For this assignment, I am going to look at the main points regarding Mr. P’s case using given information whilst also giving a brief about depression of the reactive types followed by recognised treatments, developing a plan of treatment with set goals at each stage, respecting his Individuality, Dignity, ensuring Confidentiality, using a Non-Judgemental and Fair approach.
Reading through the information provided in Mr P’s case, I do feel that there are different ways to tackle the presenting problems in his life as a widower following his wife’s unexpected death from a heart attack soon after returning from a holiday 21 months after his retirement. Both were excited about plans to travel the world together in his retirement, but unable to accomplish following Mrs. P’s death leaving Mr P feeling lost, isolated and that his life should be over. His son being always busy lived 100 miles away which made it difficult for him to visit seeking his supports and to see his 2 grandchildren. He started drinking alcohol heavily to drown away his sorrows, which made him feeling disgusted knowing that his late wife would be upset on seeing his behaviour taking a turn for the worst. He kept away from his friends which increases his pain of losing his wife when in their company. Mr. P’s behaviour is typical to someone reacting to a big loss in life presenting with depressive symptoms following him being alone, not wanting to be with his friends and turning to alcohol which has depressive effects on the brain.
AN INSIGHT INTO DEPRESSION
Depression is a mental condition characterised by feelings of extreme sadness, rejection and dejection. It is very crucial to detect depression early as untreated, it can lead to suicide. Depression occurs after the loss of an important source of self-worth when an individual becomes stuck in a self-regulatory cycle there being an absence of responses to reduce the discrepancy between actual and desired states. Consequently, the individual falls into a pattern of virtually constant self-focus, resulting in intensified negative affect, self-derogation, further negative outcomes, and a depressive self-focusing style emphasising a great deal on negative outcomes with very little on positive ones leading to a negative self-image providing an explanation for the individual’s plight and to help in the avoidance of further disappointments. The depressive self-focusing style then maintains and exacerbates the depressive disorder.
Most major theoretical perspectives on depression seem to fit into one of the following four categories: (a) Psychoanalytic, (b) Control, (c) Cognitive, and (d) Behavioural, with some theories featuring one or more of these categories.
The Psychoanalytic Perspective
Sigmund Freud (1917/ 1986), psychoanalytic theories of depression have emphasized the importance of losses of central sources of love and emotional security in the onset of depression.
In his classic work on depression, “Mourning and Melancholia,” he observed that such losses often produce severe and seemingly irrational self-criticism and castigation saying that, “One part of the ego sets itself against the other, judges it critically, and, as it were, takes it as its object”. Explaining this extreme self-criticism, Freud hypothesised that the reproach of self is really not directed toward the self at all, but rather, towards the lost object unconciously implanted into the person’s own ego. Because open hostility toward the object produces guilt, the individual directs his or her anger inward onto the self, explaining according to Freud that depression is the result of the directing of the hostile side of ambivalent feelings toward a lost object inward toward the self.
Rado (1928) presented a variation on Freud’s theory emphasising to the need for self-esteem, likenning the depression-prone individual to a child whose sense of self-worth is dependent on his or her parents’ or others approval. After the loss of a central object, such people react with anger and bitterness, but, because such tactics are unlikely to be effective in restoring the object, they soon adopt the strategy of self-punishment, repentance, and guilt in an attempt to gain the object’s sympathy and love ultimately, restoring their sense of self-worth.
The Control Perspective
The control perspective on depression emphasizes life changing losses as a primary factor in the onset of depression due to an absence of contingency between behaviour and outcomes. Seligman (1975) argued on the relation between learned helplessness and depression which impacted on explaining depression. Although there have been many variations (e.g., Abramson, Seligman, & Teasdale, 1978; Klinger,1975; Wortman & Brehm, 1975), the general notion is that after experience with uncontrollable outcomes, the individual develops low expectancies for exerting control over later outcomes that could, in fact, be controlled producing a wide range of motivational, cognitive, and affective deficits that constitute the state of depression. .
