QUESTION

The following case study is connected to the questions below: Please assist with answering the following questions related to case study:
Brief Overview of Client
DSM Diagnosis and rationale (Including code)
Approach to Treat Disorder (including assessment techniques or tools)
Treatment Plan (Minimum THREE goals with measurable objectives) with following format:
Goal 1:
Objective 1:
Objective 2:
Objective 3: (Complete for minimum three goals)
Anticipated discharge criteria (i.e., When is process complete?)
Additional Information (What more information about the client would need to be gathered to better understand the client?

What are the first signs that a person might be depressed?
Why did Phil initially see his primary care doctor?
What symptoms did Phil present that prompted his primary care doctor to suggest a psychologist?
What was the purpose of the social worker who talked to Phil after the primary care doctor?
Why did Phil choose cognitive-behavioral therapy over medications?
What helped Phil feel comforted by and trusting of Rosemary?
What concerns did Scarlet, Phil’s wife, have about her husband’s depression?
What type of psychotherapy did Rosemary use with Phil?
What were the criteria for Phil’s diagnosis of major depressive disorder?
What are some of the methods that were used as part of behavioral activation?
Phil wanted to know how long it would be before he felt normal again. Why did Rosemary not want to give him a definite timetable?
What was the first assignment Phil was given for the first week of therapy?
Why did Rosemary want Phil to clarify his values near the beginning of therapy?
What was the homework assignment given in session 2? What was the purpose of this assignment?
Why was it important to get Phil to set up an evening routine of activity?
What were the three main components of BA that Rosemary used?
At approximately what point in treatment did Phil return to full function?

Phillip was born in 1973 in Chicago, Illinois, and grew up on the infamous South Side. His parents were both from Chicago and their parents, his maternal and paternal grandparents, had immigrated to the area from Ireland in the early twentieth century. Trained as a masonry worker, Phillip’s father had worked from company to company in the industrial areas of the South and Southwest neighborhoods outside the city. When Phillip (who was always called Phil or Philly by his parents) was in middle school, his father got a job as a supervisor in a manufacturing facility on the West Side. It paid a salary, which was better than the other jobs, which had been hourly. His father worked hard to succeed as a supervisor in order to maintain the steady income and consistent schedule. For Phil and his three younger siblings, everything was better after their dad started this job. Before being a supervisor, the rent or bills might not get paid on time, the power could be turned off, and some days they went without enough food for family meals. Worse, Phil’s parents would scream and yell, fighting about how there wasn’t enough money to meet the family needs. It was a hard childhood, and one that Phil would later describe as “scarring.”

Phil worked during high school under his dad’s tutelage as a mason’s apprentice, learning many of the fundamentals of the trade. As he learned he became proud of his skills, and enjoyed the time spent with his dad. Phil had come from a working-class neighborhood. Most of the kids he knew would not go on to college. Many of them didn’t finish high school. Some of them would end up in prison or in and out of jail for various crimes born out of poor education, poverty, and lack of opportunity. Phil had been in fist fights, narrowly avoided dangerous crossfire from gangs, and witnessed people being beaten or robbed dozens of times by the time he was 16. After high school graduation, Phil began working in the masonry business full time, landing an entry level job at his dad’s company. He helped move pallets of raw materials in the warehouse, cleaned machinery, and made sure all the tools were safely secured for his more senior coworkers to use successfully. It was a decades-old family company that sold supplies to builders, hardscapers, and contractors in the tri-state area. Phil’s family assumed that he would make a career for himself in the masonry supply business. Only an average student in school, he couldn’t imagine what would have become of him if he had had to make it on his own. He was proud to carry his load in the business and had aspirations to make a salary and one day have a family of his own.

