Answer the following questions. Please reference any outside reading. Follow guidelines for number of paragraphs per question.
- The following client sees you in your office:
You are asked to assess an 82 year-old Caucasian woman in her home. Her daughter and son-in-law live with her and are concerned by her recent behavior. She cries frequently and rarely leaves her bed. Instead she stares at the TV. She is no longer interested in playing cards or visiting her friends. She eats very little, except that she will always eat chocolate pudding. Her memory is intact and she is able to engage pretty well with other people. In other words, her cognitive status appears within normal limits and no signs of dementia are evident. When asked how she feels, she says, “depressed…well wouldn’t you be if you were 82 and all alone?” She denies being suicidal but that she is waiting to die. She states with distress, “Why doesn’t God take me? Why does he let me be just a burden? I can’t do anything anymore!”
Her daughter reports that the symptoms began gradually and are evident all the time now. She rarely expresses happy feelings. She first noticed the depressive symptoms 8 months ago after a fall where her mother broke her hip. She was laid up in a hospital for several weeks and she never returned to her prior level of functioning and activities. While in the hospital, she was diagnosed with hypertension, but otherwise, she was in good health. Her daughter is very distressed because the patient keeps stating that she is “all alone,” yet she (her daughter) is there throughout the day. She is a medical transcriptionist and only leaves to pick up and drop off the work. She is feeling “rejected” and helpless to affect her mother’s mood. Observing the interaction between the patient and her daughter, you notice that the patient is withdrawn and does not engage much and even looks annoyed when her daughter helps her.
A brief history reveals that the patient was the second of 10 children raised during the depression. Her youngest brother died shortly after birth and father died when she was 16 years old. Her family was very poor and would often eat carrot soup for dinner. Her mother parented with great strictness, and as a result, the patient reported that she felt tough- that she could “push” through anything. She was married two times and widowed two times. The first husband was an alcoholic and did not provide well for her and their three children. He died of complications related to drinking when she was in her forties. She reported that, like her mother, she raised her children through such difficult times. She married again after her children were married. The second husband was kinder and financially comfortable. After his death, when the patient was 68, he left her enough money for her to be comfortable.
A major life event occurred after her son’s return from the Gulf War. He was a war hero and received many decorations for his actions. He was also wounded and was left in permanent pain and a limp. He began to drink to self-medicate apparent PTSD symptoms and killed himself when he was 35. Talking about this increases the patient’s apparent distress.
Based on this limited information, do the following (a paragraph each question):
- Make a formulation (one paragraph) for this client’s depressive symptoms from the CBT perspective, including suspected causal and maintaining variables. What further information do you need to know to support your formulation and why this information will be helpful?
- Based on your formulation, create a treatment plan using specific treatment strategies and discuss why you chose this plan and these strategies. Also include how you would promote compliance.
- How would you manage the suicidal ideation if she expressed them?
- Let’s say she also reported excessive pervasive anxiety and worry. She worries excessively about her health- reporting excessive distress with every unexplained bodily sensation. Based on what you know, how would your formulation be similar and different than the formulation you made for the depression? What would be the common features in the formulation (between her depression and pervasive anxiety), and thus the common treatment strategies based on these formulations? What would be the contrasting formulation factors and, therefore, differing treatment strategies for addressing the depression and anxiety? (1 paragraph)
- Exposure methods have been found to be a very effective technique at reducing acute anxiety, especially when there is an identifiable trigger/avoided object. Because of how well you treated this client, you are asked to treat her son’s acute anxiety triggered by loud sudden noises (that is, for the sake of this assignment, before he died). In a paragraph, a) present the CBT formulation (using learning theory) for his acute anxiety and the subsequent treatment for this formulation. b) How does the cognitive formulation (and therefore, treatment) differ from the learning theory perspective? In another paragraph: based on this formulation, explain how the exposure treatment is made less effective if 1) he is non-compliant to homework (i.e., exposure on his own between sessions), 2) he is consistently arrives 20 to 30 minutes late to the exposure session, and 3) his drinking problem continues during the exposure (i.e., he drinks prior to the session), and 4) how to increase compliance to such an uncomfortable activity. (2 paragraphs)
- NOT PERTAINING TO THE ABOVE CASE: If an OCD client asks you to model the behavior before she does every exposure session to be sure that it is safe or ask for many specific examples from you to challenge her obsessive thinking (i.e., asks you to come up with examples of evidence against her obsessive thinking), what is she likely doing and how might it interfere with treatment? Be specific in how it relates to the learning or cognitive theory. How should these client’s efforts be managed most effectively? (1 paragraph)
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