The aim of this case study is to show through the use of a client study, how cognitive behavioural therapy (CBT) can be applied in the treatment of depression. The patient is a woman with a 2-year history of depression connected with low self-esteem, guilt and shame. An account of the CBT treatment carried out over 12 sessions is given. Noticeable improvements on measurements of mood and hopelessness, with an improvement in social and occupational functioning were achieved.
Mary is a 26-year-old nurse, who was referred for treatment for the management of depression. She presented with a 3-year history of depression along with issues related to low self-esteem and relationship problems, she was referred by her GP after being prescribed various forms of antidepressant medication over a 2-year period, this medication did not seem to be effective.
Mary’s depressive symptoms lead to her social and occupational functioning being impaired. She found it difficult to complete tasks related to her job, and had been disciplined at work even though she had previously excelled in her role. She explained that she felt somewhat uncomfortable at work and found making conversation with colleagues quite challenging. She considered herself to be ‘dull’, ‘boring’ and ‘unlikeable’, which as a result lead to her isolating herself socially. Over the course of her depression she decreased her pastimes and social activities, and started to use all her free time on her own, in bed or “attempting to catch up on tasks related to her job.”
Mary was in a relationship with Angela, who lived in Scotland with her two year old son. Angela was still married to her husband when they first met and Mary felt guilty for “ruining a marriage,” and “being involved in a same-sex relationship”, therefore, this was a part of her life that she didn’t tell people about. She explained her reason for keeping this to herself was due to a fear of people judging and rejecting her over it. She also did not feel secure in the relationship and had fears about Angela’s commitment to her although she did not want to end the relationship.
Mary has a sister who is two years older than her who also has a history of depression, she sees this sister as being a good form of support. She states that she also has a good relationship with her father although “he is not in touch with my generation” and therefore “he’s not really able to understand me”.
Mary’s mother died in a car crash when she was 10 years old. She described them as having a close relationship and found the first year after her mother’s death a particularly difficult time. Mary remembers her childhood as being a happy one where she spent lots of time with her parents, who had a good relationship with one another.
Mary has no previous history of therapy but 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
Variations in levels of depression and anxiety were assessed using the Beck Depression Inventory (BDI) (Beck & Steer, 1993a), and Beck Hopelessness Inventory (BHI), (Beck & Steer, 1993b). Both the BDI and the BDI have been extensively tested for reliability and validity (Conoley, 1987; Dowd, 1992; Owen, 1992). These Measures were administered pre-therapy, mid-therapy, and post-therapy. The Improving access to Psychological Therapy service (IAPT) also recommends routine use of a combination of questionnaires, the PHQ-9 for depression, GAD-7 for anxiety, and three IAPT phobia scales (social, agoraphobia, and specific phobia) as well as the Work & social adjustment scale which assesses problems in functioning with work, home management, social leisure activities, private leisure activities, and family & relationships and therefore these measure were administered at the start of each session. Mary’s score on both phq-9 (16) and the BDI (32) indicate moderately severe depression, her GAD-7 score was 9 which translates as mild anxiety, WSAS scores for Mary were 18 which is associated with significant functional impairment. The IAPT phobia measures indicated that she would markedly avoid social situations and she would definitely avoid certain situations for fear of having a panic attack. Becks Hopelessness scale which was administered in order to help assess where she was at risk of suicide, Mary scored 17 on this scale which identifies severe hopelessness, Mary confirmed occasional thoughts of a suicidal nature however she denied any intent to act on these thoughts as she felt she would be letting everyone down.
A cognitive case conceptualisation is a method of considering a client’s problems and issues using the cognitive model of emotional disorders (Beck, 1987). It includes beliefs (automatic thoughts, underlying assumptions, and schemas), emotional reactions, behavioural strengths and deficits, social factors that influence problems, and consideration of biological factors and maintaining cycles of the client’s difficulties. The conceptualisation, constructed with the client, can be amendment through the course of treatment and can used as a directive for any problems that arises for the client both outside of therapy and in the therapeutic relationship, it can also can act as a “map” for the therapist (Persons, 1989).
Figure 2. The cognitive model as applied to depression (Persons, 1989).
