Description: This assignment is about presenting a case study of single client that has been in therapy with myself (trainee therapist) employing cognitive behavioural therapy. The patient came to therapy because of symtoms of depression and measured severe on PHQ 9 and fitted a diagnosis of depression. Of course I will have to supply you with data about the patient case history and interventions offered for this to be completed. The attached details the specific requirements for this assignment.
A CASE STUDY FOR A PARTIALLY COMPLETED THERAPY FOR A PATIENT WITH DEPRESSION
A Case Study for a Partially Completed Therapy for a Patient with Depression
Introduction
The case study below is about a partially completed therapy for a patient with depression. The patient is 26 years old, employed at a local restaurant, unmarried, and lives alone in a medium-sized apartment off the town. The patient developed romantic feelings for a man who used to work in a supermarket opposite the patient’s workplace. Initially, the two were great friends, spending much of their free time in nature parks around the town or sampling different plates in the numerous restaurants in the town. After six months of great friendship, the patient was convinced that the man was also in love with her and she decided to confront the man. She discovered, however, that the man was not in love with her. All that the man wanted was friendship. The unexpected turn of events adversely affected the patient’s emotional wellbeing. She could not come to terms with the new reality. She made desperate efforts to convince the man otherwise; however, her efforts bore no fruits. Frustrated by the situation, the patient quit her job at the restaurant and resolved to spend most of her time indoors. After about a month of sorrow and self-condemnation, the patient finally decided to seek medical attention.
Assessment
This was the first session of the patient’s therapy. After examining the patient orally, I discovered that the she suffered from internal depression; often felt sad, worthless, and empty; had lost control of her food intake, and was gradually withdrawing herself from family and friends. A further physical evaluation revealed that the patient frequently had chest tightening, especially when the negative emotions wreaked havoc. The trigger for the depression was the rejection she suffered several weeks back and the notable impact of the depression was weight gain as a consequence of losing control over food intake and gradual alienation due to emotional instability.
For more clarity, I decided to carry out a psychometric test on the patient. The patient had a PHQ of 9 thereby confirming my suspicions of a case of severe depression. Moreover, the case became clearer from the patient’s own statement of the problem. “My main problem is that I have low motivation for most things, a low degree of self-control, and lack of connection to most things around me,” she said.
Therefore, it became apparent that the patient’s major problem was depression with no co-morbidity. The patient was greatly disturbed by the fact that she continuously gained weight and was losing control over her social life. This concern significantly influenced her decision to seek medical attention. This was the first time the patient was seeking medical attention of this nature; therefore, there were no useful medical records from her past.
Based on the diagnosis, the patient needed urgent treatment because she was at risk of growing overweight and breaking down emotionally. After explaining to the patient the link between the emotional turmoil and the gradual loss of control over her life, we decided to use Cognitive Behavioural Therapy (CBT) as the intervention method. The patient agreed to attend a total of four therapy sessions within the context of a community therapy centre where I work as a trainee therapist under supervision. With the help of the patient, I also came up with the goal of the therapy to be undertaken which, according to the patient’s needs, is to enable her control her thoughts and her feeding habits.
Literature Review
Kilbourne et al., (2012) define depression as the persistent feeling of sadness and being down for an extended period usually months and even years. Depression affects approximately 30 million Americans and over 30% people around the world (Hoffman, 2014). Studies indicate that one out of five people globally exhibits emotional disorder and only one-third of all depressions will require clinical interventions (Barton et al., 2017). The condition is frequent and severe among individuals aged between 25 and 45 years (Janmohamed & Steinhart, 2017). According to Gallagher (2014), there are several types of depression, and some of them are hereditary while a significant proportion of this emotional disorder is acquired due to life experiences (Mukhtar & Oei, 2011). The American Psychiatric Association states that over 80% of people with the condition can be helped once the right diagnosis has been carried out by a clinician and other medical issues have been ruled out (Treatment, 2017).
Several treatments have been suggested to address depression from pharmacological to psychotherapy interventions (Peteet, 2012). This literature review provides an analysis of Cognitive Behavioural Therapy (CBT) which was used as treatment model in the case of the aforementioned patient.
Cognitive Behavioural Therapy (CBT)
CBT is an evidence-based type of psychotherapy in which the bottom line argument is that “people respond to situations based on how these situations are consciously and automatically evaluated in terms of relevant underlying beliefs” (Beck, 2011). This outline is vital to comprehending CBT. The successful employment of CBT is therefore dependent on two key variables: a situation that arouses a response and how this situation is evaluated and interpreted in the light of underlying beliefs. The purpose of cognitive techniques is to define and test the patient’s particular misconceptions and maladaptive assumptions (Beck et al., 1979). CBT as a treatment method in the case of depression is made up of highly precise learning experiences intended to teach the patient the operations listed below:
• Observing negative, involuntary thoughts (cognitions).
