Case Conceptualization of Patient with Depression

Case Study

Include the following information regarding the client you will use for the Case Conceptualization assignments.  (Information below may be submitted in bulleted format.  Include at least 2 sentences for each component.  If no information is available for a section please insert “no information available or does not apply”)

1.  History and Background Information

1. Identifying Information (age, height, weight, gender, gender expression, gender identity, SES, geography, married, divorced, cohabitating, single, etc.)

• 52 years old
• Approximately 5’6”, weight unknown
• Cisgender female, heterosexual
• Middle class, college educated, lives in the suburbs of a major city
• First marriage to college sweetheart at 21 years old ended in divorce after 3 years, currently in second marriage of 25 years, married at 27 years old
• 3 children, 2 boys, 1 girl; aged 19, 23, 30; oldest child (daughter) from first marriage, younger children (sons) from second marriage
• Former school teacher, now stay-at-home wife and mother, volunteers occasionally
• Identifies as a Christian

2. Presentation/Behavioral Observations (i.e., appearance, mood, affect, speech, thoughts)

• Well-dressed/groomed, seemed nervous to be in a therapist’s office, expressed that she has never sought counseling before and does not know what to expect; some closed body language but answered questions from therapist eloquently and fully

3. Presenting Problem(s)

• Client is experiencing symptoms of depression and feels like she “lacks purpose.” She explained that she has been struggling to find joy in her everyday life.

4. History of the Presenting Problem(s) 
*frequency/duration/severity

• Client says that she began experiencing the current feelings of depression about a month after her youngest son left home to attend college out-of-state.  She states that for a while she was able to “shake it off” by participating in community engagement activities, such as volunteering with her church congregation, but that after a while that no longer felt like enough and she began volunteering less regularly and withdrew from her friends and family as well as other community activities.  Client reports that some of her close friends have noticed the change in her mood and encouraged her to seek counseling.  She states that she had felt similar feelings after her divorce from her first husband, but did not seek counseling at that point due to financial constraints.

5. Psychosocial History (only include the history of things that are applicable)

•     Family History (include information you deem relevant for conceptualization)

• Parents (father aged 75, mother aged 73) have been married for 55 years; father worked as an auto mechanic and owned his own shop, mother was a homemaker; client has an older sister (age 54), and a younger brother (age 48); client reports that she had a happy childhood and that her parents have a happy and healthy marriage.

•     Developmental and Social History (including significant events in the client’s development, history of relationships with peers and adults outside the family, sexual history and behavior, and history of intimate relationships)

• Client reports “normal” childhood and adolescence, and she still lives near where she was raised; she states that she was not incredibly popular in school, but she had a very tight-knit group of friends throughout her school years, some of whom she still remains in contact with today.  She says that she was active in her church from a young age, and that she continues to enjoy involvement in her congregation, but she has not been as involved since the start of this depressive episode.  The client states that she enjoyed helping her mother around the house and often doted on her younger brother, taking on an motherly role early in her life.  She was always very respectful of authority figures in her life, from teachers to church elders, and rarely had any disciplinary issues.  She had one serious romantic relationship in high school that began during her junior year and ended shortly before she left home to attend a state university.  She says that it was during this relationship was when she had her first sexual experiences.  Client states that the breakup was mutual, as the parties were attending different colleges hours apart.  At college, the client joined a sorority and studied elementary education.  She reports that she very much enjoyed her college years and is still in touch with many of the friends she made during her time.  She met her first husband in the spring of her freshman year through mutual friends, and they were married in the summer between her junior and senior year.  She became pregnant near the end of her senior year, and gave birth to her daughter that fall.  She stayed at home for the first two years of her daughter’s life while her husband worked outside the home as an architect.  The marriage ultimately ended after 3 years due to non-acrimonious reasons, and the client began teaching elementary school to support herself and her daughter.  This is where she met her second husband, a fellow schoolteacher.  They began dating after 2 years of working together and were married when the client was 27.  At age 29 and 33 respectively, the client gave birth to her second and third children.  During the first years of their marriage, her husband earned a Masters degree in Education Administration and became the principal of the elementary school where they met, making it more feasible for the client to stay at home and take care of her children, now 11, 4, and 2 months, a job in which she took great joy.  Client states that there were very few issues between her daughter and second husband, and that her daughter split time between the client’s home and her father’s, who still lived in the area.  The client and her first husband are still on good terms, and they will occasionally see each other at family events hosted by their daughter.  She is close with both of her siblings, although they both decided to leave their hometown after college, and she speaks with them both regularly.  She states that she is content in her marriage, but that her recent depression has caused her husband to become concerned about her.  The client reports close relationships with each of her children, all of whom have moved away from their hometown, but come back to visit regularly.  

