Cognitive Behaviour Therapy in an In-patient with Chronic Difficulties: A Case Report. Myra Cooper. Aylesbury Vale Community Health Care Trust. Introduction.
Behavioural and Cognitive Psychotherapy, 1994, 22, 171-176
Cognitive Behaviour Therapy in an In-patient with Chronic Difficulties: A Case Report Myra Cooper Aylesbury Vale Community Health Care Trust Introduction It is not clear from the literature whether successful outcomes can be obtained with CBT in chronic, drug refractory patients who require admission to hospital and whose problems date back to childhood. Anecdotal evidence suggests that they can be treated with CBT (e.g. Beck and Freeman, 1990; Young, 1990). However, no detailed reports of successful treatment in this group have been published. The present report will describe the treatment and outcome of one patient, Alison, who was suffering from depression and who was treated with CBT. She had failed to respond to medication and required admission to hospital. She had chronic difficulties that dated back to childhood and had most of the features described by Scott (1992). Her treatment illustrates how the many different aspects of her complex problems could be examined and treated using CBT techniques as these provided a simple way of understanding and dealing with the difficulties she faced.
Background Alison was a 36 year old married woman with three small children. She had been sexually, physically and verbally abused by an alcoholic father as a young child and teenager. Her husband, Peter, also abused her. She had felt depressed for a long while but had been too frightened to seek help because Peter threatened to end their marriage if she did so. Over the five years since she had sought help from her present GP she had been admitted to hospital on fao occasions for periods of six weeks and five months. On both occasions she had been suffering from depression. She had also taken several overdoses. She had been treated with numerous antidepressants and with ECT. She had received counselling for childhood sexual abuse and for marital problems. She had attended an out-patient support group and, for two years, a survivors' group. Throughout the five years she had received regular support from her GP and from a CPN. None of these interventions had resulted in any lasting improvement in her symptoms.
Reprint requests and requests for an extended report to Myra Cooper, Aylesbury Vale Community Health Care Trust, Tindal Centre, Bierton Road, Aylesbury, Bucks HP20 1HU, UK. © 1994 British Association for Behavioural and Cognitive Psychotherapies
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Assessment Alison was seen for two assessment sessions. She had not responded either to medication or to ECT since being admitted. She had many symptoms of depression. These feelings had been with her for as long as she could remember. Her self esteem was low, she felt a failure and said "I don't want to be me". She expressed many negative thoughts about herself, including "no one cares about me", and "no one likes me". She admitted that she wanted to kill herself. She reported that Peter was unsympathetic and was continually telling her to pull herself together and get back to caring for him and the children. Her score on the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock and Erbaugh, 1961) was 46. Her score on the Hopelessness Scale (HS; Beck, Weissman, Lester and Trexler, 1974) was 19 (20 is the maximum score). These scores indicated that her depression was extremely severe and that she was at risk of suicide. A problem list and working formulation were developed. A preliminary cognitive behavioural formulation was made (see Table 1). Treatment Alison was seen for 39 treatment sessions and was followed up for a further ten months at monthly intervals. No active treatment took place in the follow-up sessions. Scores on the BDI during treatment and follow-up can be seen in Figure 1. First treatment session At the end of the assessment Alison was given Coping With Depression (Beck and Greenberg, 1974) to read. At the first treatment session the cognitive model, problem list and preliminary formulation were shared and discussed. Predisposing, precipitating and maintaining factors were distinguished and it was emphasized that the formulation would be modified as treatment progressed. The implications of the formulation for treatment were then discussed. It seemed important, as a first step, to deal with the thoughts and behaviours that were maintaining her depression. There seemed to be two maintaining factors, thoughts that she could not solve her problems and that she had nothing left to try for and her low opinion of herself. With the help of the therapist, Alison chose what seemed to be the most urgent problem to focus on. Alison was encouraged to begin a therapy file for copies of handouts and photocopies summarizing important issues discussed in treatment sessions. Her keyworker was kept informed of the different stages of treatment. After discussion with the therapist, the keyworker wrote appropriate careplans to support Alison's attempts to deal with her problems in therapy. Treatment part 1 Self Harm. Alison and the therapist agreed that the first problem to be tackled should be the self harm and thoughts of suicide. These were dealt with by discussing the formulation to increase insight and by using behavioural, cognitive and supportive techniques. The formulation gave Alison an explanation for behaviour that she
