Mrs. M, aged 40, came to the clinic complaining of insomnia, weight loss, sadness, and suicidal thoughts after discovering her husband's affair. She was diagnosed with depression. Cognitive behavioral therapy was proposed to help change her negative thought patterns and behaviors. The therapist would explain the treatment rationale and collaborative approach. Several sessions would be needed to formulate the case, identify cognitive distortions, generate alternative thoughts, and teach problem-solving skills to improve her mood and independence.

1. Cognitive therapy of depression

2.  I saw Mrs M, aged 40 years at my clinic
last week.
 She came to me with complains of not
being able to sleep for the last 1 month.
She has also lost 2.5 kgs in the last
month. It started after she realized her
husband was having an affair with his
junior in office.
 Following this she is feeling unwanted by
her family, can’t control her tears (she
fought back tears during the interview),
has lost interest in all work and has even
thought of suicide.

3.  She tried her best to fight back,
complained bitterly to her husband and
in laws. She also went to the
neighbourhood beauty parlour to
straighten her hair, bleach her face
and sort of ‘revolutionized’ her
wardrobe.
 All these have not helped improve her
mood, instead it is worse now

4.  At interview she is well presented, clear and
articulate. Her predominant emotion is
sadness. She feels worthless, uncared for, and
an object of ridicule by friends and family.
 She was the middle child of three. She had
missed a lot of schooling because she was not
very good in studies, and her family did not
place much importance on a girl’s education.
 Nonetheless she always knew she was good
looking and felt kind of relieved and vindicated
when this smart, rich and handsome man took
her on as his wife.

5. What is the diagnosis?

6. If we have to do cognitive
behaviour therapy with her…
 Explain treatment rationale.
 Explain principle of Collaborative
empiricism
 Discuss approximate number of
sessions required, cost etc.

7. Evaluation of suitability for
cognitive therapy
 How willing is the client to accept the
treatment rationale?
 Is she ready to form an equal,
collaborative relationship?
Rule out: fear of revealing thoughts
and feelings, insistence on managing
alone, believing that therapist will do
all the work.

8. Case formulation
Family of
origin
Marital
status
/family
Education
Social
network
Career
Interests
Problem
list
Middle class. Little importance on a girl’s
education. Submissive mother, distant father.
Married in a rich business family. Was cared for
by husband. Maintained a good house.
Studied till 1st year in college.
Many friends, used to be popular. Enjoyed her
status as belonging to a rich family, having a
handsome and attractive husband, a successful
homemaker.
Homemaker
Trying new recipes, listening to music
See next slide

9. Problem list
 I feel stupid, unattractive, useless
 Others will make fun of me/pity me
 I won’t be able to cope with practical things
without him
 If this marriage breaks I will have no place to
live, no financial backup.
 All my life I have done nothing to become
self sufficient, now I am paying the price.
 My family (including children) used me, now
they no longer care. Why did I give the best
years of my life to them?
 Nobody cares for me, I am all alone.

10. CLIENT’S PREVIOUS FUNCTIONING
Not good in studies Girl child in male dominated family
Believed it was her duty to be ‘nice’
so that they could marry her to a good
family and keep the family honour
intact
I am kind of stupid. I
am not smart.
Since I am not intelligent/smart, I
must gain acceptance by being physically
attractive (to husband) and by being a all
compliant submissive homemaker
EARLY LIFE
EXPERIENCE
CORE BELIEF
COMPENSATORY
BELIEF

11. CURRENT SITUATION
Trigger: husband falling for a much younger woman
Additional triggering event: In laws not being as supportive
as she had expected. Children too
busy
with own lives
Impact (cognitive)
My husband has stopped loving me: the truth has slipped out.
It’s my fault, I couldn’t keep my man.
I worked so much for this family; in time of crisis no one bothers.
No one cares
What I fool I made of myself by asking for a beauty makeover: can
I ever match a 30 year old’s charm?
My old friends will laugh at me.

12. Impact (emotional)
 Sadness
 Anger at oneself
 Anger at husband, in laws, children
 Shame

13. Impact (behavioral)
 Emotional and physical withdrawal from
husband
 Avoiding friends out of shame
 Not doing household chores (which used to
be pleasurable)
 Periods of pathetic self blame, self pity,
crying, contemplating suicide.

14. Problem list problem
reduction
Group her problems
 Life situation: husband’s affair,
financially dependant, no particular
skill (?)
 Intrapersonal: lack of confidence,
emotionally dependant
 Interpersonal: perceived lack of love
and concern.

15. Goal definition
Go back among
friends
Be able to do
household
chores
Lose weight
(5kgs), join
aerobics
Be able to earn
appx Rs 8000
per
month
Importance
urgency

16. Psychoeducation

17.  WHAT NEXT?

18. If she is too depressed
 Daily activity schedule
 Cognitive strategies:
 Distraction techniques
 Focus on an object
 Sensory awareness
 Mental exercise
 Pleasant memories and fantasies

19.  Behavioural strategies
Monitoring activies
Scheduling activities
Graded tasks assignment

20. Once she feels better ...educate
her more
Negative automatic thoughts
 Characteristics of NAT
 Methods to identify them:
 Ask
 Note changes in affect during interview
 Guided discovery
 DAS form
 Automatic thought record
 Role play
 Imagery

22. Discuss common errors of cognition
 Arbitrary inference
 Selective abstraction
 Magnification
 Personalization
 Overgeneralization
 Blaming
 Dichotomous thinking
 Perspective taking (thinking about one’s own
thoughts)
 Mind reading (jumping to conclusions)
 And many more

23. ASK HER TO IDENTIFY HER OWN
COGNITIVE ERRORS
My husband has stopped loving me: the truth has
slipped out
It’s my fault, I couldn’t keep my man.
I worked so hard for this family; in time of crisis no one
bothers. No one cares.
What I fool I made of myself by asking for a beauty
Makeover; can I ever match a 30 year old’s charm.
I am just stupid.
My old friends will laugh at me.

24. Help her reconstruct
 Examine evidence
 Experimental method
 Double standard technique
 Cost benefit analysis

26. Alternative thoughts
Index cards
My husband has
stopped loving me.
My husband is loving
another woman
besides me.

27. Alternative thoughts
Index cards
I have worked so hard
for this family. In time
of crisis no one
bothers. No one cares.
I care for myself. That
is reason enough to
live and live well.

28. Other examples of alternative
thoughts
 Many attractive, good natured and
intelligent women’s husbands have had
extramarital affairs before. It need not be
due to their shortcomings.
 I do stupid things sometimes.
 My friends are there for recreation, support
and/or sharing.
 If one of my friends faced a similar life
situation, I would have told her not feel
shattered.
 All this negative self talk is making me lazy
and more miserable.

29. Subsequent therapy sessions
 Setting the agenda
 Review of events
 Feedback of previous sessions
 Homework review
 The day’s major topic

30. Additional help: teach problem
solving skills
 Identify problem and prioritize
 Generate solutions:
 Brainstorming:
as many solutions as possible, no criticism,
allowed mix and match solutions
 Weigh pros and cons
 Chose best possible solution
 Plan before implementation
 Monitor and change if necessary.

31. Preparing for future
 As end of treatment approaches,
many patients worry that they will be
unable to cope alone. These worries
are dealt with in the same way as
other upsetting cognitions. It is
important to encourage the patient to
express them, and to evaluate the
evidence for their validity.

32.  THANK YOU