The aim of the case study is to show how cognitive behavioural therapy can be used in the treatment of depression. The patient has a history of depression and is connected with low self-esteem, guilt and shame. The account of the treatment is given. Mood and hopelessness were measured and there were improvements achieved.
Mary is a nurse who was referred for treatment for depression. She had a history of depression for 3 years and was referred by her GP after being prescribed various forms of antidepressants for 2 years.
Mary has a depressed personality that affects her social and occupational functioning. She had excelled in her role but found it difficult to complete tasks related to her job and was disciplined at work tms. She said that she felt uncomfortable at work and that it was difficult to talk to her colleagues. She was so boring, uninteresting and unlikely that she isolated herself socially. She began to use her free time on her own, in bed or to catch up on tasks related to her job, after she was depressed.
Mary was in a relationship with a woman namedAngela who lived in Scotland with her son. Mary was involved in a same-sex relationship with her husband’s wife, but she didn’t tell people about it because she felt guilty for ruining a marriage. She explained that she kept it to herself because she was afraid of people judging her. She did not feel secure in the relationship and had fears about her commitment to her, but she did not want to end the relationship.
Mary sees her older sister as a good form of support because she has a history of depression. She states that she has a good relationship with her father, but he is not in touch with her generation and therefore not able to understand her.
Mary’s mother died in a car crash when she was 10 years old. She found the first year after her mother’s death to be particularly difficult. Mary remembers being a happy child, where she spent a lot of time with her parents.
Mary had a good awareness of her difficulties and was willing to engage in a time-limited treatment of CBT as well as continuing to take the antidepressants which her GP prescribed.
Treatment outcome measures
The Beck Depression Inventory (BDI) and Hopelessness Inventory (BHI) were used to assess levels of depression and anxiety. The validity and reliability of the BDI have been extensively tested. Pre-therapy, mid-therapy, and post-therapy were administered. The IAPT recommends that people use a combination of questionnaires, the GAD-7 for anxiety, and three IAPT scales for social, agoraphobia, and specific phobias. Mary had a score on phq-9 that indicated moderate depression and her GAD-7 score was 9 which was associated with mild anxiety. She would avoid certain situations for fear of a panic attack, and she would avoid social situations more than she would have ever before. Mary scored 17 on the Becks Hopelessness scale which identifies severe hopelessness, however she denied any intent to act on her thoughts of suicide, as she felt she would be letting everyone down.
A cognitive case conceptualisation is a method of thinking about a client’s problems and issues. It includes beliefs, assumptions, and biases, as well as emotional reactions, strengths and deficits, social factors that influence problems, and consideration of biological factors. The conceptualisation can be used as a guide for the therapist and can be used to help the client outside of therapy.
The second figure is a depiction of a scene. The model is applied to depression.
The therapist drew up a longitudinal formula to help her consider Mary’s difficulties and plan treatment. This longitudinal formula included the following.
The need to please mother and parents not socializing outside the family home were early experiences.
I am not good enough, I am bad, and my sister and classmates were always better than me.
If I date someone of the same sex, I will be rejected by my friends and I will be blacklisted from work.
Mary had a same sex relationship that started in her life. Mary thinks that people wouldn’t accept her because of this. She prevented others from getting close to her to avoid having to reveal her secret. She spent more time at home by herself because of her avoidance of social activity.
Figure 3. Mary and Mooey collaborated on the formulation based on the depression model.
The therapist used Mooray’s model to investigate Mary’s thoughts, feelings, behavior and physical response and to model Mary’s presenting difficulties in a way that would help her socialize. The diagram was used to help the therapist identify and focus on factors that are likely to be important in Mary’s depression and a rationale for the therapy interventions that the therapist would include in treatment.
Mary was helped by the therapist to look at a number of maintenance cycles which were feeding back into her difficulties, for instance when she is around her workmates she often has the thought that nobody likes her, as a result she becomes upset and feels rejected.
1. Negative Automatic Thoughts
Mary’s had more negative automatic thoughts about certain situations because she felt low. These NAT’s were credible and came up frequently without much of her knowledge. Mary’s negative core experiences may have been kept going by these NAT’s.
2. Ruminations and self-attacking
Mary was getting locked in a cycle of thinking that she made so many mistakes and should have done things differently, and that she was weak and not good enough as a person.
Mary identified various emotions that she experienced when she was depressed, such as stress, depression, unhappiness, dejection, guilt, shame and feeling sad all of which feed back into her difficulties.
4. Withdrawal and avoidance
Mary did not allow others to become close to her during her depression and she isolated herself from others. She believed that she wouldn’t be able to do the things she wanted to. She was not allowed to test her beliefs and find joy in activities because of her avoidance.
5. Unhelpful behaviours
Mary tried to improve her emotions by taking on excessive work loads and seeking approval from others. She felt better in the short term but her difficulties remained.
6. Motivation and Physical Symptoms
Mary had physical symptoms of depression, including feeling tired, teary, and depressed. Mary’s depression leads to even less activity and contributes to a downward spiral.
Mary stated that she would like to focus on achieving the following.
To tell her sister and friends about her relationship with her friend.
To discuss their relationship and plans for the future.
To allocate more time for leisure activities.
To become better at communicating with people at work and not have to work as much.
To feel more at ease in social situations.
The guidelines suggest that most of the progress made in the first twelve sessions is thought to take place, and that additional improvements are moderately low when treatment continues for further sessions. The duration of the treatment should be kept within this time frame if this is the case. The initial contract of 6 sessions was extended for 6 more sessions.
