Treatment of Women Diagnosed With Dysthymia

Treatment of Women Diagnosed With Dysthymia

This proposal for a clinical case study of the treatment of a woman diagnosed with dysthymia employs a cognitive behavioral approach to identifying effective treatment modalities for patients with depressive disorders. In cognitive behavioral sessions, psychotherapists seek to help a patient identify his or her harmful thinking patterns in order to develop better coping strategies and social skills. The focus of the research in this study is on how people in general think, behave, and communicate in the present rather than on their early childhood experiences.

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Proposal for a Clinical Case Study Dissertation – Doctor of Psychology in Clinical Psychology

Chapter One. Introduction

Statement of the Problem



Chapter Two: Review of the Relevant Literature

Background and Overview

Etiology of Dysthymia

Symptoms of Dysthymia

Theoretical Bases for Clinical Treatment

Chapter Three: Methodology

Client Information

A. Presenting problem

B. Client’s current symptoms

C. Therapist’s observations of client’s symptoms

D. Family history

E. Medical history

F. Psychotherapeutic history

G. Substance use/abuse

H. Initial diagnosis

I. Impressions of client

Beck: Cognitive Behavioral Therapy

Storm Clouds – Beginning Phase

Sessions 1-4

Unbearable Pain – Middle Phase

Looking for Relief in All the Wrong Places

Sessions 5-15

Making Peace – Final Phase

Sessions 16-24

Future Treatment Considerations

Chapter Four: Concluding Thoughts


Case Study Proposal: Identifying Efficacious Treatment Modalities for Chronically Depressed Dysthymic Patients

Chapter One: Introduction

This study is comprised of four chapters; this chapter provides an introduction and overview of the research, a statement of the problem to be considered, the purpose of the study and the rationale in support of the client selected. Chapter Two presents a critical review of the peer-reviewed and scholarly literature, and Chapter Three describes the methodology employed. The final chapter summarizes the findings of the research and provides a discussion of concluding thoughts that resulted from the research and the treatment sessions that formed the basis of the project.

Overview of the Study

This is a proposal for a clinical case study on the treatment of a woman diagnosed with dysthymia. Dysthymia, or minor depression, is characterized by the presence of a depressed mood for the majority of the day for a minimum 2-year period with no more than 2 months’ of respite from the symptoms during this period. Further, at least two of the following symptoms must occur concurrently with the depression: disruption in eating habits — poor appetite or overeating; disturbed sleeping pattern — insomnia or hypersomnia; low energy or fatigue; low self-esteem; poor concentration or difficulty making decisions; and a feeling of hopelessness (Rakel, 2004). This case study will employ the relational model, cognitive behavioral therapy (CBT). This technique is a relatively short-term, focused psychotherapeutic approach that can be used for a wide range of psychological problems including depression, anxiety, and personality problems. The cognitive behavioral approach has provided an effective framework in which to better understand individuals and their unique problems and circumstances, and, further, it provides an effective approach to use developing individual therapy modalities (Fine & Schwebel, 1994). The focus of this research project will be on how the client thinks, behaves, and communicates currently rather than on early childhood experiences.

Statement of the Problem

Depression is the most prevalent mental disorder in the United States today, and all signs indicate that the condition is on the rise (Helm, Boward, McBridge et al., 2002). The costs associated with this range of depressive disorders are enormous. In fact, it has been estimated that depression results in more than 200 million lost workdays and costs the U.S. economy $43.7 billion annually; further, much of those costs are hidden, including $23.8 billion lost to U.S. businesses in absenteeism and lost productivity (Myslinksi, 2004). Claims for short-term disability for those with depression are comparable to other chronic medical conditions, including diabetes, heart disease and lower back pain. People who experience unrecognized depression are also greater users of healthcare resources for their physical ailments (Myslinksi, 2004). On a final note, it should be pointed out that there are currently no data supporting qualitative differences in symptomatology between major depression and dysthymia (Klein, 1991).

Purpose of Study

The purpose of this investigation is to highlight those aspects of cognitive behavioral therapy that have been shown to be effective in treating depressive disorders in general and those that affect the patient in this study in particular. It is the intent of this dissertation to demonstrate how an application of the basic tenets and theoretical principles of cognitive behavioral theory may be applied and utilized in the treatment of the client, Mary.

It is relevant to note that these theoretical constructs bridge into clinical practice and are not only theoretically central but also help the therapist to think about the nature of the therapeutic relationship, the analysis of which is at the heart of cognitive behavioral practice. Cognitive Behavioral Therapy has always grown from a fertile interaction between theory and clinical practice. Clinical experience comes to challenge the contemporary theoretical understanding and demands a development of that theoretical understanding so as to accommodate the emerging clinical experiences.

All the chapters in this volume address the Mary’s struggle to come to know and tolerate some of the indisputable facts of life, including dependency and the inevitability of loss.

This dissertation is concerned with the conceptual foundations of cognitive behavioral theory. I undertake an integration of the theory and technique of cognitive behavioral theory in this dissertation. It is designed to introduce essential theoretical tenets of cognitive behavioral theory, especially as they apply to the client, and to illustrate how this theoretical model lends itself to the clinical situation. It is important to remember that cognitive behavioral theory is a clinical science. The test of the goodness of its theory is that it generates actions leading to change in a direction taken to be desirable by the client.

This is not a dissertation about looking into the past and finding fault so that all of our present-day problems can be explained away. Too often these days, it appears that people are looking to place responsibility for their problems everywhere except in their own lives and in their own choices. This is not to say that early events in our lives don’t influence our current functioning — they do. It is to say, however, that events in the past cannot be changed. Instead, what we do with those events, how we think about those events, and how we use those events to make us stronger in our present day lives is what is important.

There are times when it is good to pause for a moment and ask ourselves: Whence have we come? Where do we stand now? Where are we going? This dissertation attempts to answer these questions for the field of cognitive behavioral therapy. As I resisted the idea of a dissertation consciously, I was already at work writing it on a preconscious level. When I found myself one afternoon running through points of interpretation ‘in my head,’ I realized that the question had been decided for me. A fresh rethinking created opportunities to return to the received canon, to rescrutinize cognitive behavioral theorists and themes and, additionally, to treat at length thinkers I incorporated selectively or inadequately earlier: I had in mind Beck and…. And so the die was cast.

In this dissertation I attempt to do two things. First, I try to trace the history of cognitive behavioral theory. Second, I try to incorporate the theory with clinical practice. My major aim in writing this dissertation has been to develop an integrated position with respect to knowledge about cognitive behavioral theory.

Psychologists neither live nor work in a vacuum. Each day, students of psychology learn concepts and techniques that will affect their interactions with other people, whether as clients, co-workers, or as companions, for the rest of their lives. Each day, instructors face the responsibility of teaching those students. Each day, researchers gather data and draw conclusions upon which both the knowledge of psychology and its application are based. And, each day, clinical practitioners must apply the concepts and techniques they were taught in graduate school, as well as newly developed theories and applications that they later learn, in order to assist to the greatest extent possible the individuals and families that they serve.

Regardless of the environment in which psychologists work, whether they are involved in basic research or education or applied psychology or clinical practice, they are seeking out real world issues and functional methods for understanding the impact of those issues on individuals.

There is still much to be learned. Some processes and methods of coping that may be “healthy” at one moment in an individual’s life may, 6 months, a year, or 5 years later, be less effective as a coping strategy. Psychologists — who are as intensely concerned with generating new knowledge about human reaction and interaction as they are with helping others — have a vital, day-to-day role to play in identifying, assessing, and treating those individuals faced with personal and shared life crises.

At one point or another in our lives, we are all beginners. We begin college, a first job, a first love affair, and perhaps a first dissertation project. We bring a great deal to these new situations, including our temperament, previous education, and family situations. Yet, as adults, we also learn. In romantic relationships, couples report having to learn how to interact successfully with their partners. College students routinely report being better at reading, studying, paper writing, and test taking as seniors than as freshmen. They have learned how to be students while they were students. Now close to graduating, some view they have finally mastered the role.