After Mary’s initial assessment the therapist drew up a longitudinal formulation to help her consider Mary’s difficulties and plan treatment. This longitudinal formulation included the following.
Early experiences: Need to please mother, parents not socializing outside family home, loss of mother.
I am not likeable (As I’ve never had a lot of friends at any time in my life), I am not good enough and can never achieve enough (My sister and classmates were always better than me), I am a bad person (As I started a relationship with person of the same sex).
‘If I date someone of the same sex, I am a bad person’, ‘If I tell my friends about my same sex relationship, they will disapprove and reject me’, ‘If I take on all the duties assigned to me at work’ (regardless of my large workload), ‘my workmates will like me, If I tell anyone that I suffer from depression, they will think that I am crazy’.
A precipitating factor for Mary’s in her life was the start of a same sex relationship. Mary feels that people would not accept her because of this. As a result she prevented others from becoming to close to her to avoid having to reveal her secret. This avoidance of social activity resulted in her spending more time at home by herself which precipitating her depression.
Figure 3. Formulation drawn up collaboratively with Mary based on Mooey’s (2010) depression model.
The therapist used Mooray’s (2010), “The Six Cycles Maintenance Model” model to investigated Mary’s thoughts, feelings, behaviour and physical response (Figure 3) and collaboratively conceptualize Mary’s presenting difficulties while socializing Mary to the cognitive model by showing links between thoughts, feelings, behaviours and physical sensations. This diagram was used as a “road map” 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 (see figure 3).
The therapist helped Mary looked at a number of maintenance cycles which were feeding back into Mary’s difficulties, for instance when Mary is around her workmates she often has the automatic thought “Nobody likes me, I will never be able to form friendships”, as a result she becomes upset and feels rejected and goes on to isolate herself from workmates by avoiding them and having lunch on her own and therefore does not break the pattern of feeling uncomfortable around her workmates and rejected by them.
1. Negative Automatic Thoughts
As a consequence of feeling low Mary’s was having more negative automatic thoughts (NAT’S) about particular situations. These NAT’S seemed highly credible to her and came up regularly without much of her awareness. These NAT’s may have kept Mary’s negative core experiences going.
2. Ruminations and self-attacking
Mary sometimes found herself getting locked in ruminative, self-attaching thinking cycles of how she made so many mistakes and should have done things differently along with other self-attacking thoughts related to being weak and not good enough as a person.
Mary identified various emotions connected to her depression which she frequently experienced such as stress, depression, unhappiness, dejection, guilt, shame and feeling sad about feeling sad all of which feed back into the her difficulties.
4. Withdrawal and avoidance
Throughout Mary’s depression she had isolated herself from others and avoided socializing and did not allow others to become close to her. She believed that she would not enjoy activities or be able to accomplish the things she wanted to. As a result of this avoidance she was not allowing herself the opportunity to test the truth behind her negative beliefs and limited her opportunity to find enjoyment or a sense of achievement from activities.
5. Unhelpful behaviours
Mary’s attempts to improve her emotions or balance her negative beliefs included taking on excessive work loads and seeking approval from others. These behaviours made her feel better in the short term but were part of what maintained her difficulties in the long term.
6. Motivation and Physical Symptoms
Mary’s physical symptoms of depression included feeling tired, tearful, on edge and having sleeping difficulties. These physical symptoms feed back into Mary’s depression leading to even less activity and contributing to a downward spiral
Mary stated that through therapy she would like to focus on achieving the following:
- To disclose to her sister and friends about her relationship with Angela;
- To feel more secure with Angela, to discuss their relationship and plans for the future;
- To achieve better ways of managing her time, and allocate more time for leisure activities;
- To become better at communicating with people at work and no longer take on an excessive workload; and
- To feel more at ease in social situations particularly at work.
Guidelines on the duration of treatment length suggest that most of the progress made in CBT treatment is thought to take place in the first twelve treatment sessions, and additional improvements are moderately low when treatment carries on for further sessions (Barkham & Hardy 2001). If this is the case, the duration of the CBT treatment offered should be kept within this time frame. With this in mind an initial contract of 6 sessions was agreed on which was extended for a further 6 treatment sessions.
