Depression Patient Psychological Assessment
- History taking was done through Clinical interview
- BDI was administered
- Dysfunctional thought record was given
- Mental state examination was done
- History taking was continued
- DTR was reviewed
- Psychoeducation was done
- ABC model was done
- DTR was reviewed
- Activity scheduling was given
- Link between B-C of ABC model
- Socialization with CBT model
- Coping statement was given
- Previous activities was reviewed
- PMR was done
- Mastery and pleasure was added in activity schedule
- Previous activities was reviewed and given feedback
- Sleep hygiene principle was taught the patient
- Vicious cycle of anger was explained to patient
- Previous activities was reviewed
- Coping statements were given
- Written ventilation was done
7th – 10th session
- Previous activities were reviewed
- Anger management was done
- Distraction techniques
- Anger managing tips
- Written ventilation
- Previous activities were reviewed
- Assertiveness training
- Taking it all away technique was done
- Previous activities were reviewed
- Anger management techniques
- Assertiveness training- fogging
- Taking it all away technique was done
- Previous activities were reviewed
- BDI was administered for post assessment
- Subjective rating of patient’s problems
- Therapy blue print was given to the patient
The patient S.S was 33 years old female, married, educated till high school and was youngest among her 6 siblings. She came to Psychiatry Department of Hospital with the complaints of low mood, weeping spells, anger outburst, irritability, muscle tension as well as lack of interest in daily routine activities and disturbed sleep. She was referred to the trainee Clinical Psychologist for Psychological Assessment and Management. Assessment was done on formal and informal level to get detailed information regarding her problems. Informal assessment was done through Clinical Interview, Mental State Examination, Visual Analogue and Dysfunctional Thought Record (DTR). Formal assessment was done through Beck Depression Inventory (BDI-II). In accordance with the presenting complaints and on the basis of informal and formal assessment, the patient was diagnosed with Major Depressive Disorder. Apart from case Conceptualization was done on idiosyncratic model of Depression, different techniques of Cognitive Behavior Therapy were implemented to manage the symptoms of the patient included ABC model, Activity Scheduling, Coping Statements, Progressive Muscle Relaxation (PMR), as well as Anger Management, Sleep Hygiene, Taking It All Away, Assertiveness skills and Problem solving . The outcome of therapy was reported about 50% in 13 sessions.
|No. of siblings||6 (5 Brothers and 1 Sister)|
|Children||1 Daughter (adopted)|
Source and Reason for Referral
The patient came to Psychiatry Department of Hospital, with the complaints of depressed mood, weeping spells, anger outburst, irritability, muscle tension as well as lack of interest in daily routine activities and disturbed sleep. The patient was referred to trainee Clinical Psychologist for the assessment and management.
|Gets angry on even small things|
The thing is to talk about
|Cannot control anger|
The mind remains silent
It is not tolerable for optimism
|Mind and heart does not like to do anything|
History of Present Illness
Patient reported that when her father died in 2000, she became very low and upset. It was a sudden heart attack. She was very close to her father and was unable to overcome the grief. Meanwhile she got married after few days of her father’s death, her marriage was held in simple way. It was difficult for her to cope from that loss as well as manage her marital life. At that time, she was about 17 years of age and her husband was 10 years older than her. Patient reported that her husband was sexually weak and did not maintain sexual relation with her which she found after few days of her marriage. Although her husband and his family knew about his sexual problem but they did not disclose it with her family before marriage. Her husband also pressurized her not to discuss this issue with anyone. Patient reported that her parental family was also rigid and she had no close relation with her family members as her father died earlier and her mother had distant relation with her so she preferred to remain quiet. She reported that her husband started to give sleeping pill to her every night so that she did not demand any physical contact with him. During that time, they frequently consulted different doctors who suggested them to adopt a child and try to manage their sexual relationship. On the other hand, patient reported that her husband was cooperative with her as he fulfilled her all basic needs. He also supported her in every matter and showed concern towards her. She also reported that her husband felt guilty but he avoided discussing on this matter.