Ideally, of course, we would have the necessary information in hand before we needed it. We would already know, without being told, what makes a loved one angry or frustrated. All students would be spared the frustration of working hard on a paper and having it not be well received. Especially, researchers would never make mistakes.

Indeed, some individuals go through life believing that they should know how to do something ahead of time. In this view, mistakes are aberrations. After making a mistake, individuals can torture themselves with repeated accusations and self-blame. They see their foibles as an indication of their own lack of capability as a person. Some plunge into despair and conclude they will never sustain a romantic relationship, succeed in college, or complete a valuable research project.

Nevertheless, the reality is that learning is a process and that mistakes, including costly ones, are integral to that process. Although reading, teaching, and guidance are helpful, there are key aspects — for example, of romantic relationships, college course work, and research methodology– that are mastered through experience. Usually, although not always, humans get better at something through practice. This learning process can be exhilarating, difficult, boring, uplifting, lonely, exciting, frustrating, and scary.

This dissertation is about learning to do therapy suitably called “Cognitive Behavioral Therapy.” It is a common yet fascinating aspect of human behavior. Over time, and many personal and professional transformations later, the cognitive behavioral model of change emerged and evolved.

Writing an introduction is, perhaps, an author’s most personal statement. It is a frame through which we hope the reader will view and interpret what we offer, and it is a final attempt, placed paradoxically at the beginning, to influence how one’s thoughts and, in the case of cognitive behavioral theory, one’s clinical work will be received.

A write this introduction at the end of my journey, aware that it is only as I myself emerge from my embeddedness in this dissertation that I can hope to gain some perspective from which to view it.


The client selected for this dissertation study is a 43-year-old single parent. This client was selected for the following areas of clinical interest: (a) her self-esteem, depression, and anxiety issues; (b) her continuing difficulties in romantic relationships with men; and – her fight with obesity from an eating disorder.

Chapter Two: Review of the Relevant Literature

Background and Overview. Clinical depression can occur in a variety of forms; the three primary types are known as major depression (or unipolar depression), dysthymia, and bipolar disorder (or manic depression). According to Myslinski (2004), “Taken together, they appear to be the most common group of mental health problems in the world, affecting people of every race, culture, and ethnicity. While a small percentage of children are affected, the elderly are much more vulnerable” (p. 150). Generally speaking, the lifetime prevalence of all types of mood disorders in the United States has been estimated to be 17% by recent epidemiological studies and current prevalence estimates range from 4.6 to 10.3% (Kessler et al., 1994). Furthermore, a number of trends suggest that the rates of depression may be on the rise (Bernal, Hargreaves & Miller et al., 1995; Austrian, 2000). Recent findings show that depressive symptoms, with or without depressive disorder, can impair functioning and well-being to levels comparable with or worse than chronic medical conditions such as hypertension, diabetes, angina, arthritis, back problems, lung problems, and gastrointestinal disorders (Bernal, Hargreaves & Miller et al., 1995). While there have been some significant advances in the treatment of depression, a number of problems remain; for instance, less than 20% of individuals who meet the criteria for affective disorders seek treatment from mental health specialists and between 20 and 50% of those who begin psychiatric treatment in controlled trials terminate their participation prematurely (Bernal, Hargreaves & Miller et al., 1995). Finally, only about 40% of those completing treatment remain relatively free of symptoms one year following treatment (Bernal, Hargreaves & Miller et al., 1995). Based on the high prevalence of depression and existing constraints to efficacious treatment approaches, more research is clearly needed to develop methods to prevent and treat depressive disorders.

Depression in General. Despite some significant progress in the conceptualization of depression over the past two decades, much remains unclear concerning its incidence and etiology. The typical measures used in past studies are heterogenous, varying from self-reports to diagnostic interviews; further, the term “depression” connotes a wide range of meanings depending on the setting (Marcotte, Fortin, Povtin et al., 2002). The depressive syndrome is defined by Marcotte et al. As a combination of symptoms that are frequently found together that affect functioning of the individual in the cognitive, behavioral, affective, and somatic domains. Table 1 below sets forth the DSM-IV Diagnostic Criteria for Major Depressive Episode (296.xx):

Table 1. DSM-IV Diagnostic Criteria for Major Depressive Episode.

A. Five (or more) of the following symptoms have been present nearly every day during the same two-weeks period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

1) depressed mood most of the day

2) markedly diminished interest or pleasure in (almost) all activities most of the day

3) significant weight loss, when not dieting, or weight gain (e.g., more than 5% of body weight in a month); or decrease or increase in appetite

4) insomnia or hypersomnia

5) psychomotor agitation or retardation (observable by others)

6) fatigue or less of energy

7) feelings of worthlessness or inappropriate guilt

8) diminished ability to think or concentrate, or indecisiveness

9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation, a specific suicide plan, or suicide attempt

B. The symptoms do not meet criteria for a mixed mood episode.

C. The symptoms cause clinically significant distress, or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance e.g., drugs abuse, medication) or general medical condition.

E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for more than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation (Adapted from DSM-IV).

Studies have also shown that there is high co-morbidity between depression and substance abuse. It has been suggested that, “the rates of depression in drug-using populations exceed those in the general population” (McBride et al., 2000, p. 71). The co-morbidity relationship between depression and substance use disorders is typically attributed to a causal relationship or an etiological factor that may be shared by both disorders; for instance, Swendsen and Merikangas (2000) write that “the association of alcoholism with depression is likely to be attributable to causal factors rather than a shared etiology, but the scarcity of information for other classes of substance use disorders precludes similar conclusions regarding their association with depression” (p. 173).

Dysthymia: Definitions and Discussion. Dysthymia is a hybrid construct which combines elements of the descriptive and psychodynamic literatures on neurotic depression, the depressive temperament; personality, and chronic depression (Klein, 1991). While generally presumed to be a mild form of mood disorder, the DSM — III (American Psychiatric Association, 1980) and DSM–III — R criteria for dysthymia identify a relatively severe condition (Klein, 1991). People with dysthymia generally suffer from low-grade but chronic depression that can last for years and, like cyclothymia, may be mistakenly seen as characterological. According to Austrian, “These people frequently say they do not remember a time when they were not depressed, yet they may function relatively well outside of interpersonal relationships. The initial onset may be insidious. Without intervention, this milder depression will persist” (Austrian, 2000, p. 37). Dysthymia may be preceded, and later follow, an episode of major depression; it is during this period that interventions will most likely be sought. Dysthymia can be more persistent but less severe than major depression; there is often a poorer level of baseline functioning, and there is a poorer prognosis; if dysthymia and major depression coexist (“double depression”), the prognosis is even more grim (Austrian, 2000).

According to Austrian (2000), dysthymia (formerly known as “neurotic depression”) is a term that is derived from the Greek for “ill humor” or “a bad state of mind;” the author notes that “It is a milder, more chronic depressive disorder: an individual is not free of symptoms for more than two months in a period of at least two years. It is insidious, chronic, lingering, and often misunderstood, misdiagnosed, and mistreated” (p. 34). Unfortunately, there remains a paucity of information about dysthymia and its relationship to the factors that generally contribute to depressive disorders; Crosby, Eames and Westermeyer (1998) suggest that this lack of understanding most likely relates to two fundamental constraints:

1) the long duration required for a dysthymia diagnosis (i.e., two years in adults); and, 2) the minor depressive symptoms exhibited by patients with dysthymia may resemble those caused by other conditions.

