CBT Case Example: Mrs Jacobs – a woman with physical problems and depressive illness

Mrs Jacobs was a 78-year-old woman referred for therapy by her general practitioner having developed a depressive illness following a stroke. She had been treated with a course of antidepressants, which had brought about a small improvement although she remained significantly depressed with a ‘dread of the future’. She described a loss of confidence and poor concentration and had withdrawn from a number of social activities. She had also noticed a deterioration in her memory, finding it difficult to retain and use new information although this did improve at times when her mood picked up. She had three grown-up children who did not live locally.

Mrs Jacobs had enjoyed a career as a teacher until retiring at the age of 63 years. She had coped with a number of stressful events in her past, such as the loss of her husband, without becoming depressed. Her medical history included hypertension, heart disease and arthritis. Her stroke had occurred after her return from holiday, giving rise to permanent weakness of her right leg. Evaluation by a neurologist, including magnetic resonance imaging, had confirmed the presence of cerebrovas- cular disease. Fearing further strokes, she became anxious that she would not be able to carry on with her interests which included committee work and trips to the theatre. She feared she would be unable to continue living independently and would have to move to a nursing home. Her therapy goals included being able to manage social events and being able to plan realistically for her future.

In session 1 Mrs Jacobs began to recognize the patterns of thoughts and behaviours which were taking place in her depression. She realized that she had become very conscious of the change in her walking which resulted from her weak leg, thinking that other people were noticing it and commenting on it. This added to her anxiety and caused her to avoid social situations or to go to lengths to check that people were not likely to reject her because of it. These observations were included in a simple formulation and this set the scene for a simple diary of these thoughts and behaviours as they occurred at a committee meeting before session 2. She immediately recognized the biased nature of these thoughts, which brought about some improvement in her mood.

In session 2 Mrs Jacobs was helped to notice the link between her mood, energy and activity. At times she was quite tired with her mind ‘in a fog’ which caused difficulty organizing activities such as catching up on tasks at home. This led to self-critical thoughts. She expected herself to function as she had before her stroke, discounting any achievements she was now able to make. She was also disappointed by the day-to-day fluctuations in her energy. To illustrate this process she kept a diary between sessions. She was given written information about the link between activity and depression and was asked to begin activity scheduling. This caused her some difficulty as she aimed to complete the activity schedule perfectly, bringing to attention the high standards she had always set for herself. The exercise also brought to the therapist’s attention the extent to which Mrs Jacobs was struggling with mental tasks because of her cognitive slowing. Mrs Jacobs was encouraged to plan things in advance but to allow some flexibility depending on her physical state and external events. She approached larger commitments by breaking them into smaller stages and using more written records. To support these changes she successfully challenged her self-critical thoughts with responses such as ‘the list of jobs will never finish, so why blame myself?’, ‘is it really important to do it now?’. The beliefs underlying Mrs Jacobs’s high standards were examined – for example, the belief that ‘I must always do everything to the best of my ability’ – and she began to accept that getting older allowed her the opportunity to relax her standards and take some rest.

In session 6, Mrs Jacobs was helped to use thought challenging to deal with her fear of rejection by friends. She found questions such as ‘What am I afraid might happen?’ and ‘Am I exaggerating the importance of events?’ particularly useful. She recognized a tendency to predict that people would not want her. If others were ambiguous in their behaviour (such as not initiating conversation) it was taken as evidence that they did not want her around. She tested out her thoughts using simple behavioural experiments such as initiating conversation with people and being ready to challenge unhelpful thoughts as they arose. She found that actually putting this into practice was not always easy so she needed to plan the stages in some detail beforehand then complete her thought records and observations soon afterwards. She was successful in reducing the intensity of her thought that she was being rejected from 80% to 5%.

By session 9, Mrs Jacobs was becoming more flexible in her activities and coping better with personal relationships. She was still feeling anxious and low in the mornings. She had hopeless thoughts and although she could challenge these successfully later in the morning, she had difficulty doing this at the time. She therefore developed a list of strategies to cope with depression in the morning such as keeping a reminder by her bed of the challenges to unhelpful thoughts and activities she could engage in rather lying in bed ruminating.

By session 10 Mrs Jacobs’s mood was significantly improved. She still reported mild cognitive deficits such as difficulty naming and slower thinking, related to her cerebrovascular disease. She identified unhelpful thoughts about developing Alzheimer’s disease or losing control of her life. With the therapist she also identified a distortion in her thinking that having irreversible problems (such as her cerebrovascular disease) meant she had an unmanageable problem. Understanding the physical basis to some of her problems also helped her to challenge her self-critical thoughts. At times of additional stress, such as admission to hospital, she would become anxious and depressed and her fears for the future would recur, but she managed to use thought challenging to handle this (Table 87.1). This also helped her to review the plans she had made in case of further disability in the future, such as financial planning and adding her name to the list for her preferred nursing home. At the end of treatment, Mrs Jacobs made a therapy ‘blueprint’ which included a summary of what she had done to achieve her improvement and what she would need to do if her problems recurred (Figure 87.1).

Abridged and reproduced with permission from Wilkinson¹⁰, pp. 67-71.