Kuiper, Derry, and MacDonald (1982) proposed that depression exerts a negative influence on a wide range of cognitive activities, including memory, inference, and perception with the depressive phase emerging gradually as the depressive episode increases in intensity.
The Behavioural Perspective
Lewinsohn (1975) proposed that reduction in activity level occurs when an individual experiences a low rate of response-contingent reinforcement. Because of personal characteristics (e.g., age, sex, and attractiveness), a lack of appropriate skills, or environmental scarcity, a low rate of positive reinforcement is felt, followed by poor behaviours making positive
reinforcement less likely, instigating a vicious cycle of reduced activity and increasing infrequent reinforcement. Lack of activity may itself be reinforced when the person’s friends and family members dispense sympathy, reduction in responsibilities, and increased attention to the depressed.
The Cognitive Perspective
According to Beck (1967, 1976), depression is caused by a negative depressogenic cognitive set or schema that predisposes one to become depressed when stressful events or losses occur. Depression-prone individuals are characterised by a “depressive triad;’ consisting of- 1) a negative outlook on the self, 2) the future, and 3) the world. Beck argued that stressful life events or losses activate lead to systematic distortion of the person’s thoughts and perceptions and drawing conclusions without sufficient supporting evidence. TYPES OF DEPRESSION
Changes in the brain and depression
Depression may be related to changes in certain chemicals within the brain – particularly serotonin, nor-epinephrine and dopamine, relating to depressed mood and lacking motivation. Changes to stress-hormone levels may also play a part with Long-term stress causing changes in the brain leading to severe depression.
Anyone with some or most of the symptoms of depression should seek advice from a doctor or counsellor without delay as the earlier depression is diagnosed and treated, the better the prognosis.
Types of depression-
1)Major depressive disorder
2)Bipolar disorder (used to be called ‘manic depression’)
5)Seasonal affective disorder (SAD).
Also called major depressive disorder, clinical depression, uni-polar/ bi-polar depression with Symptoms including: 1)Low mood
2)Loss of interest and pleasure in usual activities
3)Significant sleep disturbance
4)Loss of appetite
5)Unexpected weight loss
6)Loss of energy
7)Feelings of guilt or worthlessness
Someone with major depression will experience symptoms interfering with their lives bringing negative changes in their lifestyles and attitudes including their social and working lives.
Melancholia is another severe form of depression consisting of the physical symptoms of depression, (movements becoming much slower showing complete loss of pleasure in almost everything).
During a psychotic depressive phase the sufferer can lose touch with reality, thoughts and emotions being impaired with perception of external reality severely affected and experiencing Hallucinations (affecting most of the five Senses- Auditory, Visual, Olfactory, Gustatory, and Tactile) or, Delusions (false beliefs that are not shared by other people). The psychotic depressed may believe they are bad or evil, being watched or followed, that everyone is against them (paranoia), being the cause of their illness or bad events occurring around them.
1)Delusional jealousy (Othello’s syndrome) – eg believing a partner is being unfaithful. 2)Capgras’ delusion – belief that a close relative has been replaced by someone else who looks the same. 3)Unilateral neglect – belief that one limb or side does not exist. 4)Thought insertion – belief that someone is putting thoughts into the brain. 5)Grandiose delusion – belief of exaggerated self-worth.
6)Persecutory delusion- religious, somatic and grandiose
7)Nihilistic delusion – delusion of poverty/Nothingless
Antenatal and postnatal depression
Women are at higher risk of depression during and after pregnancy with complex causes immediately following birth. Up to 80% of women experience the ‘baby blues’ – condition relating to hormonal changes being longer-lasting, affecting the mother’s relationship with her baby, the child’s development, relationships with her partner and family members. Almost 10 per cent of women will experience depression during pregnancy and 16 per cent in the first three months after giving birth.
Bipolar disorder or ‘manic depression’ happens when the person experiences periods of depression and mania in between periods of normality. Mania is the opposite of depression and varies in intensity – symptoms include – feeling great, full of energy, racing thoughts, little need for sleep, talking fast, difficulty focusing on tasks, and feeling frustrated and irritable, losing touch with reality and has episodes of psychosis with hallucinations or delusions.
