Nancy described herself as being trapped by her relationships.? Her intake interview confirmed symptoms of major depressive disorder and the clinician recommended cognitive-behavioral thera

Case Example: Nancy

The art of living is more like wrestling than dancing. (Marcus Aurelius)

n this chapter, we present a complete therapy from beginning to end. The primary goal of this case presentation is to illustrate the assessment, conceptualization, and intervention methods presented in the earlier chapters; therefore, the presentation emphasizes those aspects of the treatment. We particularly emphasize several ways the therapist uses the individualized case formulation to guide his or her thinking and decision making and to tailor interventions to the needs of the patient.

I The In itia 1 Con tact

Mr. A. telephoned to discuss the possibility that I (J. B. P.) might treat his daughter, Nancy.' I spent about 20 minutes on the telephone with Mr. A.; he told me how bright and talented his daughter was and de- scribed his concern about the difficulties she was having that were im- peding her ability to excel at her new job at a prestigious publishing house. He quizzed me to verify that I was competent to treat her, and he indicated that he would pay for the treatment if I would send the bills to him. I took note of the fact that Mr. A. took the trouble to call to check me out and generously offered to pay for his daughter's treat- ment. However, he seemed to be particularly intent on informing me

'Mr. A. and Nancy are pseudonyms. Names and details have been modified to protect the identity of the patient and her family.

I 205 http://dx.doi.org/10.1037/10389-007 Essential Components of Cognitive-Behavior Therapy for Depression, by J. B. Persons, J. Davidson, and M. A. Tompkins Copyright © 2001 American Psychological Association. All rights reserved.

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2061 C O G N I T I V E – B E H A V I O R T H E R A P Y F O R D E P R E S S I O N

that his daughter had beat out many competitors to get her job at the prestigious publisher. He repeatedly described her as especially talented and unusually bright but did not say anything about any distress or unhappiness she might be experiencing. These observations helped me to establish some initial schema hypotheses about Nancy. I speculated that she might believe that she must be especially accomplished to be acceptable to others and that her feelings and distress were unimportant and did not deserve attention.

The Initial Session

A couple of weeks later, Nancy called and we agreed to meet for a consultation session. Nancy arrived on time and brought with her the measures I had mailed her and asked her to complete before the session: the Symptom Checklist 90 Revised (SCL-90-R; Derogatis, Lipman, & Covi, 1973), the Beck Depression Inventory (BDI; Beck, Ward, Men- delsohn, Mock, fr Erbaugh, 1961), the Burns Anxiety Inventory (BAI; Burns, 1998), a brief measure of substance use (a modification of the CAGE Questionnaire; Mayfield, McLeod, & Hall, 1974), and a demo- graphics questionnaire (see chap. 2, Individualized Case Formulation and Treatment Planning).

My major goals in this interview were to begin to collect a problem list, obtain information needed for diagnostic purposes, develop more formulation hypotheses and test the ones I had already developed, es- tablish rapport with Nancy, offer some initial treatment recommenda- tions if possible, and-if I recommended cognitive-behavior therapy (CBT)-give her some information about it. In addition, if we agreed to move forward with treatment, I wanted to give her a homework assignment before she left the office. These were ambitious goals, so I was aware I that might not accomplish them all.

Nancy was a 25-year-old, single White woman who had recently begun working as an editorial assistant to a well-known publisher after graduating near the top of her class from a top undergraduate school. She was an attractive young woman with curly dark brown hair and a perky, engaging, almost childlike quality. She related in a frank, open, pleasant way, and she had excellent social skills except at times she seemed overly compliant and timid. Although Nancy presented herself as generally cheerful, her mood shifted at several points during the in- terview. When she was talking about upsetting topics, particularly her relationship difficulties, she looked distressed and was close to tears.

When I reviewed her scores on the various measures, I found that Nancy had endorsed many of the items on the BDI. She reported that

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A Case Example: Nanry I 207

she felt sad all the time, felt discouraged about the future, felt guilty all the time, was self-critical, cried often, had difficulty making decisions, had difficulty getting anything done, and had early morning awaken- ings. Her total BDI score was 21, indicating a moderate level of depres- sive symptoms.

On her BAI, Nancy had endorsed feelings of anxiety and tension, difficulty concentrating, and fear of criticism or disapproval. She re- ported several somatic symptoms, including palpitations, restlessners, tight muscles, rubbery feelings in her legs, dizziness, headaches, and fatigue. She had a total score on the BAI of 25, indicating moderate anxiety symptoms.

