A Combination of Therapies in Conjunction with Physical Activity for Adolescents with Major...

Running Head: MULTIFACETED THERAPY 1

YORKVILLE UNIVERSITY

A Combination of Therapies in Conjunction with Physical Activity for Adolescents with Major

Depressive Disorder and Generalized Anxiety Disorder Traits: A Case Study

Hugh Watkins

A MASTER’S CASE PRESENTATION

SUBMITTED TO THE FACULTY OF BEHAVIOURAL SCIENCES IN PARTIAL

FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF ARTS IN COUNSELLING PSYCHOLOGY

Fredericton, New Brunswick

December 27, 2012

MULTIFACETED THERAPY 2

Abstract

The following case study describes the assessment, case formulation, literature review,

diagnosis, treatment planning, and treatment sessions for a 16-year-old male adolescent with a

diagnosis of major depressive disorder and comorbid features of generalized anxiety disorder.

This client had been referred for counselling by his family doctor because of his longstanding

history of excessive worry, depressive episodes, emotional lability, and withdrawal from social

situations, as well as somatic symptoms of anxiety.

The treatment intervention for this client consisted of a combination of Cognitive-

Behavioural Therapy methods and Pharmacotherapy which addressed: mood charting,

depression, stigma, medication, and wellness. Six individual sessions utilized treatment strategies

chosen to target specific client problems. These sessions involved various treatment methods

including solution-based brief therapy, mindfulness-based, and strengths-based therapy, as well

as exercise therapy. Treatment goals included a decrease in depressive and anxiety

symptomatology, stronger boundaries, increased self-esteem, and increased distress tolerance.

Carefully tailoring treatment sessions to target specific goals identified by the client proved to be

an effective treatment strategy, which yielded a reduction in problematic symptoms.


Acknowledgments

I would like to express my gratitude towards the entire team at the Brooklin Medical Centre, and

special appreciation to my supervisor, Dr. Roya Firouzabadi-Dashti, for stepping up in a crisis

moment when my previous practicum site had fallen through. Though being very busy in your

own practice and commitments to your patients, you were always willing to offer guidance and

modelled a work ethic that was admirable. You never saw me as a distraction and truly went out

of your way to treat me as a fellow colleague. As I look back on some of the earlier periods in

my practicum, in many ways you’ve been a life saver and an encouragement to me when all

seemed confusing and sometimes overwhelming. Thank you for being my compass as you took

the time to familiarize me with the clinic, fellow doctors, administrative and support staff. In no

time, with your investment, I was able to learn and use formal medical documents and navigate

my way through the medical software; “JonokeMED”.

To Dr. Gary Hughes, my Yorkville University practicum director, and Mrs. Eve Mills-

Nash, Yorkville University Assistant Director, words cannot express my appreciation for you

both, again at a time when I was frustrated and lost during the period when my prior practicum

site collapsed on me at the last minute. Your rapid correspondence, heartfelt words over the

phone, and calming emails were always what I needed at the right moment. Thanks for

bestowing upon me your wisdom and suggestions with all my questions and concerns, and for

creating an opportunity for me to get started on my practicum while facing some timing

challenges.

To my brother, Karl Harding and his lovely wife, thank you for being my voice of hope;

to my parents and mother-in-law, many thanks for your heartfelt prayers and for being my

biggest fans.


To my darling wife, Stacy, and my greatest treasures, my children Kyle and Chantel, I

thank you for your patience, love and support. After more than twenty years of not being in a

structured learning environment and remembering back to my previous graduation ceremony

uttering those words, “Thank you, God, but never again”, you all stood with me and encouraged

me through this long journey, while letting me know that I can accomplish anything I put my

mind to. “I love you all to infinity and beyond!”


Contents

Page

Title Page .........................................................................................................................................1

Abstract ............................................................................................................................................2

Acknowledgements ..........................................................................................................................3

Introduction ......................................................................................................................................8

Case Information ..............................................................................................................................8

Presenting Problem ..............................................................................................................8

Social and Educational History ............................................................................................8

Family History .....................................................................................................................9

Social Supports ....................................................................................................................9

Psychiatric History ...............................................................................................................9

Current Situation ................................................................................................................10

Medications ........................................................................................................................10

Client Strengths and Challenges ........................................................................................11

Mental Status .....................................................................................................................11

Risk Assessment ................................................................................................................11

Literature Review...........................................................................................................................12

Diagnosing Major Depressive Disorder.............................................................................12

Major Depressive Disorder and Generalized Anxiety Disorder ........................................15


Treatment of Major Depressive Disorder ..........................................................................16

Cognitive Behavioural Therapy .............................................................................17

Solution Focused Brief Therapy ............................................................................18

Strengths-Based Cognitive Behavioural Therapy ..................................................19

Physical Activity ....................................................................................................20

Pharmacological Treatments ..................................................................................21

Combination Treatments ........................................................................................21

Treatment Consideration for Generalized Anxiety Disorder Traits ......................22

Assessing Counselling Progress and Outcomes ....................................................22

Case Formulation ...........................................................................................................................23

Case Analysis .....................................................................................................................23

Treatment Plan ...................................................................................................................24

Treatment Summaries ....................................................................................................................26

Week 1 ...............................................................................................................................26

Week 2 ...............................................................................................................................27

Week 3 ...............................................................................................................................29

Week 4 ...............................................................................................................................31

Week 5 ...............................................................................................................................32

Week 6 ...............................................................................................................................33

Results ............................................................................................................................................34


Discussion ......................................................................................................................................35

References ......................................................................................................................................37


Combination Therapies in Conjunction with Physical Activity for Adolescents

Blake1

is a regular patient at the Brooklin Medical Centre who was referred to me by his

family doctor at a time when he was struggling with a variety of issues and was desperate for

some assistance to deal with symptoms that were plaguing him. This 16-year-old teenager had a

past diagnosis of major depressive disorder, with generalized anxiety disorder traits and ADHD.

He was currently in a depressed phase with suicidal ideation. During an intake appointment with

me he was assessed and was placed on a waitlist until he was added to my caseload.

Case Information

Reviewing Blake’s prior medical assessments and obtaining his personal history enabled

me to produce a thorough client assessment.

Presenting Problem

This client presented with complaints of depression, excessive worrying, low self-esteem,

poorly established boundaries, and suicidal ideation. His moods had been managed with

medication for about two years prior to his referral and his medical history and low moods were

well documented in his past assessments.

