Major Depression: Case Study Investigation

The following essay is a case study of a client named John who is suffering from major depression and was sent to see me for treatment by his concerned wife. I will provide brief background information about John then further discuss interventions and strategies I believe can be applied in each session with my client in order to make John’s life more manageable. In the essay, I will be writing as the therapist, and the sessions are based on a ten week period.

BACKGROUND INFORMATION (Case History)

A 27-year-old man named John came to see me with the following litany of complaints, “I’ve reached a point where I can’t go on….Got no fight left in me. And not enough guts to end it here. Best damn job I ever had almost can see my way out of the debt. Now, it’s all going to hell…and now I really don’t care about anything, except not going back to work. I can’t kid myself. I just can’t take it anymore. And I have to confess I have no faith left in anything including your profession. I came here on my wife’s insistence but I don’t think you can help me either….But, maybe I can tell someone how I feel, how balled up I am…I can’t find any work…I can’t afford to relax a couple of weeks on some warm beach, or forget my troubles with some floozy blonde. Hell that’s for the books on the best seller’s list. I’ve just got to go about acting like my normal stupid self and something’s got to blow. It goes in waves. Sometimes, I am alright and then I get anxiety feelings, and my heart pounds. I shake all over, and think I am going to die. God, it’s awful!”

PRESENTATION OF THE PROBLEM

Since the client appeared to be an intelligent, executive type with a graduate degree, who reported no other major problem, except for the fact that he couldn’t stick to a regular job and this is what appeared to be triggering acute anxiety attacks in him, I decided to use Cognitive Behavior Therapy (CBT) with him. In the course of the preliminary investigation it turned out that the client was married; that the wife was very understanding and supportive and that there was no major area of marital discord between the couple, except for the fact that the client appeared unable to hold a job for too long, so he did not have a regular income. In fact, this is what had begun to threaten the stability of their marriage, so on his wife’s insistence he had come to see the therapist.

Some years ago, the patient had even tried to launch his own business venture by renting a small store near the entrance to a large building and stocking it exclusively with neckties. For a while, he managed to make ends meet, but soon it became obvious to the wife that his business venture was doomed for failure. This was because around this time, the patient had begun to complain that the shop was “too stuffy,” that he didn’t have any “elbow room,” that the walls appeared to be closing in on him and that at times he feels compelled to go outside and get his “lungs full of fresh air.” Soon enough the frequency of these complaints intensified and eventually the couple had to shut shop.

THE CLIENT`S REACTION TO THE PROBLEMS AND SYMPTOMS

I had worked with many clinically depressed patients before, but this one, despite the severity of his symptoms appeared very motivated for change and prima facie also appeared an intelligent, reasonable patient to deal with.

CONCEPTULALISATION OF THE PROBLEM

As is clear from the patient’s description of his problems, most of the symptoms that he has described — sleeplessness, weight loss, loss of appetite, loss in interest in major activities — fit in very well with the American Psychiatric Association (APA’s) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. (DSM-IV criteria). So my diagnosis was that this patient suffered from major, clinical depression.

Further I realized that since, personal reactions, thoughts, and expectations play a significant role in the etiology and maintenance of many mental health and sociological problems, these cannot be addressed by pure behavior therapy, but with the Cognitive Behavior Therapy (CBT) model evolved by Clark, Beck, & Alford (1999).

The main goal of CBT is to help individuals and families cope with their problems by changing their maladaptive thinking and behavior patterns and improve their moods (Blackburn et al, 1981). Intervention is driven by working hypotheses (formulations) developed jointly by patient, his/her family and therapist from the assessment information. Change is brought about by a variety of possible interventions, including the practice of new behaviors, analysis of faulty thinking patterns, and learning more adaptive and rational self-talk skills. (Hawton, Salkovskis, Kirk, and Clark, 1989).

A probable reason why CBT works with depressed patients is that depression interacts with both cognitive and motivational processes. This is well evidenced in experimental analogue research with healthy and depressed individuals. Individuals with depression show deficits on a range of cognitive tests (Brown, Scott, Bench, 1994) with the pattern of dysfunction having many of the characteristics associated with fronto-subcortical impairment. Reischies and Neu (2000) found that depressed individuals displayed mild cognitive impairments in comparison with matched controls, particularly in the areas of “adverbial” memory, psychomotor speed and verbal fluency. Further in these patients there appears to be considerable variation in the recovery of cognitive function with remission of the depressive episode.

