Case Illustration

Gabrielle, a 35-year-old woman, currently identifies herself as African American but states that she was born and raised in Germany by parents of Jamaican descent. She moved to the United States in her early 20s, married an African American man, and has a young child. After receiving a 2-year training certificate in web programming from a local community college 9 years ago, she began working for a large company as a programmer. She entered therapy at the behest of her husband, after experiencing several symptoms that increased in severity over the past year. Specifically, Gabrielle described an increase in appetite that has led to a weight gain of over 40 pounds. She described a pattern of increased need for sleep and increased irritability, alternating with periods of sadness and hopelessness. She also described a lack of energy and motivation so extreme that her husband had to rouse her from bed to come to her therapy appointment, set out clothes for her to wear, and prod her to shower and dress. Gabrielle stated that she experiences difficulty concentrating and becomes paralyzed when faced with even the simplest decisions, such as what to make for dinner. Although Gabrielle denied suicidal feelings, because "that would be a sin," she did admit that she sometimes wished she would never wake up from sleep or that a car would hit her while she was driving, resulting in a fatal accident. Her symptoms had become so bad that Gabrielle stopped working but she was also pursuing a Department of Labor and Industry claim to pay for mental health treatment for what she described as the escalating pattern of racial discrimination she experienced at work. For the past 3 years, since a change in supervisors at her job, Gabrielle described incidences of race-based harassment and intimidation directed toward her, the only African American programmer in her workplace. She described racial slurs and jokes told in her presence, said that her competence was questioned despite having achieved excellent evaluations during the first 6 years of employment, and said that because of her race she was given the worst assignments and schedule by her supervisor.

Initial treatment for Gabrielle involved a psychiatry referral for a medication evaluation to determine whether an antidepressant was warranted in addition to CT. After a brief interview the psychiatry resident conducting the medication evaluation contacted the referring psychologist to suggest immediate hospitalization. The resident, a young white male, had interpreted Gabrielle's discussion of racial discrimination at work as delusional and felt that her beliefs about racial harassment, along with the depressive symptoms, were indicative of major depression with possible psychotic features. He stated that it was impossible "in this day and age" for someone actually to experience the kinds of incidents Gabrielle described. The referring psychologist, an African American woman, considered the possibility of delusional beliefs but held the perspective that racial discrimination can and does happen, although it is possible that depression may contribute to the interpretation and reaction to particular events. Without pursuing medication, the psychologist embarked on a course of treatment that utilized CT to change Gabrielle's specifically depressogenic beliefs about herself as flawed and the world as malevolent, and utilized behavioral activation to increase positive activities. Cultural adaptations included an explicit discussion of discrimination and Gabrielle's reaction to events at work based on her unique history as a woman of Afro-Caribbean descent who emigrated from another country. Instead of challenging Gabrielle's experience of racial discrimination, the therapist helped Gabrielle work through proactive responses to her situation at work, acknowledging the harm caused by her experiences but helping her increase daily functioning.

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