Social and Educational History

Blake reported having challenges focusing on his school work and meeting course

requirements at school. He stated that he had been overwhelmed by his frequent low moods,

often stayed awake at night plagued by suicidal thoughts, and had no desire to get out of bed.

Blake described his social history as rather tumultuous. Typically, while in a positive

mood, he functioned like many other athletic teenagers. He had been actively involved in

organized sports, was often the life of any party, and enjoyed spending time with his childhood

1 Client names and other information have been changed to protect confidentiality.


friends. However, he often had lingering periods where he felt crippled, not wanting to do

anything or be around anyone. This client was aware of and expressed concerns about the

instabilities in his life. During his assessment he described himself as going through a “loner

period” by his own choice.

Family History

Blake explained that he grew up in a very stable home, with loving parents and a pretty

cool sister who is five years older. He lived in the same home all of his life, which he is grateful

for. His mother is a well established lawyer with her own law practice in the community; he

described her as somewhat of a militant disciplinarian. Blake also stated that his mom was often

away from the home due to the demands of her job. His father had held management duties in

larger companies, but is currently unemployed. His father had some previous struggles with a

mood disorder similar to Blake’s, but had not had difficulties in years. Blake described his

relationship with his sister as typical, generally being good to each other, but definitely noting

that they have had their moments of sibling rivalry. Blake’s sister is currently attending

university and has always been a straight “A” student. His parents often celebrated her

achievements, which heightened the pressure on him as he felt he was a disappointment to his

parents because of his struggles to obtain good grades in school.

Social Supports

Blake described his parents, sister, and three childhood buddies as his main supports. He

also expressed a strong bond between him and his rugby team.

Psychiatric History

Blake did not recall any formal psychiatric treatment, but did recall going through

psychological assessments in grade eight when his family doctor diagnosed him with ADHD and


proceeded to prescribe mild mood stabilizers. Blake attempted suicide two times, once while in

grade eight and again during the summer of 2011. The first was an attempted overdose and the

second involved holding a loaded weapon to his temple. Blake came to the conclusion that he

would not commit suicide as this would bring devastation to his family.

The course of Blake’s illness has been plagued with depressive phases. However, he did

describe recent instances of intense worrying, accompanied by a decreased need for sleep.

Current Situation

Blake indicated in our session that he has managed to function relatively well and

attributed this to the help of his medication. One of his biggest challenges was lack of sleep and

what he calls “excessive sadness.” At our first assessment, he indicated that he had not

experienced any breakthrough in his depression and suffered unrelenting low self-esteem. His

score on the Beck Depression Inventory II (BDI-II) (Beck, Steer, & Brown, 1996) was 22, which

placed him in the range of moderate depression. With the challenges before him, he emphasized

an inability to manage his responsibilities at school and expressed a lack of desire to continue

playing on his rugby team (which he had always enjoyed). Furthermore, Blake described himself

as a failure. When he looks into his future he becomes overwhelmed with the notion that he does

not have the attributes and skills necessary to succeed. He constantly worried that he was letting

down his family. This client denied any substance abuse or use of alcohol.

Medications

Blake noted that, in the past, he had been on some medication to help him sleep.

Currently he is taking Concerta 75mg once daily and has been on this medication for the past

two years. He wishes to stop using medication and hopes that counselling will be the answer.


Client Strengths and Challenges

Blake described himself as having the following strengths: friendly, sociable, courteous,

trusting of others, respectful, athletic, and a deep thinker. Areas that Blake felt were challenges

included: low self-esteem which he associated with his depressive episodes, lack of optimism

towards the future, and academics.

Blake performed a Value in Action Inventory of Strengths (VIA-IS) (Peterson &

Seligman, 2004) and his top five character strengths were: love, kindness, fairness, equity and

justice, forgiveness and mercy, and gratitude. His weaknesses from the same assessment were:

spirituality (including a sense of purpose), judgement (including critical thinking and open-

mindedness), zest, enthusiasm, and energy.

Mental Status

Blake attended his first session appropriately dressed and groomed. He appeared to be a

well-mannered youth in great physical health. He was articulate, though at times seemed to be

struggling in thought. At times he maintained good eye-contact and was very accommodating,

but occasionally appeared distracted and would tend to look away. It became clear to me that my

client was lacking sleep, based upon his physical demeanour at the time of the session. He spoke

slowly but his volume and tone of voice were both appropriate. His thinking was logical and,

though he spoke of having thoughts of self-harm, he insisted that he would never carry it out.

Risk Assessment

As previously noted, Blake’s history indicated two past suicide attempts; one involved an

overdose of medication and the other involved holding a gun to his temple almost pulling the

trigger. He continues to express suicidal ideation. He informed me that his family owns several

guns at home that were easily accessible and agreed that, though he has not shared his last


attempt with anyone, his mother needed to be informed so that the guns could be properly stored.

He insisted that such episodes were “passing thoughts” and that his love for his family was much

more powerful than any fleeting thoughts of ending his life. The suicidality item completed on

the BDI-II (Beck et al., 1996) indicated that Blake had experienced no thoughts of ending his life

in the past two weeks prior to completing the assessment. After further consultation between our

Assistant Director at Yorkville University and my practicum supervisor, we deemed his risk of

suicide to be low.

Literature Review

Diagnosing Major Depressive Disorder

Major Depressive Disorder (MDD) is recognized as one of the most common mental

disorders and it is related to significant disability and death (Glenn et al., 2012). The World

Health Organization states that this widespread disorder has plagued approximately 121 million

people around the world (Clasen, Wells, Ellis, & Beevers, 2012). MDD can be detected at the

early stages of childhood and at various stages of adulthood, although the pinnacle of its

prevalence is in the young adulthood populous (Kessler et al., 2005). A longitudinal study of

high school students between the ages 17 to 31 identified six predictors of first onset of MDD in

young adulthood: female gender, family history of mood disorders, evidence of childhood sexual

abuse, anxiety disorder in childhood, adolescents with self-reported health problems, and

subthreshold depressive symptoms. Prior studies have also identified the following variables as

predictors of first onset (MDD) with comparable effects for gender: family history of depression

(Zimmerman et al., 2010), childhood mistreatment (Jaffee et al., 2002; Smit et al., 2004), anxiety

disorder (Eaton et al., 2008; Grant et al., 2009; Smit et al., 2004), health complications (Smit et

al., 2004), and subthreshold depression (DeGraaf et al., 2002; Glenn et al., 2012; Horwath et

al.,1992).


