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Cognitive Behavior Therapy for Depression: A Case Report

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Abstract and Figures

Depression is expected to become the most common psychiatric disorder and cognitive Behaviour Therapy (CBT) is recommended for treating depression as an effective treatment. Mental health issues in developing countries are difficult and challenging. It is suggested in many ways that intervention developed in western countries may not be effective for developing countries. Moreover, the findings of the study will help the mental health professional to reduce these symptoms and help them to make better adjustment.
Volume 8 • Issue 7 • 10001151
J Clin Case Rep, an open access journal
ISSN: 2165-7920
Ara. J Clin Case Rep 2018, 8:7
DOI: 10.4172/2165-7920.10001151
Open Access
Case Report
Journal of Clinical Case Reports
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ISSN: 2165-7920
Cognitive Behavior Therapy for Depression: A Case Report
Ara J*
Department of Clinical Psychology, Arts Building, Dhaka University, Bangladesh
Abstract
Depression is expected to become the most common psychiatric disorder and cognitive Behaviour Therapy
(CBT) is recommended for treating depression as an effective treatment. Mental health issues in developing countries
are difcult and challenging. It is suggested in many ways that intervention developed in western countries may not
be effective for developing countries. Moreover, the ndings of the study will help the mental health professional to
reduce these symptoms and help them to make better adjustment.
Keywords: Cognitive behavior therapy; Depression; Psychiatric
disorder; Mental health
Introduction
Depression is expected to become the most common psychiatric
disorder, and one of the leading causes of disease burden in developing
countries. It is an important global public-health issue, among various
other mental health problems that aect 1 in 20 people in every year [1].
Prevalence of depressive disorders in Bangladesh is 4.6% [2]. Although
these seem small but already the ultimate consequence of depression is
suicide [3]. Depression is more common in women and it is the main
cause of disease burden in Bangladesh [4]. Cognitive Behaviour erapy
(CBT) is recommended for treating depression as an eective treatment
modality for a long time in developed world [5]. Recent ndings suggest
that CBT might be as eective as medication in treating moderate to
severe depressive illness, especially in the initial phases of depressive
illness and CBT has been shown to be eective treatment for depressive
illness [6].
Case Description
Ms. A, a 22-year-old unmarried female Muslim client was referred
for psychological intervention in the Psychiatry Outpatient Department
(OPD) of National Institute of Mental Health (NIMH), Bangladesh. She
was assigned to the present therapist and was diagnosed as depression by
the psychiatrist. In the assessment sessions she presented her problems
along with history. Her problems are presented in the following in
clustered fashion according to dierent areas of functioning. e
client believed that she was suering from psychological illness [7,8].
e client complained lack of concentration, lack of self-condence,
and indecisiveness. She also complained of depressed mood, feeling of
guilt, lack of pleasure, anger and hopelessness. She felt irritability and
fear. She avoids social gathering, friends and sometimes occasionally
she used to cry. e client complained of headache, palpitation. She
also complained that family members usually irritate her especially
eldest brother. Her dress up, appearance and behavior appeared to
be culturally appropriate. At the initial interview she spoke willingly
about her problems. She was well motivated and interested to work
collaboratively with therapist.
Exploration of history revealed that the client was in a middle-class
family of a rural area with two brothers and three sisters. Her father
was 55 years old and he was a small business man. Her mother was a
45 years old house wife. From her childhood she experienced that the
relationship between her parents was not good. e eldest son of their
family maintains everything of the whole family. Her eldest brother
was very dominating. She had to lead her life as to his liking. She was
the last issue of her parents. ough she was meritorious student from
*Corresponding author: Ara J, Department of Clinical Psychology, Arts building-4th oor,
Dhaka University, Bangladesh, Tel: +8801748655577; E-mail: jesan53006@gmail.com
Received July 19, 2018; Accepted July 30, 2018; Published July 31, 2018
Citation: Ara J (2018) Cognitive Behavior Therapy for Depression: A Case Report.
J Clin Case Rep 8: 1151. doi: 10.4172/2165-7920.10001151
Copyright: © 2018 Ara J. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
childhood she was always underestimated instead of being encouraged.
e senior most brothers always used to apply pressure on her for
studies. ey were not happy with the results she obtained. During any
bad occurrence in her family if she protested, she had been termed as
“disobedient”. She likes reading story, listening to music and reciting
poetry which are not supported by her elder brother. Her brother
doesn’t even like her writing skills. She was physically tortured several
times for doing these [9].
