Cognitive therapy of depression

I saw Mrs M, aged 40 years at my clinic last week.

She came to me with complains of not being able to sleep for the last 1 month. She has also lost 2.5 kgs in the last month. It started after she realized her husband was having an affair with his junior in office.

Following this she is feeling unwanted by her family, can’t control her tears (she fought back tears during the interview), has lost interest in all work and has even thought of suicide.

She tried her best to fight back, complained bitterly to her husband and in laws. She also went to the neighbourhood beauty parlour to straighten her hair, bleach her face and sort of ‘revolutionized’ her wardrobe.

All these have not helped improve her mood, instead it is worse now

At interview she is well presented, clear and articulate. Her predominant emotion is sadness. She feels worthless, uncared for, and an object of ridicule by friends and family.

She was the middle child of three. She had missed a lot of schooling because she was not very good in studies, and her family did not place much importance on a girl’s education.

Nonetheless she always knew she was good looking and felt kind of relieved and vindicated when this smart, rich and handsome man took her on as his wife.

What is the diagnosis?

If we have to do cognitive behaviour therapy with her…

Explain treatment rationale. Explain principle of Collaborative

empiricism Discuss approximate number of

sessions required, cost etc.

Evaluation of suitability for cognitive therapy

How willing is the client to accept the treatment rationale?

Is she ready to form an equal, collaborative relationship?

Rule out: fear of revealing thoughts and feelings, insistence on managing alone, believing that therapist will do

all the work.

Case formulation Family of origin

Marital status /family

Education

Social network

Career

Interests

Problem list

Middle class. Little importance on a girl’s education. Submissive mother, distant father.

Married in a rich business family. Was cared for by husband. Maintained a good house.

Studied till 1st year in college.

Many friends, used to be popular. Enjoyed her status as belonging to a rich family, having a handsome and attractive husband, a successful homemaker.

Homemaker

Trying new recipes, listening to music

See next slide

Problem list I feel stupid, unattractive, useless Others will make fun of me/pity me I won’t be able to cope with practical things

without him If this marriage breaks I will have no place to

live, no financial backup. All my life I have done nothing to become self

sufficient, now I am paying the price. My family (including children) used me, now

they no longer care. Why did I give the best years of my life to them?

Nobody cares for me, I am all alone.

CLIENT’S PREVIOUS FUNCTIONING

Not good in studies Girl child in male dominated familyBelieved it was her duty to be ‘nice’so that they could marry her to a goodfamily and keep the family honour intact

I am kind of stupid. I am not smart.

Since I am not intelligent/smart, I must gain acceptance by being physically attractive (to husband) and by being a all compliant submissive homemaker

CORE BELIEF

COMPENSATORYBELIEF

EARLY LIFE EXPERIENCE

CURRENT SITUATION

Trigger: husband falling for a much younger woman

Additional triggering event: In laws not being as supportive as she had expected. Children too busy with own lives

Impact (cognitive)My husband has stopped loving me: the truth has slipped out.It’s my fault, I couldn’t keep my man.

I worked so much for this family; in time of crisis no one bothers.No one cares

What I fool I made of myself by asking for a beauty makeover: can I ever match a 30 year old’s charm?

My old friends will laugh at me.

Impact (emotional) Sadness Anger at oneself Anger at husband, in laws, children Shame

Impact (behavioral) Emotional and physical withdrawal from

husband Avoiding friends out of shame Not doing household chores (which used to

be pleasurable) Periods of pathetic self blame, self pity,

crying, contemplating suicide.

Problem list problem reduction

Group her problems Life situation: husband’s affair,

financially dependant, no particular skill (?)

Intrapersonal: lack of confidence, emotionally dependant

Interpersonal: perceived lack of love and concern.

Goal definition

Go back among friends

Be able to do household chores

Lose weight (5kgs), join aerobics

Be able to earn appx Rs 8000 per month

Importance

urgency

Psychoeducation

WHAT NEXT?

If she is too depressed

Daily activity schedule Cognitive strategies: Distraction techniques Focus on an object Sensory awareness Mental exercise Pleasant memories and fantasies

Behavioural strategies

Monitoring activies Scheduling activities Graded tasks assignment

Once she feels better ...educate her more

Negative automatic thoughts Characteristics of NAT

Methods to identify them: Ask Note changes in affect during interview Guided discovery DAS form Automatic thought record Role play Imagery

Discuss common errors of cognition Arbitrary inference Selective abstraction Magnification Personalization Overgeneralization Blaming Dichotomous thinking Perspective taking (thinking about one’s own

thoughts) Mind reading (jumping to conclusions) And many more

ASK HER TO IDENTIFY HER OWN COGNITIVE ERRORS

My husband has stopped loving me: the truth has slipped outIt’s my fault, I couldn’t keep my man.

I worked so hard for this family; in time of crisis no one bothers. No one cares.

What I fool I made of myself by asking for a beautyMakeover; can I ever match a 30 year old’s charm. I am just stupid.

My old friends will laugh at me.

Help her reconstruct

Examine evidence Experimental method Double standard technique Cost benefit analysis

Alternative thoughts Index cards

My husband has stopped loving me.

My husband is loving another woman besides me.

Alternative thoughts Index cards

I have worked so hard for this family. In time of crisis no one bothers. No one cares.

I care for myself. That is reason enough to live and live well.

Other examples of alternative thoughts

Many attractive, good natured and intelligent women’s husbands have had extramarital affairs before. It need not be due to their shortcomings.

I do stupid things sometimes. My friends are there for recreation, support

and/or sharing. If one of my friends faced a similar life

situation, I would have told her not feel shattered.

All this negative self talk is making me lazy and more miserable.

Subsequent therapy sessions

Setting the agenda Review of events Feedback of previous sessions Homework review The day’s major topic

Additional help: teach problem solving skills

Identify problem and prioritize Generate solutions: Brainstorming: as many solutions as possible, no criticism,

allowed mix and match solutions Weigh pros and cons Chose best possible solution Plan before implementation Monitor and change if necessary.

Preparing for future

As end of treatment approaches, many patients worry that they will be unable to cope alone. These worries are dealt with in the same way as other upsetting cognitions. It is important to encourage the patient to express them, and to evaluate the evidence for their validity.

THANK YOU