Kessler and Walters (1998) note that the impact of MDD is significant for its sufferers

and those in their sphere of influence and can result in greater interpersonal complications,

unemployment, substance abuse, delinquency, and high risk for suicide (Zimmerman, et al.,

2010). MDD is characterized as an emotional disorder that disrupts a person’s mood, motivation,

sleep, eating, concentration, self-worth, and productivity (American Psychiatric Association

[APA], 2000).Specific diagnostic criteria for MDD according to the American Psychiatric

Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) include the

existence of at least five symptoms from a list of nine and one of those symptoms must either be

low mood or loss of interest or pleasure in all, or nearly all, regular activities (APA, 2000).

This persisting sad mood encompasses feeling miserable, low, depressed, or “blue” for

the majority of the day, and a continuation of these symptoms every day for duration of two

weeks or longer (APA, 2000). This symptom plays a hallmark role in the disorder, and nagging

frustration regarding the mechanisms that perpetuate the mood persistence in MDD and the lack

of a clear understanding of what is involved often makes it difficult to ensure an effective

treatment resulting in a positive outcome (Clasen, Wells, Ellis, & Beevers, 2012). Beck (1967),

Ingram (1984), and Teasdale (1988) suggest that cognitive theories of depression recognize that

biases in which depressed individuals rationalize emotional information help propagate the

depressive symptoms. Such biases would involve a tendency to embrace mood-congruent

information in their surroundings (Clasen et al., 2012). Gotlib and Joormann (2010) explain that

cognitive theories further suggest that episodes that prompt sad mood intermingle with these

predispositions to manipulate a vast amount of pre-existing negative thoughts and feelings that

perpetuate sadness. There has been a growing body of studies that confirm these predispositions

to distort emotional information, as well as attentional biases (Clasen et al., 2012).


Wells and Beevers (2010) performed a study to look at whether attentional biases for

emotional information are related to distorted mood recovery followed by a period of sad mood

among people with and without MDD. Results indicated that as mood reactivity elevated, these

individuals did not exhibit a matching level of mood recovery. However, elevated levels of mood

reactivity did indeed match with greater mood recovery for individuals exhibiting lower levels of

attentional bias for sad stimuli (Clasen, et al., 2012). Wells and Beevers (2010) suggest that such

findings indicate that more severely depressed individuals exhibit impairments in mood recovery

that are matched with attentional biases, specifically when they are exposed to greater mood

activity (Clasen et al., 2012).

Another clinical distinction that is unique to MDD is a chronic course that impairs

psychosocial functioning. Widiger and Smith (2008) examined interpersonal pathoplasticity in

the course of individuals suffering from MDD. Pathoplasticity is recognized by a nonetiological

relationship between psychopathology and personality. Widiger and Smith (2008) suggest that

psychopathology and personality influence the expression of each other, but neither is solely

responsible for the other.

The DSM-IV-TR notes that both children and adolescents have commonly made reference

to irritability as a symptom of MDD, but does not list irritability as a symptom of MDD in the

adult population, despite the fact that in clinical samples of adults, irritability has also been a

symptom of MDD (Fava, Sampson, Walters, Kessler, & Hwang, 2010). A study of 2,307

individuals with MDD found that 1,067 (46%) reported irritability as frequent as being present

half of the time during the preceding week. Of the 46%, most were female, younger, suffered

severe depression and anxiety, mentioned a poor quality of life, and had a history of suicide

attempts and suicide ideation (Perlis et al., 2009). These researchers also found that although


irritability related depression cannot be labelled as a distinct subtype of MDD, it has a significant

influence on overall severity, anxiety, comorbidity, and suicidality (Perlis et al., 2009).

Finally, it is clear that depression is linked with reduced sleep stability and, though not a

distinct subtype of MDD, Sateia and Nowell (2004) posit that insomnia is a regular symptom

comorbid with major depressive disorder. Results of cardiopulmonary coupling analysis (CPC)

by Sateia and Nowell (2004) indicated that 1) reduced stable sleep and increased unstable sleep

and wakeful/REM conditions were more frequently observed in depressed patients in

comparison to those without depression, 2) medicated patients exhibited a degree of

improvement of stable sleep latency through the use of hypnotics, and 3) some CPC indices

revealed a connection with subjective sleep quality and the severity of depression/insomnia

(Sateia & Nowell, 2004). Sateia and Nowell (2004) state that such an exclusive prospective on

sleep stability in the context of cardiovascular physiology and the easily repeated ECG-based

procedure can, in fact, prove advantageous in the evaluation of insomnia in depression, and

could also help to facilitate treatment effects.

Major Depressive Disorder and Generalized Anxiety Disorder

Traditionally, researchers and clinicians have observed the relationship and overlap

between MDD and generalized anxiety disorder (GAD) in their shared diagnostic features and

their common coupling genetic diathesis. Despite their resemblances, the DSM-IV-TR indicates

that GAD should not be diagnosed if it is evident exclusively during MDD or a different mood

disorder (APA, 2000). The present diagnostic hierarchy rule represents an age-old dispute

regarding GAD’s status as an independent diagnosis (Lawrence, Liverant, Rosellini, & Brown,

2009). In the DSM-III (American Psychiatric Association, 1980) GAD was classified as a

residual category. A clinician was only able to assign the diagnosis as long as the patient in


question unsuccessfully met the criteria for another anxiety disorder. In the revised DSM-III-R

(American Psychiatric Association, 1987) there were significant alterations where GAD was

established as an independent category, even though the hierarchy rule was introduced to

promote diagnostic parsimony. The DSM-IV-TR states that in GAD a patient’s worries could be

extreme, feel uncontrollable, and also are followed by three of six associated symptoms (APA,

2000). This revision of the definition of GAD has been important for clinicians in that it has

produced an improved diagnostic reliability and also helped to bring clarity to relationships

between GAD and other emotional disorders (Lawrence et al., 2009).

Lawrence et al. (2009) found that high rates of comorbidity between MDD and GAD

were consistent with other studies of structural correlations between anxiety and mood disorders

and behavioural genetics (Lawrence et al., 2009). Lawrence et al. (2009) state that the hierarchy

rule contends that both MDD and GAD must be preserved independently and cannot be

considered as one factor, which again lends support for considering GAD and MDD as separate

constructs (Lawrence, et al., 2009).

