Case Conceptualization Paper

David Miller

Southwestern College

Susanne Stockman

December 7, 2021

Identifying Information: The client is David Miller, a  26-year-old who identifies as a bisexual male. The client is unmarried, although he has been in a committed relationship for the past eight years. His romantic partner is Julia, who he lives with along with two other roommates. David is attending a graduate program online and also works as a server as well as occasional work in construction. 

Presenting Problem: The client states that he has struggled with depression since he was about 10 years old. He describes his depression as “an immense sadness,” accompanied by a lack of motivation and negative self-talk. The client states that “when it gets really bad I won’t be able to get out of bed for days at a time. When that happens I feel a huge amount of shame and self-hatred.” When asked about the regularity of the depressive episodes the client reports that the episodes last from five to fifteen days, usually with the most severe period being towards the end. The client reports that the episodes occur once or twice every six months and may relate to a change in seasons.

History of the Problem: The client reports that the depression has not increased recently in frequency or severity but that he has felt more motivated to seek therapy to address it. The client says that he has seen therapists off and on since he was a teenager with the most recent being a counselor in Salt Lake City who utilized EMDR. The client says that EMDR may have been helpful but reports finding it emotionally and physically exhausting and that he eventually stopped going because of this. 

Client Strengths: The client is introspective and aware of patterns of negative self-talk. The client can separate themselves from his thoughts and recognize that he is not their depression. The client seems open to therapy and new experiences.

Client’s Support Systems: The client reports that time spent in nature is beneficial to their mental health, he spends time kayaking, skiing, and fly-fishing. The client also has a close community including his parents, romantic partner, and close friends. The client reports feeling supported by his friends and family.

Cognitive Behavioral Therapy

Working Hypothesis: Cognitive Behavioral Therapy, or CBT, is based on the idea that thoughts directly affect feelings and behaviors. The goal of CBT is to give the client insight into their patterns of negative thought and to help them develop healthier alternative patterns. This methodology has been proven to be effective in the treatment of depression. The client’s self-awareness and his ability to separate themselves from his thoughts make him an ideal candidate for this therapy. 

Goals: First, to identify negative core beliefs that the client holds about themself or the world. Second, To make these beliefs noticeably less powerful for the client. In other words to make it so these core beliefs feel less true in a meaningful way. 

Interventions: The first intervention I used was to assign the client homework to be completed between our first and second sessions. I instructed the client to create a list of his negative beliefs about himself or the world around him. Every time he noticed a negative thought, he was to write this thought down in a journal that was to be kept on his person at all times. The client was instructed to try to write down at least 20 of these beliefs. The client was open to this assignment and when he arrived at our second session he had a list of 26 beliefs. 

At the beginning of the session, I read the beliefs back to the client. After each statement was read I asked the client to rate the statement from one to ten regarding how accurate or true the statement felt. Of the 26 beliefs, 23 were rated between a four and a seven. Two were rated as eights and one was rated as a nine. I informed the client that we would spend the remainder of the session examining this final belief. The final belief was: “People shouldn’t love me because I will end up hurting them.” 

I began asking the client to explain why this statement was true. The client explained that his depression had a clear and negative impact on the people around him. “When I’m sad I make the people I love hurt. They always want to help me feel better and when they can't it makes them sad too. Not being able to help someone you care about sucks, and it feels like I have no power to control that.” 

The session was continued with the goal of examining the underlying assumption that occasional distress in a relationship leads to overall unhappiness in that relationship. Through Socratic questioning, the client was helped to understand the illogical nature of this belief.

The following excerpt took place towards the end of the session and represents the most substantial change to take place in the client’s attitude:

T: I’m hearing that you believe that the sadness that you cause to your friends when you are depressed leads to them being unhappy when they are around you, is that correct?

C: Yeah.

T: Are you always depressed?

C: No, not always. 

T: And when you are not depressed, how do you think your friends feel when they are around you?

C: Well they’re my friends. So, we have fun together. I assume that is why they continue to spend time with me.

T: You make a really good point. If you made your friends more unhappy than happy, then do you think he would still want to continue to spend time with you?

C: That’s true, I guess I should respect them enough to trust that they can make their own decision.

T: Respect is an interesting word to use, can you tell me more about that?

C: Well I guess what I mean is that if I am assuming that I make my friends more unhappy than happy and that they are still spending time with me, well, someone who would do that either isn’t very smart or doesn’t have very much self-respect. And because I don’t believe either of those things is true, it feels like I am disrespecting my friends by not trusting in their decision to continue to spend time with me.