On the SCL-90, Nancy endorsed symptoms similar to those de- scribed on the other inventories. On the CAGE questionnaire, Nancy denied any concerns or problems involving alcohol use. She reported that she drank half a glass of wine a week on average and did not use illicit drugs.

When I asked Nancy to tell me in her own words what had brought her in to see me, she replied “I feel trapped by my relationships.” Nancy reported that she was particularly troubled by her relationships with her ex-boyfriend and her roommate. The onset of her most significant dir- tress was tied to her breakup, about 2 months ago with Morrison, a young man she had dated for about 6 months. The relationship with Morrison had been uncomfortable for her because he had obviously been more enamoured of her than she was of him. After considerable agonizing, Nancy had finally summoned the courage to break up with him, but she was having difficulty making the break final. Morrison kept calling, wanting to talk about their relationship, wanting to spend time with her, and wanting her to be his confidante. Nancy found herseiif feeling torn and trapped by this situation; she feared that Morrison would be devastated if she refused to be his friend, but she realized that maintaining such a close connection with Morrison was not fair to Pete, her new boyfriend.

Nancy was also struggling with her new relationship with Pete. She had repeatedly told him she “didn’t want to get serious,” but she ad- mitted that she was fooling herself when she insisted she was not se- riously involved with him. She said that she held the relationship at an arm’s length because she feared that ”If I get involved and then I decide he’s not the right one, I’ll want to break it off and he’ll get hurt.”

Nancy’s relationship with her roommate Connie was also a source of tension. Nancy described Connie as someone she liked well enough, but Connie wanted to spend much more time with Nancy than Nancy did with her. When Nancy had recently said MU to an invitation, Connie was visibly hurt and told her bitterly “now that you have a boyfriend, you don’t want to spend time with me anymore.”

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208 I C O G N I T I V E – B E H A V I O R T H E R A P Y F O R D E P R E S S I O N

Nancy said she felt she was "messing up" in all these relationships and felt trapped in them. In fact, she considered ending them all, saying "If I can't be a perfect friend/girlfriend/roommate, I'd rather just live alone."

At work, Nancy reported that she had a heavy workload and always felt behind and fearful of not meeting her boss's expectations, which were very high. Nancy had a major project looming, a presentation she would make to her boss and other high-level editors presenting the results of her reviews of several important manuscripts; she was ex- tremely nervous about this presentation. Nancy had performed poorly when she had made a similar presentation a few months ago; a factor contributing to her poor performance on that occasion was that she had been in the middle of a major relationship crisis when she was trying to prepare the presentation. Aside from these difficulties, Nancy re- ported that she was doing well at her job and was well regarded by her colleagues and superiors, several of whom had recently consulted with her about possible collaborative projects.

At this point in the interview, I had the beginnings of a problem list: Nancy had symptoms of depression, she had relationship difficulties, and she had difficulties at work. Diagnostically, I had not yet completed a full assessment. However, Nancy appeared to meet the criteria for major depressive disorder, as described in the Diagnostic and Statistical Manual of MentaZ Disorders (4th ed. [DSM-ZV); American Psychiatric Association, 1994). She was also anxious, although it was not clear yet whether she met the criteria for an anxiety disorder (generalized anxiety disorder and social phobia seemed the main possibilities).

I reviewed with Nancy the results of my assessment so far, including my diagnostic hypotheses, indicating that I was basing my recommen- dations on the information I had and that things might change when I got more information. On the basis of my view of her as having major depression with some anxiety symptoms or an anxiety disorder, I offered Nancy information about her treatment options and suggested that CBT might be helpful to her (for more information about the issue of in- formed consent for treatment, see Pope 6 Vasquez, 1998).

I suggested to Nancy that I spend a few minutes in the session giving her a first notion about how CBT would address her difficulties to help her decide whether she wanted to pursue it; she agreed to this. To teach the cognitive model (see the chap. 5 section entitled "Teach the Cog- nitive Model"), I mapped onto a Thought Record the situation Nancy had described to me earlier when her roommate Connie looked hurt when Nancy turned down Connie's invitation to go out to dinner (see Exhibit 7.1). I asked Nancy a short series of Socratic questions to show her how these thoughts made her feel guilty, inadequate, and trapped and how they could lead to behaviors of agreeing to do things with

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210 C O G N I T I V E – B E H A V I O R T H E R A P Y F O R D E P R E S S I O N

Connie that she did not want to do as well as to urges to break off the relationship. I let her know that in therapy we would work together to develop cognitive and behavioral coping responses that would help her feel less guilty and inadequate in this type of situation and to han- dle it better. I recommended that we meet weekly, and I pointed out that homework between sessions would be a key component of her treatment.