Treatment of Major Depressive Disorder

There have been numerous interventions that have been recognized as being efficient in

treating youth suffering from MDD. Some of the more common interventions are comprised of

particular psychotherapies; for example, cognitive behavioural therapy and interpersonal therapy,

pharmacotherapy and a blend of both cognitive behavioural therapy and medication (National

Institute of Mental Health [NIMH], 2006). In 2006, professionals skilled in child and adolescent

depression gathered to examine the status of science related to the treatment of youth depression

and to consider approaches to continued research. They argued that it is essential that all patients

being treated for MDD are clinically monitored for further aggravation of depressive symptoms,


such as suicidal ideation or other behavioural traits associated with MDD. These experts also

indicated that substantial heterogeneity is evident among adolescents with MDD in respect to

clinical phenomenology, treatment response, and outcome (NIMH, 2006).

Cognitive Behavioural Therapy. Cognitive Behavioural Therapy (CBT) has been

demonstrated to be an effective treatment intervention for reducing symptoms of depression for

youth. Childre and Rozman, (2003) and Kassinove and Tafrate (2002) emphasize the

significance of the client-counsellor relationship as well as the use of open-ended Socratic

questioning to assist clients in reflection and reshaping negative and inaccurate thought

processes. Clients are challenged with homework assignments and psychoeducation. This allows

clients to engage in structured activities that test the validity of cognitions.

Jakobsen, Hansen, Storebo, Simonsen, and Gluud (2011) used meta-analyses and trial

sequential analyses of randomized trials to examine the efficacy of using CBT versus ‘no

intervention’ for MDD. They concluded that although further research was required, there was

evidence that CBT had resulted in considerable improvements in MDD symptoms. However, the

effects of CBT on suicidality, adverse events, and quality of life were vague (Jakobsen et al.,

2011). Evidence has revealed that some depressed youth do not respond to pharmacotherapy or

psychotherapy while others react quite favorably to minimal intervention. It is clear that

attempts to individualize treatment and identify specific treatment goals are needed.

Segal, Williams, and Teasdale (2002) sought to investigate the efficacy of incorporating

mindfulness-based training with cognitive behavioural therapy (MBCT). Kabat-Zinn (1994)

defined “Mindfulness” as intentional, non-judgmental and present-moment awareness. Ma and

Teasdale (2004) and Teasdale et al., (2000) highlighted evidence that MBCT helped to reduce

depressive relapses, where Beautrais, Joyce, Mulder, Fergusson, Deavoll, and Nightingale (1996)


have indicated that most suicidal behaviour transpires in those depressive relapses. Williams,

Duggan, Crane, and Fennell (2006) posit that many people tend to exhibit periods when they

disregard their habitual coping strategies. Crisis planning and ‘grounding’ meditations have been

implemented to ensure that individuals retain awareness of the tangible present. A recent

research study was conducted with 68 patients in remission or recovery from episodes of

depression, including suicidality. They were selected to participate in a MBCT group or a

waitlist control, with stratification by suicidal history (ideation or attempt) and past depressive

episodes. The outcomes revealed a significant decline of symptoms in the MBCT groups. Results

indicated improvement in mood and cognitive control, and a significant decline in intrusions and

rumination that could possibly result in a decline of motivation to suppress (Hepburn et al.,

2009).

Solution Focused Brief Therapy. Gaining more notoriety in recent years, solution

focused brief therapy (SFBT) stresses swift therapeutic modification and respect for the client’s

perspective, which is reinforced by modern healthcare beliefs. The therapeutic focus is goals

oriented and based on the clients’ expressed future aspirations. The treatment process involves

lines of questioning that engage the client by helping them to visualize their desired outcomes

and discover strengths, resources, and occasions when symptoms are not as evident (Rothwell,

2005). Bor, Gill, Miller, and Parrott (2004) posit that one component that is distinct to SFBT in

contrast to an open-ended intervention is the emphasis on an ending and that ending should be

made clear to the client and regularly articulated throughout the treatment process. They go on to

state that the treatment approach is “ethically driven yet commercially aware” (Bor et al., 2004;

p. 1). Also notable in SFBT is the idea of a contract of between six to ten sessions, with a

specified and realistic goal set at the outset (Lamont, 2012).


In 1996, De Jong and Hopwood sought to investigate the effectiveness of SFBT through

a case-series sampling of 275 clients observed at the Brief Family Centre in Milwaukee, USA.

The researchers found that 74% of the clients revealed subjective improvement on a 10 point

scale. In addition, at the nine-month follow-up, 77% reported that continued progress had been

evident as a result of therapy and after one year reported an 85% satisfaction rate from the

therapy (DeJong & Hopwood, 1996).

Highlighting an end to the treatment at the early onset of the treatment and throughout

has proven to be a key element in the success of SFBT. Clients who were told treatment would

last 10 sessions started to perform significantly by the eighth and ninth session; those who were

told it would last 5 sessions did so at approximately the fourth session (Battino, 2007). This

approach is based on the premise that, if you as the professional do not have an expectation that

you can help your client, then how can we anticipate that the client will have this expectation?

Battino (2007) posits that the effectiveness of treatment expectation is similar to the

effectiveness of the placebo pill.

Battino (2007) makes further reference to a book Change by Watzlawick, Weakland, and

Fish in 1974 that describes two types of change: First-order change refers to repeating the same

thing over and over within an existing system; and second-order change is external to (or meta)

or not confined to an existing system (irrational, paradoxical, unpredicted). He posits that

effective therapy is characterized as second-order and is processed through reframing. The

process of reframing assists clients to learn alternative perspectives (Battino, 2007).