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TABLE 1. Cognitive behavioural formulation for Alison Early experiences: Abused physically, sexually and verbally by father Unable to pursue career wanted Core beliefs: I'm bad, dirty, worthless, inferior, unimportant Dysfunctional attitudes: My self worth depends on what other people think of me; if someone criticizes me it means I'm no good, worthless, a failure I can't trust or rely on other people; if I do they'll reject me/let me down I'm responsible for other people's happiness; I have to put other people's needs before my own or they'll get angry with me/dislike me/reject me Critical incidents: Husband's criticism and abuse from age 17 Rejection by husband after first pregnancy Automatic thoughts: I'm a failure, not important, inferior No one likes me, I've got nothing to offer Peter doesn't love me - I'm worthless I mustn't question what Peter says about me—if I do he'll reject me I'd be better off dead Symptoms: Behavioural—doing less, withdrawing from people Motivational—loss of interest and pleasure, everything an effort Affective—sadness, guilt, anxiety Cognitive—poor concentration, ruminations, thoughts of self harm Somatic—loss of appetite Maintaining thoughts: I've nothing left to try for I can't deal with all the problems I face I'm not important I can't stand up to Peter
had previously regarded as inexplicable. Stimulus control techniques were taught. Alison was encouraged to dispose of the various stores of tablets that she had hoarded and to avoid places where she felt at risk of self harm. Her pessimistic thoughts about the future were examined in detail and challenged in sessions. Because Alison appeared to dissociate before she attempted to harm herself she was taught distraction and sensory awareness to anchor herself more firmly in the present when she felt at risk. She was also taught to substitute pleasant fantasies for distressing images of death and dying and was encouraged to use the ward staff to ventilate her feelings, receive support and to "reality test" her negative perceptions if she felt that she had exhausted her own coping strategies. The aim was to increase her sense of control over her actions. Activity levels. Activity scheduling was introduced to improve mood and self
40 0 Session number
10
Follow up (months)
FIGURE 1. BDI scores care, decrease the opportunity to ruminate about self harm and to increase contact with the children. Relationships with the children. Although it gave her a sense of pleasure and mastery, Alison had great difficulty in planning time with her children. She also complained of feeling disconnected from them. Cognitive and behavioural techniques were used to deal with this problem. With the therapist's help she identified and challenged the underlying assumption that she was a bad mother. She also planned increasing amounts of time with her children. This made her feel more in touch with them. Feeling inferior as a person. Believing that no one liked her and that people were not to be trusted were frequent themes in Alison's thoughts. This set of assumptions was also dealt with using behavioural experiments, cognitive and emotive techniques. Alison approached nurses to talk to about specific problems and assessed their reaction. She also feared that her therapist did not like her and would, in time, get fed up with her and abandon her. This belief was also challenged. Several core beliefs were then identified and challenged, including beliefs that she was unimportant, worthless and inferior. She was encouraged to talk about the feelings associated with her assumptions and core beliefs (Young, 1990). Treatment part 2 Marital difficulties. By this stage, Alison's self esteem had begun to improve as she made progress with some of the initial problems she had identified and worked directly on her feelings of inferiority. However, it became clear that whenever she returned from a visit home involving contact with her husband she came back
