Introduction
1.1 Depression
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Depression is a low, sad state, in which life seems dark and its challenges are overwhelming. It is believed that psychological stress plays a vital role in depression. People with depression often complain about feeling tired all the time and they tend to have trouble sleeping. Other symptoms include irritability, anger, and loss of interest in activities that used to bring pleasure before. A patient may also describe his emotions as feelings of emptiness or hopelessness. Moreover, people with depression are unable to concentrate, have memory problems, difficulty making decisions, and may have trouble maintaining a normal work schedule or fulfill social obligations.
1.2 Cognitive Behavioral Therapy
According to cognitive therapists, people with psychological disorders can overcome their problems by creating new, more functional ways of thinking. Cognitive Behavioral Therapy helps a client make sense of overwhelming problems by breaking them down into smaller parts. This makes it easier to see how they are connected and how they affect him or her. These parts include situation which is more likely to be a problem, event or a difficult situation. With this as the first part, thoughts, emotions, physical feelings and actions follow. Therefore, therapists guide clients to challenge their dysfunctional thoughts and try out new interpretations, and ultimately apply the new ways of thinking in their daily lives.
1.3 Cognitive Behavioral Therapy for Depression
For a patient with mild or moderate depression, CBT is known to be the most promising treatment. In the cases of patients with severe depression, this is an effective treatment in conjunction with pharmacological treatment. The main target of CBT is to know whether a person’s mood is directly linked to his or her patterns of thoughts.
This therapy has two key approaches to treat people with the disorder, consisting of the cognitive and behavioral approach. The cognitive approach is when the clients thinking pattern is manipulated in a positive way by working with the therapist. This is also referred to as cognitive restructuring.
Secondly, the behavioral approach consists of the therapist helping the patient assess how his daily activities can have an impact on the patient’s mood. Therapists usually help patients cultivate an action plan. In this approach, the therapist and patient create a list of activities which are then ranked from least difficult to most difficult to achieve. As the patient goes from easier to harder activities, his feeling of mastery improves as depression reduces. The technique essentially focuses on the immediate present, which helps the patient realize what and how a person thinks rather than why a person thinks that way.
Background Information
2.1 Reasons for referral
Lakshani was once an active teen who is now constantly idle at home or in bed. She displays no interest in any activity, and seems to lack any kind of motivation or energy. She is excessively sleeping and always somber. As such, Lakshani’s mother took her to a psychiatrist who then referred her to a psychologist, since he believed psychotherapy would prove most beneficial for the patient.
2.2 Presenting problems
Lakshani not only enjoyed playing badminton with her friends and neighbors, but reveled in reading, singing and dancing as well. In the past 3 months, her life has drastically changed. For instance, prior to her behavioral change, she used to enjoy helping her mother in the kitchen. However, she now spends her entire day curled up in bed. Her mother also noticed her lack of appetite. She says she feels tired and sleepy all the time. She no longer feels motivated to engage in any kind of activity and has no goals planned for the future.
2.4 Previous Psychiatric and Treatment History
Lakshani has previously gone through episodes of low mood after her father left when she was 8 years old and was thus prescribed with anti-depressants. No psychotherapy had been given to her for this. As of now, she is on a low dosage of anti-depressants.
2.4 Relevant Family History
Lakshani is the only child in her family. When Lakshani was just 8 years old, her father divorced her mother to marry another woman. Although she was close to her father before this incident, Lakshani did not get the chance to see him after he left. This was mostly because her parents ended off things on particularly bad terms. However, the father re-entered her life a year back, and with her mother’s support, the duo reconciled. According to Lakshani, she has found the reunion difficult, especially since he has as new family.
The mother did not remarry and was supposedly quite distressed about the separation. Though her mother’s suffering was evident to Lakshani, she did not know what to make of it, since Lakshani herself, was trying to cope with the situation the best she could.
Throughout this ordeal, she became rather attached to her grandparents. She is especially close to her grandfather.
2.6 Premorbid Personality
Lakshani was a social girl capable of making friends easily. She enjoyed school and displayed a keen interest in specific activities and hobbies such as playing badminton with her neighbours, reading, singing and dancing, as mentioned before.
3.0. Formulation
Lakshani’s cause of her depression is stemmed by many different incidents progressively. The earliest event which affected her was her parent’s divorce. This incident had affected her so severely that she was unable to attend school for a month afterwards. The onset of similar occurrences later on, particularly the rough break up with her boyfriend, has caused her to assume that no one in her life cares about her and they will all walk away eventually (“no I am not intelligent, I am obviously useless, nobody wants me.” ). Thus her pattern of attributing everything negatively maintains the depressive symptoms. This formulation identifies the different incidents which could have possibly contributed to Lakshani’s negative pattern in her thinking
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4. Intervention
4.1. Summary
Lakshani was offered weekly appointments and was asked to attend 12 sessions over a 6 month period. Her treatment mostly comprised of cognitive behavioral therapy approaches to identify and alter negative dysfunctional thinking as well as learning ways to prevent a relapse in the future.
4.2 Engagement and Psychoeducation
The introductory treatment session worked to establish a positive therapeutic alliance, while maintaining professionalism. Lakshini disclosed the recurring negative dysfunctional thoughts and how she has, up until now, made no valiant effort to change these contemplations. Her symptoms were discussed and a diagnosis of depression was made. Thus, a dialogue on depression was introduced and Lakshini was educated on its influence on a person’s behavior and how Lakshini, personally, experiences it. The structure, purpose and specific goals of the upcoming sessions were determined as well as the rules of therapy and limits of confidentiality. The following three goals were collaboratively identified
1) Short-Term Goal
Identifying dysfunctional thoughts and how it affects Lakshani’s mood and behavior.
