Cognitive Behavioural Therapy Best Suited for a Young Female Diagnosed with Depression

Cognitive Behavioural Therapy Best Suited for a Young Female Diagnosed with Depression

Medication alone has been successfully used to treat approximately two-thirds of patients with depression. It is, however, true that many patients do not respond to medication or may have residual symptoms and frequent relapse (Pour, 2014). Besides, a large number of patients may prefer a non-pharmacologic therapy. Likewise, some modes of depression may dictate the type of treatment to be administered to the patients (Romero & Hebbar, 2018). A mode of treatment that may solve a number of these problems is thus necessary. Since cognitive-behavioral therapy addresses many of these issues, physicians need to be familiar with its nature and uses (Driessen, Hollon, & Steven, 2010). Cognitive-behavioral therapy involves the use of psychological interventions and plans to improve a patient’s mental health (Romero & Hebbar, 2018). This is effective in changing the patient’s beliefs, values, and behaviors.

The cognitive-behavioral treatment has proven to be an effective intervention measure for depression affecting a wide variety of clinical settings (Clark, Beck, & Alford, 1999). Despite its efficiency, several cases of relapse, dropouts, and poor outcomes have been witnessed (Evans et al., 1992). Therefore, the need for more studies to enhance a better understanding of the factors associated with this treatment method for the sake of better outcomes is necessary. It is against this backdrop that this paper seeks to critically analyze literature on single case studies of the application of cognitive-behavioral therapy on young women to help design a CBT methodology for use on a female client with depression. This paper critically reviews three case studies (single systems design) on the use of CBT for similar cases to ascertain their strengths, weaknesses, and successes to help design an appropriate approach to the present case. The current situation is of a young woman aged 29 with Major Depressive Disorder according to the DSM IV-TR (2000) who through a CBT intervention, the study seeks to answers the following questions:

1. Does the therapeutic relationship between the counselor and the client enhance the effectiveness of CBT?
2. Do follow-up sessions after regular CBT sessions prevent relapse?

The study will pay attention to the scores from and by the use of CAD, BDI, and HAM-D at the end of each of the nine sessions and two follow-up sessions planned for the CBT.

Literature and Critique

This section critically reviews three single systems research on CBT interventions on young women with depression.

Case 1

Citation

Shahlaei, L., Hasan, S., & Kiumarsi, S. (2014). The application of cognitive behavior therapy (CBT) for depression: A case of Iranian female. International Journal on New Trends in Education and Their Implications, 5, 4, 85-92

Description of the study and its findings

This case utilizes the cognitive behavior therapy approach on a 32-year-old female student (Sara) from Iran, who was found to have the highest level of depression among all other depressed students in group therapy. She was then subjected to CBT sessions utilized qualitative and quantitative methods where pre-test and post-test questionnaires were used. The data from the tests was transcribed during the ten (10) sessions of counseling that were undertaken. The CAD and the DSM-IV-TRTM were used to collect data from the client (Shahlaei, Hasan, & Kiumarsi, 2014). The data collected was analyzed both qualitatively and quantitatively. The main research question for the study was whether the stress management technique used successfully helped reduce stress during the counseling sessions in CBT.

The first and second sessions were almost fruitless, but it was found out during the third session that Sara worried most about herself due to the loss of her job and boyfriend. With this, the stress management technique was used in counseling, and in the fifth session, the client openly talked about her emotions. In further courses, the counselor incorporated relaxation techniques.

During the tenth session, the counselor compared the pre-test and the post-test results of CAD, and the results showed that all her emotions were back to normal, and her interest had been gained back to establish and keep relationships. Table 1 below gives her pre-test and post-test results for the CBT (Shahlaei, Hasan, & Kiumarsi, 2014, p.89).

Total scale (CAD)

Raw Score

T-Score

%II

90% Cl

Qualitative classification

Pre-test

139

77

99

70-79

Significant Clinical Risk (SCR)

Post-test

78

47

41

≤ 59

Normal Range (NR)

These results show that the CBT intervention techniques used were effective in treating the client.

Critique

This study is essential as it highlights the use of the various techniques of CBT, such as stress management and relaxation techniques, that can be possibly used in my case. The client, in this case, was found to have the highest level of stress among other stressed clients (Hadjistavropoulos et al., 2019). The success of the therapy on this client thus signifies the efficiency of the techniques used hence the study’s significance to my case. The study, however, lacked a follow-up session this is critical to prevent the possibility of relapse, which is a common phenomenon with CBT.

Case 2

Citation

Mukherjee, A. (2015). Efficacy of cognitive behaviour therapy for a moderately depressed client: A clinical case study. International Journal of Scientific and Research Publications, 5, 5, 1-11.

