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Introduction
The client is a middle-aged female, Linda, who shows symptoms of a generalized anxiety disorder (GAD) and depression. The paper aims to examine environmental and social factors contributing to the client’s state of crisis. It will also explore the theoretical orientation of cognitive-behavioral therapy (CBT), psychodynamic, and eclectic approaches for treating Linda.
Social and Environmental Stressors
From reviewing the case of the client, it is clear that she experiences GAD which is related to “significant disability, impaired quality of life, and health costs” (Hofmann & Reinecke, 2010, p. 32). Moreover, Linda has a lack of motivation which is indicative of depression. There is ample evidence suggesting that major adverse life events are antecedents of depressive episodes. Being in the vicinity of Ground Zero can be considered an environmental stressor that has caused the onset of depression. Another sever life event, an effect of which is attributable to the patient’s crisis is the divorce. The onset of depression can also be ascribed to the death of Linda’s father. The social stressor in the form of disagreement with the patient’s sister has also contributed to the development of her condition. The events in Linda’s past such a loss of the pet and ex-boyfriend’s infidelity could have created permanent changes in her personality function.
As a result of the negative influence of social and environmental stressors, as well as negative early experiences, the patient has formed core beliefs that take the form of statements such as “Everyone wants a piece of me,” “I trust no one,” and “I don’t have faith any more” among others (Case Study). Prolonged exposure to these core beliefs, which seem to be rooted in early experiences with the cheating boyfriend, has resulted in Linda becoming tearful and anxious. She is not willing to leave her house and engage in social interaction. The main diagnostic features of GAD displayed by the client include sleep disturbance, irritability, anxiety, and fatigue (Hofmann & Reinecke, 2010). Moreover, Linda also experiences the following symptoms of a major depressive episode (MDD): sadness, loss of energy, worthlessness, disturbed sleep, and psychomotor retardation (Hofmann & Reinecke, 2010). Taking into consideration that a woman has taken a six-month leave of absence to deal with her crisis, it can be argued that environmental and social stressors have significantly impaired the quality of the patient’s life.
Cognitive Behavioral Therapy Theoretical Orientation
The client has to be interviewed with the help of the Structured Clinical Interview for DSM-IV (SCID) which would help to determine whether she meets five criteria for MDD (Hofmann & Reinecke, 2010). A therapist has to keep in mind that there is a direct connection between the effectiveness of CBT and “the extent to which patients learn to use the skills conveyed in therapy outside of the actual session” (Hofmann & Reinecke, 2010, p. 5). Therefore, in addition to stressing the importance of education, I would try to create a therapeutic alliance with the client to ensure that she develops new behaviors and cognitions. I would also use a didactic approach to equip Linda with knowledge about cognitive distortions and their types.
Relying on explorative and directive aspects of CBT, I would show her the cases where such distortions were present with the help of the examples from her life (Hofmann & Reinecke, 2010). The early sessions with the client would be focused on behavioral activation. It would involve the client monitoring and recording her daily activities to rate her mood throughout her day. It will help the client to better understand the connection between her daily activities and feelings. The middle session would be dedicated to the belief work followed by relapse prevention sessions in the end. During the sessions the client will be encouraged to recognize her core beliefs and view her past experiences “more objectively and sympathetically, acknowledging that she learned something negative and potentially damaging” (Hofmann & Reinecke, 2010, p. 6) to create alternatives to her beliefs and conditional assumptions.
Psychodynamic Theoretical Orientation
In the framework of psychodynamic theory, depression can be considered a biopsychological reaction to loss (Busch, Rudden, & Shapiro, 2016). The premature death of the client’s father could have disturbed natural fight/flight and nurturance emotional reactions. There is evidence suggesting that psychological therapy is of equivalent efficacy with medication and yields better results than CBT or behavioral therapy (Luyten & Blatt, 2012; Summers & Barber, 2012). Because the client’s medication is of no help to her, taking the psychodynamic approach might be efficient in addressing her problem.