She was sexually abused for several times. At the age of ve or six
years old, some of her playmates abused her. When she was in class
seven her cousin tried the same way. During college life one of her
uncles tried to abuse her also. She couldn’t tell these to her family with
a fear of receiving disbelief of the family. When she was 15years, she
had an aair with a boy. en due to misunderstanding that broke up.
When she was in college she again got involved with a boy only to pass
time with that boy. Now she is having third aair. She is a graduate
student. Since having all these she thinks that if she had got family
support enough, there wouldn’t be so many problems. ere was no
history of psychiatric problem in her childhood and adolescence.
Assessment
In clinical interview the client was asked the reason for referral, why
she sought for help and how long the main complaint had persisted,
when did the problem rst occur, what was the subsequent development
in her life (occupation, living with parents, at school), what were the
impairments that have been produced by the her diculties, how
have she and others coped with the problem, what her belief about the
problem, what was the attitude to her diculties, what was her cognitive
functioning, what was her prevailing mood, what was her background
history, early development history, occupational and educational
history, sexual history and what previous psychiatric, psychological or
medical help she had taken [10-12]. e client asked to nd out and list
up her main problems. ought diary was applied to assess situation
specic negative automatic thoughts (NATs) and corresponding
emotion, physiological changes and behavior for the client. It was
administered to identify the NATs about the social situation and the
relation to changes in emotion, physical reaction, and behavior [13].
Citation: Ara J (2018) Cognitive Behavior Therapy for Depression: A Case Report. J Clin Case Rep 8: 1151. doi: 10.4172/2165-7920.10001151
Page 2 of 4
Volume 8 • Issue 7 • 10001151
J Clin Case Rep, an open access journal
ISSN: 2165-7920
According to the client though she was meritorious student in early
age she was always underestimated in stead of being encouraged, she
did not get any attention and care for doing good result or doing any
thing good. In general, behavioral models claim that depression comes
about because the person is receiving inadequate or insucient positive
reinforcement or reward from him or her environment [4]. According
to the client the relationship between her parents was not so good. Her
senior most brothers always used to apply pressure on her for studies.
She likes reading story, listening to music and reciting poetry which are
not supported by her elder brother. Even she was physically tortured
several times for doing these. She was sexually abused for several times
[8]. Propose that “Sometimes individual process traumatic information
in a way that produces a sense of current threat, whether this is physical
or psychological”. Crittenden reported that a child exposed to repeated
early traumatic experiences is likely to show a disruption in normal
Personality development. Children who experience a trauma exhibit
discernable long-term eect [1]. Since she had some diculties in
making close relationship and the entire incidence seemed to develop
her problem gradually.
e client came from a restricted family. e relationship
among parents was disharmonious which maintained her problem.
Domination of elder brother and lack of support from family also
maintained his problem. She was withdrawn from daily activities &
social gathering. is avoidance was also acting as a maintaining factor
for her current illness. She was passive and angry in nature and couldn’t
express her emotion in appropriate way. But aer then when realized
the mistake she was suering from serious guilt feelings. e client had
some NAT’s which helped to maintain her problems, such as- “I am
helpless”, “I am not good enough”, “I never get any good things in my
life”. She was sexually abused for several times, for these incidents she
thinks herself as untouchable and feels guilty. She shows herself to be a
rather introverted who had some diculties in making close relation.
She has diculties in situations where she must assert herself and
lacking in self condence. She sets herself high standards in relation to
work performance and in her role as a dicult daughter. e client also
had some social skill decit which helped to maintain her problems.
All these lead to indecisiveness, lack of concentration, lack of self
condence and maintain his problem. Aer obtaining information on
predisposing, precipitating and maintaining factors, client’s problem
was formulated based on the cognitive model described by Beck
(Figure 1).
Course of treatment
e formulation of the client’s problem was drawn based on
cognitive model, cognitive behavior therapy was chosen for the client’s
problem. Formulation was shared with the client to make her prepared
to follow psychological treatment. Goals of the treatment were set and
dened collaboratively with Ms. A, which were as follows: 1) to reduce
depressive symptoms 2) to terminate avoidance and 3) reduction of
guilt feelings. Priorities were then set by negotiating to which problems
were to be dealt with rst. Following cognitive-behavior therapeutic
techniques were followed in the sessions.
e client could not express her feelings and past experiences.
In therapy session the rst treatment session focused on establishing
sucient rapport, educating the patient about depression and
psychotherapy in general, emphasizing the importance of homework,
taking responsibility for change,
empathy was given aiming to open
her feelings and thoughts
and
adjusting her expectations about what
can be gained through therapy.
