CASEFORMULATION1:BRON

ICASEHISTORY
Bronisa39yearoldwoman,professionallyqualifiedasaspecialisednurse.Sheis
marriedandhastwochildren,2and7yearsofage.Shehashadseveralperiodsof
depressiondatingbacktoherlaterteens.
Herpresentdepressionbeganaboutsixmonthsagowhensheattemptedtoreturntowork
aftertakingmaternityleaveforhersecondchild.Additionally,herfatherinlawhada
seriousillnessandcametolivewiththefamily.Hersymptomsincluded:

depressedmood,crying,anxietyandworry,

lackoffeelingofpleasure,

apervasivesenseofworthlessness,

poorsleep,

fatigue,

poorconcentration.

HerBDIscorewas33.Shescored2onthehopelessnessquestion(Q2)and1onthe
suicidalideasquestion(Q9).Shereportedoccasionalsuicidalthoughtsbutdidnotthink
shewouldcarrythemoutandhadnoplanfordoingso.
Previoustreatmentwasbyantidepressantmedication,withoneabortiveattemptat
counselling.Herresponsetoantidepressivestendedtobequiteslow,althoughsuccessful
intheend.Atthistime,herresponsetomedicationhadbeenminimalandherdoctor
switchedmedicationandencouragedhertotakeupCBTviaheroccupationalhealth
scheme.

ThisformatforformulationadaptstheguidelinesoftheAcademyofCognitive
Therapy.Seematerialforprofessionalsatwww.academdyofcognitivetherapy.
1

Brondidnothaveanyhealthproblemslikelytoinfluenceherpsychologicalproblems.
Likelydiagnosis:Majordepressiveepisode,recurrent,severe.
II:CASEFORMULATION
A. Precipitants:AlthoughBrondescribedherhusbandasagoodmanwhomshe
lovedshedidnotthinkthatheofferedherenoughsupport,especiallywiththe
youngestchildandwithlookingafterhisfather.Whenshetriedtoreturntowork,
shebecamepreoccupiedwiththeriskofmakingmistakeswithpatientsandof
beingchargedwithmalpractice.Shefeltthatthisplayedintoanincipientlackof
selfesteem.Shewasstrugglingwithlookingafterthechildren,tryingtowork
anddealingwithherworries.Shethoughtthatifshecouldhavesometimeoff
work,shecouldsteadytheshipandgetbacklater.Havingherfatherinlawwas
thetippingpointwhensherealisedthateventhisplanwasdoomed.Shefeltthat
shecouldnotrefusetolookaftersuchapooroldmanwhowassoill.Atthis
pointherlackofselfesteemwascombinedwithhersuperwomanstyleof
copingandthiscombinationledtodepletionandnearcollapse.
B. Crosssectionalviewofcognitionsandbehaviours:Bronsdayswerevery
similar,consistingofacycleofgettingthechildrentoschoolandnursery,nursing
herfatherinlawandattendingtohouseholdchores.Duringbrieftimesonher
own,shewouldbecomepreoccupiedbothwithasenseoffailure(aboutnot
returningtowork)andresentment(ofhavingtolookaftereveryoneelseinthe
family).Neithershenorherhusbandseemedtohavetimeforeachotherandthey
hadnothadsexformanymonths.Bronhadsomegoodfriendsandseeingthem
wasoneofthefewpleasurablepointsinherweek.

C. Longitudinalviewofcognitionsandbehaviours:Bronsmotherhaddiedwhen
Bronwasateenager.Whenhermotherbecameill,Bronmovedinwithanaunt

andrarelysawhermother.Shewasshieldedfromgoingtothefuneral.Heraunt
wasacaringifratherseverelyreligiousperson.Bronsfatherkeptclearofherand
remarriedquitequicklyneverresuminganythingotherthanveryminimal
contactwithBron.Bronthinksthatherauntprobablyresentedhavingtolook
afterherandBrondevelopedthebeliefthatshewasburdentoothersandwas
notreallyworthyorloveable.Duringherearlyadulthood,Brondevelopedthe
ideathatshemightproveherworthbyselflessservice,asawifeandmotheror
nurse,orbothIfpeopleneedmethenthismakesmeworthsomething.Her
husbandwasquiteamoodyandneedyperson.Theirrelationshipwasbasedon
recognisinghoweachotherfeltandrespondingtoneeds.Problemsarose,
however,whentheybothfeltneedyatthesametime.Thehusbandwashimselfin
adownturnmostlikelybecausehisowncareerseemedstuckatthistime.

D. Strengthsandassets:Bronwasactuallyasuperbnurseandamorethangood
enoughmother.Shewasintelligentandsensitiveandinspiredfiercelyloyal
friendshipfromherpeers.Whenshecaredtoshowit,shehadanengagingironic
senseofhumour.

E. Workinghypothesis:ThecoreofBronsproblemslayinherchroniclackof
selfesteemresultingfromthecircumstancesofhermothersdeathandits
aftermath.Shesolvedherlackofselfconfidencebyworkingveryhardand
dedicatingherselftolookingaftertheneedsofothers,oftenneglectingherown
needs.Thispattern,twinnedwithalackofappropriatelyassertivebehaviours,
lendtoperiodsofdepletion,collapseanddepression.Inthisinstance,thepattern
wasexacerbatedbytheunusualcircumstancesofhavingtolookafterherfather
inlawandofherfailuretoreturntoworkafterhersecondchild.

IIITREATMENTPLAN
A.Problemlist:

Lackofpleasurableactivitiesintheweek.

Depressionandnegativethinkingabouttheself.

Lackofappropriatelyassertivebehaviours.

Overcommitmenttotheneedsofothers.

Lackofalowergearinherworkingstyle.

B.Treatmentgoals:
1

Learntoconsciouslyplantheweektoincludeabalanceofworkand
pleasure.

Learntothinkabouttheselfinamorebalancedway.

Learnappropriatelyassertivebehaviour.

Learntonegotiatemeetingothersneedsmoreonherownterms.

Learntovaryworkbehaviouraccordingtoenergylevelsandother
commitments.

C.Planfortreatment
Giventheprominenceofthemaritalrelationshipinconnectionwithcertaingoals
(especiallygoals3and4),itisnecessarytothinkaboutwhichelementsofthis
workmaybedoneinthecontextofindividualworkandwhichinrelationto
coupleswork.Theclientsandherhusbandsviewofthiswilldeterminewhat
actuallyhappensbutaviablesequencewouldbethat:

Treatmentwillbeginwithcognitivetherapyofdepressioninrelationto
goals1and2.

Ifthisissuccessful,thenitmaybeappropriatetoconsidercognitive
therapycouplesworkinrelationtogoals3and4.

Theclientmaythenbereadytotackleareturntoworkinconjunctionwith
workingongoal5aseitherongoingCBTorasanelementoffollowup
maintenancetherapy.