Term Paper on "Treatment of Women Diagnosed With Dysthymia"

Quoted Instructions for "Treatment of Women Diagnosed With Dysthymia" Assignment:

I will EMAIL materials (Proposal, sample case study/dissertations).

The type of document is DISSERTATION/CASE STUDY

My 75 page dissertation (needs to be APA style), and is a Case Study/Dissertation on a woman/client with Dysthymia (depression) using Cognitive Behavioral Therapy. I’m including the proposal here and please incorporate the proposal into the dissertation and elaborate where needed. I will also email the proposal and sample case studies.

I need the following in the dissertation: Title page (FREE); Signature page (FREE); Preface; Acknowledgments page (FREE); Dedication page (FREE); Table of Contents (please use the table of contents from the proposal); Executive Summary; Statement of the Problem; Hypothesis; Rationale; Literature Review; write-up of the individual case notes (24) sessions; the write-up of the case notes could be a half page to a page for each of the 24 sessions; (for example, Session One; Session two, etc. (for 24 sessions) with an "assessment" at the end of each session (a paragraph or so of how the session went); Results; Discussion; Conclusion; Recommendations; 30 References (FREE) --- (APA style).

A brief duscussion of the diagnosis as it relates to the client (DSM-IV).

I also included (at the end) examples of “sessions” from other sample dissertations.

What I wrote in the proposal needs to be included in the dissertation, for example, the different CBT techniques that I wrote in the proposal and how they helped the client, etc. --- weaved into the sessions.

FORMAT and REFERENCE STYLE

* Times New Roman font

* 12-point font size

* approximately 275 words per page

* double-spaced pages

* APA

* 1-inch margins

* FREE bibliography/references (30 references)

The references can be different from the ones that I’ve listed.

Please say something about the title (A Budding Therapist and the Caterpillar) and weave it into the case study.

This is the PROPOSAL:

A Budding Therapist and the Caterpillar

Undergoing a Metamorphosis

From a Cognitive Behavioral Perspective

by

Murrey C. Donaldson

A Proposal for a Clinical Case Study Dissertation

To be Submitted in Partial Satisfaction of the Requirements for

the degree of

Doctor of Psychology in Clinical Psychology

Case Study Proposal

Overview of the Study

Dysthymic patients are chronically depressed. Dysthymia is a depressive disorder in which irritable mood is observed by others for 2 years or more in adults and at least 1 year or more in children and adolescents. Dysthymia lasts longer and shows milder symptoms than depression (Butcher, 1987). Symptoms are similar to major depressive episodes (including low mood, fatigue, hopelessness, difficulty concentrating and disruption in appetite and sleep). Absent from the criteria are thoughts of suicide or death. There is a 6.4 percent lifetime prevalence for Dysthymia (Austrian, 2000). This is a proposal for a Clinical Case Study on the treatment of a woman diagnosed with Dysthymia.

The client selected for my dissertation study is a 43-year-old single parent. I chose this client for the following areas of clinical interest: (a) her self-esteem, depression, and anxiety issues; (b) her continuing difficulties in romantic relationships with men; and (c) her fight with obesity from an eating disorder.

The relational model I will be using, Cognitive Behavioral Therapy (CBT), is a relatively short-term, focused psychotherapy for a wide range of psychological problems including depression, anxiety, and personality problems. The focus is on how the client thinks, behaves, and communicates currently rather than on early childhood experiences.

Client Information

The client, as described above, is the oldest of three children of a Middle-Eastern family that emigrated to the United States.

The client took the initiative to request counseling and therapy as part of her own plan to help herself adjust to the demands of community living and to manage her illness. She presented herself with a flat affect and expressed anxiety related to her interpersonal situations and tasks. Interpersonally, she was withdrawn and socially isolated. Behaviorally, she was inactive and unable to work, but able to live independently.

The client reported struggling throughout childhood to live up to her mother’s expectations and secure her father’s love; failing at both. Depression and self-hate were her ever-present and unwelcome companions. They were accompanied by an insatiable craving for food, and (from adolescence on) by a similar craving for sex with inappropriate men. She was plagued with intermittent episodes of depression throughout her life.

She claims to have empathy for the needs of others, both family and friends, that is seldom reciprocal; but feels that she gets little in return. She begrudgingly admits that this is a source of annoyance and bitterness to her.

