continue breathing slowly and deeply while imagining herself sitting in an empty waiting room. As the exercise progressed I asked her to begin adding people to her imagined room, one at a time, as she continuing to do deep breathing. She agreed to signal when she felt calm enough to add another person. I spoke reassuringly to Janelle and allowed her to self-direct the exercise as soon as she understood it. By the time she was finished, Janelle said she was imagining 8 people in the room and "feeling okay about it". I praised her for trying something new and explained she could do this exercise by herself, whenever she wanted, and that it could help reduce the discomfort that prevents her from spending time with other people and living life the way she wants to.

G: Patrick is a 35 y/o single Caucasian male. Patrick attends most of his scheduled appointments with his psychiatrist and takes his medications as prescribed. Despite being med adherent, Patrick still feels compelled to analyze every social encounter he has, trying to figure out if he did or said something he shouldn’t have. Even a casual exchange of words can result in Patrick replaying the interaction over and over in his mind, sometimes for days. Despite having no friends and feeling lonely much of the time, Patrick tries to limit his interaction with others as his paranoia and inability to avoid excessive self-examination afterwards make the interactions exhausting for him.

I. Met with Patrick at his R&B and began teaching him how to use relaxation skills. Explained progressive muscle relaxation and the value it can have in reducing anxiety. Modeled progressive relaxation, showing Patrick how to tense different muscle groups and then release the tension. I then encouraged him to try, which he did successfully. Practiced tensing and relaxing several basic muscle groups, providing coaching and feedback.

G: Patrick is a 35 y/o single Caucasian male. Due to paranoia, excessive anxiety, and a tendency to ruminate over small social errors he imagines he might have made, Patrick limits his interaction with other people despite his admission that he is lonely most of the time, especially in the evenings, and wishes he had someone to talk to and do things with. I met with Patrick today to continue working with him on managing his anxiety.

I: Met with Patrick at his R&B and continued work on teaching progressive muscle relaxation. Reviewed the skill of tensing and relaxing that Patrick learned last week, then took him through a more complete version of the exercise, starting with the head and moving to the toes. Provided coaching and feedback, encouraging him to visualize a wave of relaxation flowing over him as he released the tension in each muscle group.

G: Yasmin is a 23 y/o single Afghan-American female. Due to flashbacks, intrusive recollections, and avoidance of situations that remind her of past trauma, Yasmin cannot leave her apartment without experiencing intense anxiety. This interferes with her ability to socialize, ride the bus, hold a job, shop for food, attend appointments, and lead what she considers to be a normal life.

I: Introduced Yasmin to breathing exercises as a way of managing her anxiety. Explained the value of this technique and how it can be used in almost any situation without calling unwanted attention to herself. Modeled deep breathing for her, then encouraged her to join in. Instructed her to think only about her breathing and how it felt, and put all other thoughts out of her mind. Yasmin had trouble slowing things down at first, so I did the exercise along with her as a way of pacing her.  Provided feedback afterwards and praised her for her willingness to try something new.

G: Yasmin is a 23 y/o single Afghan-American female. Due to flashbacks and intrusive recollections, Yasmin experiences intense anxiety when she leaves her home. This interferes with her ability to socialize, hold a job, shop for food, attend appointments, and lead what she considers to be a normal life.

I:  Met with member at her CoC apartment. Introduced her to guided imagery as a way of reducing her anxiety. Explained the value of the technique and how it works. Asked her to think of a place or situation she would feel most relaxed in. She identified "somewhere deep in the forest" as a place she would feel least anxious. I then sat down with her in an area free of noises and other distractions and began a "forest" narrative, asking her to join in and help me describe things that might be seen, heard, smelled, or felt.

 

All PHI has been de-identified per HIPAA Privacy Rule