T: That seems like a very logical conclusion.

C: So I understand logically why what I just said is true. But I’m worried that in the future when I am depressed that it will be difficult to remember that it is true. In other words, I know that it is true with my mind but I don’t know that my heart believes it yet.

T: Well, if someone were to come up to you and tell you people shouldn’t love you because you will end up hurting them, how would you respond to that person?

C: I guess I would tell them that I have many friends who obviously want to spend time with me because they repeatedly do so and that I trust those friends’ judgment. 

T: Can I challenge you to rephrase that argument in a way that doesn’t make it dependent on your friends’ validation?

C: I would tell that person that I bring joy and happiness into my friends’ lives. Maybe not all of the time, but enough of the time to cause them to want to continue being around me.

T: That right there is the belief that you need to cultivate. From what you have told me, you have been cultivating and feeding these negative beliefs for a lot of time, so don’t expect them to go away overnight. But the work you did today is another step in a long process of replacing those beliefs with more productive ones. Over our future sessions, we will track your progress, and that way you can see how much you change.

The remainder of the session was spent reviewing the work done during this session and laying out a plan for future sessions as well as giving the client more journaling work to be done between the sessions. The client left with an optimistic attitude and in seemingly good spirits.

Reflection: CBT is a seemingly good fit for this client to treat his depression. The benefits of CBT are that it is easy to track progress and that said progress occurs relatively quickly. The drawback of CBT in this scenario is its surface-level nature. The work done in this session only affected the higher-level cognitive processes, and as the client noted did not immediately affect the core beliefs that are the root of the issue. The issue here is a false sense of progress that will likely be lost when the client is next affected by a depressive episode.

Solution-Focused Brief Therapy

Working Hypothesis: Solution-Focused Brief therapy, or SFBT, is a relatively simple approach. It focuses on helping clients create solutions rather than focusing on the problem. SFBT focuses on utilizing the client’s strengths and replacing problematic behaviors with positive ones. Because SFBT operates under the assumption that every client has strengths and resources it should be effective with any client.

Goals: First, to identify what the client is already doing that is working to manage their depression. And second, to identify what behaviors are not working and what alternative behaviors he could be replaced with.

Intervention: The first intervention occurred before the client’s first session. When the client scheduled the first session he was instructed to come in with a list of his effective strategies for managing his depression. What works best at limiting the episodes and what works best to decrease the duration and intensity of the episodes when they do occur? The client came in with a fairly extensive list. The client named diest, community, exercise, time spent outside, and time being ‘productive’ as the most important factors in decreasing how often the depressive episodes occurred. When episodes did occur the client had a much shorter list. The client reported feeling powerless over the episode once it had started. 

This feeling of powerlessness became the focus of our first session, to reorient the client’s attitude about how much efficacy he has in altering his mental state during a depressive episode. The following is a short transcript from our session:

C: When I’m feeling that way it feels like all I can do is wait for it to be over.

T: Let’s look at the last time you experienced a depressive episode, can you tell me when that was?

C: About a month ago.

T: And how long did that episode last?

C: Maybe ten days?

T: Okay, now thinking back on that experience. How did it feel when you recognized it was coming to an end? Was it sudden or was it gradual?

C: I guess it was gradual, it went away over the course of a couple of days. 

T: Okay, and how did you know it was getting better?

C: It was just a little easier to get out of bed one day.

T: And what did you do?

C: I think I just did a little cleaning around the house.

T: Wow! So right in the middle of one of these episodes, you found the strength to not only get out of your bed, which you said can feel nearly impossible, but you then went and cleaned your house? How did you do that? 

C: Well I just felt like it would help me feel better.

T: Now I just want to point out how truly incredible this is. You are laying there in the middle of just feeling terribly depressed, and you notice you feel just a tiny bit better. And, instead of ignoring it, you seize the opportunity and get out of bed, leave your room, and take it upon yourself to clean. 

C: Yeah, but then I just went and laid back down.

T: That doesn’t matter at all! You took the first step in helping yourself feel better. You took control and did something that must have felt nearly impossible only a few hours before, of course, you went and laid back down, that must have been exhausting!

C: I was only cleaning, it’s something I do every day.

T: It’s something you do every day when you are not feeling depressed. It’s easy to clean when you are feeling good, but you shouldn’t forget how difficult that is to do when you are feeling depressed. I want you to do something for me.