She has not formulated even vague details of a satisfying adulthood. Instead of looking ahead full of energy and plans, this client is clamped in a vise of psychic conflict and behavioral paralysis. The diagnosis was as follows:

Axis I 300.4 Dysthymic Disorder

Axis II None

Axis III None

Axis IV None

Axis V GAF = 50 (on admission)

GAF = 75-80 (at discharge)

Treatment History

As therapy commenced, the focus was on using cognitive interventions to produce changes in thinking, feeling, and behavior in the client (Kendall, 1991). The client was provided with ideas for experimentation, helped to sort through experiences, and aided in problem solving. Emphasis was placed on influencing the client to think for herself, maximize personal strengths, and acquire cognitive skills and behavior control.

Cognitive Behavioral Therapy focused on how the client responded to her cognitive interpretations and experiences rather than the environment or the experience itself, and how her thoughts and behaviors are related. It combined cognition change procedures with behavioral contingency management and learning experiences designed to help change distorted or deficient information processing (Kendall, 1991).

These new experiences helped to broaden the way the client viewed her world -- they do not remove unwanted prior history, but helped to develop healthier ways to make sense of future experiences. The focus of CBT was not to uncover unconscious early trauma or biological, neurological, and genetic contributions to psychological dysfunction, but instead endeavored to build a new, more adaptive way to process the client’s world.

CBT was used to help the client achieve lasting, positive change in therapy. This was also accomplished by modifying psychological structures through (a) relaxation strategies; (b) guided imagery; (c) meditation; (d) incentives and self-rewards; and (e) social skills training.

Outline for Dissertation

I. Introduction

II. Client Information

A. Presenting problem

B. Client's current symptoms

C. Therapist's observations of client's symptoms

D. Family history

E. Medical history

F. Psychotherapeutic history

G. Substance use/abuse

H. Initial diagnosis

I. Impressions of client

III. Theoretical Bases for Clinical Treatment

A. Beck: Cognitive Behavioral Therapy

IV. Storm Clouds – Beginning Phase

A. Sessions 1-4

V. Unbearable Pain – Middle Phase

Looking for Relief in All the Wrong Places

A. Sessions 5-15

VI. Making Peace – Final Phase

A. Sessions 16-24

VII. Future Treatment Consideration

IX. Concluding Thoughts

References

THE REFERENCES DON’T HAVE TO BE THESE NECESSARILY:

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th Ed.). Washington, DC: Author.

Becker, J. (1991). Psychosocial aspects of depression. Hillsdale, NJ: Lawrence Erlbaum Associates.

Barsalou, L. W. (1992). Cognitive psychology: An overview for cognitive scientists. Hillsdale, NJ: Lawrence Erlbaum Associates, Publishers.

Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.

Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. F. (1996). Comparison of Beck depression inventories -IA And-II in psychiatric outpatients. Journal of Personality Assessment, 67(3), 588-597.

Bolton, D., Hill, J., O'Ryan, D., Udwin, O., Boyle, S., & Yule, W. (2004, July). Long-term effects of psychological trauma on psychosocial functioning. Journal of Child Psychology and Psychiatry, 45(5), 1007.

Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York: Basic Books.

Brewin, C. R. (1996). Theoretical foundations of cognitive-behavior therapy for anxiety and depression. Annual Review of Psychology, 47, 33-57.

Brewin, C. R. (1996). Cognitive interference: Theories, methods, and findings. In G. R. Pierce, B. R. Sarason, & I. G. Sarason, (Eds.). Mahwah, NJ: Lawrence Erlbaum Associates.

Cowan, P. A., Cowan, C. P., Cohn, D. A., & Pearson, J. L. (1996). Parents' attachment histories and children's externalizing and internalizing behaviors: Exploring family systems models of linkage. Journal of Consulting and Clinical Psychology, 64, 53-63.

Dia, D. A. (2001). Cognitive-behavioral therapy with a six-year-old boy with separation anxiety disorder: A case study. Health and Social Work, 26(2), 125.

Goble, W., & Jones, V. (Speakers). (2000). ATTACH conference session: Assessment and diagnosis. (Cassette Recording No. 26-2016). Brookfield, VT: Resourceful Recordings, Inc.

Grinberg, L. (1992). Guilt and depression. London: Karnac Books.

Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., Gortner, E., & Prince, S. E. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64, 295-304.

Levy, T. M., & Orlans, M. (1998). Attachment, trauma, and healing: Understanding and treating attachment disorder in children and families. Washington, DC: CWLA Press.

Marcotte, D. (1997). Treating depression in adolescence: A review of the effectiveness of cognitive-behavioral treatments. Journal of Youth and Adolescence, 26(3), 273.

Needleman, L. D. (1999). Cognitive case conceptualization: A guidebook for practitioners. Mahwah, NJ: Lawrence Erlbaum Associates.

Omdahl, B. L. (1995). Cognitive appraisal, emotion, and empathy. Mahwah, NJ: Lawrence Erlbaum Associates.

Perlmutter, M. R. (Ed.). (1986). Cognitive perspectives on children's social and behavioral development. Hillsdale, NJ: Lawrence Erlbaum Associates.

Reber, K. (1996) Children at risk for reactive attachment disorder: assessment, diagnosis and treatment. Progress: Family Systems Research and Therapy, 5, 83-98.

Reilly, C. E. (1998). Cognitive therapy for the suicidal patient: A case study. Perspectives in Psychiatric Care, 34(4), 26.

Schwebel, A. I., & Fine, M. A. (1994). Understanding and helping families: A cognitive-behavioral approach. Hillsdale, NJ: Lawrence Erlbaum Associates.

Sroufe, L. A., Carlson, E. A., Levy, A. K., & Egeland, B. (1999). Implications of attachment theory for developmental psychopathology. Development and Psychopathology, 11, 1-13.

Willimer, J. F. (Eds.). ams, M. B. & Som (1994). Handbook of post-traumatic therapy. Westport, CT: Greenwood Press.

Wright, L. M., Watson, W. L., & Bell, J. M. (1996). Beliefs: The heart of healing in families and illness. New York: Basic Books.

EXAMPLES OF SESSIONS FROM OTHER DISSERTATIONS

Session Seventeen

She spoke again about her altercation with this older man. She asserted that she did not want to be treated that way. She noted that he accused her of being too sensitive, which she resented. She stated, however, that she did not know how to tell him how she felt without jeopardizing what had been, in many ways, a satisfying relationship. I reflected the sadness in her recognition that this man could not be who she wanted. She became sad at this point, and almost tearful. She was more calm and centered during this session. She again took notes, using her computer notebook. As a result, there were long pauses during which she typed in notes, letter by letter.

I reframed her sensitivity in a positive light, noting that she had a right to be aware of and value her own feelings. I restated the conflict between maintaining her own integrity and safety while attempting to get her needs met.

She took note of this comment, but I failed to pursue more fully what this conflict felt like, what the risk was to her safety, how this issue had arisen and been resolved in previous relationships, etc. I think that, in part, I had been trained by her to "tie things up" at the end of sessions in such a way that the most painful but possibly important observations were left unexplored.

The next Monday was a holiday, so we did not meet until the next Wednesday.

Session Eighteen

She presented as unfocused and emotionally distant from the information she was providing. She talked about her unresolved relationship with the older male friend. She also indicated that a man with whom she had a casual acquaintance was coming to town. She hoped to spend time with him, and discussed the possibility of their becoming intimate. After some discussion, she decided that she wanted only a close, platonic relationship.

She spent the remainder of the session describing her feelings of depression, which she reported had been present much of her adult life, in greater or lesser measure. She described her lethargy, fatigue, lack of motivation, tendency toward procrastination, inability to clean her home and tendency to retire to bed early in the evening to "avoid" certain unpleasant realities, including her significant financial problems. I explored these symptoms in greater detail, including their history of development. I explored her history of treatment for depression, including a prior trial of Prozac, prescribed by an internist, which she had found helpful. She said she had thought of making an appointment to obtain another prescription for this medication. We discussed the pros and cons of this decision, and I described to her the psychiatric services offered at the Maple Center. She talked about feeling dysfunctional, and I asked her what that meant to her and felt like. I noted that it was painful to get in touch with those feelings of not functioning as she would like and needing help to feel better.