Depressed individuals also show a loss of enjoyment and decreased interest in previous activities, which can result in a reduction in purposeful or “goal-directed” behavior. This is because motivational deficits also interact with a range of cognitive tasks (Bernstein de Ruiter, 2000). Left untreated, studies indicate that depression will increase patient handicap, interfere with participation in rehabilitation, and impact on the recovery of cognitive and psychosocial function.

ACTION PLAN

Upon getting details of the patient’s case history, I (his therapist chalked out the following 10-week Cognitive Behavior Therapy (CBT) intervention plan for this patient:

Week #1: Engaging the client

The first step I’d take is to try and build a relationship of trust with the client on the core conditions of empathy, warmth and respect. I would make note of all the ‘secondary symptoms’ that prompted the patient to seek my help: self-doubt, low self-esteem, anxiety, doubts whether he would be able to help him and a feeling of utter hopelessness and dejection with a loss of interest in any creative or meaningful activity.

The best possible way to engage this client would be to demonstrate to him right at the onset that his situation is not as bleak as he imagines and that he has made the right decision in seeking professional help and that change is possible if he and I decide to work together. The first one-hour session would conclude with the assigning of “homework” to the client: I’d ask him to write down all the problem areas in his work life.

Week #2: Assessing the problem, person, and situation

Assessment will obviously vary from client to client, but following are some of the most common areas that I will assess:

1. Start with the client’s view of what is wrong with his life — this insight can evolve from the John’s homework jotting

2. Determine the presence of any related clinical disorders

3. Obtain a personal and social history

4. Assess the severity of the problem

5. Note any relevant personality dysfunctions

6. Check for secondary disturbance: how does the client feel about having this problem?

7. Check for any non-psychological causative factors: physical conditions; medications; substance abuse; lifestyle/environmental factors.

Homework: Make a list of all the changes that you want to see in yourself as an outcome of this therapeutic process.

Week #3: Preparing the client for therapy

1. Clarify treatment goals — this would follow from a discussion of the previous day’s homework

2. Assess the client’s motivation to change.

3. Introduce the basics of CBT techniques (See Appendix 1). This material can be given to the client as printed handouts

4. Discuss the various possible approaches to be used and the implications of the treatment

5. Develop a contract with the client — make John understand that CBT is a collaborative therapy.

Homework: Attempt a self-analysis of your problem. A useful technique is rational self-analysis, which involves writing down an emotional episode in a structured fashion. You need to understand that an event does not cause an emotional experience, but it’s your belief about the event that does so. For instance an “A” (activating event) triggers our “B” (belief about the event – our filter), which results in our “C” (consequence). A and B are related, but only B causes C. {A B C}

Week #4 – 7: Implementing the treatment process

Week #4: At this stage, it would be important to delve into John’s past history in order to figure out the genesis of his present neurotic anxiety. A revelation of the past triggering factors can be a major breakthrough in the therapy and with patience, this event may happen any time between the fourth to seventh week of the implementation of the CBT plan.

Homework: Start a diary, where you replay some significant events of your childhood, those that you recall as particularly traumatic — important landmarks that made you question your self-worth as a child. These memories can relate to anybody — your parents, brother, sister, teachers or peers. You can make an entry in the following Week #4 – 7: Implementing the treatment process fashion:

Worksheet example: May 21, 1975: My seventh grade results were to be declared that day. I was very positive I’d score high in all the subjects, but when I shared this excitement at the breakfast table with my Dad……

Week # 5: Identifying unhelpful thinking styles

John had the tendency to overlook his strengths, become extremely self-critical and harbor several real or imagined biases against him and the world at large, thinking that he cannot tackle even the commonplace difficulties of life. He was obsessed with his current or future problems; tended to put a negative slant on things, using a negative mental filter that focused only on his difficulties and failures. In short, he had a very gloomy view of his future and tended to blow things out of proportion, while making doomsday predictions about how things will work out and jump to catastrophic conclusions about everything happening in his life. After allowing the client to vent his spleen, I, the therapist assign the following homework to him:

Homework: Write down all your symptoms and troubles and the progress that you are making in all these areas during the course of this therapy. These would be your honest perceptions of what you are gaining from the therapy. Making this inventory will help you look at your problems more objectively – it can provide a degree of emotional distance from the same.

