Assignment – Client Termination Summary (Continued–Submit This Week)
Develop effective documentation skills to examine group therapy sessions with children and adolescents *
Develop diagnoses for child and adolescent clients receiving group psychotherapy *
Analyze legal and ethical implications of counseling child and adolescent clients with psychiatric disorders *
Select two clients you observed or counseled this week during a group therapy session for children and adolescents. Note: The two clients you select must have attended the same group session. If you select the same group you selected for the Week 8 or Week 9 Journal Entries, you must select different clients.
Then, address in your Practicum Journal the following:
Using the Group Therapy Progress Note in this week’s Learning Resources, document the group session.
Describe each client (without violating HIPAA regulations), and identify any pertinent history or medical information, including prescribed medications.
Using the DSM-5, explain and justify your diagnosis for each client.
Explain any legal and/or ethical implications related to counseling each client.
Support your approach with evidence-based literature.
Client 2 Termination Discussion
In this case, CBT appeared to reduce depressive symptoms as well as dysfunctional attitudes and suicidal ideation. The number of CBT sessions needed to achieve partial remission in this case was 16; four additional sessions to the standard 12 in most CBT studies. In addition, the patient continued to show improvements several months posttreatment in depressive symptoms and other related areas of outcome such as low self‐concept and dysfunctional attitudes. Nonetheless, a possible limitation in the interpretation of these results is that improvements in depressive symptoms might be attributed to common factors (e.g. talking about one’s problems with an attentive professional, receiving a credible treatment rationale, etc.) that reduce feelings of hopelessness in the patient.23 In addition, simply the passing of time could account for the changes, since studies have found that some patients with depression recover without treatment.
This patient presented several of the characteristics that have been found to be related in the literature to partial or limited response to treatment: greater initial severity of depressive symptoms, earlier depressive episodes, co‐morbidity with other mental disorders, and parental conflict. Although she met diagnostic criteria for generalized anxiety disorder, separation anxiety disorder, and attention deficit disorder at pretreatment, these diagnoses were not evident in therapy sessions; hence, they were not specifically addressed in treatment. Also, she was participating in a research trial that tested a manual‐based CBT depression intervention, which was not designed to address symptoms of other disorders although many cognitive and behavioral strategies used in the manual could generalize to symptoms of anxiety.7 The CBT research literature is beginning to recognize that treatments for specific disorders evaluated in clinical trials may not always generalize to “real world” settings. Youth treated in community mental health clinics tend to have higher rates of co‐morbidity, and depression tends to be more chronic and severe, often resulting in lower treatment effects.9 As a result, some investigators are recommending that CBT manual‐based treatments be tested in effectiveness trials and become more flexible in content, structure, and format, in addition to involving other family members in therapy.24
The most significant stressor contributing to the maintenance of this patient’s symptoms was parental conflict. This was evidenced by her fluctuating mood throughout therapy, which appeared to be contingent upon thoughts relating to her parents’ relationship. Familismo is an important value in Puerto Rican and other Latino cultures, and there is a strong correlation between parental and family variables to adolescent depression.25, 26 Forty percent (40%) of Puerto Rican adolescents in a clinical trial of treatment for depression considered their most frequent problem to be a family problem27 and 70% considered their most frequent interpersonal problem to involve one or both parents.28 Familismo is a cultural value that refers to a traditional modality in Latino cultures that reflects the importance of family integrity, both nuclear and extended.29 It shapes members’ conduct by expecting them to protect the safety and interests of other members and thus avoid bringing negative public attention to the family’s honor. This might explain why family factors had a significant role in maintaining the patient’s depressive symptoms despite the presence of other protective factors such as positive friendships and academic experiences. She required four additional CBT sessions and a session with her parents to address parental conflict. It is not clear whether this emphasis on the family context and its acceptance by this Latino adolescent would be the same for a non‐Latino girl.
While CBT and anti‐depressants alone appear to have been partially effective in this case, a combination of the two might have proven to be a better alternative for complete recovery and prevention of relapse. In addition, booster sessions have been found to accelerate the recovery of nonresponders to CBT1 and might have helped improve response in this case after therapy termination. Other alternative or complementary treatment modalities such as family therapy should also be considered for depression in adolescence that presents limited response to treatment, particularly with Latino populations in which the family can play a significant role in the perpetuation of depressive symptoms. Family therapy has been found to be efficacious with Latino youth presenting externalizing disorders30 however, no studies using family therapy for depression in Latino youth have been identified. Family therapy has recently begun to be studied as an intervention for depressed youth demonstrating preliminary positive results.31, 32
This case study illustrates some of the challenges of using manual‐based CBT and the variability in response to depression treatment. Cases such as this one, with partial response and significant family stressors, will often require additional sessions as well as modifications in the treatment manual to specifically address these issues in order to achieve complete remission. Some alternatives can be dismantling treatment to address the patients’ particular needs and strengths by increasing the emphasis on certain treatment components (i.e. interpersonal skills, behavioral activation), and adding specific family and/or parent–child modules to address conflict and communication. This case study provides further support to the recommendations mentioned above that investigators have offered along this line in the treatment of youth depression.2, 7, 9, 32, 33 Also, identifying the characteristics associated with treatment response in the initial stages of treatment can help inform treatment planning in terms of selection of treatment format, components, and number of sessions (“dosage”) to maximize positive outcomes.
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