CASE FORMULATION

1
: BRON
I CASE HISTORY
Bron is a 39-year-old woman, professionally qualified as a specialised nurse. She is
married and has two children, 2 and 7 years of age. She has had several periods of
depression dating back to her later teens.
Her present depression began about six months ago when she attempted to return to work
after taking maternity leave for her second child. Additionally, her father-in-law had a
serious illness and came to live with the family. Her symptoms included:
depressed mood, crying, anxiety and worry,
lack of feeling of pleasure,
a pervasive sense of worthlessness,
poor sleep,
fatigue,
poor concentration.
Her BDI score was 33. She scored 2 on the hopelessness question (Q2) and 1 on the
suicidal ideas question (Q9). She reported occasional suicidal thoughts but did not think
she would carry them out and had no plan for doing so.
Previous treatment was by anti-depressant medication, with one abortive attempt at
counselling. Her response to anti-depressives tended to be quite slow, although successful
in the end. At this time, her response to medication had been minimal and her doctor
switched medication and encouraged her to take up CBT via her occupational health
scheme.
1
This format for formulation adapts the guidelines of the Academy of Cognitive
Therapy. See material for professionals at www.academdyofcognitivetherapy.
Bron did not have any health problems likely to influence her psychological problems.
Likely diagnosis: Major depressive episode, recurrent, severe.
II: CASE FORMULATION
A. Precipitants: Although Bron described her husband as a good man whom she
loved she did not think that he offered her enough support, especially with the
youngest child and with looking after his father. When she tried to return to work,
she became preoccupied with the risk of making mistakes with patients and of
being charged with malpractice. She felt that this played into an incipient lack of
self-esteem. She was struggling with looking after the children, trying to work
and dealing with her worries. She thought that if she could have some time off
work, she could steady the ship and get back later. Having her father-in-law was
the tipping point when she realised that even this plan was doomed. She felt that
she could not refuse to look after such a poor old man who was so ill. At this
point her lack of self-esteem was combined with her superwoman style of
coping and this combination led to depletion and near collapse.
B. Cross-sectional view of cognitions and behaviours: Brons days were very
similar, consisting of a cycle of getting the children to school and nursery, nursing
her father-in-law and attending to household chores. During brief times on her
own, she would become preoccupied both with a sense of failure (about not
returning to work) and resentment (of having to look after everyone else in the
family). Neither she nor her husband seemed to have time for each other and they
had not had sex for many months. Bron had some good friends and seeing them
was one of the few pleasurable points in her week.
C. Longitudinal view of cognitions and behaviours: Brons mother had died when
Bron was a teenager. When her mother became ill, Bron moved in with an aunt
and rarely saw her mother. She was shielded from going to the funeral. Her aunt
was a caring if rather severely religious person. Brons father kept clear of her and
remarried quite quickly never resuming anything other than very minimal
contact with Bron. Bron thinks that her aunt probably resented having to look
after her and Bron developed the belief that she was burden to others and was
not really worthy or loveable. During her early adulthood, Bron developed the
idea that she might prove her worth by selfless service, as a wife and mother or
nurse, or both If people need me then this makes me worth something. Her
husband was quite a moody and needy person. Their relationship was based on
recognising how each other felt and responding to needs. Problems arose,
however, when they both felt needy at the same time. The husband was himself in
a downturn most likely because his own career seemed stuck at this time.
D. Strengths and assets: Bron was actually a superb nurse and a more than good
enough mother. She was intelligent and sensitive and inspired fiercely loyal
friendship from her peers. When she cared to show it, she had an engaging ironic
sense of humour.
E. Working hypothesis: The core of Brons problems lay in her chronic lack of
self-esteem resulting from the circumstances of her mothers death and its
aftermath. She solved her lack of self-confidence by working very hard and
dedicating herself to looking after the needs of others, often neglecting her own
needs. This pattern, twinned with a lack of appropriately assertive behaviours,
lend to periods of depletion, collapse and depression. In this instance, the pattern
was exacerbated by the unusual circumstances of having to look after her father-
in-law and of her failure to return to work after her second child.
III TREATMENT PLAN
A. Problem list:
1 Lack of pleasurable activities in the week.
2 Depression and negative thinking about the self.
3 Lack of appropriately assertive behaviours.
4 Over-commitment to the needs of others.
5 Lack of a lower gear in her working style.
B. Treatment goals:
1 Learn to consciously plan the week to include a balance of work and
pleasure.
2 Learn to think about the self in a more balanced way.
3 Learn appropriately assertive behaviour.
4 Learn to negotiate meeting others needs more on her own terms.
5 Learn to vary work behaviour according to energy levels and other
commitments.
C. Plan for treatment
Given the prominence of the marital relationship in connection with certain goals
(especially goals 3 and 4), it is necessary to think about which elements of this
work may be done in the context of individual work and which in relation to
couples work. The clients and her husbands view of this will determine what
actually happens but a viable sequence would be that:
Treatment will begin with cognitive therapy of depression in relation to
goals 1 and 2.
If this is successful, then it may be appropriate to consider cognitive
therapy couples work in relation to goals 3 and 4.
The client may then be ready to tackle a return to work in conjunction with
working on goal 5 as either on-going CBT or as an element of follow-up
maintenance therapy.