•     Abuse/Trauma History

• None reported

•     Educational/Academic History

• Attended a state university, earned Bachelors of Elementary Education

•     Employment History

• Public school teacher (11 years)

•     Medical History (significant illnesses, diseases, surgeries, etc.)

• Minor surgeries in youth (tonsillectomy, appendectomy)
• Tubal ligation after third child (age 33)

•     Psychiatric History

• Reports previous bouts of anxiety and depressive symptoms after divorce, but did not seek counseling at that point due to financial constraints as a single mother

•     Substance Abuse/Dependence History

• None reported

•     Medication History

• Birth control while not actively trying for children; pain medication after surgeries

•     Legal History

• Divorce involved a brief custody case which ended in split custody of client’s daughter with her husband

•     Military History

•         None reported 

•     Religious/Spiritual History

•         Raised as and continues to identify as Christian; she and her husband raised their children in church, did not state whether or not the children are still actively involved in any congregation; reports that her attendance at church has lessened since the beginning of this depressive episode. 

Theoretical Structure

1)     What are the most important concepts of cognitive-behavioral counseling?

•         In the eyes of practitioners of cognitive-behavioral therapy (CBT), an individual’s feelings about a situation are influenced by their interpretation of the situation (cognitions) rather than the situation itself (Fenn & Byrne, 2013). CBT also outlines three levels of thought: automatic thoughts, which are the thoughts that people experience at every moment; intermediate beliefs, which influence automatic thoughts and include attitudes, beliefs, and assumptions; and core beliefs (schema), which serve as the perspective through which we view the world (Adamowicz, 2018). Additionally, CBT practitioners see the relationship between thoughts, feelings, and behavior as reciprocal, with each aspect influencing and being influenced by each other. Each intervention in CBT is individualized to the patient, and treatment is collaborative (Flynn & Warren, 2014). CBT also gradually encourages clients to make behavioral changes to help alleviate their psychological problems (Cherry, 2018).

2)     Per the theory, what are the characteristics of a healthy personality?

•         A person displaying good mental health in the eyes of an CBT practitioner will have a high level of self-awareness and be able to distinguish between “true” and “untrue” automatic beliefs, thereby impacting their intermediate beliefs and schema (“Goals of Cognitive Therapy,” 2014).

3)     What are the factors that contribute to the problem(s)? How does the process of development get stuck?

•         In CBT, psychological problems are based partly on faulty cognitions and behavior patterns (“What is Cognitive Behavioral Therapy?,” 2018). These feed into each other, leading to downward spirals of negative thoughts and maladaptive coping mechanisms (McLeod, 2015).

4)     Does the theory propose stages of the client’s life that are considered significant in the developmental process and if so, how?

•         Life stages are not considered significant in CBT.

5)     What does the theory say about “who” has contributed to the client’s development and if/why that is important?

•         One of the ways that individuals learn and develop according to CBT is through observing the people around them (social learning theory) (Sharf, 2016). Additionally, Beck believed that negative thinking patterns are established in childhood and (Martin, 2018).