SIXTH SESSION

Frank and Nina had had a terrible fight this week. He had overheard Nina having a conversation with her family on the telephone. Frank doesn’t speak any Persian, so what he had mistaken for screaming and yelling at her family members, was actually an excited conversation about her brother’s new BMW. He had been upset by the loudness, had said that he couldn’t stand it anymore, slammed the back door and left.

Nina: I didn’t sleep all night. I thought he was gone for good. And then he comes back the next morning like nothing was wrong.

Therapist: Frank, what’s that like for you to hear your partner sound so afraid and helpless?

Frank: I don’t know . . . just everyone screaming. It felt so harsh, I just want to run away from it.

Therapist: So when you heard Nina, in your experience, screaming and seeming harsh, who did she get to be for you in that moment?

Frank: I don’t know what you mean.

Therapist: Well, who did she remind you of?

Frank: (Silence). . . My father. He would scream and yell, and then someone, usually me, would get hurt.

Therapist: I see, so, when you experienced Nina being harsh and loud, childhood memories of your father got reactivated. Nina, what's that like for you to hear?

Nina: Well, it helps me try to understand what happened. I always think about me. Me being too fat. Frank had really wanted to play tennis and I said no. For me its the same as the bathing suit. He always wants me to swim, or play tennis, or dance. And yet when I wear leggings and a sweater and ask him how I look, he makes a face and says he prefers me in a skirt and sweater. He can be so critical. He never compliments me.

Therapist: So, when you experience Frank as rejecting or critical, whose face

does he have on for you?

Nina: Oh, I get it. He gets to be my father too. My father always rejected me because of my weight. He and my brothers were so critical.

From the couples initial interview and from their individual sessions, I had understood that the parents’ sexual dysfunction represented the net result of their individual histories.

Frank, like Nina had grown up in a family in which hopes for love were frustrated and substituted for physical and verbal abuse. I began to believe this resultant fear of sex was something they shared, even though both carried hopes for emotional intimacy and mutual support.

Nina’s open acknowledgement of her “love of sex” matched Frank’s unconscious fear of sex. In trying to rid himself of his own sexual wishes, trying to protect Nina (much like his mother), he was, through projective identification, trying to protect himself from “a bad father.” It was clear that the couple had a fear of sex and an idea that a mother would be harmed by a bad father, especially his penis. It became clear to me that I was keeping both of their fathers at bay, at least symbolically.

Progression of exercises went slowly for this anxious and phobic couple. One month later, they were still at the Sensate Stage, massaging each other including now breasts and genitals, with only a moderate level of arousal. Frank and Nina’s sexual life, as in other aspects of their coupled life was lacking in “contextual holding” and “centered relating,” that is, communication necessary to attenuate the strain put on the dyadic relationship. The frame around their relationship seemed almost invisible at times. In session we continued to work on the negative transferences to each other, reframing them, and understanding what was fueling them. They often experienced each other as rejecting or persecuting. Both felt unaccepted by their partner. Nina, hurting, fearing that Frank is not attracted to her and Frank because he can’t “give” her what she wants. Both, in the meantime longing to be accepted.

We explored Frank’s inability to “take,” rather than to “give.” This insight was immediately relieving for Frank. We also worked on the details of communication between exercises. Specifically, telling each other what they liked and did not like the other to do. I found that with both of them, they were often saying the same things, but the other wasn’t getting “it.” I also introduced the topic of visual of erotic material to aid in fantasy, and in distraction, so that Frank could begin to focus inwardly, and on what might please him. Nina was not open to this suggestion, again, wedded to her “ideal” fantasy of how a couple makes love and only thinks of the other. I tried several times to normalize this for her, but to no avail. She repeatedly saw this as further proof that Frank was not attracted to her. Try as I did, I could not get Frank to begin to express any negative feelings toward her or his fantasies of other women.

At the end of the sixth session, Frank announced, that because they were both in couple’s counseling, as well as their own therapy, that they would only be able to afford to come every other week. I explored this with them, and even offered to reduce my fee so that they might be able to stay in couples work every week.

Both Nina and Frank suffered from fear of exposure. For Nina, exposing herself fully to Frank in therapy, and Frank, fearful of doing the exercises wrong, or revealing that he had sexual fantasies, or negative thought about his wife. These were equivalent of the unprotected gaze of family and peers. Sex therapy and marriage too had meant being stared at, looked at , and exposed. I made this interpretation, aimed at their resistance to actively engage in treatment.

*****