At age 23, Phil married Scarlet, whose family was also from the same South Side neighborhood. She was fun-loving, had a soulful singing voice, and was into the blues. They hooked up from time to time in high school but didn’t get serious with each other until about a year before they were married. Phil came to realize after graduation that he was attracted to her and hoped to marry her one day. He courted her playfully at first. “You’re not like other girls,” he’d say. “There will come a time for us … You’ll see … And you’re gonna say you might as well … I think you know it. Lord, you can see that it’s true.” Scarlet was a South Side girl and she knew how to hold her own. She bantered with him and told him she wasn’t ready to be serious. But the attraction was mutual, and eventually she came to see how much this man loved her. She felt respected and loved, and even though they both were fairly young in her mind, she said yes when he proposed. They were married in a large church wedding. They set up a relatively traditional household around the corner from the house she grew up in. Phil worked at the masonry company, and Scarlet worked part-time as a waitress as a local coffee shop in the gentrifying neighborhood nearby. Unlike Phil, she was taking college courses online and had plans to get a degree in graphic design. Within a year of marriage, she gave birth to a daughter; another daughter followed 5 years later, then a son, and then another son. Phillip: Everything Changes

At age 41, Phillip, having spent many years rising through the ranks of his masonry business, was now a supervisor and manager of operations. He had eclipsed his father’s success in the company early in his 30s and had established himself as a respected leader among his peers and supervisors. Since his father’s retirement, Phil had found an even higher gear of success, feeling confident in his knowledge and skills as both a masonry expert and as a leader. Scarlet enjoyed success as a graphic designer. She had become quite talented and worked full-time for a company that allowed her to work from home. Phil loved her very much and respected how hard she had worked while the kids were little and he was away every day at his job. He also appreciated how much money she was bringing in to support their family. They owned a home in one of the middle-class suburbs southwest of the city, along with two cars and an old class B camper van they called Bertha parked next to the house. The kids were all in school, healthy, and had friends. It was a normal life, as he would reflect to Scarlet in their quiet moments. Indeed, things were going well for Phil and the family. And then everything changed.

His brother, who was 3 years younger than Phil, died suddenly in what was initially thought to be a heart attack. He died in his sleep without any warning symptoms of any kind. Phil’s entire extended family was shocked and deeply saddened. It made no sense. They had no history of heart disease in their family, and no one that they knew of had ever had a heart attack. Still, what else could have explained how he died at such a young age in his sleep? This was Phil’s closest sibling in age, and he had spent much of his childhood with him. Phil was overwhelmed with grief. He took several weeks off from work and was beginning to have a hard time getting out of bed in the mornings. His mood was flattening, and he felt numb most of the day. The things that he normally enjoyed were less rewarding and enjoyable. Scarlet told him he looked depressed, but Phil had never been depressed before, and he chalked his changes up to grief and sadness. In the first month after his brother’s passing, this interpretation made some sense. As the months went on, Phil continued to feel a melancholic mix of sadness, hopelessness, and worry. The simplest interpretation of grief was making less and less sense as time went on.

Significant grief reactions after the loss of a loved one are common and typically normal. According to DSM-5-TR, however, some bereaved people qualify for a diagnosis of “major depressive disorder”, and others qualify for a diagnosis of “prolonged grief disorder” if their grief symptoms continue to appear daily for more than a year and cause marked distress or impairment.

Four months after the funeral services Phil learned that his brother had been a regular user of prescription pills for years and most likely died from respiratory or heart failure caused by the combination of alcohol and legally prescribed but misused opioid medications. Phil was shocked. He had no idea his brother was addicted to painkillers, but as he thought about it he recalled many times when his brother would seem agitated and ask for money. His brother had been in an accident at the factory where he worked some years ago and had surgery on his back. He could have started to use the pain medications when he was recovering from surgery. Or maybe it started when he had the motorcycle accident last year and went to the emergency room? Phil remembered that his brother had told him they gave him some oxycodone, and it made all the pain better. Whenever it started, Phil wouldn’t know for sure. But he did know that he couldn’t stop thinking about his brother. He couldn’t stop thinking about how he wished he could have known and helped him. He wondered if maybe he missed out on seeing the warning signs. It made him feel terrible that his brother was gone. Even worse, Phil felt guilty that he wasn’t there to help.

As many as 30% of the biological relatives of severely depressed people are themselves depressed, as opposed to 10% of the general population (Krishnan, 2021a, 2021b, 2021c, 2020).

Phil didn’t use drugs and had never taken any painkillers other than the kind you can buy over the counter at the drug store. And Phil had no history of cardiac problems. But as time went on after his brother’s death, he kept wondering about his own health and the health of his wife and children. He had a primary care doctor that he was supposed to see every year, but he hadn’t been in several years. Scarlet regularly went to see her doctor, and they were diligent with the kids, going every year to the pediatrician. Phil always said he would schedule an appointment but never got around to it. Another year would pass, and Scarlet would remind him. He wasn’t against going to the doctor. He just didn’t ever seem to prioritize doing so. Now, almost a year after his brother’s death, Phil scheduled an appointment.