Patient reported that after a year of her marriage, her family came to know about it and they also suggested her to adjust with this issue by herself and by remaining quiet. Patient was a teenager at that time of her marriage, she was very charming and full of life. She married in a joint family system where her sister in laws were elder than her, they always snub her and criticize her on her smiles, dressing and looks. They also tried to create misunderstanding between her and her husband, as she had no support from her own family and even from her in laws and she started remaining quiet and alone. She faced low mood and episodes of headache. The patient reported that gradually she realized the jealousy of her sister in laws and was unable to defend herself so that she diverted herself towards religion. She joined religious school and spent most of her time in religious activities. She spent 6 years there and worked hard for the religious school as their team member but then she left it due to her increased headache and neck pain.
In 2006, she and her husband started to live in separate home but her in laws did not stop to interfere in their marital life, they used to make misunderstanding between them continuously which upsets her. she started to blame her husband that she sacrificed a lot in their sexual relation but in return his family never let her live peacefully. She started to get irritated on minor things and felt lonely at home, she had low mood and felt no pleasure in any house hold activities. She started fighting with her husband on daily basis and pressurized him to adopt a child. During that phase, she started to chat with her friend and discussed her all problems with her. Whenever, her husband did not give time to her, she started to talk to her friend even at late nights and especially when she demanded physical closeness with her husband and her husband deliberately avoided her. It was very distressing for her when her husband asked her to spend her leisure time by talking with anyone.
In 2012, patient adopted her brother’s daughter. Her in-laws objected that on that but her husband supported the patient. He gave love and care to their daughter and also fulfilled her all needs. By adopting a child, patient’s attention was shifted from her husband towards her daughter. It brought a healthy change in their life. Her depressed mood, irritability and anger outburst were reduced. They paid more attention and care towards their child, she was satisfied with her husband as he gave attention, care and fulfilled her all demands and desires.
In 2016, her in-laws again started to interfere in their marital life. Patient reported that her elder sister in-law blamed her that she had extra marital affairs with someone but she did not mention the person, she blamed and spread that rumor in the family to defame the patient. On the other hand, her husband showed trust on her but she became very upset and depressed and blamed her in laws that they were jealous from her so that they did not accept her satisfied marital life. She started many negative thoughts and negative experience of her past life almost daily which disturbed her and she did not perform her daily routine activities efficiently. She started crying almost daily, her mood remained low and irritable all the time, and she did not feel pleasure in any activity. She felt loss of energy and tired nearly every day. She had frequent fights with her husband and had suicidal ideation but she did not do any attempt. She was referred to Hospital for management of her presenting complaints.
Patient’s father died at the age of 60 years with heart attack. She had close relation with her father as compare to her mother. He was humble and compassionate by temperament. Patient reported that her father was very caring and loving towards her which made her stubborn. She was attached with her father.
Patient’s mother was 65 years old, illiterate and housewife. She was strict in nature. Patient had distant relation with her. She did not express her feelings with her mother and felt hesitation to discuss her problems with her mother. Patient reported that still she had a communication gap with her mother.
Patient had 6 siblings, 5 brothers and 1 sister. Her birth order was last. Her 1st born brother was 40 years old, did B.A and worked in office. He was married and had satisfactory relation with the patient. She felt hesitation by sharing her problems with him. Her 2nd born brother was 38 years old, married and was doing job in office. She also had satisfactory relation with him. Her 3rd born brother was 37 years old, army captain and also married. He had congenial relationship with the patient. He gave his second daughter to her. Her 4th born brother was 36 years old, married and was doing his own business. Patient also did not attach with him and had hesitation by sharing her problem with him. Her 5th born brother was 35 years old, married and was doing business. He was cool and calm by temperament. He had congenial relation with patient.
Patient lived in nuclear family with her husband and a daughter. The general home environment was tensed due to patient’s presenting problems. She used to fight with her husband on daily basis as she did not satisfy with her marital life. According to the patient, her daughter also got tensed due to her condition and daily conflicts.
Patient reported that her birth was normal. Her developmental milestones were achieved at appropriate age. She had no history of severe injury, any physiological or psychological problems. From childhood, she was an active child and stubborn in nature. She wanted to become a focus of attention as her father always paid extra attention to her.