Using the psychodynamic approach, I would try to explore a process that instigated the onset of the crisis. The client will be attending five sessions a week during which she will be encouraged to lie on a couch. Instead of imposing an agenda, I would try to use my theoretical knowledge of the principles of psychoanalysis to help Linda examine sensitive areas of her past. The treatment can last a very long time during which she would learn by internalization to feel more comfortable with her sensitive thoughts (Luyten & Blatt, 2012). I would focus on the client’s unconscious thoughts that give rise to her symptoms. These focal aims would allow Linda to concentrate on previously unknown areas of her personality which would initiate a slow process of change.
Eclectic Theoretical Orientation
Collaborative care is a method for treating depression and anxiety problems which involves a collective effort of a group of health professionals (Bower et al., 2012). Using a collaborative care model to approach and help the client, the involvement of a medical doctor, a case manager, and a psychiatrist is required. A case manager is a person with special training in treating depression and anxiety that “has regular contact with the person and organizes care, together with the medical doctor and specialist” (Bower et al., 2012, p. 5). The collaborative care model might be especially effective in helping Linda because a case manager could provide her with psychological support, which is absent from other sources, and assess her drug intake. The latter might be ineffective due to the client’s inability to adhere to pharmacological treatments. To address Linda’s issues, it is necessary to create the following instruments facilitating inter-professional communication: team meetings, individual consultations, and written feedback (Bower et al., 2012).
There is ample evidence suggesting that psychotherapy in combination with antidepressant medication produces better results than therapy alone (Cuijpers et al., 2014). Taking into consideration the fact that pharmacotherapy does not produce noticeable results, it can be expected that the client will benefit from the combined treatment.
Diversity
Therapists whose race or ethnic background differs from that of a client might experience cultural difficulties during treatment sessions. There is evidence suggesting that perception of the ethnic minority clients can enter the therapeutic dialogue and change its course (Marsella & Pederson, 2013). The problem in communication might arise if a therapist rarely addresses the issue of race or is uncomfortable while doing so. Even the absence of the discussion of a client’s race during sessions might negatively influence its outcome by lowering the level of comfort associated with therapy experiences. Excessive interest in the cultural background of a client might also distort the course of treatment. If a therapist does not account for the “cultural dynamics in the therapy process” (Owen, Tao, Imel, Wampold, & Rodolfa, 2014, p. 284) they might not be able to successfully avoid making statements which might be perceived by clients as microaggressions. Therefore, therapists should be cognizant of clients’ reactions to unintentional microaggressions as well as how they influence the therapeutic relationships. If a culturally-sensitive statement or action, which might be perceived negatively, has occurred, it is necessary to “clarify misunderstandings, and work to realign with the client” (Owen et al., 2014, p. 286).
Conclusion
The client shows the symptoms of generalized anxiety disorder and depression. After examining environmental and social factors contributing to the client’s state of crisis, it is recommended to use CBT to address the patient’s crisis. However, other approaches such as psychoanalysis, collaborative care, and pharmacotherapy might also be effective in treating the patient. Given that Linda is an ethnic minority client, it is necessary to consider the presence of implicit bias which might manifest in microaggressions, thereby negatively influencing the outcome of treatment.
References
Bower, A., Archer, P., Gilbody, S., Lovell, K., Richard, D., Gask, L.,…Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Review, 10(1), 1-276.
Busch, F., Rudden, M., & Shapiro, T. (2016). Psychodynamic treatment of depression. Washington, DC: American Psychiatric Pub.
Case Study
Cuijpers, P., Sijbrandij, M., Koole, S., Andersson, G., Beekman, A., & Reynolds, C. (2014). Adding psychotherapy to antidepressant medication in depression and anxiety disorders: A meta-analysis. FOCUS, 12(3), 347-358.
Hofmann, S., & Reinecke, M. (2010). Cognitive-behavioral therapy with adults: A guide to empirically-informed assessment and intervention. New York, NY: Cambridge University Press.
Luyten, P., & Blatt, S. (2012). Psychodynamic treatment of depression. Psychiatric Clinics of North America, 35(1), 111-129.
Marsella, A., & Pederson, P. (2013). Cross-cultural counseling and psychotherapy. New York, NY: Elsevier.
Owen, J., Tao, K., Imel, Z., Wampold, B., & Rodolfa, E. (2014). Addressing racial and ethnic microaggressions in therapy. Professional Psychology: Research and Practice, 45(4), 283-290.
Summers, R., & Barber, J. (2012). Psychodynamic therapy. New York, NY: Guilford Press.
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