This difficulty is diagnosis was confirmed by a study conducted in the Netherlands by Tiemens, Ormel, and Simon (as reported in Maruish, 2000), which found a high degree of variability in the accuracy of detection of various types of depression for a sample of 340 primary care patients. According to Maruish, “The detection rates for patients receiving International Classification of Diseases, 10th Revision (ICD-10)-based diagnoses were approximately 60% for those with current depression, 54% for dysthymia, 59% for generalized anxiety disorder, 79% for agoraphobia, and 92% for panic disorder, with approximately 54% of those with any definite disorder being detected” (p. 12). Likewise, Klein (1991) points out that “dysthymia is a more diffuse state associated with feelings of uncontrollability and hopelessness, much as anxiety is conceptualized” (p. 78). Similar to panic disorder, individuals can experience “uncued” episodes of sadness/distress which are experienced as unpredictable and/or uncontrollable, and which may then trigger dysthymia; Klein says “double depression” is a good example of this phenomenon.

Despite these constraints to diagnosis, clinicians do have some solid guidelines to follow.

Generally speaking, dysthymia is a depressive disorder in which irritable mood is observed by others for 2 years or more in adults and at least 1 year or more in children and adolescents (Butcher, 1987); prevalence rates for depression (including dysthymia) in adolescents have been found to range from 2% to 5% (Hammond & Romney, 1995). Dysthymia lasts longer and shows milder symptoms than depression (Butcher, 1987).

Etiology and Incidence of Dysthymia. Mood disorders, also referred to as affective disorders, involve episodes of depression or mania or both; DSM-IV includes two types of mood disorders:

1. Bipolar disorders a. Bipolar disorders b. Cyclothymia

2. Unipolar depressive disorders a Major depressive episode b. Dysthymic disorder

Although major depression has a lifetime prevalence of 17% and is the most common mental disorder, current diagnostic thinking uses duration of episodes as a criterion; consequently, it would appear that mood disorders actually exist on a continuum. For example, Austrian (2000) notes that many people with cyclothymia are vulnerable for episodes of mania and major depression, and many diagnosed with dysthymia experience major depression. Even though major depression is the most common mental disorder, mood disorders are the most undertreated of all mental disorders. Similarly, Bernal et al. point out that, “Depression can be conceived of as a continuous phenomenon, in which symptoms constituting the major depressive syndrome may wax and wane until, for reasons that are not yet totally understood, they cross a threshold at which we label the person’s condition a major depressive episode” (p. 200). Because the threshold is variously defined in terms of a combination of number, severity, and duration of symptoms, it makes conceptual sense to attempt to decrease these factors in order to prevent the eventual crossing over into a clinical episode (Bernal et al., 1995).

Depression is second only to coronary heart disease in the number of days people spend in the hospital or disabled at home. Today, it is estimated that the costs associated with depression amount to $11.7 billion in days lost at work, $12.1 billion in decreased productivity, and $7.5 billion in costs for psychiatric intervention, including medication, psychotherapy, and hospitalization annually (Austrian, 2000). Patients who suffer from posttraumatic stress disorder (PTSD) may experience phobias, panic disorder, generalized anxiety disorder, depression, or dysthymia; however, if there is an established history of trauma, then PTSD is the primary diagnosis (Austrian, 2000). It has been estimated that more than 20% of the population will experience some degree of depression at some point in their lives (Waldinger 1990).

The National Comorbidity Survey found a lifetime prevalence of 17.1% for a major depressive episode (12.7% for men and 21.3% for women) and a 12-month prevalence of 10.3% (7.7% for men and 12.9% for women). The same survey found a 6.4% lifetime prevalence for dysthymia (4.8% for men and 8.0% for women) and a twelve-month prevalence of 2.5% (2.1% for men and 3.0% for women). Finally, dysthymia has been shown to affect 36% of people who are seen in psychiatric clinics (Austrian, 2000).

Women are twice as likely as men to experience a major depression, and dysthymia also is thought to be more prevalent in women than in men. It is currently believed that the gender discrepancy does not have a biological base, although hormonal changes occurring with menstruation, childbirth, and menopause can cause depressive symptoms (Austrian, 2000). Social and cultural risk factors are considered to be more relevant causes; for women, these can include: a higher rate of poverty, unhappy marriages, physical, sexual, and emotional abuse, fewer opportunities to change one’s life pattern, greater cultural acceptance of women’s acknowledgment and discussion of depression, and the greater prevalence of women patients seen in psychiatric hospitals and clinics. Finally, while major depressions can occur at any point in a person’s life, the first episode usually occurs in the 20s (Austrian, 2000).

According to Austrian, and not surprisingly, the current rates of depression, ranging from adjustment reaction with depression to major depression, were higher for people who are HIV-positive or have AIDS than for the general population. These patients may also experience mania for the first time; however, there are no data developed to date concerning the prevalence of this condition (Austrian, 2000). While the age of onset of dysthymia is usually in adolescence, young adulthood, or even childhood, it typically occurs first in the twenties; nevertheless, depression in general occurs in all socioeconomic groups, and there is evidence that it has increased since the mid-20th century (Austrian, 2000).

Causes of depression. According to the National Mental Health Association, a wide array of events can contribute to clinical depression; in some cases, a number of factors seem to be involved but in others, a single factor appears to be able to trigger the illness. Furthermore, in some cases, people can become depressed for no apparent reason at all. Some of the commonly cited causes of depression include the following:

Biological. People with depression typically have too little or too much of certain brain chemicals, called “neurotransmitters.” Changes in these brain chemicals may cause, or contribute to, depression.

Cognitive. People with negative thinking patterns — people who are pessimistic, have low self-esteem, worry too much or feel they have little control over life events — are more likely to develop depression.

Genetic. A family history of depression increases the risk for developing the illness. Depression, however, can also occur in people who have had no family members with the disorder (Nighswonger, 2002); it also appears that certain forms of dysthymia are genetically related to bipolar disorder (Butcher & Speilberger, 1987).

Situational. Difficult life events, including the death of a loved one, divorce, financial problems or moving to a new place, can contribute to depression.

Co-occuring. Depression is more likely to occur along with certain medical illnesses, such as stroke, heart disease, cancer, Parkinson’s disease, Alzheimer’s disease, diabetes and hormonal disorders. This is called “co-occurring depression” and should be treated in addition to the physical illness.

Medications. Some medications for various illnesses can actually cause depression (Nighswonger, 2002, p. 39).

The results of studies over the last decade using refined imaging techniques have begun providing researchers with new insights into the potential etiology of depressive disorders. According to Marano (1999), these new imaging techniques have provided “unprecedented looks into the neurobiology of depression, showing what goes on in the brains of patients as they process positive and negative experiences. Though in its infancy, the work is already forcing a radically revised view of depression, one that promises new treatments for the future” (p. 30). The more recent findings that have emerged from these studies include:

Regarding depression as “just” a chemical imbalance wildly misconstrues the disorder. “It is not possible to explain either the disease or its treatment based solely on levels of neurotransmitters,” according to Yale University neurobiologist Ronald Duman, Ph.D. The newest evidence suggests that recurrent depression is in fact a neurodegenerative disorder that works by disrupting the structure and function of brain cells, destroying nerve cell connections, even killing certain brain cells, and precipitating cognitive decline. At a minimum, depression causes neural constraints to the processing of information and keeps people from responding in timely ways to life’s challenges.

Human emotions take shape in a neural circuit involving several key brain structures, including the hippocampus, the amygdala, and the prefrontal cortex. In depression, faulty circuitry fails both in generating positive feelings and inhibiting disruptive negative ones.

Stress-related events may trigger fully 50% of all depressive episodes and early life stress can create conditions for people to become depressed later in life. Ongoing research in animals and in people demonstrates that early strain can alter nerve circuits that control emotion, exaggerating later responses to stress and creating the neurochemical and behavioral changes of depression. In other words, the more in-depth researchers probe the brain, the more they validate the psychoanalytic view that early adverse life events can create adult psychopathology.