Strengths-Based Cognitive Behavioural Therapy. The consideration of more

optimistic mental health variables during assessment will result in a brighter clinical picture of a

client’s position than if the practitioner were to focus only on problems and diagnosis. Padesky


and Mooney (2012) point out that strengths-based CBT does not seek to train clients in new

skills, thoughts, or emotional response, but rather places emphasis on assisting clients in

identifying strengths they already possess and to construct a model of treatment from these

rediscovered strengths. Padesky and Mooney (2012) suggest that individuals already harness

personal strengths that are connected to passionate interests, personal convictions, or patterns of

activities that may help them acquire their desired outcome. The challenge is that most people

are often oblivious to their own strengths and require the assistance from the therapist to extract

those strengths discovered in everyday experiences. Rashid and Ostermann ( 2009) emphasize

that performing a strength-based assessment includes the exploration of both the client’s

strengths and weaknesses which, when taken into account together, can result in effective

treatment strategies. Padesky (2012) adds that, instead of centering on problematic areas with the

client, therapists encourage an in-depth discovery of strengths that exhibit stable activity and are

not connected to problem areas. She further stresses the importance of ensuring a sustained

action is not connected to abnormalities, as CBT researchers have found that individuals are

prone to develop distorted beliefs and maladaptive behaviour patterns in problematic areas rather

than in areas where matters are positive in their life (Padesky & Mooney, 2012).

Physical Activity. Mata et al. (2012) stated that physical activity can be an

advantageous “mood regulator” in individuals with MDD. Reed and Ones (2006) indicate that

researchers have found that light exercise produces positive effect, especially if prior to exercise,

the positive affect was low. Mead et al. (2009) further emphasized that studies of both unselected

and clinical samples have shown that individuals who are prescribed a formal exercise regimen

have been able to drastically decrease levels of depressive symptoms. Mata et al. (2012) noted

that the outcome of exercise was equivalent to those who had engaged in cognitive therapy.


Bodin and Martinsen (2004) posited that physical activity has been connected to higher self-

efficacy and better self-esteem; Bahrke and Morgan (1978) state its effects as a deterrent of

negative thoughts; and Clark, Milberg, and Ross (1983) note that physical activity improved

retrieval of positive thoughts. From a physiological perspective, exercise has been successful in

stimulating growth of nerve cells and discharging proteins recognized to sustain nerve cells, such

as brain-derived neurotrophic factor (e.g., Cotman & Berchtold, 2002). Considering the effect

that engaging in a structured physical regimen has on depressed individuals, it is likely that it

would prove to be equally advantageous for persons with MDD.

Pharmacological Treatments. Certain pharmaceuticals have shown to be effective in

treating adolescents with both symptoms of depression and anxiety. However, the prescribing

and safety of these medications continue to be a matter of research and development (Williams

& Pearman, 2010). Silva et al. (2005) argue that though there has been a vast variety of

antidepressants available to patients, some results have shown only modest improvement and

remission rates and complaints regarding troubling side effects put limitations on treatment

effectiveness (Papakostas, Cassiello, & Lovieno, 2012). Serotonin reuptake inhibitors (SSRI) are

commonly used in treating depression and anxiety in youth and have been shown to have the

fewest of side effects (Karlsson, Hirvonen, Salminen, & Hietala, 2011). Keeton, Kolos, and

Walkup (2009) state that neither serotonin or epinephrine reuptake inhibitors have demonstrated

to be effective in treating youth with GAD, but further research is merited.

Combination Treatments. Vitello (2009) notes that although there is no concrete

support for the advantages of combining medication and cognitive behavioural therapy treatment

(COMB), two controlled outcome trials have indicated that COMB has been more advantageous

for treating adolescent MDD clients than monotherapy. Vitello’s study compared the


effectiveness of fluoxetine, CBT, COMB or clinical management with placebo for treating 439

adolescents with MDD. Results revealed that after 12 weeks of treatment, both SSRI and COMB

decreased depression more significantly than with CBT or placebo alone, but also clearly

revealed that COMB is efficient in inducing remission, accomplishing functional recovery, and

decreasing suicidal ideation. It was also noted that after 36 weeks, more suicidal events

transpired in the medication-only group when compared to the CBT only group (Vitello, 2009).

Treatment Consideration for Generalized Anxiety Disorder Traits. Major depressive

disorder (MDD) and generalized anxiety disorder (GAD) share diagnostic features and have

common coupling genetic diatheses. Notwithstanding resemblances, the DSM-IV-TR posits that

GAD’s status is upheld as an independent diagnosis. The diagnostic hierarchy rule dictates that

GAD should not be diagnosed if it is evident exclusively during MDD or a different mood

disorder (APA, 2000). However, given the apparent symptom overlap and similarity, treatments

regarded as efficient for MDD may be equally effective for treating GAD (Lawrence, et al.

2009).

Assessing Counselling Progress and Outcomes. The Beck Depression Inventory II

(BDI-II) (Beck, Steer, & Brown, 1996) is a 21-item self-report scale based upon a two-week time

frame. The items are rated from 0 to 3 on a 4-point likert scale, with higher scores suggestive of

an increased severe symptomology. The total of the scores highlights severity (0 to 13 signifying

minimal depression, 14 to 19 signifying mild depression, 20 to 28 signifying moderate

depression, and 29 to 63 signifying severe depression) (Beck et al., 1996). The assessment tool

monitors the progress of treatment for MDD by administering the self-report at pre- and post-

treatment periods (Ritschel, Cheavens, & Nelson, 2012).


The Patient Health Questionnaire Generalized Anxiety Disorder (GAD-7) is a 7 item self-

report scale utilized for assessing the severity of the symptoms of anxiety (Spitzer, Kroenke,

Williams, & Lowe, 2006). Like the BDI-II, this assessment tool can be administered to examine

the progression of treatment at both pre- and post-treatment periods. Spitzer et al. (2006) stress

that, although frequently used and strong in validity and reliability, the GAD-7 only suggests a

diagnosis that needs to be confirmed by other diagnostic techniques.

Peterson and Seligman (2004) explain the use of the Values in Action Inventory of

Strengths (VIA-IS) as an apparatus to recognize and rank-order clients on a measure of character

strengths. The VIA-IS is a 240 question survey that is reliable and has promising validity.

Case Formulation

Case Analysis

Blake was referred to me with a current diagnosis of ADHD, major depressive disorder

(MDD) and a noted history indicating features of generalized anxiety disorder (GAD). At the

time of my assessment of Blake, he stated that he had been struggling with his depression over

the past couple of years and made reference to what he described as an unrelenting sad mood. He

continued to state that he felt miserable, low, or “blue” for the majority of the day, lied awake in

bed all night struggling to sleep, did not feel like doing any of his regular activities, and was

often plagued with thoughts of suicide; he recalls having these symptoms every day for durations

of two weeks or longer. His family and friends were aware of a drastic change in Blake’s

behaviour and Blake had gone to his family doctor on a couple of occasions looking for solutions

to his problems. Blake’s symptoms collectively satisfied the criteria for MDD (APA, 2000). His

prolonged and intensifying episodes of sadness were clearly suggestive that his sad mood


intermingles with his past thought pattern which has the tendency to manipulate pre-existing

negative thoughts and feelings that perpetuate more relenting sadness (Clasen, et al., 2012).

