Client is a divorced, 28-year-old female with a history of depression and social anxiety. She has had a lack of interest in things she used to find joy in, unexplained weight loss, fatigue, trouble sleeping, poor concentration, and feelings of guilt and worthlessness. She also experiences intense fear and anxiety in social situations. This fear has caused her rapid heartrate, trembling, sweating, upset stomach, nausea, and muscle tension. She often avoids places where she fears she will be judged or must socialize. Client reports that her social anxiety adds to her depression. She reports that during past depressive episodes, she experienced suicidal ideations and fears that she will experience them again. Presenting concerns are fear of losing her job due to always calling in, loss of friends, malnutrition, and lack of daily living skills. Client currently works full time in a business office. She reports a goal of attending and finishing college and getting away from her “boring job”. She fears the social aspect of college and names it as a reason she has not enrolled. She currently lives alone but has good support from a mother and father that live nearby.
Treatment will begin by building rapport and providing psychoeducation. We will then focus on cognitive restructuring of maladaptive thoughts regarding the self and social situations, mindfulness to help reframe negative thoughts, as well as exposure to different social situations. For our first month of weekly sessions, the client and I will focus on developing rapport and I will begin slowly introducing psychoeducation regarding anxiety and depression. Early sessions will also make room for discussing goals of the client and all following sessions will make time for discussing progress toward those goals. Cognitive restructuring using thought records and socratic questioning will be essential for the client to progress. The client will be given a thought record to log all thoughts, both at home and when in public. She will bring the thought record to each session so that we can discuss and restructure dysfunctional thoughts into more adaptive ones.
A worksheet will be given to help the client accurately log her thoughts. This worksheet will help the client to challenge irrational and illogical thoughts on her own, outside of sessions, as well as discuss them in session. It will be a homework tool. The worksheet will describe how thoughts are often automatic and will aid in helping the client analyze them. The following are some examples of the types of questions on the worksheet: Is there evidence that this thought is accurate? If so, what? This will help her determine whether the thought is a fact or a feeling. This worksheet will aid in both her depression and social anxiety thoughts. The second part of the worksheet will focus on how others might perceive the situation, whether the thought is an exaggeration, and whether this thought is a habit (automatic) or if there are facts that support it.
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Once there is psychoeducation regarding automatic thoughts and success in accurately filling out the thought record, exposure therapy will begin. This should start around the second month of therapy. Exposure therapy will help not only the depressive symptoms but the social anxiety symptoms as well. The beginning of exposure therapy will focus on pleasant activities and things that the client enjoyed doing in the past. This will aid in getting her comfortable to exposure therapy, working toward finding pleasure in activities, and prepare her for being exposed to gradually uncomfortable situations. The thought recording will continue during exposure therapy. This is to address fears and irrational thoughts during each new exposure.
Mindfulness skills will also be taught during this time such as deep breathing and meditation. Deep breathing techniques will be taught so that they can be assistance when exposed to uncomfortable situations. The client will also learn what coping statements are. Upon learning coping statements, the client will then write her own to carry with her and read over when faced with uncomfortable thoughts and feelings. As exposure therapy advances, the client will be exposed to things she fears the most such as public speaking, engaging within a group, and attending events on her own. Exposure therapy is expected to take approximately 3 to 4 months. The session following each exposure will discuss the automatic thoughts and feelings, progress or lack of progress, homework, and the next exposure technique. Feedback will also take place to address what is helpful and unhelpful for the client.
Focus will first be on psychoeducation. This is an important step to take early on, so that the client has a deeper and better understanding thus leaving her better prepared for therapy. Next, thought recording, automatic thoughts, socratic questioning, and what if scenarios will be the focus. This is to get the client better adjusted to paying attention to automatic thoughts and learning to restructure those thoughts into more healthy and adaptive thoughts. Following cognitive restructuring, mindfulness techniques will be taught as an aid to cope with negative thoughts and feelings and better handle being exposed to uncomfortable situations. Once mindfulness is established, we will then move into exposure therapy.
The client has a history of avoidance, so exposure therapy may take longer than approximated. It is important to not overwhelm the client by making the exposure too much at any given time. This may cause avoidance and hinder any progress made. There may also be some initial trouble with identifying pleasurable activities, as the client is currently in a depressive state. This could also initiate trouble with exposure therapy in combination with her history of avoidance. It will be crucial to give ample time to cognitive restructuring techniques before moving into exposure. Therapy for this client is expected to take approximately 8 months, but could move further into the 12 month range to give time for adjustments, setback, and further learning of a skill.
References
- National Institute of Mental Health: Depression
- National Institute of Mental Health: Anxiety Disorders
- Anxiety and Depression Association of America
- American Psychiatric Association: What is Depression?
- American Psychiatric Association: What are Anxiety Disorders?
- Mayo Clinic: Depression
- Mayo Clinic: Social Anxiety Disorder
- Ada – Personal Health Companion