Week # 6 & 7 — Employing selectively eclectic approach

I would follow a ‘selectively eclectic’ approach with this client. I would use whatever technique works with him. Since he is an intelligent human being who appears to be well-aware of his debilitating thought patterns, I would prefer to use some of following techniques to attack this faulty thought patterns in this client (Department of Health, 2001):

* Rational analysis: Analyse specific episodes from his past to teach him how to uncover and dispute irrational beliefs.

* Double-standard dispute: If the client is holding a ‘should’ or is self-doubting, I would ask him to put himself in someone else’s shoes (say his wife) and then imagine how she would react to such a situation.

* Catastrophe scale: I would invite my client to draw a line down the side of a whiteboard or sheet of paper. Then ask him to put 100% at the top, 0% at the bottom, and 10% intervals in between. He would then have to rate whatever it is that he is catastrophising about, and insert that item into the chart in the appropriate place. A brainstorming session would follow this exercise.

* Playing devil’s advocate: This useful and effective technique (also known as reverse role-playing) may perhaps get the client to argue against his or her own dysfunctional belief.

* Reframing: This may get him to put bad events in correct perspective and re-evaluate those as ‘disappointing’, ‘concerning’, or ‘uncomfortable’ rather than as ‘awful’ or ‘unbearable’.

Homework: Imagine the ‘worst case’ scenario — a day when everything in office goes wrong. Write down in minutest details your projections of such a day.

Week #8: Skills training, e.g. relaxation, social skills

At this stage the client is given tape recordings of the sessions to replay and listen to at home. He is also given a list of self-help reading material (Appendix 1). In CBT therapy sessions are really experiential ‘training sessions’ through which the client tries out, tests and uses some of the ideas learned. This session can also be used to teach some relaxation techniques to the client. When people feel depressed or anxious, it is normal for them to experience difficulty in doing things. Relaxation techniques will help them manage their anxiety after they have rationally analysed the cause of it. These simple muscle-relaxing exercises will help the client in calming down, turning off the panic button, breathing away stress, and experiencing total body relaxation.

Homework: Practice sitting still and quiet, listening to some relaxing music each day for at least an hour this whole week and share your body’s response to it at the next session with me.

Week# 9: Evaluating progress

Toward the end of the intervention it will be important to check whether improvements are due to significant changes in the client’s thinking, or simply to a fortuitous improvement in their external circumstances.

At this stage it is also important to prepare the client for coping with setbacks. Many people, after a period of wellness, think they are ‘cured’ for life. That’s when the danger of relapse begins to lurk in their lives. To avoid this from happening warn the client that relapse is likely for many mental health problems and ensure that they know what to do if and when some of the old symptoms begin to reappear.

Homework: Make a list of all you perceive you have gained from this 10-week therapeutic session, along with a record of goals that you feel were not met.

Week #10: Recapturing major gains from the therapy and preparing the client for termination

This is the gradual weaning away stage. At the same time to discuss the client’s views on asking for help if needed in the future. Deal with any irrational beliefs about coming back, such as: ‘I should be cured for ever’, or: ‘The therapist would think I was a failure if I came back for more help’.

CONCLUSION.

I have described the methods I would employ in order to treat my client John assisting in him in making his life more manageable by applying strategies and techniques in over- coming major depression. The essay outlined my week by week sessions with the client in and interventions utilized.

REFERENCE

Bernstein, D. M., & de Ruiter, S. W. (2000). The influence of motivation on Neurocognitive performance long after traumatic brain injury. Brain and Cognition, 44, 50-66

Blackburn, I. M., Bishop, S., Glen, I. M., et al (1981) The efficacy of cognitive therapy in depression: a treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. British Journal of Psychiatry, 139, 181-189.

Brown, R., Scott, L., &Bench, C. (1994). Cognitive function in depression, its relationship to the presence and severity of intellectual decline. Psychological Medicine, 24, 829-847

Department of Health (2001) Treatment Choice in Psychological Therapies and Counselling. London: Department of Health. For summary see http://www.doh.gov.uk/mentalhealth/treatmentguideline.

DSM-IV, Major Depressive Episode, http://www.mental-health-today.com/dep/dsm.htm

Hawton, K., Salkovskis, P. M., Kirk, J., & Clark, D. M. (1989). Cognitive behaviour therapy for psychiatric problems: A practical guide. Oxford: Oxford Medical Publications

Reischies, F. M., & Neu, P. (2000). Co morbidity of mild cognitive disorder and depression–a neuropsychological analysis. European Archives of Psychiatry and Clinical Neuroscience, 250, 186-193.