Patient started schooling at the age of 4 years. She was an average student and got average marks throughout her academic career. She did 10th standard with average marks then she did 12th from college. She had congenial relation with her teachers and class fellows. She also involved in extracurricular activities such as religious activities. After completing 12th standard, she left her studies due to her marriage.
Patient reported that she achieved menarche at the age of 12 years. She got knowledge about menstrual cycle from her friends. After the occurrence of her first menstrual cycle, her mother educated her about the process and how she had to clean herself. She reported no homosexual or heterosexual relation before her marriage.
After her marriage, she did not maintain sexual relation with her husband due to his impotence. She became depressed and upset due to not fulfilling her sexual needs but according to her, she scarified on it.
Patient had arranged marriage in 2000. Her husband was 10 years older than her. She reported that at the time of her marriage she was too young and good-looking as compare to her husband and sister in laws. Her in laws started to jealous from her beauty and make misunderstanding between her and her husband. Because of that, she faced adjustment problems at her in laws.
According to the patient, her husband had sexual problem which was not cured after taking different treatment. He deliberately started to avoid physical contact with the patient by giving her sleeping pills at every night. After 1 year of her marriage, when her parental family talked about her pregnancy, she disclosed the problem with them but they also suggested her to sacrifice in her marital life. Patient reported that her husband was caring and cooperative towards her and fulfilled her all needs and demands except sexual need.
Patient had one daughter adopted by her brother. She was more attached with her daughter. Patient fulfilled her all demands and spent most of the time with her. Sometimes she became frustrated and used to get angry on her.
Patient reported that after one year of her marriage, she started to join religious school where she was a member of management team and participated in religious activities for 6 years. Then she left it due to her neck pain and severe headache.
Patient was reserved in nature. She had few friends. She was talkative with her close relations. Her social circle was not so big but her all friends attached with her and shared their problems to her for getting solution. She was optimist about life. She had an interest to involve in religious activities. She became easily worried in stressful situation.
Assessment was done on two levels such as formal and informal way to assess the problematic behavior of patient.
Informal assessment was carried out on following levels
- Clinical Interview
- Mental State Examination (MSE)
- Visual Analogue (Subjective Rating of Symptoms)
- Functional Analysis of Dysfunctional Thought Record (DTR)
For formal assessment, following scale was done.
- Beck Depression Inventory (BDI-II)
Clinical Interview was conducted to patient in order to gather information regarding her history of present illness and her current complaints, as well as the nature, severity and duration of her symptoms. It was also carried out to get detailed information about her personal history, family history, social life, financial situation and other factors such as predisposing, precipitating, maintaining and protective factors that contributed to increase her present condition.
The assessment also provided a comprehensive picture of the patient’s life, which helped in determining the diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) as well as course of treatment.
Mental State Examination (MSE)
Patient was a 33 years old lady with appropriate weight and height. Her dress code was according to the weather and age appropriate. She apparently looked depressed. She maintained eye contact with therapist. Her attitude towards therapist was cooperative throughout sessions. She had low mood objectively and subjectively and affect seemed to be congruent with her mood. There was no reported history of any perceptual disturbances like hallucination and illusions as well as depersonalization and derealization. She did not report any delusions and obsessions. Patient had orientation about time, place and person. Her remote and recent past memory was intact but her recent memory was partially intact. Her attention and concentration was partially intact. Her abstract thinking and judgment was intact. She had insight about her psychological problem.
Visual Analogue (Subjective Rating of Symptoms)
The patient was asked to rate the presenting complaints during clinical interview. The subject rating was based on 0 – 10 rating scale in which “0” indicates the absence of symptoms, 5 means of moderate severity of symptoms and 10 means extreme severity of symptoms. The purpose of this rating was to assess the severity of presenting complaints of patient before and after the implementation of therapeutic intervention. It will also help the therapist to assess the efficacy of treatment. The subjective rating of patient’s problems was mentioned below.