Measurement
erapist conducted both type of measurement, subjective &
objective measurement. In assessment session client mentioned her
overall problems severity at ‘100’ point on (0-100) rating scale. For
objective measure Depression scale [14] was used to assess the severity
of depression. e highest possible score of 30 items form of depression
scale was 150 and the lowest possible score was 30. Higher score on
the scale indicates high level of depression and lower score indicates
low level of depression. Both the split-half reliability (Guttman split-
half r=0.7608) and test-retest reliability (r=0.599) of this scale ensured
that the scale is a reliable instrument. Estimation of concurrent
Validity shows that, rating of depression by the psychiatrist (r=0.377)
and self-rating of depression by the patients (r=0.558) were positively
correlated with the obtained scores on the current depression scale (p<
0.01). Discriminability (F= 85.386, p< 0.01) concluded high concurrent
validity of the scale. Construct validity were found satisfactory.
Anxiety scale [15] was developed in the cultural context of
Bangladesh. It assesses the severity level of anxiety from the very
begging sessions. Score ranges for mild, moderate, severe and profound
severity were 27-54, 55-66, 67-77, and 78-144 respectively. A higher
score indicates a higher level of anxiety. e anxiety scale poses sound
internal consistency (Cronbach’s alpha = 0.9468) and temporal stability
(test rest reliability = 0.688, p<0.01).
Procedure
Ms. A was assessed for eligibility for treatment with the Depression
Scale and Anxiety scale. Following the initial assessment, the patient
was assigned to treatment and evaluated psychologically regularly as
detailed in Tables 1 and 2.
Case conceptualization
Ms. A 22-year-old unmarried female Muslim client was referred
with the complain of depressed mood, lack of concentration, lack of
self-condence, indecisiveness, guilt feelings, anger, felt irritability,
headache, and avoidance behavior. In-depth interview and the
exploration of her thought revealed that she was suering from
depression. Based on information’s collected from the client, her
formulation was done in predisposing, precipitating and maintaining
factors [16].
Sessions Severity of the problem (0-100)
1st Session 90
2nd Session 90
3rd Session 75
6th Session 60
9th Session 50
10th Session 45
13th Session 25
Table 1: Subjective report of the client.
No of sessions Anxiety scale Depression scale
1st Session 62 (Moderate) 135 (Severe)
3rd Session 54 (Mild) 120 (Moderate)
5th Session 45 (Below cut off point) 113 (Mild)
7th Session 38 (Below cut off point) 106 (Mild)
9th Session 30 (Below cut off point) 92 (Below cut off point)
11th Session 30 (Below cut off point) 72 (Below cut off point)
13th Session 28 (Below cut off point) 63 (Below cut off point)
Table 2: Anxiety and depression scores.
Citation: Ara J (2018) Cognitive Behavior Therapy for Depression: A Case Report. J Clin Case Rep 8: 1151. doi: 10.4172/2165-7920.10001151
Page 3 of 4
Volume 8 • Issue 7 • 10001151
J Clin Case Rep, an open access journal
ISSN: 2165-7920
Figure 1: Information on predisposing, precipitating and maintaining factors, client’s problem was formulated based on the cognitive model.
Citation: Ara J (2018) Cognitive Behavior Therapy for Depression: A Case Report. J Clin Case Rep 8: 1151. doi: 10.4172/2165-7920.10001151
Page 4 of 4
Volume 8 • Issue 7 • 10001151
J Clin Case Rep, an open access journal
ISSN: 2165-7920
ought Challenge technique was used to modify the client’s
NAT’s by examining the evidence for against the NAT’s of the client.
Cognitive therapy was given to reduce her NAT’s as NAT’s maintaining
her problem.
e steps that were involved in challenging a thought
were as follows-
1) What is the worst thing that, suggested by the perceived
threat can happen?
2) What are the points that supports that the worst thing will
happen?
3) What are the points that indicate the impossibility of the
worst thing to happen?
4) What are the benets of thinking about the worst?
5) What are the costs of thinking about the worst and nally?
6) Considering these points what should I do? i.e., what does
all these points suggests.
Pie chart was used to reduce feelings of guilt (especially which
was related to sexual abuse). It helped the client to determine her
responsibility for an incident. Decision making problem is common
problem of depressed client. If decision making is not appropriate
that time person not feels comfort and self blame and guilt feeling
come. ere are some steps of decision making. ese are isolating
the problem, decide to act gather resource, plan, visualize your plan of
action and act.
To make the client more assertive she was trained assertive training.
is training helped her to communicate with her family members.
Assertive training helps people to express how they feel without
trampling on the rights of others in the process [15].
Muscular relaxation was to teach to reduce headache and tension.
