Mental health articles

OF mental health care and mentally ill

Sample Treatment Plan Major Depression

Here is a Sample Treatment Plan Major Depression. Mrs V was an extremely overweight woman who worked as a nurse. Some years before her referral, she had married an ex-patient whom she had nursed with multiple sclerosis. He had since died. Following his death she had experienced a signifi cant period of depression and had taken long periods of time off work.

Mrs V was an only child. She had been brought up in a small village some miles from Gloucester. Unfortunately, she was sexually abused by a close friend of the family for a period of 2 to 3 years from around the age of 6 years. She felt disgust at the abuser’s behaviour, but also blamed herself for much of what happened. She believed she deserved to be abused as (i) she was a bad person, because of all the people that he could have abused, he chose her and that must indicate that he saw something bad in her, (ii) her parents did not love her, because they did nothing to prevent the occurrences, and (iii) God did not love her. These beliefs were strengthened by incidents, for example, in which her parents occasionally left her with the abuser while they went away on weekend trips. Despite her low self-esteem and disgust, Mrs V had performed well at school and went on to train as a nurse, working in a local hospital. She had, however, a poor social life and her relationship with her parents was poor. She did not have any boyfriends, and did not try to make herself attractive to men. She became signifi cantly overweight, partly because she gained some pleasure from eating and partly because it made her unattractive to men.

Mrs V met her husband-to-be while he was an in-patient. At the time he was severely disabled by multiple sclerosis, and had a poor prognosis. On his discharge they established a relationship, and after some months began to live with each other, and married soon after. Due to his physical infi rmity, they did not have sexual relationships. In fact, she rapidly became his carer, eventually helping him to eat and drink as well as other basic biological functions. From her perspective, he provided company, he could not leave her however unattractive she was or poor their relationship, and was unthreatening sexually. He provided a safe focus for her love, in that she was quite literally in control of their relationship. His death was therefore not only the loss of a loved one, but the loss of a feeling of safety in the world. She was unable to gain support from her parents, whom she considered did not care for her, and the negative beliefs she held about herself came to the fore. By the time she was seen by a psychologist, she was withdrawn, disengaged from the world, spending most of her time in her house with her dog.

Mrs V had chronic low self-esteem because of events that had occurred in her childhood, and her failure to challenge the basis of those beliefs. She felt unloved and did not love herself. She was frightened of sexual relationships, but nevertheless desired ‘safe’ relationships with men. The one, safe, relationship with an adult she had achieved was not strong, but had protected her against her negative self-beliefs and self-disgust. The absence of this relationship and the lack of any supportive relationships, combined with a re-activation of her negative beliefs about herself resulted in signifi cant distress and depression.

The great challenge to Mrs V was to confront her negative beliefs about self, established in her childhood and re-evoked following the death of her husband. These beliefs were both depressogenic and cut her off from the potential support of her family at times of diffi culty. These issues were considered in therapy using the Socratic dialogue approach. One issue discussed in this context was Mrs V’s belief that her parents knew she was being abused by her abuser, and chose to let this happen. The therapist and Mrs V examined the evidence related to this belief. One key issue was that Mrs V spent occasional nights with the abuser. She took this as a clear sign that her parents both knew what was happening and condoned it. However, close questioning on this issue reminded Mrs V that she did not want her parents to worry about her or the abuser to tell her parents what was occurring, so when she went to stay with this individual she had pretended to be looking forward to the time and smiled and laughed while her parents were there. As a consequence, they could not have been aware of her concerns and distress. Through similar questioning, she began to believe that she was chosen not because of who she was, but because of her availability, that her parents were unaware of what was occurring, and was less strong in her beliefs that she was a bad person and that (as a consequence) God did not love her. These changes did not immediately transform Mrs V into a happy and carefree person. Nevertheless, she was able to establish warmer and more loving relationships with her mother, and began to develop stronger acquaintanceships and then friendships with people she knew, including one man with whom she developed a strong, if asexual, relationship. Her mood lifted and she was able to return to work. She remained a vulnerable individual, but was coping well with life.

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