Table 1: Presenting Complaints and Subjective Rating of Patient (0-10)
|Presenting complaints||Subjective Rating |
|No interaction with anyone||8|
|Lack of interest in daily routine activities||8|
Functional Analysis of Dysfunctional Thought Record (DTR)
Dysfunctional Thought Record (DTR) was given to patient to record her automatic thought, her emotions and behaviors regarding her thoughts in different situation. It was also provided to assess her connection between thought s and emotions. Following table was shown the Functional Analysis of DTR.
Table 2: Situation, Automatic Thoughts, Emotions and Behavior of Dysfunctional Thought Record (DTR)
|Situations|| Patient’s sister in law blamed her of having extra marital affairs. |
Her husband went to office early and came late at home
Her daughter insisted her to go outside
She wanted to get physical contact with her husband
|Automatic thoughts||She sacrificed of having no sexual relation with her husband but still others blamed her. |
Her in laws jealous from her and wanted separation between them.
Her husband did not spend time with her.
She did not demand sexual relation but her husband did not provide affection and love towards her.
Her husband supported her in laws rather than her.
|Emotions||Depressed, irritable, angry|
|How did the thought end||She started to cry |
She used to fight with her husband
She became frustrated and started to weep.
She started to throw things
Formal assessment was done through Beck Depression Inventory (BDI-II).
Beck Depression Inventory (BDI-II)
The Beck Depression Inventory (BDI-II), created by Aaron T. Beck, is a 21-question multiple-choice self-report inventory, for measuring the severity of depression (Beck, 1996).
The BDI-II is composed of items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex.
Table 4: Pre Assessment Scores on Beck Depression Inventory (BDI-II)
Results indicated that patient got raw score of 35 indicated the severe level of depression.
According to DSM-V
296.32 (F33.1) Major Depressive Disorder, Moderate, Recurrent episode.
Idiosyncratic Case Conceptualization (Beck et al,. 1979)
The patient was 33 years old, referred to trainee Clinical Psychologist at Psychiatry Department of Hospital, with the complaints of depressed mood, weeping spells, anger outburst, irritability, lack of interest in daily routine activities, loss of energy as well as low temperament, suicidal attempt, indecisiveness and disturbed sleep. According to DSM V, the patient was diagnosed with Major Depressive Disorder by meeting full diagnostic criteria of symptoms.
According to psychodynamic perspective, Freud argued that Individuals who are excessively dependent on other people are especially likely to develop depression after such a loss (actual loss or symbolic loss). It is relevant to case in such as way that her father was died before few days of her marriage. She was attached with her father and discussed her every problem with him. She felt her father absence and felt lonely. When she got married, she came to know about her husband impotence, she did not discuss her problem with anyone as she had distant relation with her mother and did not have courage to discuss this matter with her brothers. Also she did not get any support from her in laws which lead to her depressed mood, irritability, anger outburst and weeping spells in her.
Beck (1972), proposed the “cognitive triad”, which is the individual’s thoughts about self, world, and future. The depressed person views the world through an organized set of depressive schemata that distort experience about self, the world, and the future in a negative direction. It is related to present case explained that patient faced stressful events in her marital life such as death of her father, had no sexual relation with her husband, no support from her parental family as well as her in-law from last 17 years of her marriage. Due to having these stressors, patient was self pity about herself that she sacrificed a lot in her marital life but she did not get back anything. She did not admire the positive and caring attitude of her husband towards her and always blamed him that he destroyed her life. She also negatively perceived her in laws and doubtful about them that they wanted to humiliate her within whole family and wanted divorce between them. She started to avoid her in-laws and also asked her husband not to meet them.
In addition, Rust, Golombok and Collier, (1988) suggested that specific male sexual dysfunctions of impotence and premature ejaculation played a much larger part in marital discord than did the female dysfunctions of anorgasmia and vaginismus. This study is related to the present case explained as patient had marital conflicts due to her husband impotence. After having first intercourse, he husband deliberately avoided sexual relation with her. On the request of patient, her husband consulted doctors but all in vein. Patient felt her husband warm and affection but when her husband did not provide affection and love to her then she used to fight with him.