Nancy indicated she wanted to try CBT, so we agreed to move for- ward with treatment. She indicated that she had tried Prozac in the past and found it increased her anxiety, so she did not want to take medi- cation at this point. I told her that I was willing to try CBT alone as a treatment plan, but if we did not make good progress, I would want to revisit the pharmacotherapy option; she agreed to that.

As the session came to a close, I proposed an initial homework as- signment: I asked Nancy to read the first 3 chapters of David Burns’s (1999) book Feeling Good and to let me know her reactions to it when we met the next time. I also asked her to think about what she would like to accomplish in her therapy and to draft a list of treatment goals and bring it the next time. As a first step on the basis of her scores on the BDI (21) and BAI ( 2 5 ) , I suggested that we include on her list the goal of reducing her symptoms of anxiety and depression. To track our progress, I asked her to complete the BDI and BAI scales for me weekly before the session. I asked her to come 5 minutes early for her session and to fill out the measures, kept on clipboards in the waiting room, and give them to me at the beginning of each session, .starting with her next session.

As her first session came to a close, I asked Nancy for feedback about how the session had gone. She said that she liked the idea of a treatment approach that would teach her skills for managing her mood and solving her relationship problems. I felt we were off to a good start.

Summary of the Initial Session

I accomplished the goals I had set for the initial session. In particular, I collected some important information for the initial case formulation: I collected the beginnings of a problem list: Nancy had symptoms of anx- iety and depression, she was distressed about relationship problems, and she was having some difficulties at work. I obtained a few details about some of the cognitive, mood, and behavioral components of Nancy’s relationship problems and a bit of information about her work problems.

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A Case Example: Naniy I 211

Some information I obtained in the session led to a revision of the schema hypotheses I had developed after the telephone conversation with Nancy’s father. My initial hypothesis had been that Nancy believed she must achieve at a high level to be accepted by others. However, Nancy’s distress when Connie was angry at her, her difficulty breaking off with Morrison for fear of upsetting him, and her reluctance to attach herself to Pete for fear of disappointing him later suggested that Nancy believed that “I must meet others’ needs to be acceptable to them” and that “if another person is unhappy, this means I did something wrong.” These beliefs are similar to the “self-sacrificing” schema vulnerability described by Young ( 1999).

I noted that although Nancy was clinically depressed, she had a bouncy, perky mode of interacting. I hypothesized that this perkiness was a compensatory strategy that she had developed to protect others’ feelings and to hide her distress from them. Similarly, I hypothesized that Nancy’s compliance, which made her pleasant to work with, was also part of her mode of accommodating to others. I noted as a potential obstacle to treatment that Nancy might have difficulty asserting herself if she disagreed with me about something.

Ea r ly Sessions : Begin n ing to Intervene and Continuing to Assess

Assessment, formulation, and treatment occur in tandem through0 ut treatment, as the therapist uses the hypothesis-testing mode of clinical work described in chapter 1. Of course, in the initial sessions, the pro- portion of time spent on assessment and formulation is higher than it is later. We attempt, in the first four sessions, to collect all the infor- mation needed for a complete psychiatric writeup, including a compre- hensive problem list and a complete Cognitive-Behavioral Case For- mulation and Treatment Plan (see chap. 2, Individualized Case Formulation and Treatment Planning). While collecting this informa- tion, the therapist also begins intervening both to get the treatment underway and to generate information based on the patient’s response to the interventions, which feeds back to the formulation.

SESSION 2 BDI = 11

I went into the second session wanting to ask for Nancy’s response to our initial meeting, follow up on her homework, continue to orient her

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212 1 C O G N I T I V E – B E H A V I O R T H E R A P Y F O R D E P R E S S I O N

Progress Plot for Nancy BDI BAI

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to the treatment, finish developing my problem list, begin to establish treatment goals and, if possible, begin intervening. I also wanted to make a new homework assignment.

Nancy came on time to the second session, and she brought a com- pleted BDI but not a BAI. Her score on the BDI had dropped consider- ably (from 21 to 11). Such improvement often happens in the early sessions of CBT (see Ilardi 6 Craighead, 1994), for reasons that are not well understood, although the decrease in Nancy’s BDI score was un- usually large.* I entered this score on the Progress Plot I had set up after our first session (see Exhibit 7.2), and I showed her the plot and how

’1 hypothesized that one factor contributing to this large improvement was Nancy’s wish to meet my need to be a successful therapist.

