Part I: Client Information
Professional Setting
The following case analysis involves a patient in a nursing home who has been suffering from a major depressive disorder for many years. The reasons for such disorder have not yet been established but can be attributed to the lonely life he has led and a tendency of alcoholism. The treatment goal for my client is acceptance of his current situation and how to deal with depression. In addition to treatment goal, psychodynamic intervention for the client would include ‘holding’ on to environment with empathy. Absurdly, a counter transference of looking at myself, spouse, and parents in a nursing home will help me to try expediting the process of healing. The mission in this professional setting is to ensure that my client regains his normal living style without experiencing depression. With this mission, it will be important to note that coming out of the nursing home depression free entirely rests on my client’s willingness to accept change, which he has already shown through our talk.
Client’s Background
The client, JR who lives in a nursing home has a major depressive disorder that has caused a decline in his morale, peace of mind, and happiness. He is a 69-year old Jewish male who was married for 10 years and is borne of Miriam and Clifton from New Jersey. JR’s father was a doctor while his mother was a perfect homemaker. The family had two other children; a son and a daughter. JR’s brother is a doctor while the sister is a teacher working with the disabled. During his 10-year marriage, JR sired one daughter who is currently 25 years old. JR is very close to his daughter and depends on her for much love, support, and visitation. JR’s working experience includes 15 years in car business and 17 years in hotel business, totaling to 32 years in services before he was incapacitated by the major depressive disorder that is now holding him hostage.
JR is an alcoholic who has attended rehabilitation center to help him out of the problem but never succeeded. After the rehabilitation, JR was moved to Daughters of Miriam independent living facility to seek further help. He was diagnosed with brain tumor, which led to a surgery and consequently sub-acute rehabilitation at the Daughters of Miriam independent living facility. Other than suffering from brain tumor, JR has diabetic neuropathy. Living in the apartments for independent living within Daughters of Miriam did not help him much hence the transfer to a nursing home. This was, however, out of his free will since he is determined to get a solution to his problems. JR and his daughter thought it was wise to seek help at the nursing home hence the transfer. They strongly believed that the nursing home was the best place for him. Nevertheless, JR has so far developed serious depression especially due to the presence of dementia patients around him. This has led to his spending much of the time in house factory that manufactures stuffing envelopes. Much of his time is spent wheeling himself outside to smoke. In addition, JR is an enthusiastic reader.
During the session of trying to help him out of the major depressive disorder, JR seemed very happy to be with me. He appreciated and was very much happy to have a company other than the dementia patients. Surprisingly, JR feels that he should be working with me as an intern. Many people, especially within the nursing home refer to JR as a manipulative person. The only way to help JR out of this problem is by first letting him accept his situation and what contributed to him being in that state before guiding him on how to deal with depression. In this case, JR will be able to hold onto the environment with a lot of empathy and as a result, come out positive with so much focus in life. Indeed, JR needs urgent attention to enable him to move on with life in the smoothest way possible, especially given that he is of age.
Contribution of Contextual and Environmental Factors
Notably, both contextual and environmental factors have significantly contributed to JR’s sliding into a major depressive disorder. Hopelessness is one of the contextual contributing factors having a significant impact on JR’s depression. Every individual seeks certain essential things in life, which includes happiness and hope. Without hope, the future of an individual is blurred, leading to wasteful activities such as drinking. JR found himself in this same scenario before he started drinking to the point of being an alcoholic. Even though it is hard to explain why he was hopeless, it may be obvious as Ezpeleta, Granero and Doménech (2006) put it that depression could have arisen from the fact that he was in a marriage for 10 years. JR is not clear about his wife that is, whether she is still alive or died during their marriage.
From the conversation we had, it is not possible to conclude that the wife died within marriage, which might have been one of the reasons that pushed him into drinking. Jordan (2000) affirms that hopelessness is capable of driving individuals into actions they are likely to regret later on in life. JR’s hopelessness is enhanced even more by the fact that he has not been able to overcome the major depressive disorder from the nursing home as he expected thereby complicating the issue even further and calling for more elaborative and inclusive solutions and reforms.
Other than contextual factor of hopelessness, his environment especially the contemporary place where he willingly chose to go to with a hope of getting better has also affected JR. Within the nursing home, JR stays closer to dementia patients. These patients suffering from mental disorder are not in a position to providing better and more loving and caring company to JR. As a result, this does not only add to his hopelessness but also contributes to his loneliness. No wonder JR is so much happy with my company and would wish even to work with me as an intern (Teyber & McClure, 2011). This clearly indicates that JR’s loneliness is weighing down on his morale and possibility of recovering. The daughter only visits him but his current environment (nursing home) is influencing his condition a lot. Therefore, it is evident that both contextual and environmental factors have significantly contributed to JR’s condition of depression. Consequently, it would be better to deal with these factors in order to ensure that the client obtains the best out of the nursing home. This explains why it is necessary for JR to accept his current situation and environment for a quick recovery process from the major depression disorder he is experiencing.