• Recognizing the links between perceptions, affect, and behaviour.
• Examining the indication for and against his distorted instinctive thoughts.
• Substituting more reality-oriented elucidations for these biased cognitions.
• Learning to recognize and modify the dysfunctional views which incline him to distorted involvements. (Beck et al., 1979).
Based on the definition of CBT and what techniques aim to achieve in a given patient, it is apparent that it is the best possible intervention technique to employ in this case. The patient’s behavioural tendencies (eating disorders and withdrawal from friends) can be reasonably tied to the emotional effect of the rejection. Since CBT involves establishing an “interconnection between thoughts, feelings, behaviour, and resultant consequences”, CBT is undoubtedly the best treatment method (Meichenbaum, 2009, p.10).
Apart from being suitable for the case at hand, CBT has a wide and reliable evidence base from clinical outcomes. Recent research indicates that out of 117 patients who undertook CBT as a treatment model for depression, 46% reliable improved, 34.5% completely recovered from the depression, and only 2.3% of the patients reliably deteriorated (Westbrook & Kirk, 2007). This is a strong evidence of the clinical efficacy of CBT, especially in the treatment of depression. The most noteworthy strength of CBT is its flexibility as a model. “CBT can be tailored to many different populations including children and adolescents, trauma survivors, developmentally delayed individuals, people with traumatic brain injuries and their families and many others” (Meichenbaum, 2009, p. 12). Once modified to a group’s peculiar needs, therefore, CBT can be employed on any given set of clients. On the other hand, the fact that CBT requires a significant amount of trust between the patient and the clinician is one weakness that may limit the success of the intervention method (Meichenbaum, 2009). This weakness informs the challenges that are likely to be encountered during the delivery of the treatment. Not every patient will be willing to open up completely, especially on matters concerning their feelings and belief systems.
I followed a clear Beck 1976 CBT model for the patient in this case and, for a short time, Ross-Kubler’s model to cater for the loss and grief aspect of the scenario. The Beck 1976 CBT model affirms that “negative cognitive content is an integral part of the depressive symptomatology and is as much a symptom as the effect of sadness or the behavioural impairments or deficiencies (Leahy, 2002, p. 31). This descriptive model was originally based on the assessment of some 966 psychiatric patients (Beck, 1967). The assessment confirmed the presence of pervasive thoughts in the minds of patients who suffered from depression. The number of negative thoughts was proportional to the nature and intensity of the symptoms exhibited by the patients. It was characteristic of highly depressed patients to exhibit high levels of negative expectations, negative self-criticism, and distorted views of past experiences (Leahy, 2002).
It is evident that the behaviour of the patient in this case study is directly linked to her emotional status and self-perception. “I loved him deeply and I cannot just believe that he does not want anything to do with my love.” The patient admitted during the assessment.
From the therapy sessions, it is clear that the patient believes that she was rejected because she is not physically attractive—a distorted view of herself. With self-esteem hitting critically low levels, the patient decided to withdraw herself from the social scenes. The levels of negative cognitive content in the patient’s mind were found to be quite high necessitating the employment of CBT. In this case, CBT was employed as outlined in the course therapy and treatment outcomes section below.
Course Therapy and Treatment Outcomes
Session 2: with the patient willing to progress with the therapy, we moved on to the next session of the treatment. This section focused on the Beck’s cognitive triad and brought in psychoeducation around a loss to address the client’s grief after a rejection by the potential partner. To begin with, I went through the Beck’s cognitive triad together with the patient. Beck’s cognitive triad is a negative, often irrational and pessimistic way of looking at three building blocks of a person’s beliefs: the self, the world, and the future (Beck, 1976). At this point, I asked the patient to explain the rejection she suffered in terms of the three key elements of a person’s beliefs. Her explanation was that the man rejected her because she was not physically attractive enough. Moreover, she decided to seclude herself because the refusal affirmed that no one really cared for her and she will always be ignored. Finally, I asked her if she was optimistic that things might change in the future and she was quick to answer that “things will always work against me.”
