1. Running Head: SPINAL CORD 1
Philip Guillet
Research Report
PC 778: Treatment of Psychopathology
Loyola University Maryland
Pastoral Counseling Department
Dr. Ajita Robinson
December 3, 2014

2. SPINAL CORD 2
C is a married, (with three kids), heterosexual male in his 40’s. Three months
ago, he was involved in a horse riding accident. He was thrown from his horse, and
landed on the ground head first. His neck was broken at the second vertebrae in the
cervical region, (i.e. “C2 injury”). This has left him paralyzed from the neck down; what
is also referred to as quadriplegia. Currently, he lacks sensory awareness (both
proprioceptive and tactile) of his body from the neck down, as well as bodily control of
functions. He requires mechanical assistance to aid functions such as respiration and
sanitary excretion.
Since his accident, C has expressed deep sadness and grief over his loss of ability
to move or stand. He has even pled with his physicians to euthanize him. He has also
expressed feelings of hopelessness with a bleak outlook on the future, difficulty falling or
remaining asleep, low self-esteem, and difficulty concentrating. He has also expressed
feelings of generalized fear and anxiety upon learning that a spinal cord injury can
typically leave patients with higher susceptibilities of additional medical illnesses.
Counselor has been referred to C’s case to provide services as a pastoral counselor in the
hopes of easing the intensity of his symptomology.
Despite C being a relatively new case, an exhaustive diagnosis has yet to be
determined. However, it is with sound clinical judgment that, at this point, C has
presented a sufficient amount of symptomatic criteria to allow for dual diagnoses of:
“Persistent Depressive Disorder (Dysthymia) 300.4 (F34.1)”, and “Anxiety Disorder due
to [Spinal Cord Injury] 293.84 (F06.4)”.
For the application of the diagnosis of Persistent Depressive Disorder, a
minimum of two of the provided criteria listed in the DSM-5 are needed. C’s expressed

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hopelessness, low self-esteem, somnatic disturbances, and issues with focus amount to
four of the criteria. Due to his depressive symptoms occurring post-accident, a diagnosis
of “Major Depressive Disorder” does not currently apply. According to the DSM-5
(2013), responses to a significant loss, including disability, may include intense sadness
and rumination. However, such symptoms may be understandable, and what may be an
appropriate response should also be considered, and the individual’s history should also
be taken into account. Since C received no psychological diagnoses prior to the accident,
and considering the relatively recency of the accident, no empirical information can
allow for a pre- and post- comparison. Lastly, the diagnosis of “Anxiety due to [Spinal
Cord Injury]” is distinguished from “Generalized Anxiety Disorder” due to predominant
anxiety, impairing social areas of functioning, that does not present itself exclusively
during the course of a delirium.
Current treatment options include Cognitive Behaviour Therapy. Craig et al.
(1997) tested for the effects of CBT in patients with spinal cord injury and compared the
results to the control group which received no therapy in addition to what physical
treatments they were already receiving. There were no significant pretreatment
differences among either groups’ severity of depressive and anxious symptoms. Patients
were assessed immediately before the commencement of CBT, immediately after the
course of treatment, and one year after that. Three assessment batteries were used:
Spielberger-State Trait Anxiety Scale (STAIC), the Beck Depression Inventory (BDI),
and the Rosenberg Self-Esteem Scale. Both treatment and control groups showed an
improvement of scores in all three assessments over time. No significant results could
be found between groups assessing anxiety and self-esteem that would show a

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significant different between treatment and control groups. There were, however,
significant results that showed an improvement in depressive symptoms in the
treatment group over the control group.
Kemp et al. (2004) was also able to significant differences in patient reported
severity of depressive symptoms between pre- and post-treatment assessments. Over a
period of two years, assessment scores from the Beck Depression Inventory were
compared with a group of spinal cord injury patients against a group of patients who
declined treatment. Treatment involved weekly psychotherapy groups along with
antidepressant medication. No significant results were found in the scores of those
declining treatment. However, the treatment group showed a mean of 57%
improvement of scores longitudinally.
Treatment Plan
 Problem #1: Depression
 As evidenced by: patient reported symptomology
 As evidenced by: Dysthymia diagnosis
 As evidenced by: patient requesting euthanasia
 As evidenced by: depressed affect
 Problem #2: Anxiety
 As evidenced by: patient reported symptomology
 As evidenced by: impaired social functioning