Likewise, Beach, Jones and Franklin, (2008) suggested that interpersonal problems and social deficits especially in the marital context, are strongly associated with the development, intensity, and course of depression. In the present case, patient had conflicts with her husband due to having no sexual relation and having problems to adjust in in-laws. She started to fight with her husband on daily basis which frustrated both of them that affected the quality of their relationship. It might be the cause to develop her depression.
Moreover, Gabriel, et al., (2010) proposed the study which explained as depressed women may be more likely to confront, ruminate and engage in self-disclosure, criticism, and complaints, resulting in greater arousal and greater display of negative emotions during the interaction with others. In present case, patient started to irritate on minor things and used to argue with her husband on daily basis. She had complaints that her husband did not pay attention to her. If she had sacrificed on sexual need then her husband should provide extra care and affection to her. She also complained that her husband was not much concerned about her problem and issues.
The management plan was devised on the basis of Cognitive Behavioral Therapy.
|Short term Goals||Therapeutic Intervention|
|To build therapeutic alliance and engagement of patient in therapy||· Rapport building|
|To provide information regarding patient’s disorder, etiology, as well as management plan.||· Psychoeducation|
|Awareness about factors of predisposing, precipitating, maintaining depression and normalizing her disorder||· Socialization with CBT model|
|To identify the connection between thoughts and behavior||· ABC model |
· B-C connection
|To regain patient’s sense of achievement, lift her sad mood and control her weeping spells.||· Activity scheduling |
· Mastery and pleasure
· Coping statements
|To alleviate distress, physical tensions, body ache and feel comfortable||· Progressive muscle relaxation (PMR)|
|To make the patient able to transfer her inner thoughts and stressors into writing and got relief.||· Written ventilation|
|To make the patient managing her anger outburst||· Anger management techniques|
|To enable to patient to realize the important aspects of her life||· Taking it all away|
|To deal with critics of other and control her anger||· Assertiveness training |
|To provide the patient relevant techniques for his future use.||· Therapy blue print|
Long term Goals
- Continuation of short term goals.
- Follow up sessions will be carried out.
Summary of Therapeutic Intervention
Rapport can be defined as “a positive emotional connection”. It is about building relationships through a sense of trust and confidence in each other, establishing good communication and identifying common beliefs and knowledge (Buskist and Saville, 2001).
In the first session, rapport was built with the patient in order to engage her in therapy and continue a smooth flow of therapy. Therapist actively listened the patient, gave unconditional positive regard and warm acceptance to patient which helped her to discuss her problems in comfort zone. Patient was talkative and easily explained her problems and daily routine activities in detail.
Psychoeducation refers to the process of providing education and information to patient about her illness, medication and psychological intervention. The patient was psychoeducated by providing insight about her problem and her role during therapy (Chamber & Pinnock, 2011).
Psychoeducation was done with patient in order to make her aware about the severity and nature of her illness. She was educated about her role in therapy. Therapist guided the patient about treatment sessions and their duration which helped her to understand what to expect from the treatment sessions and how long the treatment might take. Therapist also guided her about collaborative work that she has a major role to do homework assignments at home which leads her improvement effectively (Appendix D2, a).
The ABC Model is one of the most famous cognitive behavioral therapy techniques for analyzing the thoughts, behavior and emotions. It was explained to the patient to make her understand the connection between her own belief and consequences (emotions and behaviors) (Beck, 1993).
It was explained to the patient by giving example of her daily life situation and asked her to identify the link between her thoughts and consequences (emotions and behaviors) in stressful situation. Patient reported that she had understanding about her thought and behavior but she was still unable to change her thinking pattern. She did not control her ruminating thought about her past experiences and got depressed. Her ability to identify the link between her thoughts and behaviors was not much improved. She still complained about her tough time spending at her in-laws (Appendix D2, b).
Coping statements are positive statements used to replace the negative and untrue thoughts that take-over when feels angry or facing other overwhelming situations (Lee, 2014).
