The Problem and the Intervention to Be Used - Essay Example

The Problem And The Intervention To Be Used The case of Jazz is of a young women suffering from depression, and who has had problems in her relationships. In the light of the available data, it can be seen that Jazz had a tense relationship with her parents when she was in her teens and that resulted in her moving out of home. She has been admitted to a psychiatric institution a year and a half ago, and since then has been on medication of depression. Later, her recovery has been substantial, as she came back to a regular job, re-established her relationship with her parents, and had also married. The therapeutic intervention that was provided to Jazz consists primarily of chemotherapay or treatment with chemical substances. (Robbins, ). This was most probably started when she was admitted to the psychiatric unit for severe depression, and it continued till very recently. For the time that Jazz was on medication, she was able to return to work and her relationships improved. A second form of intervention was also being provided by the her Community Psychiatric Nurse (CPN). The CPN are trained in assessing the needs of patients and on following up on their medication. (Wolverhampton City Council, 2005) . They also provide some form of counseling to the patient, and as such, Jazz was also getting this form of therapy. Jazz was receiving the services of the Community Psychiatric Nurse once a month, until her husband opined that she should reduce her visits. As Jazz started experiencing the symptoms of depression once again (feeling low in mood and anxious, constantly on edge and unable to relax or concentrate), it is important that she be given an appropriate intervention. The most probable choice for therapeutic intervention is Cognitive Therapy, administered by a trained counselor. This is desirable as the Community Psychiatric Nurse (CPN) interventions are not found to be always effective for ensuring a long-term relief and recovery for the patient. Studies have found that CPN has little or no impact on clinical outcome measures of people with depression, general anxiety disorders or adjustment problems. (Gournay & Brooking,1994, 1995). The CPN interventions, are however found to be more helpful in treating people suffering from Schizophrenia. (Gournay, 2000). Thus it is recommended that a full-fledged Cognitive Therapy should become the focal intervention for Jazz. It is also important that Jazz resume her medication, though with some modification in dosages or drugs so that her fertility is not affected and she can pursue her desire of getting pregnant. It is absolutely must that she gets proper psychiatric consultation regarding the change of her medicines. If she stops taking her medication abruptly, as she did, she might suffer from withdrawal symptoms. In addition she might see a return of her severe depression with full force. The medication can be administered in conjunction with the Cognitive Therapy. This combination of using anti-depressants and Cognitive therapy has been found to be effective achieving a full remission of symptoms in a majority of cases. (UT Southwestern Medical Center, 2006). Using Cognitive Therapeutic Intervention For Jazz Cognitive Therapy is a class of intervention that is built upon the belief that maladaptive behaviours emenate from maladaptive idea or cognitions. Thus the proponents of this type of intervention advocate directing therapy to modify or re-structure these cognitions. (Robins,). Such a therapy is aimed at creating self-awareness about one’s thought and belief system, and at practicing modifying them towards a more positive outcome in behavior. There are basically two approaches to Cognitive Therapy. The Rational-Emotive Therapy (RET), proposed by Ellis (1962), is used to probe deep down into the irrational cognitions and beliefs, expose their irrationality, and re-frame those beliefs into realistic modes. Another approach is the one proposed by Beck (1976). Beck’s cognition therapy is carried out by directing “pointed though friendly questions” at the patient so that he is able to reach to the bottom of his depressive cognitions. (Robins,). This is a more interactive approach than RET, as the therapists and the patient work together towards achieving insights into the patients thought process. The intention of therapy here is to teach the patients to become their own therapists. (Beck and Weishaar, 2000). The intention of using Cognitive Therapy is to modify Jazz’s cognitive patterns that are leading her to view herself and her position negatively. The objective of this therapy is that by changing her thought processes, Jazz will be able to view condition in a more rational and objective manner, and will adopt constructive beliefs and behaviour. This will help Jazz in leading a normal life and balance her roles of wife, daughter, mother and employee. She can also hope to develop the skills required to control her negative thoughts and to take initiative to better her life and achieve her objectives. The Cognitive therapy process starts with clinical interviews, and psychological testing. The clinical interviews are used to understand the history of the patient and to assess his current state. It also lays down an environment of trust, understanding and commitment for therapy. The Cognitive therapists instills the importance of time-limitation in the patients mind, and slowly guides him through a systematic and step-wise self-evaluation. Thus, Cognitive therapy sessions might start with a functional analysis – or understanding how the problem manifests itself, when does it occur, and with what frequency and intensity it occurs. In the case of Jazz, such an analysis might prove beneficial in making her aware of the external stimuli that lead to her depressive thoughts. She may be able to specifically point out the instances, e.g. her boss being non-cooperative with her, her husband not-understanding her needs, or her parents being pushy with her. The Cognitive Therapist will help her in monitoring the situations that lead to her depression – by maintaining a diary. This will