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A Case Example: Nancy I 213

we would use it to monitor her progress. I asked her to bring both a completed BDI and a completed BAI to her next session.

I began the session by orienting Nancy to the structure of the ther- apy session (see the chap. 3 section entitled Orient Patient to the Struc- ture of the Session). I suggested that we begin with a check in because I would like to hear how things had gone during the week and any thoughts she might have about why her BDI score was so much lower. After the check in, I let her know that I would work with her to set an agenda for the session and, as part of that, I wanted to get her reactioris to our last interview and to follow up on her homework.

During the check in, Nancy reported she was feeling considerably better because things were going more smoothly with her roommate. When she elaborated, I learned that things were going better because Nancy had found an apartment and planned to move out and she had been yielding to Connie's requests for time, so she felt less guilty. I was glad that Nancy felt better but was sorry to hear the reasons for her "improvement." My working formulation suggested that Nancy felt tern – porarily better because she had allowed her behavior to be driven by her maladaptive belief that she was inadequate unless she did what others wanted. The formulation also suggested that moving was (at least in part) maladaptive avoidance behavior, resulting from Nancy's discom- fort in asserting herself with others and tolerating their negative feelings when they were unhappy with her. Because the decision to move ap- peared to be a "done deal" and Nancy and I were just getting our ther- apy underway and had not discussed my tentative formulation in any detail, I did not volunteer my speculations.

Next, I followed up on her homework. Nancy indicated that she hatl read and liked the first 3 chapters of Feeling Good and that she liked the approach Burns described. I asked her for her reaction to the previouy week's interview; she indicated that she felt pleased at the way we hatl started and repeated that she liked the idea of a goal-oriented, structured therapy.

Another homework assignment had been to draft some treatment goals; Nancy had not done this, saying she had forgotten about this assignment. I was surprised at this because my formulation Suggested that Nancy held a belief such as "I must meet others' needs"; this belief can contribute to excellent homework compliance. However, I realized that part of the noncompliance may have been due to my own failure to provide sufficient structure to the task. I also realized that another part of the formulation (Nancy's views of her own needs as unimpor- tant) predicted that the task of asking herself what she wanted to ac- complish in therapy might be particularly difficult for her. I suggested we spend some time in the session setting goals together; Nancy was agreeable to this.

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214 I C 0 G N I T I V E – B E H A V I 0 R T H E R A P Y F 0 R D E P R E S S I 0 N

I asked Nancy if she had any other topic she wanted to put on the agenda for the session today. (My working formulation predicted that this was a question that she might have difficulty answering.) Nancy indicated that she did not have any urgent business, so I proposed that I collect more information and we set treatment goals, to which she agreed.

To complete my problem list, I asked for more information about Nancy’s work difficulties. Nancy indicated that she was well liked and well regarded at work; her problem was that she was chronically behind and anxious about being behind. In particular, she had trouble handling her quarterly report, a detailed summary of her assessments of all the manuscripts she had reviewed that quarter. Nancy always felt behind on this project and had to scramble at the last minute to put something together. Nancy reported that most editors at her (junior) level worked long hours, putting in lots of evenings and weekends and that she was having trouble doing this as much as she wanted to because she found herself agreeing to social dates with friends that she really did not want. This information supported my hypotheses that Nancy believed that she must meet others’ needs to be acceptable to them and that her needs were unimportant. This information also helped me to understand how these two beliefs contributed not only to her relationship problems but also to her work problems (see the working hypothesis portion of Nancy’s complete case formulation in Exhibit 7.5).

I also asked for more information about Nancy’s relationship diffi- culties. Nancy indicated that her major interpersonal difficulties arose with Connie, Morrison, and Pete (she had described these in our initial session). Nancy also found her relationship with her father to be prob- lematic at times. She described him as unpredictable: angry one mo- ment, warm and supportive another. Nancy’s job, although prestigious, was low paying, so she relied on her father, who was a highly successful businessman, to pay for extras such as therapy. Her mother had remar- ried and now lived on the East Coast, so Nancy had little contact with her.

Nancy stated that she suffered from migraine headaches about once a month but did not have any other significant medical problems. I collected some additional data and concluded that Nancy’s anxiety symptoms, concern about her schoolwork, and difficulty in exam situ- ations did not appear to meet the full DSM-IV criteria for generalized anxiety disorder or social phobia.

Nancy’s psychiatric history showed that she had had several bouts of anxiety and depression and had received outpatient therapy on sev- eral occasions. She had received treatment for an episode of depression following the death of her maternal grandmother, to whom she was close. When her grandmother died, Nancy, who was 16 years old, was

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A Case Example:

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