He went to the clinic near his home in the suburbs. When he checked in, the person at the desk took his copay and then handed him a tablet to complete questionnaires in a kiosk adjacent to the wait area. Phil was surprised. A lot had changed in the clinic in the years since he saw his doctor last. He used the tablet to answer questions about his health history and any current concerns or medical problems. He clicked on the bottom of the screen. The next page asked him to answer questions about mental health. Phil started to feel uneasy. The questions asked about his mood, anxiety, alcohol and substance use, a history of trauma, and how he was coping with stress. As he answered them, Phil knew he wasn’t telling the entire truth. He had admitted to feeling sad and anxious sometimes, but he downplayed his overall level of stress and the amount of alcohol he was drinking per week. He handed the tablet back to the man at the front desk, then waited for the doctor.

Instead of a doctor, Phil was greeted by a young woman who said she was the doctor’s clinical assistant. They walked back, and she took Phil’s vitals, then brought him to a clinic room. When his primary care physician arrived, they exchanged pleasantries, and the doctor completed a basic review of his systems. She explained that his routine blood tests taken before the appointment had come back normal. She asked Phil whether there were any concerns about his health. Phil told her he needed to exercise more and wondered if his eyes needed checking for glasses. “I’ll make a referral to the ophthalmologist in the clinic,” she said. They talked about his lack of exercise. She then asked him about the screening questions he had answered earlier. She related his lack of exercise to his reportedly lowered mood. Phil shrugged his shoulders. “Do you think your mood has been much worse than normal for at least the last two weeks or more?” she asked. Phil nodded affirmatively. She continued to ask questions about Phil’s sleep, appetite, and weight. Phil acknowledged that he was sleeping much more than normal, nearly 10 hours per night. His appetite was lower than usual for him, and he had unintentionally lost roughly 10-15 pounds in the last 6 months. She continued, “Phil, in the last two weeks or more have you had less interest or pleasure in the things that normally would give you enjoyment?” Phil explained that this was definitely true, and that he didn’t understand why or what was wrong. His doctor leaned toward Phil from her desk. She told him that he seems to meet criteria for major depressive disorder, and that she would like for him to consider one of several treatment options.

Phil couldn’t help but agree with her that he may be depressed. After all, what had started as grief was now a long list of symptoms. His mood was down. He wasn’t feeling enjoyment anymore. He wasn’t sleeping or eating well, and he had lost weight. Phil was not thinking about suicide, but he did feel hopeless about his future and was spending a lot of time thinking about his own death. At work, he was moving more slowly and having a hard time concentrating. All of these things were bothering him, and his boss and wife had both noticed a change in him. Both had been frustrated with his lack of energy and the uncharacteristic number of times he seemed to forget his responsibilities. Phil knew when his doctor said the word depression that she was right. He was depressed.

She described his treatment options. He could begin on an antidepressant medication that she would prescribe, likely a low dosage of a selective serotonin reuptake inhibitor — possibly bupropion, to help boost his energy, she speculated. After she described the possible side effects (for example, headaches, constipation, insomnia), Phil asked about his other option. He told her he had always been someone that disliked taking medications and was feeling even stronger about this since his brother’s death. She told him that the other option was a kind of talk therapy called cognitive-behavioral therapy, or CBT. Just like there are different types of antidepressants, there are different types of CBT he could do for depression.

Phil was not the only person affected by his emerging depression. His wife, Scarlet, and their children — the people who lived with him and cared about him — were hurt by it as well. And like Phil, they were confused by the dramatic changes that they had seen in him. As Scarlet explained to her sister:

For years I lived with this strong man who was a good father and caring husband and who worked hard every day to provide a good life for all of us. Then over the course of weeks, I watched him change into a sad, frightened, hopeless person who could think of nothing but himself — his fears, his future, his unhappiness.

It seemed innocent enough when it first started. When his brother died, we were all upset, and it was natural to think about how young he was and how something like that could happen to any of us. But while the rest of us — his siblings, his cousins, and I myself — got over it and got back to our lives, it seemed to trigger something in Phil that wouldn’t let go of him.