6)     Place the following in order from most important to least important in the theory, how would you order them?: emotion, cognition, behavior, interpersonal relationships, and physiological symptoms

•         Cognition

•         Emotion

•         Behavior

•         Interpersonal relationships

•         Physiological symptoms

Integration

1)     How does the theory account for the presenting problem?

•         According to CBT, the depression this client is experiencing is likely caused by a problematic disposition on life events, which then leads to negative feelings and maladaptive coping skills in order to deal with the thoughts and emotions. Additionally, there may be core or intermediate beliefs that are negatively influencing the client’s automatic thoughts.

2)     How are other aspects of the situation accounted for by the theory?

•         The client drawing out of activities that formerly brought her joy, like community volunteering, could be seen as a symptom of her depression by a CBT practitioner.

3)     Based on the theory, what changes need to occur?

•         The client needs to examine the negative thoughts and emotions she is experiencing and what intermediate and core beliefs could be impacting those thoughts. The client should also develop better coping mechanisms as that will help to improve her cognitions and mood.

4)     How can you, as a professional, help make those changes?

•         I would first need to establish a strong therapeutic relationship with the client, so that she feels as though she can trust and be honest with me.  I can help the client differentiate between “true” and “untrue” thoughts by challenging them, and see how those thoughts are impacting her emotions and behaviors. Then, I can assign homework and help her develop better behavioral practices to help lessen her psychological problems.

5)     How will you recognize improvement?

•         I believe that I will recognize improvement when the client begins feeling a lessening of her symptoms, and when she begins to be able to identify negative thoughts and behavior patterns and shut them down by using CBT techniques, such as looking for evidence to support negative thoughts.

Treatment Plan

• At first meeting, begin to establish rapport with client, take history, explain confidentiality and informed consent; also discuss length of treatment, as CBT can tend to be more brief than other therapies
• Ask client to describe her problems in terms of her thoughts, feelings, and behaviors
  • Ask about duration and severity of symptoms
  • Can also use various assessments to gauge problems
• Help client to identify negative cognitions and begin to question them/look for evidence to support them
• Examine underlying intermediate and core beliefs that are contributing to her feelings of depression
  • May have a core belief that motherhood is her highest calling, and now feels as though she isn’t fulfilling that call
    • There may be core beliefs related to being a woman that the therapist should be aware of.
• Help client to identify any maladaptive coping mechanisms/cognitive distortions she may be utilizing
  • Personalization, catastrophizing, etc.
• Assign homework to help client develop behavioral skills that will aid in healthy coping
  • May suggest that she try to go to more church and community events, even if she does not feel up to it, as behaviors influence cognitions and emotions

References

• Adamowicz, M. W. (2018). Retrieved from https://www.mentalhelp.net/articles/cognitive-behavioral-therapy-for-major-depression/
• Cherry, K. (2018, October 8). What is cognitive behavioral therapy?: Process, types, uses, and effectiveness. Retrieved from https://www.verywellmind.com/what-is-cognitive-behavior-therapy-2795747
• Fenn, M. & Byrne, M. (2013). The key principles of cognitive behavioral therapy. InnovAiT, 6(9), 579-585. doi: 10.1177/1755738012471029
• Flynn, H. A. & Warren, R. (2014). Using CBT effectively for treating anxiety and depression. Current Psychiatry, 13(6), 45-53.
• Goals of Cognitive Therapy. (2014). Retrieved from https://washingtoncenterforcognitivetherapy.com/philosophy-of-treatment/cognitive-therapy/goals-of-cognitive-therapy/
• Martin, B. (2018). In-depth: Cognitive behavioral therapy. Psych Central. Retrieved on November 7, 2018, from https://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/
• McLeod, S. (2015). Cognitive behavior therapy. Retrieved from https://www.simplypsychology.org/cognitive-therapy.html
• Sharf, R.  S.  (2016). Theories of psychotherapy and counseling: Concepts and cases.  (6th ed). Boston: Cengage. 
• What is Cognitive Behavioral Therapy?. (2018). Retrieved from https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral.aspx