Therapist gave the patient positive statement to practice them and replace them with negative thought when she got angry and upset. Therapist asked her to try to keep repeating these coping statements in daily routine, the more she used them, the more chances to counter negative automatic thoughts with positive thoughts. It was also educated the patient that it takes time and consistency to create new habits. Patient reported that by reading these statements her angry and irritable mood was reduced (Appendix D2, c).
Progressive Muscle Relaxation
Progressive muscle relaxation (PMR) is a technique in which a person is trained to voluntarily relax individual muscles. It induces both physiological and psychological relaxation by reducing the response to stress, reducing skeletal muscle contractions, and decreasing the sensation of pain (Field, 2009).
To reduce the muscle tension, neck pain and fatigue reported by patient, therapist taught her PMR to release her tension and relax her body muscles. It was done by giving instructions to the patient during session. Therapist instructed her to tense her body muscles one by one and then relax them. Then she asked the patient to practice this exercise twice a day to relax her body muscles. She reported that this exercise was very effective to release her body pain and she easily slept at night.
Behavioral activation is a development of activity scheduling to regain patient’s sense of achievement, lift her sad and depressed mood as well as inactivity and ruminating thought. It was useful to involve the patient in normal activities and increase social interaction.
The core of behavioral activation is gradually to identify activities and problems that the patient avoided and to add those activities that patient felt pleasure by doing them on daily basis. These are set out on planned timetables (activity schedules). Patient was encouraged to start activity scheduling with short-term goals and pursue those activities that are soothing and pleasurable, as rewards for her (Veale, 2008).
Therapist asked the patient to monitor the effect of her scheduled activities on her mood on daily basis and got the feedback in every session. Patient reported that her inactivity was reduced by engaging in household tasks and she felt energetic than previous days. Patient reported 60% improvement by doing work at home (Appendix D2, d).
Sleep hygiene principle
Sleep hygiene is a variety of different practices that are necessary to have normal, quality nighttime sleep and full daytime alertness. As per patient report, she had difficulty to sleep at night. She wanted her husband closeness but when he refused, she became disturbed and started to think about her miserable condition and past events then she got angry and started to weep. She reported that she wanted contented sleep without any thinking pattern. She also reported that she took nap in noon every day and inactive in whole day.
Therapist educated the patient to get on a regular schedule, daily walk, avoid tea and coffee late in the day, be active during day, create a comfortable sleep environment, avoid long nap during a day, and turn off the mobile phone (Zarcone, 2000). She was asked to implement them on daily basis to improve her sleep. Patient reported the 40% improvement by using these principles (Appendix D2, e).
In the free expression of emotion that is ventilation, patients recall a troubling event and write down a detailed description of it, paying close attention to the emotions that surface and the meaning of the event. Although the immediate effect may be an increase in negative feelings as the negative event and the memories become more salient, there is often a decrease in negativity and a reduction in stress within days or weeks (Leahy, 2003).
Therapist asked the patient to think about her stressful event and to get recollection of the experience that she had. Therapist then asked the patient to take 20 minutes and write down all her thoughts and feelings about the conflict with her husband and her in laws that made her tensed and worried. She was also asked to write diary on daily basis to displace her frustration and tensions on paper and get relief. The patient reported that she started to write occasionally and got better about 40%.
Anger management is about unlearning ineffective coping mechanisms and re-learning more positive ways to deal with the problems and frustrations associated with anger (DeFoore, 2007).
As per patient report, she became angry on minor things and used to fight with her husband daily. She reported that she had no control on her anger and wanted to control it. Therapist educated about her emotional states through ABC model and asked her to control her anger through distraction techniques. Therapist taught the patient different techniques to control her anger such as deep breathing, backward counting, written ventilation, pleasant imagery, focus on surroundings and move to other place.
Taking It All Away
As per patient’s account, she did not forget the past events and started to ruminate on them which provoked her anger and irritable and depressed mood. She did not notice the good things around her as her husband gave her all facilities and supported her in every matter of life. But she still started to blame her husband almost every day and used to fight with her. To manage ruminating thoughts about past and her anger outburst about having nothing, therapist used this technique to patient to realize the importance of her family and her possessions.
