Case Illustration

Alex, a 58-year-old, divorced European American woman, entered treatment for major depressive disorder with a score of 41 on the BDI and a score of 24 on the HRSD. On both of these measures, she also endorsed feeling that life was not worth living, although she denied any specific thoughts of suicide or wish to die. She also had a history of significant weight problems, which had worsened recently; she was concerned about her lack of physical conditioning and her obesity, both of which made it difficult for her to engage in even routine physical activity. Alex also met criteria for avoidant personality disorder, symptoms of which began in her youth and contributed to her current social isolation.

Treatment began with a discussion of Alex's reasons for seeking treatment and her experience of her current depression. Alex reported that her depression had begun approximately 2 years earlier, when her son David died from a debilitating chronic illness. Alex had provided care for David for several years prior to his death. Although she had been employed before that point, Alex was currently unemployed and had many financial concerns. She had moved in with her adult daughter, who supported her financially;

although Alex reported feeling grateful for this support, she also noted that her dependence likely contributed to her unhappiness. She was socially isolated and sad about her lack of regular contact with friends. Alex also reported one previous episode of depression that had occurred 20 years earlier, triggered by early marital problems; she and her husband experienced significant conflict during their 10-year marriage, which ultimately ended in divorce.

At the end of the first session, the therapist asked Alex to read the booklet Coping with Depression for a homework assignment. The therapist also discussed with Alex a plan for scheduling sessions during the next few weeks, suggesting that they meet twice a week.

"We've found that it's helpful to meet frequently when you are more depressed, so that you can become more active. Then you can more quickly begin to start the process of changing any thinking patterns that may be related to your depression. Meeting more frequently also helps to counter any challenges you encounter. We find that this progress helps to undermine the discouragement that many depressed people experience when starting to learn some of the strategies in this therapy. Once you are feeling a little better and have more practice with the tools, we can move to weekly sessions, and ultimately to periodic booster sessions. By then you'll have many new skills and, hopefully, a new outlook on life and yourself, which will help with any future relapse of depression. How does that sound to you?"

Alex agreed to this approach, although she expressed some concerns about getting to therapy sessions twice a week.

The second session began with further discussion of the CT model and Alex's reaction to the Coping with Depression booklet. Alex's thoughts and feelings about this homework assignment provided a valuable starting place for a discussion of the treatment model and an overview of therapy. Alex began by reporting some confusion about the model.

Alex: I think I get that connection between thoughts and feelings at times. But does that mean that all of my sadness and is just because of my thinking? I mean, are you saying it's all in my head? I thought that is what the book was saying, but then my daughter read it, and she thought it was right on target and was really excited for me to be doing this.

Therapist: How did you feel when you thought that this therapy was saying "it's all in your head"?

Alex: Well, I guess I felt pretty lousy. I felt like maybe I was just making myself miserable.

Therapist: I am so glad that we are talking about this! Can I tell you how I think about these things? I think that most people would feel a great sadness and grief, as you do, after watching their child die after suffering through a long illness.

Alex: So, you are not saying it is all in my head.

Therapist: Absolutely not! And, at the same time, isn't it interesting how you and your daughter both read the same book and had such different reactions?

Alex: Yeah, I guess we did.

Therapist: So, the situation—reading the book—was the same, right? But your reactions were different. One of the key ideas in cognitive therapy is that the kinds of thoughts we have in response to a situation will influence how we feel. Can you summarize the thoughts that you had when you were reading the book?

Alex: Well, I thought it was saying that I was overreacting to my son dying.

Therapist: And when you thought that, you felt sad or discouraged?

Alex: Yeah, I thought, "what's the point of going back there?"

Therapist: And what about your daughter? What do you think her thoughts were?

Alex: I think she thought it was interesting and a new perspective on things, and she was excited about it. I guess that is a little different take on it, huh? (laughing)

Therapist: Yes! So the point is really that it's possible to see the same situation in different ways, and that the way you see a situation can have a big impact on how you feel. When you thought I was saying "It's all in your head," you felt sad and hopeless. When your daughter thought, "Wow, here is some new valuable information," she felt excited.