Cyclothymic disorder is a milder form of bipolar disorder when the sufferer experiences chronic fluctuating moods over at least two years, periods of hypomania (a mild to moderate level of mania) and periods of depressive symptoms – with very short periods (no more than two months) of normality between. The symptoms last for a shorter period being less severe, and not as regular as those of bipolar disorder or major depression.
Dysthymia (or dysthmic disorder)- similar to major depression, but less severe with symptoms lasting longer. A firm diagnosis can only be done following someone who has suffered a milder form of depression for more than two years.
Seasonal affective disorder (SAD)
SAD is a mood disorder with a seasonal pattern, of unclear cause related to the variation in light exposure in different seasons, characterised by mood disturbances (either periods of depression or mania) that begin and end in a particular season with depression in winter the most common with sufferers likely to experience- lack of energy, sleeping too much, overeat, weight gains and cravings for carbohydrates.
There have been varied “cures” for depression for years – ranging from talking therapies, to electroconvulsive therapy – ECT, to SSRI’s (Selective serotonin re-uptake inhibitors, like Prozac), hypnotherapy, over the counter herbal and non-prescriptive medicines.
Careful considerations need to be given when planning the treatment of a depressed client, which can help in deciding the correct treatment and establising the client safety. For client being a danger to the self or others, advice will be sought from my supervisor and depending on the severity of the danger, the responsible authorities will be made aware of the situation, with the client handled with care and empathy. It is crucial to make a list of the client’s current medication and be aware of the masking effects the medications may have on their behaviour and emotions..
For therapy to start, Mr P should have been taken through the Initial Consultation, given clear and comprehensive information on treatment agreed, with consent forms signed and dated willingly. The ethical principles of counsellor-client relationship are that the counsellor shall:
1)Approach their work in the spirit of a vocation
2)Honour the client’s subjectivity, views, beliefs, and goals
4)Require to undertake a rigorous self-examination on their work and
5)Provide service to clients solely in areas of their competencies with the relevant professional indemnity insurance secured.
6)Be non-judgemental and non-discriminatory in approach.
7)Ensure that the workplace and all facilities offered are suitable and safe
8)Ensure for continuous maintenance of confidentiality
The Client-Centred Approach is useful in making the client feeling at ease in a safe environment where they can express themselves and explore likely achievements with therapy. In giving the therapist an overview of their lives and feelings, an insight into the client’s conditions and aims to attend therapy may be achieved. It is important to make the client feel that there is hope and light at the end of the tunnel – without making unrealistic promises and to making the client feel in safe hands and listened to.
Treatment plan dealing with the following issues:
1)Bereavement – Being the cause of Mr P’s presenting condition having lost his wife soon after returning from a holiday with Mr P still grieving her death. 2)Abuse of alcohol- Alcohol has taken over his life even though he is aware that his late wife would have been angry seeing him in this state 3)Self-defeating Behaviours – Mr P felt his life should just be over finding himself alone feeling lost and isolated.. 4)Relationships – Mr P is keeping away from his friends who remind him of his late wife.
His anger or resentment are directed towards his unsupportive son and family. 5)Anger – Mr P being angry with himself at being left alone, with his son living 100 miles away which prevent from seeing his grand children. He showed his motivational ability on starting therapy to change his behaviour. 6)Stress & Anxiety – Emotionally feeling flat due to the recent hard times he’s been through.. 7)Motivation – This is the only POSITIVE element from Mr P as his acceptance and attendance for treatment show as far as I am concerned says a lot of his “give it a go” character as he attended therapy to help improve his situation by taking control of his anger.
I chose Bereavement to start which if successful will gradually diminish his anger. Given time and for him to overcome any shortfalls, he would need to be Fair, Frank and Free to Fight back the Negative feelings embedded in him. Once he accepts his late wife’s death, he will able to move away from the grief curve, manage to deal with his anger, self-defeating behaviour and ridding himself drinkig alcohol for good is a Positive turn making it much easier for him to get his negative emotions under control with the suicidal feelings leaving for good feeling ready to start seeing his friends and his son and family in good spirit .