Depression is not just a disorder from the neck up but a disorder involving many body systems. It both leads to heart disease in otherwise healthy adults and magnifies the deadliness of existing cardiac problems. What’s more, it accelerates changes in bone mass that lead to osteoporosis. “The lifetime risk of fracture related to depression is substantial,” researchers have declared in the New England Journal of Medicine.

Just as nerve cell connections can be destroyed in depression, perhaps they can be rebuilt. The common denominator in effective antidepressant treatments, including electroshock, may be their ability to stimulate the sprouting of neurons in key brain regions, literally the forging of behavioral flexibility. A neurochemical pathway newly identified promises to revolutionize therapy by suggesting ways to do this better and faster.

The adult brain has a degree of plasticity that is astonishing researchers. “The big news is the structural plasticity of the adult brain, the remodeling of neurons,” says neurobiologist Bruce McEwen, Ph.D., of Rockefeller University. “The idea that there are long-lasting, even permanent, changes in structure and function that can affect the way brains process information is the most important part of what we’re doing in the lab. We thought that after birth, the brain is a stable organ like a computer that just works away, and no more new nerve cells are produced. The emphasis was on chemical imbalances, as if the circuitry itself was fairly stable. All these changes — cell loss, atrophy of connections — that’s very new, and still catching people by surprise” (Marano, 1999, p. 31).

There is a 6.1% chance that a person will develop major depression or dysthymia in his or her lifetime, and the likelihood that a person will suffer some depressive symptoms in his/her lifetime is currently estimated at 23.1%. The average age of first onset of major depression is 25-29 years, and the average duration of all depressive episodes is 20 weeks. The percentage of patients who recover within a year after onset of symptoms is 74% and the likelihood of a second or more episodes of major depression stands at 80%; the likelihood of a second or more episodes of minor depression is an alarming 100% and the median number of major depressive episodes during a patient’s lifetime is four. The percentage of patients whose depression takes a chronic unremitting course is 12% and the incidence of depression in women vs. men is 3.62 versus 1.98 per 1000 per year (Marano, 1999).

Symptoms of Dysthymia.

The symptoms of dysthymia are similar to major depressive episodes (including low mood, fatigue, hopelessness, difficulty concentrating and disruption in appetite and sleep). These criteria do not include thoughts of suicide or death, and there is a 6.4% lifetime prevalence for dysthymia (Austrian, 2000). According to Butcher and Speilberger (1987), “The cardinal feature of dysthymic disorder is chronic-intermittent depression that lacks the severity of a major depressive episode” (p. 23). Because chronic depression is a concomitant of numerous psychiatric and medical illnesses, dysthymic disorder encompasses an extremely heterogeneous group of afflictions; consequently the relationship between dysthymic disorder and full syndromal bipolar affective disorder is not unitary. Using Akiskal’s (1983) nosologic framework, Butcher and Speilberger suggest that the heterogeneity of dysthymic disorder can be viewed according to the four principal subtypes of dysthymia:

1. Chronic primary dysthymia, which supervenes following incomplete recovery from a major depressive episode. Patients with chronic primary dysthymia apparently do not manifest dysthymia premorbidly, so they are not pertinent to a behavioral high-risk paradigm.

2. Chronic secondary dysphoria, which complicates the course of a preexisting medical or nonaffective psychiatric illness. Dysphoria parallels the course of the underlying illness and does not appear to represent a primary affective process.

3. Character spectrum disorder, which encompasses a melange of conditions in which personality disturbance and chronic dysphoria are prominently intermixed. These conditions begin insidiously before adulthood and pursue a chronic, lifelong course.

4. Subaffective dysthymic disorder, which represents a mild form of primary affective illness. Like cyclothymia, this disorder has an early developmental onset and an intermittent, fluctuating course (Butcher & Speilberger, 1987, p. 23).

Citing guidance from the National Mental Health Association, Nighswonger (2002) reports that professional assistance should be sought if an individual experiences five or more of the following symptoms for more than two weeks or if the symptoms interfere with daily life:

Persistent sad, anxious, nervous or “empty” moods;

Sleeping too little, early-morning awakening or sleeping too much;

Reduced appetite and weight loss, or increased appetite and weight gain;

Loss of interest in activities once enjoyed;

Restlessness or irritability;

Persistent physical symptoms that do not respond to treatment (such as headaches, chronic pain or digestive disorders);

Difficulty concentrating, remembering or making decisions;

Fatigue or loss of energy;

Feeling guilty, hopeless or worthless; and Thoughts of suicide or death (Nighswonger, 2002, p. 38).

Measures of Depression

Clinicians have a number of scales that have known reliability and validity to choose from when assessing depression, depending on their unique requirements, including:

1) Beck Depression Inventory (BDI);

2) Center for Epidemiological Studies’ Depression Scale (CES-D);

3) Depression Adjective Checklists (DACLs);

4) Minnesota Multiphasic Personality Inventory Depression Scale (MMPI-D);

5) Self-Rating Depression Scale (SDS);

6) Profile of Mood States (POMS);

7) Visual Analog Scale;

8) Hamilton Rating Scale (HRS);

9) Schedule for Affective Disorders and Schizophrenia (SADS);

10) Diagnostic Interview Schedule (DIS);

11) Raskin Three Area Rating Scale;

12) Brief Psychiatric Rating Scale;

13) Feelings and Concerns Checklist (FCCL);

14) Social Adjustment Scale; and 15) Hopkins Psychiatric Rating Scale (Miletech, 1995).

The Beck Depression Inventory (BDI), first introduced in 1961, can be used to assess depression; a 1971 revision correlated highly with the original version. Since 1961, there have been over 1,000 research studies associated with the BDI. According to Miletech (1995), an individual with a fifth-grade reading level can comprehend the twenty-one items on the BDI and the self-administered inventory can be completed in five to ten minutes. Further, in order for practitioners to develop effective case conceptualizations of the nature of the problems facing their clients, they must first integrate a sophisticated understanding of the cognitive model with a thorough understanding of their individual clients; Beck’s Modal Information Processing Model provides another method by which this can be accomplished (Needleman, 1999).

Theoretical Bases for Clinical Treatment

Cognitive behavioral therapy (Beck et al., 1979) remains the best-studied modality in treating dysthymic disorder (Klerman et al., 2000). The popularity of the technique suggests that it has proven itself effective in a variety of clinical settings, a suggestion that has been borne out in the studies to date (Bower, 2003). The technique’s popularity may be attributable to the manner in which treatment session are developed in a collaborative “therapeutic alliance” between the therapist and patient. From Bower’s perspective, “The therapeutic alliance is probably more important to psychotherapy’s effectiveness than specific techniques are” (p. 357). Citing research by Klein et al. who studied 367 people who had suffered from major depression for at least 2 years, Bower reports that the cognitive behavioral techniques were shown to be highly effective. The participants in the study by Klein et al. (2003) received 16 sessions of cognitive-behavioral therapy over a 3-month period. Bower reports that, “In such sessions, psychotherapists help a patient identify his or her harmful thinking patterns so as to develop better coping strategies and social skills. More than half the patients were also prescribed an antidepressant” (p. 358). The study required subjects to complete surveys at weeks 2, 6, and 12, that asked whether a mutually agreed-upon plan existed for achieving goals in the therapy and that gauged the perceived quality of the patient-therapist relationship.

According to Bower, depressed respondents, who, on the survey, reported a strong therapeutic alliance by week 2 demonstrated the most significant improvements by the end of treatment sessions. Bower writes, “This pattern held after the team accounted for factors that could have influenced whether a patient formed a therapeutic alliance, such as sex, the severity and length of the depression, childhood abuse, and anxiety symptoms” (p. 358). The respondents who received a combination of medication and psychotherapy reported slightly stronger therapeutic alliances than the others reported; the extra attention from a pharmacologist for people taking medication may have contributed to this effect, the scientists suggested (Bower, 2003).