Alex: Yes, that is true.

Therapist: I wonder, when you think about your depression these last couple years, do you think it is possible that some of how you have been feeling is related to how you are thinking about David's death or perhaps the situations you have faced since then?

Alex: Oh, yes. Well, I know I failed him in a lot of ways, and I do feel much worse when I dwell on those thoughts. And I guess I feel worse, too, when I think about how I have nothing left to give or do that is worthwhile anymore—when I think, "What is the point of any of it?"

Therapist: Yes, my guess is that those sorts of thoughts are closely connected to your feelings of depression. And those are just the kinds of thoughts we can look at together, maybe get curious about them together. We can explore those thoughts and perhaps see whether there may be some other perspectives to bring to the table. Would you be open to doing that?

Alex: Yes, I think so. Therapist: Great!

Openly and genuinely discussing the treatment model and Alex's concerns allowed the therapist and Alex to establish a foundation of collaboration for therapy. Based on this foundation, they moved on to focus on behavioral activation strategies. The therapist introduced the activity schedule as a way to track both feelings and the links between feelings and activities. The therapist asked Alex to complete the activity schedule each day until their next session, which was 3 days later. She specifically suggested that Alex record the activity in which she engaged and a corresponding depression rating (from 1 to 10) for each hour of the day.

When assigning the activity schedule, it is important to inquire about the patient's thoughts and feelings about completing the assignment. More severely depressed patients may think that the assignment is overwhelming or impossible, but they may be reluctant to disclose this to the therapist. It is important for therapists to elicit such information and to be open to modifying the assignment to maximize the patient's experience of success (e.g., keeping the schedule for a briefer period of time).

In the third session, Alex and the therapist reviewed the activity schedule. Alex commented on how much she had learned about herself, although the assignment had taken some time and effort. She reported that she could see certain patterns emerging as she recorded day-to-day activities. Alex recorded having no social contact for 2 days, and accompanying feelings of sadness. On the third day, however, when she received a phone call from a friend, she found that her mood improved. The therapist inquired about Alex's beliefs about her depression and lack of social contact. Alex reported that she avoided social contact because she "didn't want to bring people down." Although she took great pleasure in helping others and acknowledged that her isolation decreased her self-worth, Alex was convinced that her presence had a negative impact on others. The therapist asked Alex whether she was willing to do an experiment before the next session, to explore what happened when she spent time with others. Alex was amenable to this and made a commitment to call her friend back to schedule a visit. The therapist and Alex also identified possible thoughts and situations that might interfere with Alex's commitment. Alex reported that if she felt down in the morning, she might be tempted to stay in bed instead of going for the visit. Together, Alex and the therapist decided that she could experiment with telling herself, "Even though I want to stay in bed, staying in bed usually makes me feel worse. Getting up, showering, eating breakfast, and calling my friend is more likely to help improve my mood." Alex wrote this statement down on a card to take home with her. She also suggested and recorded the following thought: "I'm not giving myself any more reasons to get down on myself for being lazy. That thinking gets me nowhere."

Review of the activity schedule also illustrated the relationship between Alex's depression, and her eating and physical activity routines. Alex had recorded several episodes of overeating, followed by exacerbation of her mood. In reviewing these times, Alex reported feeling very discouraged about her recent weight gain and lack of physical activity. The therapist asked Alex what she thought her activity routines would be if she were not depressed. Alex talked about taking her dog for long walks twice a day before David became seriously ill. Based on this, the therapist introduced the principle of graded task assignment. They agreed that Alex would first walk for 5 minutes total. The next day she could walk for 5-7 minutes, adding 2 minutes each day (or at least maintaining the previous day's total as a minimum) for 5 days a week. A homework assignment of walking the dog once a day, with gradual increases in distance or time, was planned as an experiment.