Summary of the Therapeutic Sessions
In the first few sessions with Mr P, besides building rapport and trust I would need to understand Mr P’s life at the time. The summary given does not mention his previous experiences with grief and loss, anger or self-defeating behaviours. There is a mention of his late wife getting upset on seeing him unkempt, drowning his sorrows with alcohol, hoping for his life to be over. I’ll start dealing with his griefs and loss followed by Anger being a direct reaction to his wife’s death. Looking at Mr P’s present with him and establishing his goal/goals in accepting therapy is a good starting point to gather his thoughts, emotions and expectations for a better future.
Acceptance of his loss
Mr P may have regrets about his relationship with his wife that is making it harder for him to move on. From the summary, it is clear to see that their marriage was just right hence his inability to cope without her. Mr P would need freedom to talk of life with his wife and to share his feelings. Her unexpected death being a blow to him, he wished to have been able to save her and wishing for himself to go first. He may have thought of being unworthy of his wife. Acknowledging these feelings, and, working through them will, over time, help Mr P to move forwards.
Some REBT and CBT may also be useful for Mr P to help change his negative thoughts and feelings to positive ones which would give him something to focus on feeling in control while working through these issues. He would be given homework, like diary writing or recognising triggers and thought processes, giving him a sense of purpose between sessions.
Dealing with the Anger
As mentioned above, Mr P acknowledges that he is angry and disgusted with himself. Therefore it can be assumed that this anger won’t vanish until achieving victory over his self-defeating behaviours gradually feels able to cope with his loss. However, there is probably a great deal of emotion on a subconscious level which he will not be aware of. Feelings of anger towards his deceased wife would possibly only make him feel more angry with himself as well as guilty; angry and frustrated towards his son and family. Mr P would need careful guidance during the sessions to explore his feelings; working out their origins. On discovering and acknowledging any feelings, Mr P will need reassurances; made to realise they are normal and understandable being all part of the healing process. Mr P used alcohol to block out the emotions which he wants to do away with, but once he allows himself those feelings without trying to supress them, he can begin the healthier process of dealing with them and start to move on with his life.
The approach for this stage of the therapy would be determined during the course of the sessions. Mr P may find he wants to talk and explore his negative emotions more freely being in a safe environment using a person centred-approach. Gestalt approach may be useful here too, for bringing him into his present and being aware of the here and now, rather than focusing on the past and what should have been. The empty chair approach could work very well for Mr P. He could use it with his wife to say things that were left unsaid or explain to her why he is behaving the way he is; or equally useful, to put himself in his wife’s position to get a true enough feeling towards his current behaviour.
Drinking to drown his sorrows hoping to get rid of his loss may not have been something that Mr P would have been aware of possibly just cutting his friends and family out of his life. Going through the therapeutic processes outlined above would maybe be painful for Mr P, giving him a lot to think about, hopeful that his needs of alcohol or social isolation would gradually make him feel more in control, safe and positive culminating in Mr P realising that the more he is exposed to his friends and family, the less pain he will feel from seeing them and the more they can help him getting his life back.
Suicidal thoughts and the move towards a healthier life.
Mr P was depressed wishing for his life to be over. People with suicidal feelings are without expectations for a brighter future, seeing their situation as being hopeless. Working with Mr P, it is vital to help him maintain his place in society and believing that there is a future worth having.. Mr P needs to find a sense of purpose – where continued therapy is going to lead him and of his expectations. Attending therapy after being to his GP shows his motivation to help himself move forward positively.
Each and everyone of us have or still have something dearest to us irrespective of size and shape, young or old which we cannot see ourselves parting away from. In like manner, losing someone through death which is inevitable, yet, the acceptance of that loss becomes very difficult. But, thanks to modern approaches, it is pleasing to know that there are still caring professionals always ready to offer their service even if it is for a price.. Many of the most common losses that precipitate depression involve events apparently beyond the individual’s control, such as the death of a loved one or the loss of a job due to recession.