5. SPINAL CORD 5
 As evidenced by: persistent fear of illnesses due to weakened immune system
Goal 1: Patient will learn to express negative feelings with the intention of preventing
build up, as evidenced by:
Objective 1: Verbalize sensations of discontent with counselor, and subsequently
acknowledge to counselor if any feelings of relief arise as a result of sharing in session.
Intervention 1: Patient and counselor will create a running logbook of feelings pre- and
post- sharing. Over time, the pairs of feelings will be reviewed so that the patient will be
able to see a trend that correlates a venting of frustration with subsequent relief.
Goal 2: Patient will learn a positive emotional way of thinking, e.g. in regards to self,
outlook on future, perception of outside world, view of others, etc, as indicated by:
Objective 2: Patient will learn of additional resources through counselor that may be
able to provide additional assistance so that feelings of loneliness diminish. Patient will
rate feelings of loneliness, (e.g. arbitrary scale of 1 to 10), and over time, there should be
a noticeable positive change in rating.
Intervention 2: Creating lists on a regular basis of “What I like about myself”, (the “I”
indicating the patient). Over time, as the list grows, the patient will be able to see a list
of qualities and strengths that may have been difficult to acknowledge during periods of
heightened stress.

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Goal #3: Patient will learn new coping skills to learn how to balance negative and
unpleasant emotions with positive ones, as evidenced by:
Objective 3: Verbalizing positive aspects of patient’s Self, and acknowledging that a
solely negative self-regard is a distortion resulting from depression.
Intervention 3: Patient and counselor will practice regular role-playing activities as an
exercise of self-compassion. During these exercises, patient will become in touch with a
compassion he’s able to tap into for others and then learn how to reflect that
compassion back onto himself. Role-playing exercises may allow for a greater ease of
access to compassion by allowing the patient to “step out of his Self”.
Intervention 4: Following up on the list mentioned in Intervention 2, the patient may
also be able to utilize items in the list as a self-soothing mantra to use during periods of
stress with the intention of diminishing the stress intensity.
Critique
Now that the brief summary of the client’s condition is as well as a potential
treatment plan, I have to sit back and wonder how I would respond to a client sitting
across from me whose pathology is identical to the one I described.
I can imagine that having a patient in counseling who is suffering from severe
depression brought on by a spinal cord injury would be a difficult experience for me. I
would think that it would be hard for me to empathize without getting overwhelmed by

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the patient’s emotional severity. I have never experienced any periods of even temporary
paralysis, I have no experience of having no voluntary movement of any part of me. I
cannot imagine the levels of impotent rage those with paralysis must experience at some
point. Although I would try to maintain as professional as I can, the fact remains that I
pursued the field of pastoral counseling because I do feel and I do care for others. And I
would be concerned that a protective instinct in me would cloud my clinical judgment.
The possibility of me breaking down emotionally in session may be a valid concern.
While it may, in some way, provide comfort to the patient that someone else cares that
deeply about his/her situation, I seriously doubt that display of emotion would provide
any long lasting therapeutic benefit. Therefore, I believe my biggest challenge within
that situation would be to remain balanced on remaining emotional empathic without
falling to far within the patient so much so that I absorb his/her feelings of sadness and
grief.

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References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Craig, A.R., Hancock, K., Dickson, H., Chang, E. (1997). Long-term psychological
outcomes in spinal cord injured persons: results of a controlled trial using cognitive
behavior therapy. Archives of Physical Medicine and Rehabilitation, 78, 33-38.
Jongsma, A., Peterson, M., & Bruce, T. (2014). The Complete Adult Psychotherapy
Treatment Planner (5th ed.). Hoboken: John Wiley & Sons.
Kemp, BJ, Kahan, JS, Krause, JS, Adkins, RH, Nava G. (2004). Treatment of major
depression in individuals with spinal cord injury. The Journal of Spinal Cord Medicine,
27(1), 22-28.
Spinal Cord Injury. (2014). Retrieved from http://www.christopherreeve.org/