help in highlighting and prioritizing her problems and assigning treatment to her symptoms (low mood, anxiety, inability to relax or concentrate). This is where the therapists can suggest medication to treat her symptoms, and also suggest behavioral changes that might help in alleviating Jazz’s condition. Once the cognitive analysis is done, Cognitive analysis is performed. This is a method by which the therapist highlights the patient’s thoughts and feelings and makes the patient realize the connection between the two. This is done by asking probing questions to the client that are aimed at discovering the automatic thoughts that surface when the patient faces a difficult or depressive situation. Another method of monitoring these automatic thoughts is to assign the patient with a homework – to record these thoughts as and when they occur. Once these recurring thoughts are manifested, its time to look into the underlying beliefs that help formulate such thoughts. Such schemas, or structure of peoples’ beliefs and assumptions, (Beck, 1997), serve to influence the way a person interprets environmental situations. This belief system is acquired by social learning, childhood traumas like peer abuse, parental discord, or negative treatment. (Beck, Freeman et al., 1990). Dysfunctional beliefs lead to a distortion in the understanding of the reality, and also trigger autonomic thoughts that are recurring. The negative thoughts are maintained by several factors – the inability to reality test the dysfunctional interpretations or due to resistance, out of fear of consequences to change. (Beck, Freeman et al., 1990). The dysfunctional beliefs can take the form of the patient seeing himself as unlovable, worthless and helpless; of seeing the world as overly demanding and themselves incapable of coping; and viewing their future with hopelessness. (Beck, Rush, Shaw and Emery, 1979). Such belief systems, as stated earlier are acquired by life’s experiences. When similar experiences occur later in life, or when a person goes through traumatic events, the dysfunctional thoughts are reinforced and further debilitate his capacity to analyze information and situations objectively. The Cognitive analysis of Jazz may reveal that her thoughts run something like – “I am incompetent and hence can’t organize my work”, or, “I am not a good wife, and unworthy of my husband”, or, “I am worthless and have done nothing for my parents”. Jazz will therefore be able to recognize and monitor her negative recurring, autonomic thoughts. The therapist will then lead her to explore the underlying beliefs that she has been holding onto, and which make her have these autonomic thoughts. Here, Jazz may realize that she hold a belief that “It’s essential that I do my job perfectly”, or, “a failed marriage will be the end of me”, or, “It’s impossible to please my parents”. As therapy progresses, Jazz will get more adept at pointing out her thoughts and gaining insights into the underlying beliefs. The role of the therapists will now shift from exploration to the facilitation of therapy, with Jazz assuming more responsibility for her therapy. Jazz can now understand the linkage between her beliefs and thoughts, and her thoughts and feelings of depression. This is the time when the Cognitive Therapist will intervene to make the patient test his beliefs against objective reality, and to correct his thoughts. This requires the patients to assess their thoughts as hypothesis, and test them against reality. The therapists asks deductive questions like, “what is the evidence for and against the patient’s interpretation of the situation”, “what does the patient fear will happen at worst”, or “what might the causes or results of a particular situation”. (Beck, 1976). For Jazz, this will mean answering questions like, “what is the evidence for my thoughts that I am incompetent and can’t organize my work”; “that I am not a good wife and unworthy of my husband”; and of “being worthless and not doing anything for my parents”. She will be required to present evidence, and as such, will also come across evidence that might be contrary to her beliefs. The psychologist will lead Jazz to logically deduct if there is any logical connection between the reality and her beliefs. She may discover that in reality, her boss is himself too pressed and hence is driving his staff to push in more. Evidence may also surface as to her being a good housekeeper and obedient wife (as she already agreed her husband’s advice to reduce her CPN sessions). She may also discover that her parent’s cherish her for who she is, and that they are happy with her as she is. The above revelations will contradict with her distorted beliefs, and Jazz will be forced to think of alternative thoughts. She will realize that she has been inferring her circumstances arbitrarily and that she has been magnifying her problems manifold. The Therapist can then help Jazz to see her situation as less catastrophic. The next step will involve attacking the dysfunctional belief system of Jazz. Again, the beliefs are tested as hypothesis and the analysis is done through rigorous questioning. Jazz will be asked to question her beliefs like “It’s essential that I do my job perfectly”, or, “a failed marriage will be the end of me”, or, “It’s impossible to please my parents”. She may realize that she doesn’t need to be perfect at job and home – it’s enough to do her best, which she actually does. She may also discover various occasions that her parents had been happy with her. There are several ways that the Cognitive Therapists might ask Jazz to give up her dysfunctional beliefs. These may include using imagery, reliving childhood memories. Thus Jazz will be able to re-align her beliefs to match reality The therapy may also require Jazz to test her new beliefs in an experimental manner – she may practice with adopting the belief that it’s not essential that she be a perfect employee, wife or daughter; just being herself is rewarding and brings happiness. A successful Cognitive therapy will culminate with Jazz having re-fashioned her belief system, and thus gaining benefits from her new