At the following session Alex reported that she had in fact spent time with several friends, which helped her mood, although she reported still believed that they were visiting with her out of pity. Similarly, she had walked the dog on 4 of the days since the last session. Moreover, she had taken the bus and walked a short distance to the therapy session (as opposed to being dropped offby her daughter). The therapist highlighted these walks as significant increases in Alex's activity and inquired about their impact on her mood. Alex reported feeling better but dismissed her increased activity as something anyone ought to be able to do, thereby disregarding her own progress.

The subsequent six therapy sessions focused heavily on activity scheduling and monitoring. Over time, Alex increased her social contact, physical activity, and skill at monitoring her activities and feelings. She responded well to small behavioral steps, especially those that targeted avoidance, improved her physical activity, and increased social interaction. Alex began to attend her eating self-help group again and found it rewarding; she brought her "healthy eating charts" to discuss in session.

As Alex's depressive severity improved, the therapist began to target some of Alex's negative thinking patterns more explicitly. Alex understood and accepted the cognitive model of depression and could discuss with her therapist examples of thoughts influencing feelings. On this basis, the therapist introduced in the session and assigned for homework a Daily Thought Record. Alex returned the following session, stating that it was impossible to do thought records on her own, although she found that her mood improved when she and the therapist completed the log together in sessions. The therapist experimented with different versions of the thought log, and found that Alex preferred the Testing Your Thoughts form (J. S. Beck). She identified the thought, "I don't have a reason to go on. There's no purpose in my life," which made her feel "very tired." As in standard CT, the therapist used Socratic questioning to help Alex explore and examine these key thoughts. The following dialogue illustrates these discussions:

Alex: My purpose was to be a parent. I guess I did good work at my job, too, but when David got sick, the most important thing I could do was to take good care of him. And I failed at that. He suffered a lot at the end. And now my daughter is suffering, too. I am such a burden on her, and I know her life would be easier without me.

Therapist: What do you feel and think when you picture your last days with David?

Alex: I really want David to be alive (crying). It's just so hard to imagine what my purpose is now. I wish I could have cured him or kept him alive. I miss him all the time, just seeing him and hearing his voice.

Therapist: I know this is so hard. There is so much sadness and grief now when you think about how much you wanted to help him and how powerless you were to cure his illness.

Alex: Yes, I do think that if I couldn't do something so important, what is the point now? What is my purpose at all?

Therapist: I wonder, Alex, if you had a friend who had cared for her child like you, and experienced such a sad loss and was feeling she had no purpose in life, what might you tell her?

Alex: Oh, I do have a friend like that. And I know what I say when I see her, which is "You can still do something good with your life." My friend Mary feels at loose ends since her husband died, but I know she still has a lot to give, even though she doesn't think so.

Therapist: Do you think that there is any chance the same might be true for you?

Alex: I guess there is. I know when I think that I can't help anyone and that I have nothing to contribute, I feel a lot worse. Sometimes it's just so hard to see what to do, but as I think about Mary, I'm realizing that it might be possible for me to help others again, like my daughter. I guess maybe I help Mary when I see her, too.

With Socratic questioning, Alex remembered that she had done an effective and important job raising her children, caring for David as best that she could, and that even the most loving and hardworking parents cannot protect their children from all sources of pain and suffering, particularly illness. Gradually, Alex came to the realization that she could work to develop another purpose in life. Although she could not bring David back, she could have an important influence on her daughter, reengage with her friendships, and enjoy the independence of this phase of her life.

The foundation of collaboration and positive regard was critical in exploring and evaluating Alex's thoughts about her care of David and her future. The therapist frequently expressed hope that Alex's mood would improve, particularly during times of acute sadness, grief, and hopelessness. The therapist consistently encouraged an experimental approach and also utilized aspects ofthe therapeutic relationship as a vehicle to address some of Alex's therapy goals. For instance, when the therapist expressed respect for Alex's many skills and talents, Alex would frequently minimize or dismiss this feedback. The therapist used humor to draw attention to Alex's tendency to dismiss her own progress and to take responsibility for all that ever went wrong, but never for success. The therapist gave examples of when this had transpired in therapy, calling attention to Alex's tendency to attribute all progress to the therapist, rather than to their collaboration and to her own hard work outside of sessions.

