Summary of Working Hypothesis
When Maria was challenged to take responsibility for herself and family, she began to feel "less than." This cognitive schema of inadequacy, irresponsibility, inferiority, shame, and guilt brought about depression, and the spiral of depression into poor self-care has made it difficult for Maria to see an end to this stressful and sad life.
Strengths and Assets
Maria is intelligent, well educated, resilient, and caring. She has both children and a family of origin who can be brought into treatment to provide additional support. She is part of a culture that values the family and social group.
• Reduce depressive symptoms.
• Increase self-esteem and confidence.
• Increase social support through family or extra-family support.
• Individual CBT that is culturally sensitive.
• Group-based CBT with women who have been abused.
• Focus on the present by assessing current depression and suicidality using the Beck Depression Inventory and clinical interview.
• Develop social support through a group treatment program.
• Incorporate meditative relaxation.
Asking Maria to describe her problem will help the counselor or therapist identify the primary presenting problem and provide the basis for deciding on goals for counseling or psychotherapy. This is not clearly presented in the case description; Maria may not know what she can get out of counseling or psychotherapy. A first step will be to help Maria describe how she wants her life to be different than it currently is. The goals can be expressed in cognitive, behavioral, or affective statements. For example, Maria may indicate that she wants to feel less depressed or have increased energy. What Maria wants is not clear from the case description provided.
How can progress in counseling or psychotherapy be measured and monitored? The counselor may select cognitions, behaviors, or feelings to monitor. Maria may be asked to complete thought diaries or record the kinds of maladaptive thoughts she has during the day. She may be asked to keep track of these thoughts or some other target behavior. She can record a rating of feelings, which will provide useful information about how behaviors and thoughts contribute to her negative affect. The counselor or therapist can also use a variety of self-report measures such as the Beck Depression Inventory to provide a record of depression.
What are the environmental contingencies maintaining the behavior? In this area, it is important to study Maria's issues in the particular contexts of her daily life. What happens at work that contributes to her negative thoughts and feelings? It may be that she is telling herself that if she cannot teach perfectly, then she should stay home and in bed all day. Likewise, what are Maria's thoughts about her children? Does she think that they want to spend more time with her? Or does she believe that they wish she would leave them alone? We do not know the thinking that is underlying her depression.
Which interventions are likely to be effective? It seems that the cognitive-behavioral interventions described in this chapter will be valuable for working with Maria. I have selected Beck's cognitive therapy to demonstrate how a particular approach can be used. Establishing rapport is a critical part of Beck's approach. The counselor or therapist will have to take special steps to establish good rapport with Maria.
A cognitive-behavioral counselor or therapist will establish a plan to work with Maria that focuses on developing an understanding of the role her thinking is having in her current situation. Maria can be challenged to identify the thoughts that go through her mind at work and at home, especially thoughts that are bed to depression. Patterns of thoughts can be classified into general categories of cognitive distortions, such as all-or-nothing thinking, overgeneralization, or disqualifying the positive. As Maria learns how to identify thoughts, she may also begin to talk about some feelings and see that the thoughts and feelings are related to her problems. It is the primary task of the counselor or therapist to demonstrate that the thoughts, feelings, and behaviors are interrelated and that the counseling or psychotherapy will work through changing the maladaptive thoughts.
Once there is an understanding of some of the thoughts that Maria may be having, the counselor can begin the process of changing the thoughts. Questions such as "What's the evidence?" "What's another way of looking at the situation?" and "So what if it happens?" (Beck & Emery, 1985, p. 201) are useful. Hypothesis testing, generating alternative interpretations, and decatastrophizing are some cognitive strategies that might be used. Self-monitoring thoughts can be used as a homework assignment to help Maria focus on thoughts and how they affect her behavior and feelings.
It seems that one of the ways Maria copes with depression is to withdraw from contact with people. Although the withdrawal behavior is a consequence of the depression, it ultimately increases the depressed feeling she has because it isolates her from making real connections with others.
There are certainly other factors of Maria's case study that a counselor would want to address, including her risk for suicide and her parental and family relationships. I have focused primarily on her depression because it seems to be the primary problem and the one for which there is great motivation to seek solutions. As Maria learns the strategies of CBT, she may be better equipped to address the other problems in her life.