DSM-IV-TR Multi-axial Assessment
DSM-IV-TR multi-axial assessment is a manual published by the American Psychiatric Association to help in the understanding of psychological problems facing various individuals. DSM-IV-TR multi-axial assessment has five axes that can assist in assessing JR’s problem. It is important to carry out an analysis of JR’s problem with reference to DSM-IV-TR multi-axial assessment manual as it makes it easy to develop better and effective interventions that will help in solving the problem. The axes include the following components;
Axis I for clinical syndrome,
Axis II for Personality and Mental Retardation,
Axis III for Medical Conditions,
Axis IV for Psychosocial and Environmental Problems, and
Axis V for Global Assessment of Functioning.
Observing JR’s problem of major depression disorder, he meets the criteria for axes I and II. The major depression disorder meets criteria for axis I on the basis that there are clinical symptoms associated with JR’s diabetic neuropathy. Diabetic neuropathy is a condition that can be treatable within the healthcare facility through the clinical process. In addition, the problem meets criteria for axis II as well since such a disorder has led to a brain tumor, which sometimes back had forced JR to go for surgery. JR’s problem of major depression disorder has significantly affected his productivity hence the need to have it resolved as soon as possible.
Part II: Interpersonal/Psychodynamic Assessment 3
Contributing Family Factors to JR’s Current Situation
Interpersonal/psychodynamic assessment is essential in trying to understand causes of JR’s major depression disorder. Swartz (2007) duly confirms that through interpersonal assessment, it becomes easier to administer a given therapy that will go a long way in enhancing stability of an infected person. It is true that solving a problem without identifying its root cause is the most difficult thing and in most cases ends up being unsuccessful. This means that applying the interpersonal or psychodynamic assessment on JR will help us define the root cause of the major depression disorder hence develop conforming, effective, and efficient ways of treating it. In any case, Reamer (2005) believes that within social work, interpersonal and psychodynamic assessment is a therapy on its own. The main aim of this therapy is to identify interpersonal difficulties through a client’s life that is responsible for contemporary psychological problems (Gambrill, 2005 ). In this regards, there was need to look at JR’s interpersonal difficulties that led to the major depression disorder he is currently suffering from.
Looking at JR’s life it is evident that all through his childhood he lived a happy life with a father who is a doctor, perfect mother, and two of his siblings. Buckner, Lopez, Dunkel, and Joener (2008) confirm that individuals would wish to remain in some scenarios for a longer time especially if they derive satisfaction from the same. In this case, JR would have wished to enjoy the happy moments and peaceful time he had with his family for eternity. In the process of growing old, JR decided to get married and was blessed with a daughter of whom he loves very much. This scenario conforms to what he had experienced earlier. Nonetheless, problems started when the he started feeling lonely within the nursing home given that most of the people were suffering from various psychological problems. The idea of loneliness and hopelessness cropped in and this contributed largely to his current major depression disorder. Therefore, it is evident that JR’s family origin and development experiences contributed significantly to his current problem. His desire to have a peaceful and happy life was cut short. The perfect mother, father, and siblings created in him some form of reality that there is peace, happiness, and love and these are the virtues he wanted all through. Unfortunately, JR was unable to experience them any more with a total conviction that he was never going be happy in the nursing home despite the fact that he went there due to his own will; it was his decision.
Interaction with the Client
During this interview, JR interacted freely with me telling me most of the inner things that he has always kept a secret. In addition, JR enjoyed so much my company and wished that our conversation never ended. His freeness and willingness to open up was a real boost to making sure that he recovers from the major depression disorder. Such free interaction was attributed to the fact that despite the client’s major depression disorder he was not comfortable being closer to dementia patients hence the desire to stay with me a little longer. Interviewing JR with that freeness and closeness enhanced identification of the main problem that he had been facing. His openness proved that one of the reasons as to why people refer to him as manipulative is because he would always want to experience some peace, happiness, and love from people around him hence the need to influence their actions. This is something he had for many years when he was staying with his family and thereafter an additional 10 years during his marriage. I was therefore able to comprehend why JR was behaving the way he was and his relationships with other people around him.