Together, Alex and the therapist built on these conversations with specific activity scheduling assignments to enhance Alex's sense of contribution and her competence in doing so. In addition, the therapist continued to use Socratic questioning to review Alex's history and to look for examples of competence and resilience in her life. For example, they identified that she had given birth to David in her late teens, then helped her husband build a house while raising their family. When the marriage was at its worst, Alex had asked her husband to leave, and she was proud of her "strength and stubbornness" in ensuring that her children did not grow up in a home characterized by a high level of conflict and alcoholism. After the divorce, Alex finished high school by attending night classes, then studied business at a technical college, so that she could earn money to send both of her children to college.

As Alex began to identify her sadness and grief about her son's death, she began to cry more in sessions—some of the first times she had cried openly since David's death. As Alex grieved, she also began to discuss her experience of David's death in a more comprehensive way. For instance, she reported that she had felt very controlled by David's illness. When he was very sick, he often asked her to sit with him for long periods of time, and the sedentary and consuming nature of much of her caretaking resulted in much of her weight gain and in losing her sense of purpose outside of her parenting and caretaking role.

Alex also found it very helpful to complete the cognitive conceptualization diagram (J. S. Beck, 1995). Use of this strategy undermined her negative core belief and enabled Alex to see her current life and her past more realistically and with a broader view. In particular, she saw how verbal and physical abuse by a rejecting stepfather had encouraged her early marriage and her belief in his opinion of her, summarized in the core belief "I'm not a good person." As a result of being self-reliant early, she had developed many skills but devalued them with the negative assumption, "I have some skills, but I'm really a fraud." At home, Alex had also learned, "If I build myself up or brag, I'll fall or be pushed back."

Compensatory strategies associated with this history and way of thinking were to suppress her talents, to hide her real self and never feel pride, to work hard, always to do for others, and never to take credit. For example, Alex enjoyed painting with watercolors and had won some awards, but she never told anyone about this. After describing this in therapy, Alex began again to paint and to give her small watercolors to others; she received many compliments, which she practiced describing with pride in therapy. She developed a new belief about herself——"I'm good at things I love"—that caused her to smile and to feel hopeful.

By the end of treatment, Alex reported feeling "fantastic" and being very busy. She was planning to do more watercolors and to go on a long outing with her eating support group. The therapist and Alex planned for the third anniversary of her son's death, about which she said, "I am so deeply sad that he died, but I know I gave him love and care to his last moment." She also found that looking at his picture brought her comfort:

"His memory is always with me." Alex acknowledged that she was a hard worker and discovered that she liked to learn new things.

At the final session, Alex was smiling and happy, having enjoyed a trip with her group. She reported that she had met many of her goals for therapy and felt understood, respected, and challenged. She stated that she found the activity logs extremely helpful and was continuing to use them on a regular basis to plan activities and occasionally monitor her mood. She disliked the repetitiveness of the thought logs, but found that the Core Belief Worksheet helped her change her self-perceptions (e.g., as someone who likes to learn new things). Alex made herself a folder of her paintings and her photographs of David, which she intended to use to prevent a relapse of depression. She planned to look at this folder to remember good times with David and her daughter, and her hard work caring for both of them. The paintings also reminded Alex that she was creative and that others appreciated this part of her. She was sad to end therapy and continued to mourn the loss ofher son; however, she did not feel the weight ofdepression. She was now working on finding a new purpose in her new life, and she felt hopeful about this process.

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A time for giving and receiving, getting closer with the ones we love and marking the end of another year and all the eating also. We eat because the food is yummy and plentiful but we don't usually count calories at this time of year. This book will help you do just this.

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