First it was his relentless need to talk about his worries that he could die suddenly like his brother. Then he became obsessed with me or our children dying. Then worrying about every little thing, overprotecting himself, seeing doom everywhere. I would walk into the family room and find him sobbing. Over what? He was healthy, he was successful, he had a beautiful family, yet he was sobbing.

Time and again, I tried to point out the brighter side of things, to snap him back to his old self, but nothing helped. I talked my guts out, but it was always, “Yes, but this” or “Yes, but that.” He felt doomed and hopeless about everything; nothing made a difference.

It was horrible to see him so upset, but worse was the way he stopped doing anything. At home he stopped being a father and husband. The kids would need help with their homework or have to be driven somewhere. The sink or car would need fixing. Or I would need to talk about finances with him. He could do none of it. He would just sit there, usually staring into space, sighing, or crying. He became like a fifth child. Actually, it was worse than that. At least I could reason with the children, get them to do things, have fun with them.

At work it was the same. His boss called one day, wondering where Phil was, because he had not showed up to work for two days. He was forgetting things at home and work. He hardly was doing anything to help around the house as time went on. We all were walking on pins and needles worried we might upset him. The kids would ask me what was wrong with dad all the time. I kept asking him “What is happening to my husband?” He wouldn’t admit to being depressed. Instead, he came up with excuses and reasons for all of these changes. But I knew better. It was like I was losing him.

I was relieved when he finally went to see the doctor. When he came home and told me what happened I was furious at him for not taking the prescription for medicine. It seemed like the easier solution. I don’t really know if he will take therapy seriously. But I don’t know what to do. Nothing I have done has made much of a difference. What if he decided to do something to himself? He certainly was headed in that direction. It’s all so scary. I just want my husband back. Weeks after meeting with his doctor and the social worker, Phil scheduled an appointment with a CBT therapist named Rosemary for their first therapy session. The clinician was a master’s level therapist who had devoted herself to years of training in CBTs since completing her master’s in clinical psychology. He looked her up online before meeting her. She was an older woman who looked to be in her late 60s and who shared on her website profile that she had been trained in lots of different therapies in her career, including things Phil had never heard of before like Rogerian therapy, gestalt therapy, logotherapy, and something she called eye movement desensitization and reprocessing (EMDR). Phil’s eyes scanned intently as he continued to read about her professional training and therapeutic style. He had been diagnosed by his doctor with major depressive disorder, and he was relieved when he saw that Rosemary described herself as someone who had expertise in the treatment of depression. For depression, she wrote, she commonly used something called cognitive-behavioral therapy, or CBT for short. This was the same type of treatment his primary care doctor had told him about. He still didn’t think he knew what it was, but knowing Rosemary would use the same approach that his doctor suggested made him feel less nervous about seeing her.

As he scheduled the appointment, Phil wasn’t sure what to think. On the one hand, she had lots of experience and looked like she knew what she was doing. On the other, this would be Phil’s first time ever going to a therapist, a “shrink” as he called her, to get help. Before clicking “confirm” on the appointment request, Phil sat back and reflected. Growing up, he never heard of anyone seeing a therapist in his low-income, working-class community. People were just trying to make ends meet. A roof over their head, a decent job, food on the table — these were the things he remembered people he knew worry about. But he also recognized that there was a stigma he learned around mental health: the kid in sixth grade who everyone called “spaz” who was unmedicated and had behavioral outbursts in class all the time; the depressed neighbor his friends called “crazy Charlie” who, when Phil was 10, died by suicide after he lost his job and wife left him; the homeless man who sheltered under an elevated train platform, whom Phil and his friends used to make fun of by imitating his confused speech. Phil teared up thinking about all of the people he had come into contact with in his life that may have had depression or other mental health problems. He had so little compassion or empathy for them, and now he was one of them. He clicked “confirm” and saw on his phone an immediate confirmation e-mail that said he would be contacted by Rosemary or her staff to schedule an appointment.