Klein and his colleagues also reported that in well-controlled studies of depression and other conditions, placebo therapies such as supportive counseling have achieved results comparable to those of specific psychotherapies. “The therapeutic alliance influences this placebo effect,” Bower adds. Beck, the creator of cognitive therapy, maintained that if thoughts can perpetuate unhappiness, learning to think in different ways should make patients feel better; as a result, cognitive therapists have aimed at altering the intracranial conversations that theoretically sustain the client’s misery (Fein, 1992). Even Beck, though, has pointed out that there are still many gaps in the power of cognitive, behavioral, psychodynamic, or pharmacotherapeutic analyses to explain common clinical events (Blau, 1993).

In their book, Using Cognitive Approaches with the Seriously Mentally Ill: Dialogue across the Barrier, Ellis and Olevitch (1995) note that it is not the events that happen to people that can lead to depression, but rather their beliefs about the events. These authors call certain thoughts “irrational”; these thoughts cause the individual to suffer from unnecessarily painful emotions, such as anger and depression. “By learning to talk themselves out of these irrational beliefs,” they say, “people can reduce their emotional suffering” (p. 8). A major contributor to this approach to therapy is Aaron Beck, who calls his technique “cognitive therapy” (Ellis & Olevitch, 1995, p. 8). Beck was trained in psychoanalysis; however, one of his earliest professional enterprises was to evaluate Freud’s assertion that depression is simply anger that has been turned inward. According to Fein (1992), “When his research seemed to show that this was not the case, Beck turned in a different direction. He rejected the validity of the unconscious and emphasized the role of cognitive processing errors in keeping people unhappy. This in turn led him to proselytize for short-term therapies directed at solving specific client problems, such as depression” (p. 180). Beck speculated that unhappy people are trapped in cognitive distortions that do not allow them to solve their problems, and that in their unhappiness they are victimized by “automatic thoughts” that perpetuate their misery. Fein says, “The solution to this dilemma was to lead them to correctly perceive their situation and stop sabotaging their own efforts. As a cognitivist, he believes that the key to reducing emotional distress lies with correct thinking” (p. 180). A fundamental tenent of Beck’s therapeutic strategy was the belief that the path to the emotions invariably was reached through the client’s cognitions. Beck’s perspective is that feelings are reactions to judgments of fact and that when these judgments are changed, the feelings must change as well. As a direct consequence, if depression results from an interpretation that a loss has occurred, a different interpretation should occasion a different feeling; likewise, interpreting a situation as dangerous provokes fear, while perceiving it as safe is reassuring (Fein, 1992).

According to Brewin (1996), “Cognitive-behavior therapy (CBT) for anxiety and depressive disorders is well established as a promising and frequently effective treatment. CBT is a generic term referring to therapies that incorporate both behavioral interventions (direct attempts to reduce dysfunctional emotions and behavior by altering behavior) and cognitive interventions (attempts to reduce dysfunctional emotions and behavior by altering individual appraisals and thinking patterns)” (p. 33). A practitioner of cognitive behavioral therapy would likely believe that depression is producing distorted thoughts and perceptions of the patient’s current situation; the patient also “buys into” these mood-congruent, irrational negative thoughts such as “I’m worthless” and “Nothing ever goes right for me”; or, “Things are just terrible in my life right now, and they will probably never get any better.” This syndrome allows these thoughts to negatively influence the patients’ behaviors; however, if patients can learn to examine, test, and challenge the irrational thoughts, they may start to eliminate them and live their lives fully once again (Beck et al., 1979). This type of intervention is based on the assumption that prior learning is currently having maladaptive consequences, and that the purpose of therapy is to reduce distress or unwanted behavior by undoing this learning or by providing new, more adaptive learning experiences (Brewin, 1996).

CBT practitioners believe that symptomatic change follows cognitive change, this cognitive change being brought about by a variety of possible interventions, including the practice of new behaviors, analysis of faulty thinking patterns, and the teaching of more adaptive self-talk. Although incidental cognitive change can be brought about by a variety of interventions, including pharmacological ones, evidence is starting to mount that in behavior therapy and in CBT itself improvement is linked to a corresponding change in cognitions. Subsequent maintenance of gains is also often related to cognitive measures. Despite this growing consensus, the actual mechanisms underlying CBT are perhaps better described in the scholarly literature than they are understood, and there remains considerable controversy concerning precisely what has been learned and how change actually take place (Brewin, 1996). While cognitive behavioral techniques have received a significant amount of research attention and support in recent years as a treatment for depression, there have been relatively few studies conducted concerning its effectiveness in the treatment of anxiety disorders; however, the results of these studies have been generally encouraging (Beck, Emery & Greenberg, 1985).

Cognitive-Behavioral Intervention Strategies and Goals

Studies have shown time and again that therapists can use cognitive-behavioral interventions to help individuals and families improve the quality of their lives: “Depression is a problem for which cognitive therapy has long been recognized as effective treatment” (Ellis & Olevitch, 1995, p. 56). The process is not without its challenges and constraints, though: “Although the use of the cognitive approach can be fruitful,” Fine and Schwebel point out, “it challenges those that apply it because the search for underlying cognitions in an individual can be difficult, because differentiating between one’s perceptions and reality is often difficult, because individuals are unaccustomed to such self-study, and because of a multitude of other reasons” (1994, p. 18). Because every person is unique, the key to successful CBT interventions is to develop a good working relationship between the therapist and patient in which the information required for assessment and resolution can be identified and brought out into the open.

According to Needleman, in cognitive therapy, the therapeutic relationship is entirely collaborative, with the therapist and the client both being full partners in the therapeutic process; within this framework, the client and therapist must each make a unique contribution: “Clients provide the ‘raw data’ for therapeutic work. This is because only they have direct access to their inner experience, the events that occur outside sessions, and their personal history. The therapist provides expertise, skills, guidance, and a supportive interpersonal context, all of which encourage positive change” (Needleman, 1999, p. 55). The collaborative nature of the process is emphasized by Bower (2003), who notes that psychotherapists frequently characterize their techniques as being scientifically grounded and able to alleviate a wide range of specific mental disorders.

Bower says, “These professionals increasingly consult manuals that describe specific procedures for treating depression and other conditions. However, much of psychotherapy’s power in quelling chronic depression comes from a less-formal aspect of therapy, according to a new study. A 3-month course of cognitive-behavioral psychotherapy proves most beneficial if the therapist and patient establish an emotional bond early on and work toward common goals” (p. 357). Needleman suggests that yet another way that therapy is collaborative is that the therapist and the client must work jointly on the various therapeutic tasks involved; for instance, together the therapist and the client select therapy goals. Therapy goals for these sessions should be specific, measurable, and, preferably, positively framed. Some of the common goals for cognitive therapy include:

a) improving mood states (e.g., improving mood, increasing mood stability, increasing relaxation or calmness, increasing ability to cope with stressful interpersonal situations), b) decreasing symptoms (e.g., the frequency and intensity of obsessions and compulsions, suicidal ideation, and panic attacks), c) understanding the subtleties of one’s maladaptive responses, d) increasing social activities, e) increasing motivation, f) learning social skills such as appropriate assertiveness, and g) developing a sense of purpose in life, among others (Needleman, 1999, p. 56).

According to Needleman, the line between assessment and treatment is an artificial one: “Questions that therapists ask during assessment can begin to elicit changes in the client. For example, when therapists assess for the various elements of the cognitive model related to clients’ problems, clients often become more cognizant of the role of various factors in establishing or maintaining their problems” (p. 70). This is not to say, of course that assessment should not continue throughout the treatment process; Needleman points out that, “The therapist should continue to ask about and gather new information about the client and the situation. Ongoing assessment of this kind helps fine-tune the therapist and client’s conceptualization of the client’s difficulties” (p. 71). The initial assessment of the client is an important component of the CBT approach.