Client’s Treatment Goals
Other than the fact that JR is wishing to have the diabetic neuropathy treated he also wish to come out of the nursing home. According to him, the main reason as to why he is in the nursing home is due to his major depression disorder. JR was very open to me that he has wasted not only resources but also time, which would have been used in creating utility for himself as well as the daughter. After a life of hopelessness and sadness JR believes that he can be happy and peaceful again with his daughter. JR’s treatment goals during our conversation are that he come out of the nursing home free of the depression disorder and also be healed from the diabetic neuropathy that he is currently suffering from. Having gone through rehabilitation center for alcoholism unsuccessfully, JR wish that he should never in his life touch alcohol again since this has been the catalyst in his current situation. In the end JR is hoping to regain his normal life living each day as it comes. This can only be necessitated through providing efficient and thorough therapeutic intervention programs and activities that will assist JR come out of these problems.
Part III: Interpersonal or Psychodynamic Intervention 2
Corrective Emotional Experience Intervention
One of the interpersonal or psychodynamic interventions that can be used to help JR attain his treatment goals is providing a corrective emotional experience. Evidently JR has been suffering from the lost love, happiness, and peaceful that he had wished to have for eternity. There are people who have been able to undergo such scenarios but instead of falling down they managed to walk tall and today they are living testimonies. In this case, JR needs an inspiring emotional story to make him understand that all is not lost despite the fact that he will never have what he had wished for in his life. Such corrective emotional experiences provide basis of reasoning within the mind of a client whilst he tries to search himself. Notably, JR is also suffering from major depression disorder from the fact that he his hopeless about the future. Therefore, providing a corrective emotional experience where one individual who had been hopeless regain his hope is a better interpersonal and psychodynamic intervention therapy that will help him recover from such depressions.
Rationale for using Corrective Emotional Experience Intervention
It is important to note that depression is a major killer especially if not cared for at the right time and in the right manner. The rationale for using corrective emotional experience is to create that urge in JR that if others have been able to make it in life, why not him. Essentially, hopelessness, lack of or insufficient happiness, love, and care are usually treated with time and creating an understanding that the patient is not the only one. Bentley, Walsh and Farmer (2005) agree with Franz Alexander for developing the concept of ‘corrective emotional experience’ in 1946 under the psychotherapy theory of solving depression disorder. In this theory or concept, JR will be exposed to more favorable circumstances and emotional situations that have been handled in the past. According to Knight (2004), intellectual insight is insufficient in correcting a depression disorder. There is need for intellectual insight to be backed by emotional component as well as systematic reality testing, which helps a patient develop real understanding of the current situation.
JR situation perfectly correlates to the corrective emotional experience since during the interview he admitted the he had developed strong negative attitude towards life hence resorting to alcohol as the sole friend (Knight, 2004). With such a strong negative effect it is important that JR be subjected to a corrective emotional experience having both sides where a person was discouraged but picked up very well and the other side where a person took the same direction as the one he had taken ending up in destruction. In addition, there was some expression of unique experience since entrance into the nursing home only to find people suffering psychologically especially noting the fact that JR had lived in a happy and peaceful family full of love and care. Amazingly JR indicated that he was disillusioned hence the drinking habit. He was however remorseful and regretted to have allowed anger and hopelessness take better part of him and this is reversible through corrective emotional experience (Bentley, Walsh, & Farmer, 2005).
Part IV: Cognitive Behavioral Interventions
Cognitive behavior interventions are derived from cognitive behavioral therapy, which is a psychotherapeutic measure for helping various patients come out of psychological problems such as major depression disorder like in the case of JR. Farmer and Chapman (2008) confirm that amongst the list of evidence-based treatments cognitive behavior therapy (CBT) dominates and is currently being used increasing for purposes of finding treatments and solutions to patients suffering from psychological problems like JR. Some of the examples of cognitive behavioral therapy interventions include self-monitoring, behavioral experiments, behavioral activations, and exposure therapy as they make the core features of the therapy (Cross & Casanueva, 2009). Helping JR will therefore demand for one of the cognitive behavioral interventions in a bid to ensure that treatment goals are sufficiently enhanced within the individual. The following provides a description of two cognitive behavioral interventions that can be used in helping out JR to achieve his treatment goals and live another normal life.
Dialectical Behavior Therapy (DBT)
Dialectical behavior therapy refers to a scientific form of cognitive behavior therapy or intervention that is commonly applied to solving depression disorders. Dialectical behavior therapy is an intervention that was developed in 1991 Marsha Linehan in order to treat specifically patients with borderline personality disorder. Nevertheless, the development of this intervention has so far given a chance and opportunity in treating other forms of mental disorders that lead to depression (Gambrill, 2005). In most cases, dialectical behavior therapy is a form of cognitive behavioral therapy intervention that gives emphasis on psychosocial aspects of the treatment. In this perspective, JR’s major depression disorder can be treated using the dialectical behavior therapy as a form of CBT.