Evidence suggests that relaxation procedure have been eective for a
vast array of problems including headace, insomnia, anxiety, temper
outburst [12-16]. e client was taught how to express anger in a
constructive way. ese include dening the anger, being assertive and
nding some mutual way of solving the problem.
e client oen underestimated her positive qualities which
maintained her problems. So, the client was asked to write down at least
two good qualities every day. So that she could aware about her positive
qualities, it would help her to perceive herself in another perspective.
Sessions 8-13 focused on monitoring activities. e client complained
of lack of pleasure, so a record-sheet was given to client to record what
he did on an hour-by-hour basis, and to rate each activity out of 10 for
pleasure (P) and for mastery (M). It was used to improve mood and to
increase level of pleasurable activities.
Results
Subjective rating of the client’s problem was taken intermittently
in assessment and treatment sessions. Verbal rating of the clients’
problem was taken in a 0 to 100-point scale, where 0 means lower level
and 100 means high level of problem.
Table 1 indicates that client’s subjective rating about the problem
was reducing gradually. Standardized scale was applied in most of the
session to get an objective measure of the improvement and to provide
an objective feedback about improvement to the client and therapist.
Anxiety and depression scale were used as objective measures of
improvement. Session wise scores of these scales are presented in
following (Table 2).
e subjective and objective report of the result of intervention
strongly suggests that improvement have occurred.
Discussion and Conclusion
e client was very much sensitive about her problem.
When she got the impression that the therapist understood her
problems she became very much motivated and
showed high
level of compliance with psychotherapy, it’s helped the therapist to
deal with her problem. She accepted psychotherapeutic formulation of
her problems and she could internalize therapeutic technique and its
rational. Her NAT’s was reduced, and she started thinking positively.
She could generalize psychotherapy and applied skills in dierent
settings. So, it can be said that it will be disturb his improvement
and chance to future relapse.
e client was asked to practice all
technique which he learnt.
But if the she continued 2nd and 3rd follow
up session the therapist could feel more condent about the client’s
improvement due to psychotherapy.
References
1. Barnes GE, Prosen H (1985) Parental death and depression. J Abnor Psychol
94: 64-69.
2. Beck AT, Epstein N, Brown G, Steer RA (1988) An inventory for measuring
clinical anxiety: psychometric properties. J Consul Clin Psychol 56: 893.
3. Byrn MA (1993) Gestational diabetes depression and the impact on maternal
child health outcomes. J Consul Clin Psychol p: 21.
4. Rutter M, Sroufe LA (2000) Developmental psychopathology: Concepts and
challenges. Develop Psychopathol 12: 265-296.
5. Crittened PM (1987) Maltreated infants: Vulnerability and resilience. J Child
Psychol Psychiat 26: 85-96.
6. Deeba F, Begum R (2004) Development of an anxiety scale for Bangladesh.
Bang Psychol Stud 14: 39-54.
7. DeRubeis RJ, Hollon SD (2005) Cognitive therapy vs medications in the
treatment of moderate to severe depression. Archiv Gener Psychia 62: 409-
416.
8. Ehlers A, Clark DM (2000) A cognitive model of post-traumatic stress disorder.
Beh Res Thera 38: 319-345.
9. Embling S (2002) The effectiveness of cognitive behavioural therapy in
depression. Nurs Stand 17: 33-41.
10. Firoz AH, Karim ME, Alam MF (2007) Community based multi-cen- tric service
oriented research on mental illness with focus on awareness, prevalence, care,
acceptance and follow-up in Bangladesh. Manual on Mental Health for primary
health care physicians. (2nd edn). Natl I Ment Health WHO 2007.
11. Garratt G, Sawalani G (2007) Cognitive processes in cognitive therapy:
evaluation of the mechanisms of change in the treatment of depression. Clin
psychol Prac 14: 224-239.
12. Jacobson E (1938) Progressive relaxation: A physiological and clinical
investigation of muscular states and their signicance in psychology and
medical practice. Univ Chicago Press pp: 19-38.
13. Pervin MM, Ferdowshi N (2016) Suicidal ideation in relation to depression,
loneliness and hopelessness among university students. Dha Univ J Biol Sci
25: 57-64.
14. Uddin MZ, Rahaman MM (2005) Development of a scale of depression for use
in Bangladesh. Bang Psychol Stud 15: 25-44.
15. Wolpe J (1958) Psychotherapy by reciprocal inhibition. Stanford University
Press, Stanford, California, USA.
16. Rahman D, Ali S, Ali M (2003) Nutritional status of depressive patients: A study
in an urban hospital, Bangladesh. Orion p: 14.
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