Blake’s presentation and past history did yield evidence for some GAD features as well.

Most notable were his patterns of chronic worrying and his inability to control it, thinking he was

being regarded as a failure to his family, and not believing he had the fortitude within to have a

thriving future.

The dynamics of the case were also influenced by Blake’s poor self-esteem. Low self-

esteem is noted to be rather common in persons with MDD (Kessler & Walters, 1998) and

ramifications can escalate to greater interpersonal complications and high risk for suicide

(Zimmerman et al., 2010) (see Figure 1 for my complete diagnostic impression).

Figure 1: Multiaxial Assessment of Blake

Treatment Plan

Developing Blake’s treatment plan began with a collaborative effort to identify concrete

goals and a discussion regarding what a successful outcome might look like. Once I had this

information, I was able to draft Blake’s treatment plan and prepare my intervention strategy.

These goals, interventions, and desired outcomes are described below.

Axis I: Major Depressive Disorder

Axis II: Generalized anxiety features

Axis III: None

Axis IV: Educational Problems

Axis V: GAF 60 11/07/12

Score Date


Goal #1: Reduce depressive symptoms. Blake found some reduction in his symptoms

of depression as a result of taking his mood stabilizer medication. Given that a vast majority of

his time was spent suffering these depressive symptoms of sadness, feeling miserable, low, or

“blue”, as well as disruptive sleep, offering a means to reduce and prevent future depressive

recurrences was a very significant goal. From the beginning of my assessment, Blake had

indicated that these feelings remained with him all day, every day, consistently for the past two

weeks, if not more.

My planned intervention to help Blake with depressive symptoms was to teach some

basic cognitive behavioural therapy (CBT) strategies such as monitoring thoughts, identifying

think traps, and challenging negative thoughts. Secondly, together we were to establish a regular

exercise routine that could increase endorphins in the brain. Bodin and Martinsen (2004) posit

that physical activity has been connected to higher self-efficacy and better self-esteem. Bahrke

and Morgan (1978) note its effects as a deterrent of negative thoughts.

My plan to measure the outcome of this intervention was to administer the BDI-II (Beck

et al., 1996) both pre- and post-treatment. Also, Blake would evaluate his depressive symptoms

post-treatment and agreed that, if the intervention were effective, he would feel depressed less

than every day.

Goal #2: Coping Behaviours. The formulation of a coping plan is an essential

component of CBT (Williams & Pearman, 2010). By examining Blake’s preferred activities and

safe behaviours, we constructed a list of helpful coping behaviours for Blake to practice. Blake

was taught some breathing and relaxation techniques using art and music. He described a

successful outcome as independent implementation of his coping behaviours.


Goal #3: Cognitive Restructuring. Changing the way Blake thought about situations

was a key part of his treatment plan. Blake admitted to obsessive negative thought patterns, of

not measuring up, and lack of optimism for a bright and prosperous future; as anxious

adolescents tend to overestimate negative outcomes (Rapee & Heimber, 1997). With the

introduction of solution-based brief therapy, I intended to utilize techniques of reframing as a

way of changing his perspectives. Blake was taught an interesting “as if” instruction to perform

every morning as a means of challenging these negative thoughts (Rothwell, 2005). This was a

way to help Blake discover his personal strengths and begin to explore ways in which he might

utilize them. Blake’s responses on the VIA-IS (Peterson & Seligman, 2004) would be used to

identify his character strengths. This would be accompanied by a collaborative discussion to

understand how he might use them in new behaviours and activities.

Blake described a successful outcome as one that would increase sense of confidence and

heighten his awareness of his personal strengths.

Treatment Summaries

Week 1

I started the session with a check-in to determine how Blake felt about his experience

with the BDI-II and the GAD-7 assessment questionnaires, and how he felt the assessment

process went overall. Blake expressed that he felt the intake and assessment session went very

well, and that it had confirmed for him that things just weren’t right and that the step taken to

seek counselling was a step in the right direction. I revisited the topic of confidentiality and

possible exceptions that include but are not limited to the following situations: child abuse, abuse

of the elderly or disabled, sexual exploitation, criminal prosecutions, and if the client has the

potential to be harmful to himself or to others. He was thankful and stated that he felt that he was


in a safe place. From there, Blake expressed a concern about not wanting to disappoint me, and

more importantly himself, because he had always struggled to follow through with things. He

talked openly about projects and previous commitments he had made to others and himself, all

which he failed to complete. He felt disappointed and didn’t want counselling to be another

failure. It was here that I encouraged him and introduced a contract of six sessions with a start

and end date clearly identified; outlining the specific and realistic goals we collaboratively

constructed during our assessment (Lamont, 2012). With the brief and clear timeline and an

enthusiastic approach, Blake’s concern was diminished and he seemed determined and

reciprocated enthusiasm.

I introduced mindfulness techniques to Blake during this session, starting off with a

simple breathing exercise. I instructed him to give consideration to the thoughts that come to

him, without judgment, and then to return to focus on his breathing. He enjoyed the exercise and

explained how it had relaxed him. Next, I administered the VIA-IS (Peterson & Seligman, 2004)

to identify strengths that Blake possessed. I explained that examining his strengths would be a

key to his success. He loved the test and looked forward to discussing the results in our next

session.

For his homework, I asked Blake to practice his breathing exercise and to take the time to

write down any project or objective he had, giving it a start and a finish date. He was also to try

and participate in three workouts at the local gym where he held membership.

Week 2

Blake was away on a family vacation for two weeks (which he forgot to inform me about

in our previous visit) and reported that things went okay while he was away. When posed the

question concerning the degree in which he would characterize his depression over the vacation


period, he indicated the score of 7 out of a possible 10. During extended periods of inactivity,

Blake found that depressive emotions would elevate. He also indicated that, during the vacation

period, he did have one thought of suicide, but quickly dismissed the thought. His sleeping also

continued to be disrupted. He informed me that he practiced mindfulness breathing during his

time away, at least once a day and often two to three times a day for periods of five to seven

minutes each. Many of his thoughts were about feelings of inadequacy, but he did not find it a

struggle to focus back on the breathing. He indicated that the exercise also helped him greatly.