Assessment sessions 1-3
The early sessions were spent collecting client information, building therapeutic rapport, discussing issues around confidentiality and taking baseline treatment measures (see table 3). The therapist and Mary also looked at the foundations of the CBT approach and how it might be useful, the idea of working together using a structured, and focused method, with the requirement of weekly out-of-session assignments, and the opportunity to regularly review the treatment. The meaning of core beliefs, assumptions, and NAT’s were looked at and Mary started to recognize and document a number of these, many of which the therapist and Mary planned on returning to later when completing thought Records and developing Behavioural Experiments in sessions. The therapist and Mary also constructed the cognitive case conceptualisation (Figure 2.) over the three assessment sessions drawing up maintenance cycles and getting Mary to consider what could be done to try and break out of these patterns.
As part of her out-of-session assignments Mary completed Weekly Activity Schedules (WAS) in order to monitor the activities she was involved in for each hour of each day, and to note the amounts of pleasure and mastery (feelings of accomplishment and effectiveness) actually experienced during each activity. She assigned a percentage rating to her mood for each activity she participated in and we made the connection between her mood and the activity. It discovered that Mary’s mood was worst when she was least active. After making this discovery the therapist worked with Mary to help her come up with a list of activities that she currently enjoys or used to enjoy as well as activities that gave her a sense of achievement. The therapist used Beck’s (1987) evolutionary model of depression to explain to Mary that when people have depression these activities might not be easy to do but if there is no investment there is no return. Therefore it can be useful to plan these activities in an attempt to strike a balance between pleasure and achievement. The therapist encouraged Mary to make time for these activities several times a week and explain how scheduling something makes people more likely to commit to it and that she should try to do the activities she has planned regardless of her mood. Mary monitored the outcome of this activity scheduling by taking regular mood ratings and noticed her mood ratings improved on the days she engaged in the pleasurable activities she had planned.
Mary completed a Daily Thoughts Record (DTR), which we used to investigate her thinking patterns. At first she found it hard to recognize her “hot thoughts” (automatic thoughts that carry the strongest emotional charge) and “alternative balanced thoughts.” To overcome this difficulty the therapist suggested that Mary try to note down the thoughts and feelings that go through her mind as close to the time she is feeling the strong negative emotion as possible. Mary started to enter brief notes onto her mobile phone when she felt a strong negative emotion and would later enter the information into a thought record. The therapist helped Mary use the items she had identified on the DTR as a ‘courtroom’ to challenge her hot thoughts by looking at evidence to support the hot thought and evidence that does not support the thought and consider a more balanced alternative. One of the ‘hot thoughts’ that Mary identified was on the DTR was ‘All hell will break loose if tell anyone about my partner’. After identifying this thought the therapist helped Mary consider further what might take place if she were to disclose to her housemate Tamara about her partner Angela. The therapist asked her to think about how Tamara might respond if roles were reskilled and if Tamara was the one who disclosed the information; or how Mary would react if her friend did not choose to reveal the information to her? Mary was amazed at how her beliefs and automatic thoughts as well as the intensity of her feelings could change so much.
In session seven the therapist and Mary set up a behavioural experiment to test out what would happen if she disclosed her sexuality to her flatmate. Despite the previous work on Mary’s thoughts related to this she still believed 90% that people would reject her in some way if she disclosed her sexuality. In relation to her flatmate she believed in the worst case she would chooses to move out after the disclosure or in the best case she would start spending less time with her. An alternative belief that Mary considered was that people would be surprised at the disclosure but they would not treat her any differently which she stated she believed 10%.
Mary returned in session 8 and had revealed the truth about her relationship with Angela to her housemate who at first became angry that Mary had hid it from her. During further talks with her housemate, Mary told her about her depression, the fact that she was seeing a therapist, and her problems coping with the death of her mother. Mary was surprised by her roommate’s positive reactions and later went on to share similar information with her sister. Mary re-rated her belief that people would reject her in some way if she disclosed her sexuality as 40% and re-rated the alternative believe as 60%.