Theory of DBT.
DBT theory maintains that some people behave abnormally to given emotional stimulation as a result of invalidating surroundings under which they grow and develop. Such surroundings and behavioral factors significantly affect reactions of people towards emotional situations and circumstances (Cross & Casanueva, 2009). During such incidences, the mentioned persons usually experience arousal that goes much quicker to highest peaks but takes the time to level down to baseline. As a result of the high peaked arousal, an individual develops depression disorders at minor stages that eventually grow to be major problems given that the emotional reaction and arousal take a longer time to level back. The good thing is that after arousal has normalized, affected individual gets back to his or her senses though there might have been a lot of destruction already done.
The rationale for DBT in JR’s Case.
JR’s case can be solved through DBT since he overreacted on the emotional discov. The fact that he was never going to have the happiness and peaceful life as before discouraged him leading to high emotional reaction. Joining a nursing home with people that he could not interact with was a traumatic event that led to his negative reaction leading to high peaked arousals. As a result, JR started drinking. During this time the arousal was still at high peak hence the continued drinking, which resulted into him being alcoholic. In the event, JR lost his mind and further fantasies of a beautiful, happy, and peaceful life with his family worsened the situation. Nonetheless, it is really commendable how JR has come to his senses. From the theory of DBT, an individual will always acquire a stable condition in terms of cognitive behavior after subsiding of emotional arousal experienced during the occurrence of the event in question. This indicates that JR’s arousal had subsided hence realization that he made a mistake in resorting to alcohol, which resulted in diabetic neuropathy and further depression. From this perspective it was vital and paying to employ DBT on JR through two main processes;
i. Psychotherapy sessions every week that defines the problem and necessary alternatives and interventions applicable in solving the same.
ii. Group therapy sessions for approximately two and half hours that is meant to improve effectiveness of interpersonal relationships, regulating emotions, and enabling stress tolerance.
Indeed, these two therapy forms are going to be very useful for JR in attaining the treatment objectives, aims, and goals already set. Therefore, this proves efficiency and effectiveness of dialectical behavior therapy as a form of CBT.
Trauma-Focused CBT
Trauma-focused is another form of cognitive behavioral therapy that is used in treating several psychological disorders. Evidence has shown effectiveness and efficiency of treating psychological disorders in children, adolescences, as well as adults who have become of age. Trauma-focused cognitive behavioral therapy is based on learning and cognitive theories (Bliss, 2010). The following paragraph describes learning and cognitive theory directly relating to trauma-focused. In any case, the role of trauma-focused CBT is to develop a deeper understanding of the various aspects of trauma that an individual undergoes in the unlikely event that an emotional torture has occurred, for instance, death or disappearance of loved ones of betrayal (Gilgun, 2005).
Cognitive Learning Theory for Trauma-Focused CBT.
Learning and cognitive theories are well explained through the concept of cognitive learning theory proposing that brain is the most incredible form of the network an individual can have for purposes of processing and interpreting information (Cross & Casanueva, 2009). In addition, this theory asserts that behavior of individuals can be analyzed through various mental processes. Most behavioral activities experienced within an individual is as a result of the action between environmental factors that include both extrinsic and intrinsic factors in an individual. It is important to note that there is a positive correlation between the behavior of an individual and the extrinsic and intrinsic factors. As a result, most individuals would react with anger to traumatizing situations hence the need to understand the source of trauma before administering the trauma-focused therapy.
The rationale for applying Trauma-Focused CBT.
In JR’s case it will be of use to apply the trauma-focused CBT in administering the therapy to help in achieving the aforementioned treatment goals. The rationale for applying this therapy intervention is to understand source of trauma that made JR very bitter to the extent that he even hated himself thus drinking that much. When a person faces a lot of mental anguish and trauma as a result of emotional experience it becomes difficult for the individual to be himself and reason up rationally thereby preventing other awful actions. In this case, JR was traumatized by the fact that he was never going to live in peace, happiness, and joy experienced while he was growing up in the midst of his family (Gilgun, 2005). This emotional experience was as a result discovery that the nursing home had no people that he could interact with; an act that left him hopeless, sad, and with not care or love. It is for this reason that we have to apply trauma-focused CBT therapy in order to help JR out of his problem. The only way for helping JR is making him understand that bitterness with life is uncalled for and causes so much hurt at the end of the day. Through developing an understanding for JR that the only way to get through this problem is accepting situations as they came no matter how hard they may be hitting an individual’s life. For this reason, it becomes vital for JR to admit that bitterness, hunger, hopelessness, and sadness will never solve his problem but with steadfast commitment and focus on life every tough and challenging event will vanish.