Weeks after meeting with his doctor and the social worker, Phil scheduled an appointment with a CBT therapist named Rosemary for their first therapy session. The clinician was a master’s level therapist who had devoted herself to years of training in CBTs since completing her master’s in clinical psychology. He looked her up online before meeting her. She was an older woman who looked to be in her late 60s and who shared on her website profile that she had been trained in lots of different therapies in her career, including things Phil had never heard of before like Rogerian therapy, gestalt therapy, logotherapy, and something she called eye movement desensitization and reprocessing (EMDR). Phil’s eyes scanned intently as he continued to read about her professional training and therapeutic style. He had been diagnosed by his doctor with major depressive disorder, and he was relieved when he saw that Rosemary described herself as someone who had expertise in the treatment of depression. For depression, she wrote, she commonly used something called cognitive-behavioral therapy, or CBT for short. This was the same type of treatment his primary care doctor had told him about. He still didn’t think he knew what it was, but knowing Rosemary would use the same approach that his doctor suggested made him feel less nervous about seeing her.

As he scheduled the appointment, Phil wasn’t sure what to think. On the one hand, she had lots of experience and looked like she knew what she was doing. On the other, this would be Phil’s first time ever going to a therapist, a “shrink” as he called her, to get help. Before clicking “confirm” on the appointment request, Phil sat back and reflected. Growing up, he never heard of anyone seeing a therapist in his low-income, working-class community. People were just trying to make ends meet. A roof over their head, a decent job, food on the table — these were the things he remembered people he knew worry about. But he also recognized that there was a stigma he learned around mental health: the kid in sixth grade who everyone called “spaz” who was unmedicated and had behavioral outbursts in class all the time; the depressed neighbor his friends called “crazy Charlie” who, when Phil was 10, died by suicide after he lost his job and wife left him; the homeless man who sheltered under an elevated train platform, whom Phil and his friends used to make fun of by imitating his confused speech. Phil teared up thinking about all of the people he had come into contact with in his life that may have had depression or other mental health problems. He had so little compassion or empathy for them, and now he was one of them. He clicked “confirm” and saw on his phone an immediate confirmation e-mail that said he would be contacted by Rosemary or her staff to schedule an appointment.

Session 1

Phil waited nervously in Rosemary’s waiting room. He kept his head down but managed a forced courteous smile when Rosemary introduced herself. Her hair was long and silver and she walked slowly and with purpose. When she smiled as she extended her hand to meet him, Phil saw that her face seemed welcoming and kind. She had a scent of vanilla and cardamom and well-defined crow’s feet. They walked back to her office. It was cozy. There were two comfortable-looking reclining chairs seated facing each other and flanked by bookcases that were adorned with an abundance of succulents, gemstones, and books. She invited Phil to sit and welcomed him, then gave a well-rehearsed orientation about the limits of confidentiality and clinic policies. She asked him if he wanted any hot tea and got up to pour herself some. “There,” she said as she handed him a mug of probiotic peppermint, “now we are ready to begin.”

Most of the first session of psychotherapy was devoted to a discussion of Phil’s current condition and the events leading up to it. In spite of his obvious distress, Phil related the events of the past year in a coherent and organized fashion. At the same time, the desperation on his face was almost painful to observe, and his voice trembled with distress. She assessed him for symptoms of major depression, just as his primary care doctor had recently. His answers were no different. He was still depressed, and Rosemary noted that he met criteria for more than five symptoms of major depressive disorder. She told him that she was going to be diagnosing this and including it in her notes and the insurance billing. Phil nodded and said that made sense.

Rosemary then began describing CBT as a general approach for depression that she suggested. She began by talking about the “C” in CBT for depression. Her style was irreverent and engaging, and even though Phil was very nervous — and still unsure about doing treatment altogether — he found Rosemary someone he thought he could trust. Rosemary explained that “the ‘C’ stands for the term ‘cognitive,’ which is nothing more than a fancy word for thinking.” She chuckled. Phil noticed as she talked that he felt less anxious. Using cognitive interventions, she could treat depression largely by focusing on a person’s style of thinking. Although a disturbance in mood is the most obvious symptom of this disorder, she highlighted that research suggests that disturbances in cognition have an important — some think primary — role in the disorder. People with depression have a severe negative bias in their perceptions and interpretations of events, a bias that leads them to experience themselves, events in their lives, and their futures in very negative — depressing — terms. The goal of cognitive interventions is to change this negative bias and style of interpretation, and in so doing, remove the source of depression.