We looked at the beliefs Mary’s held regarding how she thought others saw her. She believed that everyone she knew found her boring, and then gave an account of how someone would act if they found someone “boring.” We agreed on carrying out a behavioural experiment that could be done during her break at work. This consisted of her observing her workmates and purposely watching for any proof of them being bored by what she was saying. Before the experiment, she assigned a rating to her belief (on a scale of 0-100%). After doing the experiment, she found no definite confirmation of people being bored and she rated her belief again. The rating of her belief after the experimental belief was less (55%) than before the experiment (95%). She carried out the behavioural experiment a few times in different situations, which eventually helped her see that in fact people did not regard her as boring. As a result Mary started to engage more in conversations with her workmates and attended a social event that her colleagues invited her to outside of work.
At the time of discharge, there were noticeable improvements in Mary’s mood, levels of hopelessness, as well as overall social and occupational functioning. Mary became able to discuss her history of depression, the relationship with her partner, and the bereavement of her mother with people in her life. She disclosed her depression to her manager, who was understanding and compassionate. He arranged to temporary decrease her workload and planned regular meetings to talk about any difficulties at work. She was able to manage her time better and included leisure activates into her week. This progress can also be seen in the scales that were administered at intake, mid-therapy and discharge (seen table 4).
Table 3. Treatment outcome measures. (Beck & Steer RA, 1993a, 1993b & 1993c; Saunders et. al, 1993), (PHQ-9, GAD-7 & WSAS; part of the IAPT Minimum data set).
The rating of depression decreased significantly over time, shifting from being in the severe depression range to being in the mild depression range (BDI: 15, PHQ-9:4). The BHI scores also improved over time, showing a decline in the intensity of hopelessness. The score on the BHI of 6 was no longer showing an indication of high psychological distress. Mary’s GAD-7 (4) and Work and Social Adjustment Scale scores (2) also decreased to subclinical levels.
In relation to preventing set backs she has kept records of material from the therapy sessions (homework and sheets from sessions) and a relapse prevention plan and states that she looks over them at times, particularly when she is experiencing low moods or particular difficulties. This self-conducted regular review of therapy sessions may assist in increasing her chances of maintaining the improvement achieved.
The ending of therapy with Mary was carefully thought out particularly because of the losses she experienced in the past. At the start of treatment we block booked all the dates we would meet on and Mary was reminded by the therapist midway through the sessions of the date they would end therapy on, the therapist again reinstated this a number of weeks before the end. The therapist regularly checked out how Mary was feeling about ending therapy and allowed Mary the space to discuss any fears she had about ending.
This case study looked at using a cognitive behavioural approach with a client with depression. The client improved in terms of mood, hopelessness, and overall social and occupational functioning. This outcome backs up various published research findings which provide evidence for the benefit of CBT in treating depression, (Rush, Kovacs & Beck, 1981; Scott, 2001; Department of Health, 2001).
Mary stated that she views her positive outcome as being a result of a mixture of CBT and medication treatment; though, she expresses the CBT treatment as being the more beneficial. She stated that CBT had “changed her way of seeing things” and provided her with a “method or system,” allowing her to steadily sort through and resolve any difficulties she experienced. This schema modification together with the restructuring of her cognitive account of depression may reduce her risk of relapsing.
Upon receiving this referral the therapist had some initial anxiety about working with a case presenting with difficulties related to her sexuality as the therapist did not have previous experience of working with patients with this type of presentation. Another difficulty was that this was only the therapist’s second depression case she had treated and this lack of experience added further concern for the therapist initially. However the therapist found the support of supervision beneficial and quickly realised that many of the techniques she had used before could also be applied to this case.
A limitation to Mary’s treatment was that she was only offered 12 sessions of CBT due to organisational restrictions which is less than recommend dose of 16-20 weeks for moderate to severe depression, (NICE, 2007a). It may have been beneficial to offer a further four to six sessions to allow the opportunity to tackle some of Mary’s rules and assumptions and therefore reduce the risk of relapse. However evidence which is contrary to this suggests that most of the progress made in CBT treatment occurs in the first twelve sessions, and further progress is moderately low after this (Barkham & Hardy, 2001). It will have been interesting to follow-up the outcome of this case at a later date to investigate the long-term effects of the treatment.
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