We then had a discussion about the VIA-IS (Peterson & Seligman, 2004) results and

highlighted the fact that his top strengths were love and kindness. This led us into a discussion

about the important role of his family in his life. He went on to talk to me about the bond he had

with his father. “We are exactly alike”, he stated. We also had a brief discussion about the last

attempt he made to commit suicide with the guns in the home; he had opened up to me about this

event during our assessment session. He went on to explain that his love for his family is what

kept him from ever taking his own life. I told him again about my concern that there were so

many weapons in the home and that he had easy access to them. Not wanting to hurt his father or

cause him any undue alarm, we agreed together that we would ensure his mother knew of the

instance and that it would be her duty to properly secure the weapons (which were typically used

for hunting). It was a very emotional session and he was glad to have someone to unload the

weight of such an experience without judgement. For homework, I asked him to practice his

mindfulness breathing daily and also spend some “guy time” with his father, even if it were to

just watch television together. He said they actually had a Saturday fishing day planned, so we

agreed to count that as homework. I also wanted him to spend at least three sessions at the gym.


Blake seemed quite motivated during this session and agreed to complete his assigned

homework.

Week 3

I started this week with a check-in and, by Blake’s demeanour, he seemed to have

improved quite a bit. He indicated that just by implementing some of the techniques we

discussed in our last session, he was already feeling better about the future and about going back

to school in the fall. He talked about his fishing trip with his dad; what he thought was just going

to be a day trip ended up being a weekend camping expedition. Blake expressed that things went

considerably better than the previous trip. He spent much time canoeing and engaging in other

outdoor activities. He said he had no real depressive episodes and no thoughts of suicide at all.

Overall, he stated that it was a very enjoyable weekend. His sleep patterns were on and off

during the week, but he found that while away in the open air, he slept better. This progress

motivated Blake to book an appointment with his family doctor to discuss discontinuing his

mood stabilizing medication.

In the area of solution-based brief therapy, I introduced a new activity that involved him

imagining that he was granted a miracle, posing the question as described by Battino (2007):

“That as you were sleeping a miracle transpires, and as a result of that miracle, you’ve come to

talk with me today because your problem with depression had been solved. This is a miracle.

You woke up and it indeed came true! What will have changed in your life? What will be

different? How will you know that the miracle has occurred?” (Battino, 2007, p. 22). For the

next 30 to 45 minutes, we engaged in a dialogue, going through every detail about how the

miracle had transformed his life. Blake seemed to gain a significant amount of positive energy

from doing this exercise.


I also inquired about the amount physical exercise and activity he had engaged in during

the past week. He attempted to stay busy with the family, but noticed that during moments of

inactivity, his negative thoughts would return. He said that he was really fighting hard not to

remain in bed. I told him that I was proud of him for doing this. I emphasized the need to

establish regular activities, such as physical exercise and/or sporting activity, because when he

was idle time seemed to work against him, triggering his negative emotions and depression. For

homework, Blake would continue to practice his mindfulness breathing and try another miracle

exercise. For the following week, when he awoke he was to ask himself, “What would I do

differently today if I was living the first day of the miracle, and am now totally recovered from

this problem”? Of all the things he thought of, he was to choose the easiest concrete thing and

implement it into his daily routine; and every day after, he was to ask himself the same question

and repeat the exercise.

Week 4

I started this session with a check-in, and immediately Blake indicated that he has been

feeling pretty low for the last week and did not know the source of his feelings. He also stated

that the emotions that he was feeling were somewhat different from his usual feelings of

depression. It was not something he recognized as helplessness, but more like boredom. He

found that the last week was uneventful. I replied, “Good news about your keen observation and

that it didn't trigger depression”. He just knew things were different. I encouraged him for

keeping it together, despite the fact that he was going through a low period. Through reflection,

we did identify that he had been staying up quite late a few times over the past couple of weeks

and could be experiencing some fatigue. I introduced some psychoeducation about the

importance of sleep and strategies for getting enough sleep.


Blake also followed up with me with regard to the discontinuation of his medications. He

and his doctor agreed to the discontinuation of the mood stabilizers as long as he felt the

counselling was making progress. I checked in on his homework assignment, and he stated that

the breathing exercises are becoming a useful coping mechanism and a part of his daily routine.

He was cooperative in doing the “miracle question” exercise. In response to the miracle question

exercise Blake indicated that the activities ranged from hanging out with his buddies to throwing

around the rugby ball with his father, to going on a hike, to working out at the gym, to mixing

beats with his DJ music interface on his computer. He said, “Two weeks have passed since our

last session, during that first week things went well but during the second week, I don’t know

what happened”. I thanked him for all the effort he was making to which he responded that he

was feeling quite optimistic about life.

Collaboratively, we worked on preparing Blake for his return to school the following day.

Going into grade 11 and anticipating the adjustment in course load and degree of difficulty, we

role played hypothetical solutions to employ if he was feeling overwhelmed by certain subjects,

like math which was typically a challenge for him. I chose this approach because if Blake did not

maintain a keen interest in taking charge of his own life, the pressures of the unknown would be

a trigger for his depression. Blake loved the idea of learning the discipline of setting goals and

objectives. In the following week’s session we would evaluate Blake’s first week of school.

Blake indicated an interest in completing The Harrington-O’Shea Career Decision-Making

System Revised (CDM-R) (O'Shea & Feller, 2008). The CDM-R system is a self-scored

assessment that helps students and other career planners identify their occupational interests,

values, and abilities - and match these dimensions to career options. In consideration of both

methods of solution-based brief therapy and strengths-based therapy, I felt this tool would be


informative and also demonstrate to Blake how the strengths and interests that he already has can

be utilized in numerous areas of vocations and opportunity. For homework, Blake was going to

continue to practice his breathing exercises and work out at the gym three times this week. He

was also eager to do more of the “miracle question” exercise and implement something simple

and concrete into his routine. On the way out, Blake expressed that things in his life have

improved drastically.