C: Okay.

T: Do you ever watch war movies?

C: Yeah, all the time.

T: Okay now imagine you are the hero in one of those movies, except instead of fighting bad guys you are battling your depression. Usually, while you may be at war with your depression you are simply taking preventative measures. You are digging foxholes and setting up perimeters. But sometimes you get into a full-on firefight with your depression. 

C: Okay.

T: Now before you were in this fight would it be difficult to go make yourself lunch, or fill up your canteen?

C: No.

T: But now that you are in this battle, what would it be like to do those things?

C: It would be very difficult if not impossible. 

T: And so do you think that normally mundane activities would be astounding to accomplish if he were done while in the midst of this fight?

C: So, me getting out of bed when I am depressed is the equivalent of a man leaving their foxhole while they are in a battle?

T: Exactly!

Reflection: This therapeutic modality seems very promising on paper, and with the right client it would likely live up to this expectation. My concern is that the forcibly positive nature of this modality does not leave room for a client to feel however they are feeling. I worry that a client with depression may receive the message that it is not okay to feel any way but positive, and this, in turn, may cause them to feel shame when feeling sad or upset. Sometimes we need to feel sad and that is okay.

Somatic Therapy

Working Hypothesis: Somatic therapy is a response to new research that shows that our experiences are stored in our bodies. It operates under the belief that sometimes the body is responding to stimulus even when the mind is unaware of it. Somatic therapy helps clients’ bodies feel the progress that their minds may be made in other forms of therapy. This technique has been shown to be effective in the treatment of depression so may be effective in the treatment of this client.

Goals: The first goal in our work will be to identify the main places in the body of the client where the depression is being felt, this will be done by helping the client to cultivate body awareness through mindfulness and the use of descriptive language. The second goal will be to alleviate some of these feelings and sensations through meditation and tapping exercises.

Intervention: The client reported that this would be his first experience with somatic therapy. So, the first step taken was to walk him through somatic therapy. The basic ideas and tenets were explained and the client appeared engaged and interested, although his body was communicating small amounts of apprehension or anxiety. 

The second step in our orientation process was to get the client to a calm and relaxed state. To achieve this the client was walked through a calming meditation practice that emphasized deep breathing. During this mediation, the client was asked to picture a figure or figure that represented safety and healing. These could be real or fictional, human or animal. The client was asked to keep this figure in mind and to bring them into their practice today if he ever began to feel unsafe. During this meditation, the client’s body was noticeably relaxed.

The next step was to invoke the feelings of depression that we would be treating. Before doing this, the client was given a grounding practice and told that if he were to start feeling the depression too deeply to stop and use this grounding practice to come back to the present. If the client were to feel the depression too deeply we would risk him disassociating and at that point, any progress would become futile.

The client was asked to remember the last time he felt depressed. he was to picture where he was and what it felt like to be there. The client’s body immediately began to show physical signs of distress so I asked the client to stop and go through the grounding process. Once he was back to baseline with a calm and relaxed demeanor, he was instructed to go through the same process but to stop once he began to feel the depression. Once he was there the client was asked to describe the physical sensation of the depression. The client reported a feeling of tightness in his stomach and throat, as well as muscle pain in his lower back and shoulders. 

The client was asked to sit with these sensations. To not try to dismiss or ignore them but just to recognize and notice them. At this point, the client’s body was communicating a small amount of distress but not so much that he could not continue with the process. After sitting with these sensations we were ready to begin the process of relieving them.

The client was then guided through a tapping exercise focussed on relieving his depression. This specific tapping sequence is from the tapping solution (https://www.thetappingsolution.com/tapping-101/). The process begins with statements of self-love and acceptance while initiating the tapping sequence. This allows the client to think about his depression without sending stress signals to the brain. The client was then guided through different tapping points accompanied by affirmations. An example being “Even though I still feel my depression, I accept how I feel and choose to relax.” The client left the session with their body communicating relaxation and calmness. 

Reflection: Somatic therapy seems to be one of the most effective modalities to treat depression. The effectiveness comes from the inherent receptiveness of emotions in all their forms. Other modalities seem to focus on changing or negating negative emotions. In my experience attempting to alter negative emotions can lead to shame spiraling due to a perception of failure. Somatic therapy, and especially tapping aims to give the client the ability to hold space for their depression without it traumatizing them.