During the initial interview, Klerman, Markowitz and Weissman suggest that a detailed review of the patient’s symptoms (of their presence, duration, and severity) should be undertaken. This initial assessment of patient symptoms serves three fundamental purposes:

1. It allows the psychotherapist to confirm the diagnosis;

2. It reassures the patient that the symptoms fit a pattern that is anticipated by the psychotherapist and is understood as a clinical syndrome; as a result, the patient understands that seemingly inexplicable, aberrant, and unrelated symptoms and behaviors are part of a pattern, time-limited, and, although uncomfortable, treatable; and, 3. It sets the symptoms in a specific time frame and in the interpersonal context that will be the focus of the psychotherapy (Klerman et al., 2000).

During this assessment, any of the systematic assessment scales described above that include the full depressive range of symptoms can be used; however, at a minimum, Klerman et al. recommend that the review of symptoms should cover as many of the following areas as possible, many of which were particularly relevant in Mary’s case:

1. Depressed Mood.

Mood is assessed through such questions as:

How have you been feeling over the past two weeks, including today?

Can you describe what your mood has been?

Have you felt blue, down in the dumps, depressed, or sad?

Have you wanted to cry?

Does crying help?

Have you felt that you would like to cry, but that you were beyond tears?

Have you had these feelings most of the day, nearly every day, for the past two weeks? How long have you felt this way?

2. Diminished Interest or Pleasure in Activities.

Have you lost interest or pleasure in most of the activities you usually enjoy?

Is there anything you can still enjoy? (How long does the pleasure last?)

Has your lost of interest or pleasure been for most of the day, nearly every day?

3. Change in Weight or Appetite.

Has your appetite changed during this period?

Have you been eating much more or less than usual?

Do you have to push yourself to eat? Nearly every day?

Has your weight changed in the last weeks or month?

If so, how much weight have you lost (or gained)?

Have you been dieting or trying to lose weight?

Have your clothes been fitting you differently?

Assess the patient’s maximum weight loss (or gain) since the start of the illness.

4. Insomnia or Hypersomnia.

Have you had trouble sleeping over the last two weeks?

Early insomnia:) Have you had trouble falling asleep most nights?

Have you been taking sleeping pills?

How long does it take you to fall asleep?

What goes through your mind as you lie there?

Middle insomnia:) When you fall asleep, do you sleep soundly?

Are you restless, or do you keep waking?

How many times a night do you wake up?

Do you get out of bed? Is that just to go to the bathroom?

Late insomnia:) Do you wake up early in the morning?

If you awaken early in the morning, can you fall back asleep?

Do you get up earlier than you would normally get up?

Hypersomnia:) Have you found that you’ve been sleeping too much lately?

How much time are you spending in bed?

How much more than normal is that? Do you take naps during the day?

5. Psychomotor Agitation or Retardation.

Has it been very hard for you to sit still lately?

Have you been so worked up and restless that other people have noticed?

Or have you felt slowed down? So slowed down that it’s been hard to do anything, or even to think clearly?

According to Klerman et al., questions of this type will help the therapist assess the client’s functioning during the past weeks; however, the therapist should still principally assess psychomotor agitation or retardation on the basis of observation in the interview, instead of simply focusing on subjective complaints of restlessness or slowing down.

Chapter Three: Methodology case study methodology was used for this study based on its superior qualities compared to other research methods. According to Zikmund (2000), the case study method is “an exploratory research technique that intensively investigates one or a few situations similar to the researcher’s problem situation” (p. 722). The primary advantage of this approach is that a subject area can be investigated in depth and with greater attention to details that might be of interest to the researcher (Leedy, 1997). One test of the appropriateness of one research methodology over another generally involves counting the number of quality criteria that are satisfied in a study; according to Jensen and Rodgers (2001), “The higher the count, the better the quality of the study. That is, the criteria are additive” (p. 235). This is because when a whole range of quality measures are applied to a single case study, it will inevitably result in poor results; likewise, when a whole range of quality measures are applied to a study using a different methodology (survey research, for instance), this approach will most likely result in poor results as well. According to Jensen and Rodgers, “The errors of this logic lie with the application of all quality criteria to each single, isolated study pertaining to a particular point in time (or several points in time), and with the assumption that all measures of quality are appropriate for all methodologies” (p. 235).

Data-gathering Method and Database of Study

The critical review of the peer-reviewed and scholarly literature was accomplished by using a variety of sources, including EBSCO, Questia, selected premium online services, reliable online governmental and organizational sources, as well as university and public libraries. Wood and Ellis (2003) identified the following features as being important outcomes of a well-conducted literature review:

It helps describe a topic of interest and refine either research questions or directions in which to look;

This technique presents a clear description and evaluation of the theories and concepts that have informed research into the topic of interest;

It clarifies the relationship to previous research and highlights where new research may contribute by identifying research possibilities which have been overlooked so far in the literature;

It also provides insights into the topic of interest that are both methodological and substantive; and,

It demonstrates powers of critical analysis by, for instance, exposing taken for granted assumptions underpinning previous research and identifying the possibilities of replacing them with alternative assumptions;

Finally, a well-conducted literature justifies any new research through a coherent critique of what has gone before and demonstrates why new research is both timely and important.

Client Information.

The client, as described above, is the oldest of three children of a Middle-Eastern family that emigrated to the United States. The client took the initiative to request counseling and therapy as part of her own plan to help herself adjust to the demands of community living and to manage her illness. She presented herself with a flat affect and expressed anxiety related to her interpersonal situations and tasks. Interpersonally, she was withdrawn and socially isolated. Behaviorally, she was inactive and unable to work, but able to live independently.

A. Presenting Problem. The client reported struggling throughout childhood to live up to her mother’s expectations and secure her father’s love; failing at both. Depression and self-hate were her ever-present and unwelcome companions. They were accompanied by an insatiable craving for food, and (from adolescence on) by a similar craving for sex with inappropriate men. She was plagued with intermittent episodes of depression throughout her life.

B. Client’s Current Symptoms. She claims to have empathy for the needs of others, both family and friends, that is seldom reciprocal; but feels that she gets little in return. She begrudgingly admits that this is a source of annoyance and bitterness to her.

She has not formulated even vague details of a satisfying adulthood. Instead of looking ahead full of energy and plans, this client is clamped in a vise of psychic conflict and behavioral paralysis.

C. Therapist’s Observations of Client’s Symptoms.

D. Family History. Mary’s father was described as a strict disciplinarian. He was “moralistic and critical” and although very concerned about punishing Mary for misbehaving, rarely, if ever, physically controlled her. Instead, he would discuss with his daughter the sinful nature of his daughter’s behavior. Consequently, Mary developed a strong sense of morality and accompanying guilt. Active in the community, her father spent a great deal of time with other people and away from the house.

Her developmental history revealed a fairly uneventful course. Significant problems were not noted by Mary in early childhood or early-middle adolescence. Mary lived with one son; the other was in a group home. Mary also reported she had periodic difficulties in getting along with her parents, especially her father, who would become belligerent and critical of family members. She did not elaborate.

Extrapolating from these findings, it is possible to make several recommendations. First, therapeutic work must still place a premium on the establishment of a working alliance, with this being the critical initial focus and essential to setting the stage for subsequent supportive-expressive work directed toward helping Mary understand her depression and disappointment in relation to self and others.

E. Medical History. Under development.

F. Psychotherapeutic History. As therapy commenced, the focus was on using cognitive interventions to produce changes in thinking, feeling, and behavior in the client (Kendall, 1991). The client was provided with ideas for experimentation, helped to sort through experiences, and aided in problem solving. Emphasis was placed on influencing the client to think for herself, maximize personal strengths, and acquire cognitive skills and behavior control.

