Eleven Hours a Day and a Headache Every Morning
Ravi, 16, is preparing for the Intermediate examination. For four months he has studied eleven hours a day, slept five hours and given up cricket. He now reports headaches and stomach aches almost every morning before school and has twice refused to go. Over the past month he has started chewing tobacco 'to stay awake'. His parents describe him as always having been 'bright and confident'; his mother sits beside him while he studies and checks his phone every night. On a stress questionnaire he scores high on 'parental pressure' and low on 'perceived control'. He tells you, 'If I don't get 90%, my life is over. There is no other option for my family.' Last week he missed a mock test because of a headache and afterwards felt relieved rather than worried. His father dismisses the whole thing as 'exam tension' and wants a tonic from the chemist.
1. Analyse Ravi's situation using the transactional model of stress. Identify his primary appraisal, secondary appraisal and reappraisal, quoting the evidence for each.
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Primary appraisal is the evaluation of whether an event is irrelevant, benign-positive or stressful - and if stressful, whether it is harm/loss, threat or challenge. Ravi's 'If I don't get 90%, my life is over' is a textbook threat appraisal, and the relief after missing the mock test shows he has already begun to experience harm (loss of confidence, avoidance). Note that the examinations are objectively the same for everyone; the appraisal, not the event, is doing the damage. The 'no other option' phrasing signals an absolute, catastrophising appraisal with no alternative outcomes generated.
Secondary appraisal is the judgement of what can be done - coping options and perceived control. Ravi scores low on perceived control and reports no options; he has given up cricket (a source of efficacy and recovery) and his strategies reduce to longer hours and tobacco. He cannot name a single thing that would help him other than studying more, which is precisely the evidence that secondary appraisal has collapsed.
Reappraisal is the changed evaluation after new information. The missed mock test produced relief, not anxiety - he is reappraising avoidance as effective, which strengthens it.
Practical consequence: the target of intervention is not only the syllabus but the appraisal. The catastrophising belief, the absence of perceived control and the avoidance-relief loop are the three points where a psychologist can work; the headache is a somatic expression of the same appraisal, not a separate illness to be medicated away.
2. Classify Ravi's current coping strategies as problem-focused or emotion-focused, judge whether each is adaptive, and then design a four-week life-skills plan with measurable outcomes.
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Classifying what he already does:
- Studying eleven hours: problem-focused, but over-used - beyond a point it costs sleep and returns nothing.
- Chewing tobacco: emotion-focused, avoidance-based, and pharmacologically harmful; it treats wakefulness, not the stressor. Clearly maladaptive.
- Missing the mock test: avoidance, which is negatively reinforced because it produces relief. Maladaptive and self-amplifying.
- Giving up cricket: removal of a genuine emotion-focused resource (exercise, mastery, social contact) - a net loss of coping capacity.
So he has no adaptive emotion-focused strategy at all, and his only problem-focused strategy is being run at a harmful dose.
Four-week plan (life skills, not advice):
- Sleep anchors - fixed wake time, 7–8 hours, no study after a set hour; nightly sleep diary.
- Study restructuring - cap at 8 focused hours with spaced practice and active recall; weekly plan written by Ravi, not by his mother.
- Cognitive restructuring - thought record of '90% or nothing', generating three alternative outcomes and the evidence for and against; the goal is a graded standard, not lowered ambition.
- Assertive communication - scripted conversation with mother about phone-checking and sitting in the room, rehearsed in session.
- Restore cricket twice weekly and one relaxation or breathing practice daily.
- Tobacco cessation - brief advice plus referral, not a lecture.
Measurement: sleep diary hours, morning headache frequency per week, mock tests attended, self-rated stress 0–10 weekly, and number of alternative thoughts generated. Review at two weeks, not four, because non-response should trigger referral.
3. Ravi's father wants a tonic from the chemist and does not know about the tobacco. How do you handle the disclosure and the request, keeping confidentiality in view?
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Start with what confidentiality permits. Ravi is 16 and competent to consent to counselling; his tobacco use is health-relevant, so the first move is to negotiate disclosure with him rather than to announce it. Say what you think his father needs to know and why, agree who says it, and offer to be present. Coerced disclosure from a psychologist destroys the alliance and drives the behaviour underground.
Limits that override his preference: risk of harm to self or others, and significant medical danger. Nicotine dependence in a 16-year-old is a health issue but not usually an immediate danger; document the discussion and keep pushing for a planned disclosure within the plan.
Refuse the framing of a 'tonic' without refusing the father. Reasons: (a) a tonic will not address sleep loss, catastrophising or avoidance; (b) it converts a psychological problem into a chemists' transaction, delaying the real work; (c) a psychologist does not prescribe anyway. Offer instead a physician review for the headaches - this is legitimate, checks for other causes, and gives the father a concrete action he can take.
Bring the father in as a resource, not a defendant. Explain the negative reinforcement loop (relief after missing the test makes avoidance stronger) and the fact that eleven hours on five hours of sleep is producing diminishing returns. Ask him for one behaviour change - a fixed lights-out time - so his involvement becomes part of the solution. If he refuses all of this, document and continue with Ravi; the therapeutic contract is with the adolescent.