thoughts and positive feelings. Applicability and Effectiveness of Cognitive Therapy A vast amount of literature exists to support Cognitive Therapy as the best intervention for treating depression. In a study conducted by the University of Pennsylvania and the Vanderbilt University, researchers found that Cognitive therapy has more lasting effects in patients. (Gallop, 2007). The research that segregated 240 depression patients into 3 groups – one medication, one on Cognitive Therapy, and one on placebo – found that thought the beneficial results for the first two groups were identical and better than for the group that was on placebo, those receiving Cognitive therapy showed more resistance to relapse at the end of the research. (Gallop, 2007). This is most probably due to the fact that medicines work only till they are being consumed (as happened with Jazz), while cognitive therapy trains the patient in self-therapy – that functions effectively, long after the therapist-patient sessions are over. Other studies have also corroborated the above. In an another study, researchers carried out a meta-analysis of four researches. These researches had been carried out using 169 patients with major depression, and who were selectively treated with either medication (tricyclic antidepressants), or received Cognitive Therapy. The analysis found that cognitive therapy was equally potent in reducing the symptoms of depression as were the medications. (DeRubeis et al, 1999). Influencing Factors The case of Jazz depicts several influencing factors that might have contributed to her depression. According to Beck (1990), the genetic factors play a significant role in creating vulnerabilities for the causes of depression. However, it is the experience of life that lead a person on the path of depression – those who are genetically inclined, will succumb more. The life experiences that Jazz has undergone, as illustrated in her case-study, include a traumatic relationship with her parents. This may have been a result of negative treatment in childhood, or her inadequate experiences for the learning skills to cope with pressures and criticism. After marriage, it appears that Jazz has been under tremendous pressure from her husband, to appear and behave normal. Her husband seems to be in denial of the fact that Jazz obviously needs treatment and help – thus aggravating her problem. This, in addition to her parents continuous insistence on her quitting her job, may have further influenced the relapse of her depression. As the negative thoughts started resurfacing, Jazz again started distorting her reality – she started seeing her boss as demanding, herself as incompetent, and her relatives as stressful. Critique of Cognitive Therapy Though numerous researches have found Cognitive Therapy to be effective for the treatment of depression, there are a few points that must elucidated to give a holistic picture of the above intervention. Firstly, Cognitive therapy places immense reliance on the understanding and skill of the therapist. It is the therapists’ awareness of human nature, his experience with different clients and situations, and his ability to articulate and interpret situations, that are of great significance in the delivery of the therapy. Secondly, Cognitive Therapy can only be effective if the patient is willing to take steps towards a reassessment of his or her negative beliefs and thoughts. Its effectiveness also depends on the patients ability to understand and evaluate her predicament – which may not be the case with all the patients of depression. Thus, for patients suffering from severe depression, medication could be the first line of treatment, followed by Cognitive therapy. As such, it can be stated that Cognitive Therapy is best used in conjunction with medication for depression. References Morgan C. T., R. A. King, J. R. Weiz, J. Schopler. 1993, “Therapy For Psychological Distress”. Introduction To Psychology”. Tata-McGraw Hill: India Wolverhampton City Council. 2005. “Community psychiatric nursing”. Available online at http://www.wolverhampton.gov.uk/health_social_care/medical/mental/cpn/. Accessed on 8 – Feb -2007. Gournay, K. & Brooking, J. (199 (1995) The community psychiatric nurse in primary care: an economic analysis. Journal of Advanced Nursing, 22, 769–778. Gournay, K. 2000. “Role of the community psychiatric nurse in the management of schizophrenia” Advances in Psychiatric Treatment. 6: 243-249. available online at http://apt.rcpsych.org/cgi/content/full/6/4/243 Accessed on 8 – Feb -2007. Sanderson, W. C. and S. Woody. 1995. “Manuals for Empirically Validated Treatments-A Project of the Task Force on Psychological Interventions Division of Clinical Psychology, American Psychological Association”. Psychcentral. Available online at http://psychcentral.com/txmanul.htm . Accessed on 8 – Feb -2007. UT Southwestern Medical Center. 2006. “Carefully monitored treatment can help two-thirds of those who suffer from depression”. Available online at http://www.utsouthwestern.edu/utsw/cda/dept37389/files/325946.html, accessed on 7-Febb-2007 Ellis A. 1962. Reason and Emotion in Psychotherapy. Lyle Stuart: New York. Beck, A. T.1976. Cognitive Therapy and the Emotional Disorder. New American Library: New York. Morgan C. T., R. A. King, J. R. Weiz, J. Schopler. 1993, “Therapy For Psychological Distress”. Introduction To Psychology”. Tata-McGraw Hill: India Beck, A. T. and M. E. Weishaar. 2000. “Cognitive Therapy”. Current Psychotherapy. Peacock: Itasca Beck, A. T., A. J. Rush, B. F. Shaw and G. Emery .1979. Cognitive Therapies for Depression. John Wiley: New York. Beck, A. T.1976. Cognitive Therapy and the Emotional Disorder. New American Library: New York. Gallop, R. 2007. “Cognitive therapy as good as antidepressants, effects last longer”, Medical News Today. 11 February 2007. available at http://www.medicalnewstoday.com/medicalnews.php?newsid=22319, accessed on 11-Feb-2007 DeRubeis RJ, Gelfand LA, Tang TZ, Simons AD. Medications versus cognitive behavior therapy for severely depressed outpatients: meta-analysis of four randomized comparisons. Am J Psychiatry 1999;156:1007-13. Read More