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feeling extremely distressed. She would be depressed and tearful, saying that she felt worthless, a failure, unloved and uncared for. She would also have thoughts of self harm. Alison wanted to end her marriage but was frightened that her husband would become angry and take the children away from her. Once again, the formulation was discussed and relevant behavioural, cognitive and emotive techniques were coordinated during treatment. The assumptions that surrounded her relationship with Peter and the core beliefs that lay beneath them were examined, including the core belief "I'm unimportant" and the belief "I'm worthless". Depression about being depressed was discussed and addressed in sessions. These discussions seemed to give her the confidence to think of visiting her solicitor and initiating discussion about separation from Peter. Graded task assignment was used to help her to tackle the practical problems she faced. Self esteem. Therapy continued to focus on building her self esteem using cognitive, behavioural and emotive techniques. Alison's low opinion of herself was traced back to childhood, dysfunctional assumptions and core beliefs were identified and challenged in sessions, including the tendency to put others' needs before her own and fears of abandonment. Emotive techniques were also used as previously described. Alison made a list of things that might help to improve her self esteem. One of the items she listed was getting a job (she had not worked for 12 years). Her BDI score decreased to 10. Discbarge. Peter finally moved out and Alison was discharged from hospital. However, after a few days her BDI score went up to 31 again. It became clear that this was related to Peter's frequent telephone calls, uninvited visits and comments. This contact with him reactivated her assumptions and core beliefs. She dealt with this by challenging the validity of these assumptions and beliefs and by asking Peter to phone less often and to warn her in advance if he planned to visit. After doing this, her BDI score came down again. Relapse prevention. Alison then began to make long term plans to ensure that she did not relapse. She thought of moving to be nearer her sisters, put the house on the market and joined a bank secretarial agency. Follow-up. Alison was followed up at monthly intervals for a further ten months. Her BDI was 13 when she was last seen, ten months after the end of treatment. She was continuing to work, making plans for the future and trying to implement plans to improve her self esteem. Conclusion Until now there have only been brief reports that it is possible to use CBT to successfully treat patients with chronic depression whose problems date back to childhood. Alison was successfully treated over a period of eight months and her improvement was maintained at follow-up of ten months. A CBT formulation of her difficulties was made. Most of the five elements which Scott (1992) identified as important clinically in determining outcome in CBT for chronic depression were
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evident in Alison's case. She had chronic low self esteem, although this seemed to be the consequence of childhood experiences rather than simply the result of recurrent depression. She had a high Hopelessness Scale score and, like the patients in Scott's study, she was "depressed about being depressed". Her changes on subjective measures (the BDI) lagged behind changes suggesting objective progress, e.g. increased time at home, taking greater responsibility for the children. Finally, she had difficulty transferring skills learnt in hospital to the community. This was evident in her relapse following initial discharge. It is interesting to speculate about what were the critical factors in treatment. Several features seem to have been important in determining outcome. The success of treatment suggests that the formulation and its development as therapy progressed was accurate. Making the formulation explicit may have helped to build trust and thereby counteracted one of Alison's negative schema, giving her clear support and a stronger basis from which to move forward. It also seems relevant that Alison had some very healthy aspects, including her ability to make and stick by her decision to leave Peter, and her ability to make friends and to keep in touch with her sisters. For whatever reason, Alison seemed ready to make the decision to leave Peter in a way that she had not been previously. This could have been fortuitous, to do with the ages of her children or, as is suggested above, to do with the therapy she received, including the provision of a therapeutic relationship as a supportive basis from which to move forward.
References BECK, A. T. and FREEMAN, A. (1990). Cognitive Therapy of Personality Disorders. New York: Guilford Press. BECK, A. T. and GREENBERG, R. (1974). Coping with Depression. New York: Institute for Rational Living. BECK, A. T., WARD, C. H., MENDELSON, M., MOCK, J. and ERBAUGH, J. (1961). An inventory
for measuring depression. Archives of General Psychiatry 4, 561-571. BECK, A. T., WEISSMAN, A., LESTER, D. and TREXLER, L. (1974). The measure of pessimism:
The Hopelessness Scale. Journal of Consulting and Clinical Psychology 42, 861-865. SCOTT, J. (1992). Chronic depression: can cognitive therapy succeed when other treatments fail? Behavioural Psychotherapy 20, 25-36. YOUNG, J. E. (1990). Cognitive Therapy for Personality Disorders: A Schema Focussed Approach. Sarasota, Florida: Professional Resource Exchange.