Description of the study and its findings

The study, in this case, is about a young female client called Amrita who after being presented with features of depression and death wishes as well as decline in her personal, social, and occupational performance is subjected to CBT techniques. Amrita, 25-year-old female reported feelings of loneliness, fatigue, lack of pleasure in everything and sadness after continuous deteriorating progress in her place of work (Mukherjee, 2015). Both the Beck Depression Inventory (BDI) and Hamilton Depression Rating Scale (HAM-D) showed that she was moderately depressed (Sayal et al., 2019). She was then subjected to nine (9) one-hour sessions of cognitive behavioural therapy and one additional follow-up session once a week (Mukherjee, 2015).

The objectives of the therapy were to help Amrita counteract the negative cognitive biases and hence develop a balanced view of issues. These would restore her activity levels and help her regain interest in most activities she previously liked. In each session, a visual analogue scale was used to determine her distress level. In order to cope with the inability to concentrate, distraction techniques such as focusing, sensory awareness, mental exercises, and counting thoughts were used in the sessions. Activities that were mood elevating were also incorporated in her sessions to counter her automatic negative thoughts. She was asked to follow activity scheduling and the homework assignments were given to her. She reported that the homework engaged her and made her think of productive work. The Dysfunctional Thought Record was introduced through the homework to also help her eliminate the negative automatic thoughts. She was eventually able to write down the alternative thoughts for the negative thoughts (Mukherjee, 2015). The final phase of the therapy aimed at prevention of relapse and decreasing vulnerability to future episodes. Generally, the distress ratings (NAT, HAM-D, and BDI) were noted to be constantly decreasing through each session though she terminated the therapy sessions after the eighth session.

Critique

This study involved a 25 year old client; this client is thus in the same age bracket as my client hence the findings in this case can be easily replicated as this independent variable (age) is kept constant. It is however important to note that the client terminated the session before the end of the planned therapy session. There was significant improvement before the client terminated the sessions; this implies that follow-up session was not actualized. This leads to the pertinent question of withdrawal. My study will thus have to put in place measures to prevent withdrawal.

Case 3

Citation

Easterbrook, C., & Meehan, T. (2017). The Therapeutic relationship and cognitive behavioural therapy: A case study of an adolescent girl with depression. The European Journal of Counselling Psychology, 6, 1, 1-24

Description of the study and its findings

This case is about Noluthando, a 17year old girl, who had attempted suicide and was displaying the criteria for Major Depressive Disorder according to the DSM IV-TR (2000) (Easterbrook, & Meehan, 2017). The objective of the study was to underscore the importance of therapeutic relationship during the CBT sessions and its contribution to the efficiency of CBT for depressive adolescent girls. Noluthando had discovered her father’s positive HIV status and one time after failing to get help from her parents, she drank a poisonous liquid in an attempt to commit suicide but was rushed to hospital (Easterbrook, & Meehan, 2017). She had difficulties conveying her feelings and showed a depressed mood state. She was not interested in activities she enjoyed most and had lost weight for loss of appetite; she also suffered bouts of insomnia. The client was subjected to the Six-Cycles Maintenance Model of depression that include automatic negative thinking, rumination and self-attacking, mood and emotion, withdrawal and avoidance, unhelpful behaviours, physical symptoms and motivation (Moorey, 2010).

Little information was obtained in the first and the second sessions of the therapy, in the third session, the client’s BDI increased from 16 points to 19 points. This prompted the counsellor to introduce the use of automatic thought record that would help her respond to and challenge the NATs. The BDI report after the fourth session was still 19, implying that nothing had changed despite the introduction of the automatic thought record (Easterbrook, C., & Meehan, 2017). However, the counsellor noted that a therapeutic relationship was growing between her and the client; this made the client to begin opening up and to be more communicative. In session 5 more progress was recorded as her BDI read 10 points. By the end of the 11th session, her BDI score had dropped to 4 points; implying that the CBT was eventually successful after developing a therapeutic relationship.

Critique

This study showed that despite the use of diverse techniques of CBT, a therapeutic relationship is critical and must be first developed between the client and the counsellor for a CBT to work effectively. This study is important for my case because it brings in an important aspect that the first two studies have not considered. My study should thus strive to build therapeutic relationship before introducing other techniques in the later sessions.

Conclusion

The three studies reviewed will form the basis of my study as they all showed the effectiveness of the CBT intervention techniques that produced positive results on the clients. Throughout my interaction with my client in the CBT therapy, I will employ the use of CAD, BDI, HAM-D and NAT measurements to ascertain the levels of distress after each session. My study will be aimed at not only confirming the findings that most CBT techniques are effective but will also reaffirm the importance of developing a therapeutic relationship with the client prior to serious CBT sessions as this is integral for any therapy (Yalom & Leszcz, 2005; Beck, 2011). Therefore, my study will show the relationship between the efficiency of CBT techniques with increased therapeutic relationship and follow-up sessions; this is because more attention is usually given to the techniques and not the relationship (Leahy, 2008).