The Cognitive Behavioral Therapy used focused on how the client responded to her cognitive interpretations and experiences rather than the environment or the experience itself, and how her thoughts and behaviors are related. It combined cognition change procedures with behavioral contingency management and learning experiences designed to help change distorted or deficient information processing (Kendall, 1991).

These new experiences helped to broaden the way the client viewed her world — they do not remove unwanted prior history, but helped to develop healthier ways to make sense of future experiences. The focus of CBT was not to uncover unconscious early trauma or biological, neurological, and genetic contributions to psychological dysfunction, but instead endeavored to build a new, more adaptive way to process the client’s world.

CBT was used to help the client achieve lasting, positive change in therapy. This was also accomplished by modifying psychological structures through: (a) relaxation strategies; (b) guided imagery; – meditation; (d) incentives and self-rewards; and (e) social skills training.

G. Substance Use/Abuse. Under development.

H. Initial Diagnosis. The diagnosis of the client was as follows:

Axis I 300.4 Dysthymic Disorder

Axis II None

Axis III None

Axis IV None

Axis V GAF = 50 (on admission)

GAF = 75-80 (at discharge)

According to Austrian (2000), the use of Axis IV, psychosocial and environmental problems, and Axis V, global assessment of functioning, is optional, although both would be considered essential to a robust psychosocial assessment. For example, according to DSM-IV, an individual could be considered to have dysthymia, a chronically depressed mood for at least two years (349), and intervention planned without the clinician’s being aware of additional stressors, such as a history of unemployment, single parenthood, many losses, or a chronic medical condition, will be ineffective.

I. Impressions of Client. The emotional trauma that accompanies low self-esteem is the challenge I had when facilitating growth for Mary. This growth is a mental metamorphosis. It is a change in attitude. It is a change in beliefs. It is a cognitive change that allows for a better future; a future where self-esteem is positive, where ability has been realized, where fear has been replaced by love. Therefore, the butterfly is a symbol of hope. For, through her painful life experiences (struggles), Mary can become strong, capable and compassionate, giving opportunities to self-actualize, to heal, to love and be loved in return, and to find fulfillment.

Mary appeared to possess little insight into her problems, became periodically guarded and defensive when queried about areas where she was having problems, and tended to offer explanations couched in denial, rationalization, and minimization. Her mood and affective response to the interview suggested mild variability. Initially apprehensive, this gave way to a more loquacious, comfortable, and animated presentation in which she seemed reasonably at ease. At times, Mary appeared able to modulate her emotions, appearing calm and composed; at other times, she appeared more upset, distracted, disorganized, and almost overwhelmed. Her mood revealed a more even quality: serious, somber, and, at times, pensive and reflective. In rare instances, there was a fleeting suggestion of irritation and anger, but this was contained and did not herald more regressive shifts.

There is the strong hint of diffuse and poorly defined boundaries between herself and others. She appears to have little appreciation of the fact that relationships possess emotional substance or depth: people seem unempathetic, empty, almost nonexistent — simply coexisting. She appears uncomfortable with the possibility of intimacy or emotional closeness and becomes more disorganized when asked to embellish on her own or others’ internal feelings or motivations. There is indication of an increasingly avoidant and distancing style of relatedness.

Mary made an appointment for an evaluation because her depression had increased over the previous two years. Just prior to coming in, she could not find the motivation to go to work and sat overeating in her house for almost a week. At the suggestion of a friend, she made an appointment to see if something could be done to help her out of her condition.

When seen for evaluation, Mary presented as pleasant, cooperative, and chatty, telling the therapist that things were going okay for her. She steered clear of any discussion of problems. She appeared guarded and reserved in her relatedness despite her ostensible friendly posture. She showed little indication of affective upset, not manifesting significant signs of irritation, anxiety, or dysphoria. She did not reference odd or unusual thoughts or concerns, and denied any suicidal fantasies.

She was rather easily engaged in the interview and spent a considerable amount of time talking about the difficulties she was experiencing in relation to school.

Mary then launched into a lengthy discourse about her relationship with her mother, whom she also said she did not like because they had major differences of opinion most of the time. As she gradually depicted her sense of the mother-daughter relationship, it became increasingly apparent that estrangement characterized the status quo. Mary did not see her mother as a source of support or intimacy and portrayed her as a focus of wrath and anger.

Mary’s “story” is of utmost importance to the chronicle of the depressed. Comprehending how those losses affect her enhances my ability to be effective in therapy. As a therapist, I augmented the value of the interview by creating a safe environment in which to talk. The interview opens up old wounds and allows repressed memories to surface.

The emotional boundaries between Mary and me were not as clear as they would be if a stranger were doing the interview. The advantage we had in most situations was that a modicum of trust had already been established.

Knowing the therapist also has its drawbacks. At times, it is easier to talk to a stranger than to someone you know. One often is cautious about revealing material that is highly sensitive, particularly if the person feels he or she will “look bad” in the eyes of the interviewer. Trust, a major emotional and psychological issue, becomes complicated for the client when facing the question, How much can I tell?

Talking about oneself in a safe, comfortable situation is in itself therapeutic. The general feeling expressed by Mary was that it was good to talk. She stated it was the first time she had talked in such depth to anyone. She felt good to unburden herself to someone who understood what she was talking about.

Mary had no verbal memory of parts of her life. Fear is a way of life for some. One of the fears about the interview was that it would bring back not only unwanted memories but unwanted feelings. She experienced the black forest of experience and, after that, entered the jungle of life.

The greatest benefit of the interview was that it gave permission to Mary to “talk.” The talking is no longer just talking; it is now a “telling” and “sharing.” The interview gave her the opportunity to talk about her fears and her anger. Being encouraged to vent her feelings was both an unusual and helpful experience.

Here in the interview, she can talk about those feelings. She knows that the person listening is not only listening but also hearing what she is saying with a willingness to respond. The therapist’s full attention is focused on the person being interviewed. The interviewer is interested in every aspect of the person’s life.

Storm Clouds – Beginning Phase: Sessions 1-4.

Session 1. We began to talk more about her relationship with Ron. It became clearer to me that he was emotionally needy and therefore very controlling. Client felt reluctant to disagree with him and was fearful of his anger. She often dreaded the weekends with him, but felt that he really did love her. When I asked why she did not date other men, she said that she was afraid Ron would fall apart without her, and that there were no other men out there anyway.

Client kept her opinions to herself, preferring harmony to his angry outbursts. She did not pursue friendships with others nor other interests because her job and her relationship were so consuming. Her world was becoming smaller and smaller as she tried to live on the terms set by her job and by Ron. The result was depression. The situation in life in which Mary ignored herself was the trigger to an episode of depression.

The relationship with Ron was difficult to deal with therapeutically. So much in her background, and so much in the culture, told her that first of all, her worth was found in a relationship with a man, and second, she had better maintain relationship harmony or else.

Session 2.

She was having a terrible time in relationships. She could not speak up because she was terrified of making mistakes, so she wound up with very domineering men who had all the opinions and made her feel increasingly small, until she left them or they tired of her. She wanted to be invisible. Once we identified this basic problem, she traced it back. A consistent memory was eating dinner in her parents’ home, where she was ridiculed by her older brothers. Her brothers were noisy. They never understood how much they terrorized her. She became frightened of having an opinion of any kind and tried to become invisible. Mary became an angry young woman. She had trouble believing anyone would care for her, so she simply tried to go along, and she became an expert at keeping quiet. In therapy, she had to relearn to think, to feet, and then to speak up again.

Unbearable Pain – Middle Phase.

Looking for Relief in All the Wrong Places. According Beck et al. (1985), “Cognitive therapy often emphasizes encouraging a patient to do the unexpected, to surprise himself, to step out of character. This strategy is presented as one of the best ways to defeat the anxiety” (p. 184). Beck and his colleagues (1985) report that when given the assignment to “surprise themselves,” may patients have reported they have taken specific risks and surprised themselves with the positive outcomes.