Assessment sessions 1-3
The early sessions were spent gathering client information, building a therapeutic rapport, and discussing issues around confidentiality. The idea of weekly out-of-session assignments, the opportunity to regularly review the treatment, and the foundations of the CBT approach were all looked at by the therapist and Mary. Mary and the therapist looked at the meaning of core beliefs, assumptions, and NAT’s and began to document a number of them, which the therapist and Mary planned on returning to later. The therapist and Mary created a cognitive case conceptualisation that was used to draw up maintenance cycles and discuss what could be done to break out of these patterns.
Mary completed Weekly Activity Schedules in order to keep track of the activities she was involved in for each hour of each day, and to note the feelings of accomplishment and effectiveness that actually occurred during each activity. She assigned a percentage rating to her mood for each activity she did and we connected it to the activity. Mary was the most depressed when she was least active. The therapist helped Mary come up with a list of activities that she enjoys and also activities that give her a sense of achievement after making this discovery. The therapist explained to Mary that if there is no investment, there is no return on the activities that people with depression do. It can be useful to plan these activities in order to strike a balance between pleasure and achievement. The therapist told Mary to schedule these activities several times a week and to try to do them regardless of her mood. Mary took mood ratings on a regular basis and noticed that her moods improved on days she planned to do pleasurable activities.
Mary completed a daily thoughts record. She was not able to recognize her hot thoughts and alternative balanced thoughts. Mary was told by the therapist to keep a record of the thoughts and feelings that she was feeling as soon as possible. Mary started to write on her phone when she felt a negative emotion and would later record the information into a thought record. Mary was helped by the therapist to use the items she identified on the DTR as a courtroom to challenge her hot thoughts by looking at evidence that does not support them. Mary identified a hot thought on the DTR, which was “All hell will break loose if anyone tells anyone about my partner”. Mary was helped by the therapist to think about what would happen if she told her housemate about her partner. The therapist asked her to think about how she would react if her friend did not reveal the information, or if she would respond if roles were re-skilled. Mary was amazed at how her beliefs and thoughts could change so much.
Mary and the therapist set up a behavioural experiment to see what would happen if she disclosed her sexuality. Mary believed that most people would reject her if she disclosed her sexuality. She believed in the worst case, that she would move out after the disclosure, or that she would spend less time with her. Mary believed that people would be surprised at the disclosure but they would not treat her differently.
Mary revealed the truth about her relationship with Angela to her housemate who was angry that she had hid it. Mary told her housemate about her depression, her therapy, and her grief over the death of her mother. Mary shared similar information with her sister after her roommate was surprised by her positive reactions. Mary believed that people would reject her if she disclosed her sexuality as 40% and that the alternative belief was as much as 60%.
We looked at how Mary thought others saw her. She believed that if someone found her boring, they would act like it. We agreed to do a behavioural experiment during her break. She was watching her workmates and looking for any evidence that they were bored by what she was saying. She assigned a rating to her belief before the experiment. She rated her belief again after doing the experiment, after she found no proof of people being bored. The rating of her belief was less than before the experiment. She carried out a few behavioural experiments in different situations to see if people thought she was boring. Mary started to talk to her workmates more and went to a social event that her colleagues invited her to.
Mary had noticeable improvements in her mood, levels of hopelessness, and social and occupational functioning after she was discharged. Mary was able to discuss her history of depression, her relationship with her partner, and the death of her mother with people in her life. She told her manager about her depression. He arranged to have regular meetings to discuss any difficulties at work. She was able to manage her time better. The scales that were administered at intake, mid-therapy and discharge can be seen in the table.
Table 3. Measures of treatment outcome. The IAPT Minimum data set includes the PHQ-9, GAD-7 and WSAS.
The rating of depression went from being in the severe depression range to being in the mild depression range over time. The BHI scores improved over time, showing a decline in the intensity of hopelessness. The BHI score was no longer showing an indication of high psychological distress. Mary’s GAD-7 scores decreased to subclinical levels.
She keeps records of the therapy sessions and the sheets from sessions, as well as the relapse prevention plan, and she looks over them at times when she is having low moods. She may be able to increase her chances of maintaining the improvement achieved by self-conducted regular therapy sessions.
Mary experienced losses in the past and so the ending of therapy was carefully thought out. The therapist told Mary that they would end therapy on a certain date and that they had to book all the dates again. The therapist allowed Mary to discuss her fears about ending therapy, as she was regularly checked on how she was feeling.
The case study looked at using a cognitive behavioural approach with a client. The client’s mood improved in terms of hopelessness and social functioning. The outcome supports the findings of published research which show the benefits of cognitive behavioral therapy in treating depression.
Mary believes that her positive outcome is a result of a mixture of CBT and medication treatment, but she also believes that the treatment is more beneficial. She stated that she had been provided with a method or system that she could use to sort through her difficulties. The reorganization of her cognitive account of depression may reduce her risk of relapsing.
The therapist was initially nervous about working with a case with difficulties related to her sexuality as she had not worked with patients with this type of presentation before. The lack of experience of the therapist in treating this second depression case added to the concern of the therapist initially. The therapist found the support of supervision beneficial and realized that many of the techniques she had used before could be applied to this case.
Mary was only offered 12 sessions of CBT due to the restrictions on the number of sessions that could be offered, which is less than the recommended 16-20 weeks for moderate to severe depression. It may have been beneficial to offer more sessions to allow for the chance to tackle some of Mary’s rules and assumptions and reduce the risk of relapse. The evidence shows that most of the progress made in the first twelve sessions is low after this, and that the progress is not as good after this. It will be interesting to follow up the case later on to see how the treatment affects the long-term.
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