Part V: Professional Use of Self
Countertransference
Countertransference within the process of providing therapy to individuals who are facing psychological problems occurs when the therapist responsible for a given treatment starts to project his or her personal unresolved conflicts onto a patient (Cross & Casanueva, 2009). Countertransference can also be referred to as the transfer of patient’s conflicts onto the therapists despite the fact that it is a requirement for people administering psychoanalytical treatments to remain neutral. For a long period, countertransference has always been considered as an impediment to administering proper, effective, and efficient psychoanalytical treatment to suffering patients (Epple, 2007). This is because once the feelings of the client have been transferred to the therapist as a result of being reminded of a situation experienced earlier on then it is very unlikely that the therapist will hold him or herself together and proceed with treatment.
After being considered as an impediment for long, psychoanalysts have transformed the perception creating some positivity in countertransference (Cross & Casanueva, 2009). Therefore it is true that with countertransference a therapist can actual deliver more effective and efficient treatment to a patient who is suffering from psychological problems (Gambrill, 2005). This is because countertransference is a tool that serves as a sensitive barometer for therapists to measure the extent to which the client has been suffering hence treating him or her out of the situation (Epple, 2007). For instance, when a therapist is reminded of his or her suffering or even that of a close relative then it will be much easier for him to do all he or she can in order to prevent the client from suffering.
Within the JR’s case, countertransference significantly influenced my participation into helping him out of the problem. With an experience of a close friend who actually wasted his life due to hopelessness and sadness, which was caused by loss of his parents through a tragic accident, I knew that without helping JR the situation could get worse. The job was my best friend but decided to commit suicide few days after his parents died in a tragic accident. From Job’s, I knew very well that JR needed serious help since had Job been given more hope, happiness, peace, love, and care after the demise of his parents I strongly believed he would be here with me since we really loved each other. This affected me to the point that I started shedding tears making JR think that I was crying because of him. He actually asked why I was crying but never let it out directly. Therefore, despite the fact I lost my emotion due to countertransference, I was able to reclaim myself and help JR out since I could perfectly understand what he was undergoing at that time.
Lessons from JR’s situation
From JR’s case, I have been able to learn so many things especially with relation to clinical social work. The situation assisted in a better understanding of the fact that clinical social work is a systematic up-to-date review of classically developed theories and practices coupled with various techniques and methods within the social field work. Through this practice, I was able to apply the knowledge learned in class to give another person hope and new life. Such knowledge included the idea of different theories that a social worker must be conversant with, for instance, development, personality, and practice theories. Indeed, JR’s situation was an eye opener as well as grounds to learn more about clinical social work thereby being in a better position to handle further problems.
Amongst the concepts that I learnt, which will be useful in similar and even more complicated cases include;
i. A social work must have all the information regarding psychoanalytical treatment of different disorders. In this regard it will be easier to know the right type of treatment that should be applied in order to assist a patient out of a problem.
ii. In addition, it is vital to be able to know how to identify exact problems that a patient is suffering from (Gilgun, 2005). In this case it took me time to ascertain that JR was actually suffering from major depression disorder. Funny enough even after discovering that he was suffering from major depression disorder; I realized that it was difficult to find out the root cause. With more interview questions and conversations i discovered that it was due to hopelessness and sad life that he was living.
iii. From this perspective, it is important to have as many interactive interview questions as possible so that the therapist can be able to understand the root cause of patient’s problems and situation and this even makes it easier to find solution.
iv. Lastly, I also learnt that a social worker is as important as a doctor since the therapies they give provide hope and new life to patients just like doctors.
Faced with a similar situation, therefore, I will be very keen in identifying the actual problem and root cause. This will be necessitated by engaging a patient in an interactive forum through asking as many involving questions as possible. However, this is unattainable without creating a rapport with the patient and ensuring that there is adequate closeness to make the patient be open thus telling you every aspect of his or her life. In such similar or even more challenging cases, it will be my duty to ensure that at the end of the conversation both of us leave smiling and happy again since I have established that it is our duty and responsibility as social workers to provide hope and rejuvenated life to people suffering from psychological problems. Lastly, it will be my pleasure to uphold confidentiality and privacy of all information discussed with the client whilst trying my best that countertransference is not an impediment but a ladder to making a patient have rejuvenated life again.