CASE FORMULATION1: BRON

I CASE HISTORY

Bron is a 39-year-old woman, professionally qualified as a specialised nurse. She is

married and has two children, 2 and 7 years of age. She has had several periods of

depression dating back to her later teens.

Her present depression began about six months ago when she attempted to return to work

after taking maternity leave for her second child. Additionally, her father-in-law had a

serious illness and came to live with the family. Her symptoms included:

depressed mood, crying, anxiety and worry,

lack of feeling of pleasure,

a pervasive sense of worthlessness,

poor sleep,

fatigue,

poor concentration.

Her BDI score was 33. She scored 2 on the hopelessness question (Q2) and 1 on the

suicidal ideas question (Q9). She reported occasional suicidal thoughts but did not think

she would carry them out and had no plan for doing so.

Previous treatment was by anti-depressant medication, with one abortive attempt at

counselling. Her response to anti-depressives tended to be quite slow, although successful

in the end. At this time, her response to medication had been minimal and her doctor

switched medication and encouraged her to take up CBT via her occupational health

scheme.

Bron did not have any health problems likely to influence her psychological problems.

Likely diagnosis: Major depressive episode, recurrent, severe.1 This format for formulation adapts the guidelines of the Academy of Cognitive Therapy. See material for professionals at www.academdyofcognitivetherapy.

II: CASE FORMULATION

A. Precipitants: Although Bron described her husband as a good man whom she

loved she did not think that he offered her enough support, especially with the

youngest child and with looking after his father. When she tried to return to work,

she became preoccupied with the risk of making mistakes with patients and of

being charged with malpractice. She felt that this played into an incipient lack of

self-esteem. She was ‘struggling’ with looking after the children, trying to work

and dealing with her worries. She thought that if she could have some time off

work, she could ‘steady the ship’ and get back later. Having her father-in-law was

the tipping point when she realised that even this plan was doomed. She felt that

she could not refuse to look after such a ‘poor old man who was so ill’. At this

point her lack of self-esteem was combined with her ‘superwoman’ style of

coping and this combination led to depletion and near collapse.

B. Cross-sectional view of cognitions and behaviours: Bron’s days were very

similar, consisting of a cycle of getting the children to school and nursery, nursing

her father-in-law and attending to household chores. During brief times on her

own, she would become preoccupied both with a sense of failure (about not

returning to work) and resentment (of having to look after everyone else in the

family). Neither she nor her husband seemed to have time for each other and they

had not had sex for many months. Bron had some good friends and seeing them

was one of the few pleasurable points in her week.

C. Longitudinal view of cognitions and behaviours: Bron’s mother had died when

Bron was a teenager. When her mother became ill, Bron moved in with an aunt

and rarely saw her mother. She was shielded from going to the funeral. Her aunt

was a caring if rather severely religious person. Bron’s father kept clear of her and

remarried quite quickly – never resuming anything other than very minimal

contact with Bron. Bron thinks that her aunt probably resented having to look

after her and Bron developed the belief that she was ‘burden’ to others and was

not really worthy or loveable. During her early adulthood, Bron developed the

idea that she might prove her worth by selfless service, as a wife and mother or

nurse, or both – ‘If people need me then this makes me worth something.’ Her

husband was quite a moody and needy person. Their relationship was based on

recognising how each other felt and responding to needs. Problems arose,

however, when they both felt needy at the same time. The husband was himself in

a downturn – most likely because his own career seemed stuck at this time.

D. Strengths and assets: Bron was actually a superb nurse and a more than ‘good

enough’ mother. She was intelligent and sensitive and inspired fiercely loyal

friendship from her peers. When she cared to show it, she had an engaging ironic

sense of humour.

E. Working hypothesis: The core of Bron’s problems lay in her chronic lack of

self-esteem resulting from the circumstances of her mother’s death and its

aftermath. She solved her lack of self-confidence by working very hard and

dedicating herself to looking after the needs of others, often neglecting her own

needs. This pattern, twinned with a lack of appropriately assertive behaviours,

lend to periods of depletion, collapse and depression. In this instance, the pattern

was exacerbated by the unusual circumstances of having to look after her father-

in-law and of her ‘failure’ to return to work after her second child.

III TREATMENT PLAN

A. Problem list:

1 Lack of pleasurable activities in the week.

2 Depression and negative thinking about the self.

3 Lack of appropriately assertive behaviours.

4 Over-commitment to the needs of others.

5 Lack of a ‘lower gear’ in her working style.

B. Treatment goals:

1 Learn to consciously plan the week to include a balance of work and

pleasure.

2 Learn to think about the self in a more balanced way.

3 Learn appropriately assertive behaviour.

4 Learn to negotiate meeting others’ needs more on her own terms.

5 Learn to vary work behaviour according to energy levels and other

commitments.

C. Plan for treatment

Given the prominence of the marital relationship in connection with certain goals

(especially goals 3 and 4), it is necessary to think about which elements of this

work may be done in the context of individual work and which in relation to

couples work. The client’s and her husband’s view of this will determine what

actually happens but a viable sequence would be that:

Treatment will begin with cognitive therapy of depression in relation to

goals 1 and 2.

If this is successful, then it may be appropriate to consider cognitive

therapy couples work in relation to goals 3 and 4.

The client may then be ready to tackle a return to work in conjunction with

working on goal 5 as either on-going CBT or as an element of follow-up

maintenance therapy.