Sessions 5-15.

Making Peace – Final Phase.

Sessions 16-24.

Future Treatment Considerations.

Chapter Four: Concluding Thoughts

People who are recovering from dysthymic disorders can be viewed as being in a state of transition, or metamorphosis. According to Carl Jung, “The secret of alchemy was… The transformation of personality through the blending and fusion of the noble with the base components, of the differentiated with the inferior functions, of the conscious with the unconscious.” Yet the analogy with a caterpillar is particularly appropriate, for, just as it metamorphoses into a butterfly, so too do people have the capacity to transform and heal themselves. The Greek word psyche means butterfly, the emergence from the caterpillar state.

There is continuity between the caterpillar and the butterfly. They need each other for their different states. Because depression is best viewed on a continuum, an individual who suffers from dysthymia can be viewed as a caterpillar who will ultimately achieve a state of freedom from the cocoon of depression. And so it is with Mary. She is an example, in a modern psyche’s individual rendition, of the ancient and ubiquitous analogy between human transformation and the metamorphosis of the butterfly. Complete metamorphosis is a dramatic transformation, out of which a creature emerges that bears no resemblance to the one that existed before. Who would guess, just by looking at it, that a swiftly darting butterfly once was a thick worm lumbering heavily along the ground? How does this happen?

First of all, this actually is the same creature. Only in appearance is it utterly different. At a deeper level, it carries what were formerly latent structures, now made vibrantly manifest, along into this new stage of life. The form has changed, but it is not a different being.

The caterpillar that metamorphoses into a butterfly has been one of the most enduring symbols of human transformation. This dissertation is not just a story about caterpillars and butterflies…. It is a story about human potential. The findings represent a powerful declaration that the past does not have to equal the future. True, butterfly metamorphous, the caterpillar crawling and struggling to survive, spinning and existing for a time within its chrysalis and the struggle emerging from the chrysalis to freedom and the ability to fly is a powerful analogy regarding Mary’s mental development; however, it is interesting that a most significant stage in the metamorphous process is the struggle. It is an active stage where the caterpillar is found emerging from its chrysalis. A rebirth, if you will, because it will no longer be a caterpillar. It will be a magnificent creature capable of flight. Research has proven that the struggle to free itself from the chrysalis is what prepares its wings for flight. If the emerging creature has assistance in cracking open the chrysalis, it will never fly. It will fall prey to its immediate environment. The struggle is what makes the complete creature a butterfly.

A butterfly’s metamorphosis from larva to pupa to adult is a useful metaphor for discussing Mary’s psychological process of transformation in adulthood. Butterflies undergo what is called a complete metamorphosis. However, they also pass through a long series of preliminary moltings before they arrive at the complete metamorphosis. I view Mary’s life as an example of “preliminary moltings” of psychological transformation, and I use the analogy of the butterfly’s metamorphosis as a model to help understand what was going on in Mary’s introverted personality during this time. In one sense, as Jung repeats in his writings many times, individuation is never finished or completed, because there is always more unconscious potential to bring into the personality’s full integration. The life of the butterfly may be short or long, but from now on it will remain true to its achieved imago. It will take awhile for Mary, and it may be painful – but what a metamorphosis!

It can be concluded that there were significant improvements in increased happiness, lightheartedness, and creativity, and Mary was freer, calmer, prouder, more loving, and more open. Clearly, the therapeutic process was a beginning and not an end in itself. Therapy with Mary has had a multiplicity of healing effects. It helped her to untangle the knot of complex relationships, provide a comforting environment in which to express deeply hidden emotion, and move the process of mourning from the stage of denial to the stages of confrontation and emotional response.

In any event, both the therapist’s interventions and the client’s subsequent reactions to them inevitably changed the course and content of the discourse. What follows these interventions is then no longer an account of the person who set out to give testimony; it is an account of a life story by a person whose perspective has been altered by the therapist. For both parties, this crossroad can be an emotionally agitating place. The process of development through intense interactions with others leads one, through successive metamorphoses, to an ever-evolving authentic self. Through the process of resonance and coordination, returning to the bedrock of personal internal experience and that which marks the patient’s inner experience as pure and true, and by fostering access and facilitating core affect, the patient’s authenticity grows and solidifies. Encouraged to be as authentic as he can possibly be, with another who is as authentic as she can possibly be (through the therapist’s own contact with core affective experience), the patient sheds the layers of skin calloused by inauthentic, affect-phobic interactions. Through successive metamorphoses, the experience of the true self becomes increasingly easier to access. The voice of the true self is found and grows strong; when this happens, as one patient said, it’s like “the sound of a flute in a brass band.”

Mary feels that there are some people in the world who seem destined to lead a life of pain, sorrow and suffering. They try their best but somehow things don’t seem to work for them. There is total chaos and darkness in their lives. That is how the struggle begins, a tug of war, whether to fight or surrender. If there is no solution to their problem, many become negative. Sometimes, it drives the individual to suicide. Mary has gone through it all. Yet, now, she is convinced that she wants to lead a positive and successful life. The process of transformation has not always been easy. I wish I could say that the road has been smooth and filled with sunlight. There have been storms, times when I felt things were just as before. Fortunately, these have been short-lived and the sun has always come out again.

One of the most significant changes that occurred in me as a result of my experiences with Mary is the development of a much stronger trust in the therapeutic process. Although each new client represents a new challenge and triggers my concerns of responsibility and skill, my trust of the process and excitement at the prospect of participating in such an intimate challenge contains my fears and propels me forward. Since this experience, I have come to understand the importance of entering the client/therapist process in a respectful and caring manner in order to achieve change.

This case study encapsulates the essence of psychotherapy — doing what is needed to enable the Mary to achieve or regain competence and the sense of control and self-esteem that accompanies it. When Mary was first seen, she believed that she had no control over her life and could no longer influence her destiny. Like a baby who goes to sleep when things are beyond its capacity to manage or tolerate, Mary wanted only to escape what had become too painful and meaningless. Without the exercise of control, there is neither interest nor pleasure; Mary experienced only distress and the expectation of pain. She acted as if she were a passive victim of her environment, an environment that had implicitly labeled her helpless because she was dependent, and her behavior indicated that she had accepted that designation. Mary believed that her illness, coupled with her father’s needs, precluded her from any initiative that would lead to competence and self-assertion. With therapy, Mary regained the confidence to see herself as a person capable of having desires and implementing her decisions. She found herself interested and interesting, and even though she had dependency needs, she regained her self-esteem: she became once again a competent, self-respecting person.

Mary didn’t want to get bogged down in and anchored to the past but rather pursue the objectives of the future. She considered the consequences of living the rest of her life excusing her depression. And yet, she was not convinced that it was “too late”… that she was “too old to change”… that her situation was “too much to overcome.” These immortal lines from Longfellow (come to mind) apply to her:

It is too late!” Ah, nothing is too late

Cato learned Greek at eighty; Sophocles

Wrote his grand “Oedipus,” and Simonides

Bore off the prize of verse from his compeers

When each had numbered more than fourscore years;

And Theophrastus, at fourscore and ten,

Had begun his “Characters of Men”

Chaucer, at Woodstock, with his nightingales,

At sixty wrote the “Canterbury Tales.”

Goethe, at Weimar, toiling to the last,

Complete “Faust” when eighty years were past.

What then? Shall we sit idly down and say,

“The night has come; it is no longer day”?

For age is opportunity no less

Than youth itself, though in another dress.

And as the evening twilight fades away,

The sky is filled with stars, invisible by day.

It was never too late for Mary to start doing what was right for herself. Never.

The butterfly is a symbol of Mary’s new nature. She now has her imago, her adult form. Through this transformation she indeed has become a new being, but a being whom she always fundamentally has been.


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