The conclusion from the patient’s explanation was that she fell into depression because of her distorted view of herself, the world around her and the future. To be able to progress with the treatment, I resolved to intensive, interactive mini-sessions of psychoeducation in which the efforts were geared towards stabilizing the patient’s feelings of sadness, loneliness, emptiness, and worthlessness. During this session, it was also discovered that the patient often spends a good part of the day trying to find out the reason for the rejection. This only worsened her situation. To help her overcome the clearly destructive thoughts and feelings, we agreed that instead of rushing home after her eight-hour long workday she would spend some time playing basketball with her friends to keep engaged during the evening—the time when emotions wreaked havoc. The patient was enthusiastic about such idea and pledged to adopt it with immediate effect. In addition, I spent a significant amount of time trying to make the client understand that the man rejected her due to some other reason which was not, as she believed, due to her unattractiveness.
Session 3: The session was conducted approximately two weeks after the second one. At this stage, the patient indicated feeling more at ease with herself after normalizing her reaction to the loss. Further, into CBT, we continued to dig out some of the patient’s negative behaviour that was fuelling her condition. In this session, the patient indicated that she had been staying in bed up to midday over the past several weeks. The long hours in bed were not spent sleeping but weeping over the loss and eating huge proportions of junk food. I explained to the patient the danger of this newly formed habit: she was not only putting on weight at an alarming rate but also harbouring thoughts that were poisonous to her soul. We proceeded to do a hot-cross bun which served as an eye-opener to the patient. The procedure made her realize just how much the habit of staying late in bed propelled her down the road of misery. At the end of the session, the patient committed to waking up early each day and engaging in constructive activities like morning runs, devotions, and meditation.
Having made significant steps towards becoming stable emotionally, we sought to explain the trigger event in a new objective way. At this stage, I tasked the patient with the initial assignment of explaining the rejection incident. This time around, the patient was more objective. She recognised the possibility that the man might have rejected her because of a reason that had nothing to do with her personality or physical appearance. This was a huge step towards the acceptance of the situation and moving forward to embrace the reality. Looking at it from Ross-Kubler’s view, this was the onset of the acceptance phase of grief. The patient was gradually developing the ability to say that even though the man I loved rejected me, life has to go on.
Session 4: the session was conducted approximately six weeks after the first session. At this stage, the patient had dealt with, to a satisfactory extent, the two major destructive habits. Formulating continued and this helped the client to identify that most of the behaviours she was exhibiting were against her beliefs and values regarding life which, in a nutshell, stated that she was obliged to do the right thing whatever the circumstance. Since the patient had made positive progress towards regaining control over her life, the rest of this last session was spent rounding the corners of the “rules I live by” just to make sure that the patient makes a fresh commitment to acting and behaving according to the principles she laid out, and not according to the circumstances surrounding her. The treatment was to be completed on a later date as time was needed to study the effectiveness of the sessions thus far.
Relapse Consideration and Prevention
One of the most important factors of any kind of treatment is relapse: the possibility of the return of symptoms sufficient to indicate the presence of a condition after the completion of treatment (Hollon et al., 2005). In this case, since the cause of the depression is cognitive, there is a good chance of relapse. Hence, relapse consideration and prevention is important at this stage. Studies indicate that relapse is less likely to occur after CBT compared to medication treatment (Hollon et al., 2005); howbeit, that is not enough insurance for this case. A deliberate effort has to be put in to prevent relapse.
I discussed extensively the risk of relapse with the patient and we agreed on the following measures to prevent relapse:
• We formulated a regular work out schedule for the patient to follow and the patient readily adopted the schedule. This schedule was also designed to help the patient cut in on the extra pounds she had gained in the course of her depression.
• Building new and durable relationships: in order to overcome the pain of rejection, the patient was advised to try and make new friendship ties. The ties were not only meant to reduce her feelings of loneliness, but also to help keep her in check lest she falls back into her destructive habits.
• Maintaining the treatment plan: even though the frequency of her sessions was going to reduce with improvements in her conditions, we agreed that she would return to the facility monthly for routine check-ups.
• Sticking to a new, healthy diet: a characteristic feature of the patient’s depression days was her indulgence in junk food. This was a potential trigger of a relapse. In order to prevent relapse, therefore, the patient agreed to adopt a new diet that was going to improve her health and also aid her to lose a few pounds.
Conclusion
From the experience with the patient, I concur that CBT is a very effective treatment method for mental disorders, especially depressions. The other important fact I discovered in the course of the treatment is that finding ways of making the patient narrate the trigger event in details has a way of helping the patient get over the ordeal. A detailed narration by the patient not only helps the patient come to terms with the situation, but is also very helpful in aiding the patient to move on with her life.
That aside, I am glad to report that up to the fourth session, the treatment was highly successful because the patient was able to gradually put way the destructive habits he often engaged in after the rejection. The patient is enthusiastic about regaining control over his life and has begun to adopt a new and better diet. Therefore, I can say with confidence that so far the CBT was very effective in the treatment of this patient.
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