Week 5

Blake was excited to see me this session and quickly explained that, in the past week,

starting school had not been as overwhelming as in previous years. He attributed this to the time

we spent in role playing scenarios about classes. He was also sleeping better, although he was

getting to bed late at night. He stated that he believes he has gotten past his feelings of sadness

and has not had any thoughts of suicide for a while (O'Shea & Feller, 2008). Every day, Blake

finds he has been waking up in the morning with a new sense of optimism, knowing that he has

the inner strengths and the support at home to face each day. I took a moment to review some of

the skills we had discussed, particularly those related to goal setting. I emphasised that setting

goals could be a helpful problem-solving strategy and could also assist in the avoidance of

feeling overwhelmed by many tasks, such as school responsibilities.

Together we went over the results of the CDM-R (O'Shea & Feller, 2008), which identified

his career code as ‘Scientific-The Arts’ and his career clusters were ‘math-science, medical-

dental, literary-art’. As we went through his interpretive folder, he was encouraged to see that a

vocational option under life sciences was ‘environmental engineer/environmental

biologist/forester’; all avenues that he always wanted to pursue. He was excited about charting a

course towards his career choices.


This was our second-to-last session, so I checked in with Blake to see how he was feeling

in regard to our time coming to an end. He expressed sincere gratitude for the opportunity to

undergo one-on-one counselling and appeared optimistic about his future. I encouraged him to

think about questions for our last session and informed him that our last session would not be as

structured and would center primarily on review of what we had talked about in prior sessions. I

also informed him that I would be putting together a resource “gift pack” for his departure.

Week 6

This was my final session with Blake. I administered a check-in to see how he was feeling

about the end of our treatment time together. He indicated that he was a little nervous and that he

would miss our sessions together. He also confirmed that he has remained off of the mood

stabilizing medication and stated that he would continue to do so. He once again told me how

much he appreciated the work we had done together. He indicated that things have continued to

improve both at home and at school. He stated that his thoughts were healthy and expressed no

feelings of sadness; he even played some rugby this past week. Blake has recognized that he is

getting much more sleep than previously. Thoughts of suicide have now become a distant

memory and he looked towards the future with great optimism. Blake went on to tell me that he

met a girl and that there was mutual interest to start dating. I told him I was very excited for him.

I had Blake complete the BDI-II (Beck et al., 1996) during this session and the results

revealed the score had dropped from 22 (moderate depression) to 11 (minimal depression). At

this time, we began to talk about his depressive symptoms in comparison to how he was feeling

now, and we both agreed that the desired outcome identified in his treatment plan was achieved.

Blake indicated that he was feeling sadness less than every day, which was his established

benchmark measuring the success of this intervention.


In terms of coping behaviours, Blake felt that he has all the tools readily available if and

when symptoms of his depression or anxiety were to come back. Success, as we defined it in the

treatment plan, would have Blake better able to rely on his strengths; through his strengths, he

was able to recognize his family’s love and acceptance towards him and also to see them as a

vital source of support.

Blake was aware of his need to stay active as a means of staying healthy physically,

mentally, and emotionally. Engaging in activities, having a regular exercise regimen, and

acquiring the discipline to set clear goals and objectives with an expected timeline have helped

Blake in tolerance of distress. Although he did confirm he was less easily overwhelmed, he also

acknowledged that it was a work in progress.

Blake felt he had come a long way in his cognitive restructuring. Through mindfulness

breathing and combating negative thoughts by recognizing his strengths and implementing them

into daily routine, he has found a new optimistic approach to living. This, as defined by the

treatment plan, was a success for Blake in that it increased his sense of confidence, as well as

heightened awareness of his personal strengths.

Results

As I reflect on my intervention with Blake, I arrived at the conclusion that it was a great

success. Together we worked on defining treatment goals and carefully considered what a

successful outcome would look like as it related to Blake’s functioning. It was apparent that

Blake had improved in all domains documented in the treatment plan, and it was also understood

that there was room for improvement in terms of his ability to tolerate distress. Through teaching

some basic CBT strategies, Blake was able to monitor his negative thoughts, identify his think

traps, challenge these unhelpful thoughts, and establish a regular exercise regimen. The client


saw a drastic improvement in his depressive symptoms. Blake found that he was able to identify

and incorporate coping behaviours such as various breathing and relaxation techniques. Blake

also found that he was thinking with greater optimism and confidence as he became more aware

of his personal strengths and had a greater understanding of how they would prove to be

advantageous as he looked towards future career goals and opportunities. Blake also stated he

was feeling depressed less than every day. Blake’s scores on the BDI-II (Beck et al., 1996) pre-

and post-intervention revealed further proof that my intervention with Blake was a success. His

score dropped from a 22, signifying moderate depression, to an 11, suggestive of minimal

depressive symptoms.

Discussion

I believe I was effective in my intervention with Blake, and I appreciate the time I took

prior to regular sessions to carefully devise a treatment plan with my client’s inputs as this

assisted me in maintaining objectivity and effectiveness. I wanted to be authentic in following

my treatment plan, but also felt it was necessary to maintain flexibility and acceptance of where

my client was at during the process. Remaining in this frame of mind, I allowed myself to be

adaptable and willing to change direction if any unexpected circumstances arose. It was

imperative for me to understand that though I can have goals and plans for sessions, the clients

come in with their own ideas and goals. Accepting clients where they are and not where I want

them to be is extremely important in counselling. I also came to understand how important the

celebration of success is for adolescent clients. This encouragement has power in building

rapport and focusing on what the client has accomplished and not just on what needs to be done.

It would be beneficial to re-evaluate Blake’s functioning in approximately two to three

months. My apprehension is that, while he learned and implemented new skills quickly, our short


time together may not have been sufficient to promote life-long change. During that time, we

would determine whether or not he was continuing his mindfulness practices, thought-

challenging exercises, maintaining his discipline in goal setting, and preserving his heightened

self-esteem. It is imperative to have the assurance that techniques implemented are being

maintained.

Finally, I believe that offering the use of solution-based brief, strengths-based CBT

therapy, and the focus on exercise would be an effective approach for the treatment of major

depressive disorder with generalized anxiety features in youth. I found that it was essential to

send clients home with homework to practice and implement strategies and also provide a

starting point at the commencement of each session. I also found it invaluable to provide the

client with resources prior to the termination of our last session that supported the work in our

sessions in order to increase the likelihood that therapeutic gains would be maintained. It is

apparent to me that multi-faceted therapy can provide clients with an abundance of coping

strategies in a limited amount of time.


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