In this week’s blog, I’m applying the questions outlined in last week’s blog to a case example involving depression. These questions, which follow the 5 Levels of Integrative CBT, are:
1. How do I best connect with this particular person, and form a therapeutic relationship with them?
2. What are the immediate problems that need action?
3. What is the individual psychology/psychopathology of this person?
What are their typical cognitive distortions, automatic thoughts, compensatory behaviours?
What is the inner logic of their irrational problems?
What are the relevant emotional and physiological factors, and maintaining cycles?
4. What are the developmental sources of the above difficulties?
How does this client see the world, what are their Core Beliefs?
What has been their relevant experiential learning?
5. What core human issues are they struggling with?
"Jane", aged 37, has been struggling to cope ever since she was promoted to a higher level of responsibility in her job a year ago. She has had growing difficulty getting up in the morning, her appetite and sleep are poor, and she is increasingly neglecting both work tasks and leisure activities.
Jane comes across as emotionally flat, makes little eye contact, and says she has little hope that therapy will help her, therefore extra effort in terms of warmth and positivity is needed by the therapist to connect and to encourage. The therapist may also need to take care not to become overly influenced by Jane’s negative outlook, so that they can retain a hopeful outlook themselves in relation to the therapy.
Her global hopeless thinking may also require a gentle exploration in relation to possible suicidality.
Jane has been referred by her GP, who has also suggested that she try anti-depressants. Jane is unsure how she feels about this, or how to come to a decision, so this needs some discussion in terms of accurate information, pros and cons, how we might monitor and review either decision, etc. Other immediate issues, such as who she might tell about her situation, also need to be looked at.
The pattern of Jane’s depression will of course be both classic and individual. We expect Negative Automatic Thoughts about herself, her world and her future, and we need to find out what her own specific ruminations and self-talk in these areas are. We would expect themes such as: “I can’t cope with this”, “There’s no point in my trying”, I’m useless”, etc.
She also clearly has avoidance behaviours, which makes sense from her point of view, since her life is likely to seem both unrewarding and anxiety-provoking. Again these need to be teased out on an individual level, and the vicious cycles between her thoughts, behaviours and emotions made clearer and more visible.
This part of the case formulation will suggest where some of the most immediate interventions need to take place, in order to increase the client’s level of functioning, and to provide them with the skills to do this for themselves in the future. In Jane’s case, some of the classic CBT techniques would probably be helpful, e.g.: gradual increase in non-threatening, mildly rewarding behaviours such as going for a walk; monitoring of negative ruminations, so as to at least gain some distance from them, and possibly even test them for validity (more recent techniques such as Mindfulness practice could also be a useful addition here).
Beck’ theory of depression contends that amongst the sources of an individual’s vulnerability to depression we will find Cognitive Vulnerability. A detailed exploration of this aspect of Jane’s formulation may need to wait until later in therapy, when she is more able for it (and when relapse prevention is becoming the main focus), but an initial history-taking may well suggest some relevant early experiences and subsequent belief-formation, such as a belief in her own fundamental incompetence. As it happens, she describes a mother who both was and is highly critical, especially of Jane as the eldest in the family. Feeling that she wasn’t good enough, and couldn’t get anything right, has been a familiar experience for Jane throughout her life.
Given that Jane is highly critical of herself, she is likely to be highly critical of the fact that she is suffering from depression, and this turns out to indeed be the case. She sees being depressed as “weak” and “pathetic”. This is an attitude which needs to be taken into account by the therapist at all the other levels of work. It will influence the therapist’s efforts
- to form a functioning therapeutic relationship
- to facilitate the making of important practical decisions in areas such as seeking support
- to tease out with the client their individual vicious cycles and underlying belief structures.
This is why it may be important to explicitly discuss this issue at this fundamental level, in an effort to set depression in a more acceptable, human context. I would tend to do this at quite an early stage of therapy, if it seems necessary, by discussing the nature of depression with the client, including its prevalence as a response to ongoing stress and challenge, and its possible evolved function as a form of psychological “retreat”.
The Integrative CBT case formulation can also hold open the possibility of returning to these issues later, if the client wants to try to put a larger spiritual/philosophical perspective on their depression and recovery. Jane, as it happens, is quite a spiritually-oriented person, and may well want to put some meaning on her painful and disruptive experiences in retrospect.
Next week’s blog will look at another case formulation example, with a sexually-addicted male client.