Since my client is a highly stressed young woman, I will make use of stress management and relaxation techniques such as mood elevation methodologies before I embark in building a therapeutic relationship with the client. Then I will use the Six-Cycle Maintenance Model in enforcing the use of this model, I will use distraction techniques such as focusing, sensory awareness, mental exercises as well as and counting thoughts. In order to diminish the automatic negative thoughts, I will use homework assignments that involve a Dysfunctional Thought Record. However, it is important to note that the chronology of the use of these techniques will depend on how the client will respond along the sessions.

Project Rationale and Plan

My case is about Nelly, a 29 year old female who had lost her job as a clerk in one of the big companies. Nelly is a single mother to a 2 year old girl who lives with her aging mother who completely depends on her. After losing her job, Nelly has been looking for a job for three months in vain and was taken in having displayed the criteria for Major Depressive Disorder according to the DSM IV-TR (2000). She has lost a number of her friends and has also lost interest in many things. She has been locking herself for almost a whole day when she was brought and may be contemplating suicide.

Research Questions/Interventions

1. Does therapeutic relationship between the counsellor and the client enhance the effectiveness of CBT?
2. Do follow-up sessions after normal CBT sessions prevent relapse?

Operational definition and units of attention

The study will pay attention to the scores from CAD, BDI and HAM-D at the end of each of the 9 sessions and 2 follow-up sessions.

Planned measurement tools

Throughout dependent variables will be measured using the CAD, BDI and HAM-D

Who is to do the measurements?

I will conduct the measurements personally at the end of each session of the 9 sessions as well as 2 follow-up sessions.

Procedure for establishing reliability

Reliability of a study depends on its ability to be replicated. This being a single systems study, reliability of the study can only be ascertained through conducting a similar study on another client while maintaining the control variables such as age and gender. However, by carrying out two follow-up sessions, the reliability of the findings may be established.

References

Beck, S. (2011). Cognitive behaviour therapy: Basics and beyond. New York, NY, USA: The Guilford Press

Clark, D. A., Beck, A. T., & Alford, B. A. (1999). Scientific foundations of cognitive theory and therapy of depression. New York: Wiley

Driessen, E., Hollon, & Steven, D. (2010). Cognitive behavioural therapy for mood disorders: Efficacy, moderators and mediators. Psychiatric Clinics of North America, 33, 3, 537–55.

Easterbrook, C., & Meehan, T. (2017). The therapeutic relationship and cognitive behavioural therapy: A case study of an adolescent girl with depression. The European Journal of Counselling Psychology, 6, 1, 1-24

Evans, M. D., Hollon, S. D., DeRubeis, R. J., Piasecki, J. M., Grove, W. M., Garvey, M. J., & Tuason, V. B. (1992). Differential relapse following cognitive therapy and pharmacotherapy for depression. Archives of General Psychiatry, 49, 802–808.

Hadjistavropoulos, H. D., Schneider, L. H., Mehta, S., Karin, E., Dear, B. F., & Titov, N. (2019). Preference trial of internet-delivered cognitive behaviour therapy comparing standard weekly versus optional weekly therapist support. Journal of Anxiety Disorders, 63, 51–60.

Leahy, L. (2008). The therapeutic relationship in cognitive-behavioural therapy. Behavioural and Cognitive Psychotherapy, 36, 769-777

Moorey, S. (2010). The six cycle’s maintenance model: Growing a “Vicious Flower” for de behavioural. Behavioural and Cognitive Psychotherapy, 38, 173-184

Mukherjee, A. (2015). Efficacy of cognitive behaviour therapy for a moderately depressed client: A clinical case study. International Journal of Scientific and Research Publications, 5, 5, 1-11.

Pour, H. (2014). The effect of cognitive behavioural therapy on anxiety in infertile women. European Journal of Experimental Biology, 4, 1, 415-419.

Romero, S. S., & Hebbar, S. (2018). Effectiveness of Cognitive behaviour therapy of panic disorder in adults: A naturalistic study from a Medical College Hospital. International Archives of Integrated Medicine, 5(10), 44–49.

Sayal, K., Roe, J., Ball, H., Atha, C., Kaylor-Hughes, C., Guo, B., Morris, R. (2019). Feasibility of a randomised controlled trial of remotely delivered problem-solving cognitive behaviour therapy versus usual care for young people with depression and repeat self-harm: lessons learnt (e-DASH). BMC Psychiatry, 19(1), 1–12.

Shahlaei, L., Hasan, S., & Kiumarsi, S. (2014). The application of cognitive behaviour therapy (CBT) for depression: A case of Iranian female. International Journal on New Trends in Education and Their Implications, 5, 4, 85-92

Yalom, I., & Leszcz, M. (2005). The theory and practice of psychodynamic group therapy. (5th Ed.). New York, NY, USA: Basic Books