In this technique, therapist asked the patient to imagine that everything including her body, mind, senses, memory, husband, daughter, family, home, possessions and all things which she had, were taken away. She did not have anything. Then therapist asked her to request the Allah to restore everything back one by one by explaining the importance of each one (Leahy, 2003).
By doing this exercise, patient had to realize importance of her family and asked her to focus on her present rather than past. She also asked her to enjoy the company of her family included her husband and daughter rather than wasting her time to remember the past events. At the end of session, therapist also gave homework to her to practice this exercise at home.
Assertiveness training can be an effective treatment for depression and problems resulting from unexpressed anger. Assertiveness training can also be useful to improve patient’s interpersonal skills and sense of self-respect.
Patient was asked to express her thoughts, feelings, and needs to others in a respectful way. Therapist taught three communication styles included Aggressive explained as becoming aggravated and over-reacting to a situation. Passive included letting or even forcing people to make decisions for oneself; ignoring one’s own feelings and keeping opinions private. Assertive which explained as saying what one means in an honest, direct and appropriate manner and doing so without violating someone else’s rights.
Therapist asked the patient to act assertively with her in laws to reduce her stressors. Therapist also taught fogging technique of assertiveness training to the patient which enable the patient to manage her anger and frustrations.
Fogging is an assertive coping skill dealing with criticism. Fogging is aptly named for the dense mist that has often confused many travelers. In a fog, we lose our bearings, miss important landmarks and find ourselves off the road in a ditch that we failed to see. The assertive communication technique of fogging works the same way by confusing the verbal bully, who expects his victims to get angry and defend themselves, entering into a fight that the bully knows all too well how to win (Alberti & Emmons, 1970).
As per patient account, her elder sister in law always criticized her on her dressing, her living styles and her each act. She said the she lived in separated home but still her sister in law interfered to her life which provoked her anger and disturbed her. Then therapist taught her this technique to deal with her criticism and stay calm and cool in front of her.
Therapy blue print
A Therapy blue print comprised of brief recap of therapeutic intervention was given to the patient (Appendix D2, f).
At the end of therapy, post assessment of the patient was conducted on a visual analogue scale (0-10). The post assessment was given on following table.
Table 3: Presenting Complaints and Subjective Rating of Patient (0-10)
|Presenting complaints||Pre assessment Subjective Rating |
|Post assessment Subjective Rating |
|No interaction with anyone||08||04|
|Lack of interest in daily routine activities||08||04|
Graphical representation indicated the difference between pre and post assessment of subjective rating given by patient.
Table 4: Difference between Pre and Post Assessment of Subjective Rating given by Patient
Beck Depression Inventory (BDI-II)
Post assessment of Beck Depression Inventory (BDI-II) was done at the end of therapy.
Table 6: Post Assessment Scores on Beck Depression Inventory (BDI-II)
Results indicated that patient got raw score of 23 indicated the moderate level of depression.
Outcome of therapy
13 sessions were conducted to deal with the patient’s problems. Patient reported the improvement in her inactivity and anger outburst. She reported that her interpersonal relations with her in laws were got better by using assertiveness training. At the end of therapy she got improvement about 50%.
Limitations and Suggestions
- Patient gave excuses in every session not to follow the techniques at home due to having her persistent neck pain.
- Extensive cognitive work was difficult with the patient because of her resistant attitude to do homework.
- Couple therapy should be done to improve her marital life.
- Alberti, R. E., & Emmons, M. L. (1970). Your perfect right: A guide to assertive behavior.
- DeFoore, W. G. (2007). ANGER MANAGEMENT TECHNIQUES.
- Field, T. (2009). Progressive muscle relaxation.
- Rust, J., Golombok, S., & Collier, J. (1988). Marital problems and sexual dysfunction: How are they related?. The British Journal of Psychiatry, 152(5), 629-631.
- Veale, D. (2008). Behavioural activation for depression. Advances in Psychiatric Treatment, 14(1), 29-36.
- Zarcone, V. P. (2000). Sleep hygiene. Principles and practice of sleep medicine, 2, 542-547.
a wonderful case report