2) Medium-Term Goal
Becoming more dynamic and engaging in pleasant activities.
3) Long-Term Goal
Developing interpersonal skills and a social support network.
Lakshani was told that she will be given a personal project at the end of each session to complete before the next session. This includes completing a “mood thermometer” which will provide a better understanding of the intensity of the depressive symptoms and the client’s specific mood at the end of each day. Lakshani was also asked to record all her positive and negative thoughts in a diary. Lastly, she was asked to keep a weekly schedule of all positive activities she engaged in.
4.3. Mood Thermometer
The mood thermometer will enable Lakshani to judge her mood for the particular day for each week. The chart will be examined before the beginning of the next session in order to assess Lakshani’s progress. In the mood thermometer, Lakshani has to mark between 1 to 9, with 9 signifying the happiest Lakshani feels and 1 representing the worst.
Date
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
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9
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2
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1
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4.4 Relaxation exercises
Lakshani will be asked to carry out specific relaxation exercises at home, particularly when she feels stressed. This can include deep breathing exercises, wherein she will be asked to sit in a comfortable position at home while exhaling and inhaling slowly, ensuring that she only focuses on her breathing. This will allow her to let go of all other intrusive thoughts in her head, and she will be able to feel unperturbed and more tranquil. Other breathing exercises can include relaxation response and progressive muscle relaxations. Such breathing exercises can be followed by an imagery of visualization exercise, in which Lakshani will be asked to imagine or visualize herself in a specific scenario which she finds most comforting or relaxing.
4.3 Identifying negative thoughts (Session 1-4)
While the negative thinking errors and dysfunctional thoughts of Lakshani were identified and defined in the first session, the next three sessions will work on how these thoughts can be debated and modified to improve her mood. In-session exercises can be carried out to identify her common thinking errors. These sessions will provide Lakshani with strategies for increasing positive thoughts and decreasing unhealthy or dysfunctional negative thoughts, and thus, decreasing depressive symptoms. In other words, cognitive restructuring of her negative thoughts will be followed by behavioral experimentation wherein she will learn act in situations that acted as a trigger for her dysfunctional thoughts.
Cognitive Restructuring
Stage
Example in terms of Lakshani’s Situation
A
Activating Stage
Friends not picking up the phone when she calls and they do not return her calls when they miss them.
B
Belief
They do not want to talk to her.
C
Consequence
Sadness, Confusion, Loneliness
D
Dispute
“No they get busy in their lives too. Just because I was free at that moment it doesn’t mean that they were immediately available to answer my call too. And the reason for them to not call back was probably because they were too caught up with whatever they were doing so that is why it slipped their mind. It’s nothing personal.”
E
Effective New Belief
When I call my friends, occasionally they may not be available to answer the phone. But that does not mean that they are trying to avoid me. I will just call them back on a later time when they may possibly be free.
Behavioral Experimentation
Following the cognitive restructuring, in the behavioral experimentation stage, the Lakshani will be required to become familiar to her newly constructed thought patterns. In order to do so, she will be initially asked engage in role play while imaging a situation which is considered particularly difficult for her. Afterwards, she will be gradually encouraged to engage in these new behavioral mannerisms outside the therapist’s office. Thus this would eventually decrease her unhealthy manner of thinking and successfully reconstruct her behaviors to adapt to the situation in a better manner (Pomerantz, 2013)
4.4 Engaging in pleasant activities/ Behavioral Activation (Session 5-8)
Lakshani will be explained how the presence of depression can limit participation in pleasant activities, which in turn, increases depressive symptoms. During these sessions, activities that Lakshani finds pleasant will be determined, and the hindrances stopping her from engaging in these activities will be identified as well. Lakshani will be given a list of pleasant activities, and she will be then asked to tick each activity she engages in on that particular day. This keeps a track of her progress and motivates her to engross herself in more and more positive activities. This, in turn, will lessen her depression.
In order to make this simpler and easier for her, specific, clear goals can be collaboratively determined, and she can be taught the steps to reach these particular set of goals.
Weekly Activities Schedule
This schedule will include all the activities Lakshani will engage in during the week. She will be asked to write a plus sign (+) if they were positive and a minus sign (-) if they were negative.
4.6 Developing interpersonal relations (Session 9-12)
Lakshani will be taught how the way she interacts with the people around her can influence her “mood” and vice versa. She, thus, learns the requirement of a good social support network and how to identify and strengthen it. However, she must also understand that relationships are always changing, and that certain relationships not working out do not necessarily mean she is to blame. As such, she is taught how to maintain healthy relationships with her peers and family members while contemplating the fact that deterioration of specific relationships is unavoidable and such changes must be embraced.
Specific exercises will also be carried out to help Lakshani create a better relationship with her peers, wherein she will learn to keep realistic expectations of them. Furthermore, she will be taught assertive communication skills, so as to help her interact with her friend without feeling pressurized or insecure.
Lakshani will also be asked to create her own social support network in order to assess who are the people in her social circle she most trusts and whom she considers to be her close friends and family. If Lakshani’s social circle is significantly small, she will be asked to make it larger since she needs a group of people for her to rely on and trust. Having a good social support network will considerably reduce her depressive symptoms
4.7 Integration of themes and evaluation of therapy
The last session will integrate all the themes from the previous session while reviewing and evaluating the therapy and all the activities Lakshani engaged in. Lakshani is offered information about her participation and progress throughout the sessions. She will be asked for feedback about her personal opinions and experiences throughout the therapy. She will also be taught strategies that can prevent a relapse.
HABITS TO PREVENT
All or nothing thinking
Discounting the positively
Jumping into conclusions
Perfectionism
Labelling yourself or others
Blaming yourself
