During the first few episodes, Alexa did everything in her power to show that she didn’t want to be in treatment. While her mother made certain that she attended every treatment session (despite the various excuses she came up with), getting Alexa to participate and do the homework assignments was especially difficult. Still, there was some progress as Alexa slowly accepted that the therapist was just trying to help.
The real breakthrough came when Alexa’s mother attended some of the therapy sessions. This allowed the two of them to interact more frequently and also gave Alexa the opportunity to work through some of her resentment at being forced to attend treatment. Alexa also realized how worried her mother was about her symptoms and her willingness to help find a solution.
As she came to accept the treatment process, Alexa began doing the homework assignments and to stop shutting her mother out. Also, the medication she was taking was helping her to sleep through the night and keep her mood under control a little more than before. Though the medication needed to be carefully monitored by Alexa’s doctor, the few side effects she experienced seemed manageable.
Over the course of the treatment sessions, both Alexa’s mother and her therapist were encouraged by the progress she appeared to be making. The self-cutting had stopped, and Alexa was eating more regularly. Despite the progress being made, there were still setbacks along the way that jeopardized the treatment she was receiving. She was distressed by conflicts at school, especially in dealing with others her age who targeted her for being in counseling and accused her of being crazy. As a result of these pressures, Alexa threatened to begin self-cutting again.
After a discussion between Alexa’s mother and her therapist, they decided to place her in the weekly support group. Despite her mother’s concern that Alexa might not be ready for the group, the therapist suggested that allowing her to interact with other clients her age who were going through similar problems would allow Alexa to work on her social skills, especially considering how isolated she had become over the previous year.
While the group sessions are still ongoing, things are looking more hopeful for Alexa. Along with learning how to be more resilient in how she interacts with others, she has learned better coping strategies and has become more social. Along with the new friends she made in the group, she also resumed her relationship with some of her old friends. Though it is likely too soon to treat her as a success story, her mother is feeling more optimistic as well, and their relationship has definitely become stronger as well.
Analysis
For many young people like Alexa, the road to recovery is often rocky. Not only is there no magic cure but they are also often unwilling to enter into therapy due to the stigma that often surrounds depression and other mood disorders. When starting cognitive behavioral psychotherapy (CBT) or some other form of counseling, the therapist often needs to assess whether their young client is capable of forming a good therapeutic relationship. Whether due to problems with emotional maturity or because their depression is too severe, many young people may find themselves unable to handle being in therapy. They may also lack the confidence to open up about what they are feeling. This often leads to them either skipping treatment sessions, being disruptive during the therapy sessions, or simply refusing to interact at all. If the sessions continue to be unproductive, the therapist will need to see whether antidepressant medication can help and also work with parents and other professionals involved to come up with new treatment goals. It may also be necessary to stop the treatment entirely until the client becomes more receptive.
Fortunately in Alexa’s case, her medication, as well as the emotional support she was receiving from her mother, helped make her more receptive to the individual counseling, and later the group treatment. Also, through regular review sessions with her therapist, she was able to understand the different ways that she was undermining her own recovery. As her therapeutic journey continued, she learned to become a full partner in the treatment process and learned how to cope with her symptoms. This, in turn, helped her to understand that she wasn’t as helpless as she believed and could take control of her life.
Case 3: Adele
Adele is a fifty-two-year-old office administrator who recently went on sick leave due to problems stemming from depression. She was married for the second time two years earlier and denied any problems with her husband. Her three children from her first marriage are all living on their own, and she remains on good terms with them though she avoids talking about her first husband, their father, which still generates some family tension. The marriage had ended bitterly after twenty years, and she continues to have emotional issues as a result though she denied it was contributing to her current depression problems.
Though her children are well aware that their father had been an alcoholic, Adele had never told them about the domestic abuse she had endured in the final years of the marriage (the children had already left home by that point). As a result, she still experiences some posttraumatic symptoms, including occasional nightmares, and avoids talking about her first husband as a result. This has also influenced her relationship with her second husband though she has been careful to avoid opening up to him about her experiences.
While Adele had two previous episodes of depression (once after her marriage ended and the second not long after remarrying), she had responded well to treatment with antidepressant medication and had not been on any medication when her new symptoms began. The trigger for her latest episode of depression stems from her daughter’s recent hospitalization for breast cancer, something that runs in her family though Adele had never had any problems. While her daughter is responding well to treatment, it has been a long and difficult recovery, and Adele has been experiencing significant problems acting as her daughter’s main caregiver.
Among the symptoms that Adele is currently reporting are lack of energy, sadness (particularly when reminded of her daughter’s condition), inability to enjoy many of her regular hobbies such as gardening, and occasional suicidal thoughts. She is under the care of the same psychiatrist she saw during her previous depressive episodes and has also begun taking a newer antidepressant, as the one she had formerly used had some side effects that made her uncomfortable.
Still, while Adele is open to taking medication, she continues to resist attending supportive counseling despite the emotional problems she is facing, both in terms of her daughter’s serious health issues and her reluctance to talk about the domestic problems that ended her first marriage. When her husband suggested joint counseling, Adele became agitated and accused him of using the counseling as an excuse to end their marriage.
Finally, after talking with family members and her husband, Adele opened up slightly about how helpless her first husband had made her feel and how her daughter’s cancer had brought those feelings back. While she asked her doctor for stronger medication, the doctor suggested that Adele attend counseling as well since the medication alone wasn’t controlling her symptoms as well as before.
Following a recommendation made by her doctor, Adele began seeing a therapist who, based on the initial sessions they had together, diagnosed her with major depressive disorder. While some of her symptoms also suggested an anxiety disorder, the therapist outlined the different treatment options available to her, including CBT. They also went over the specific treatment goals that would be covered during the first weeks of treatment and what would be expected of Adele if she wanted to get better.
During the course of this treatment, they explored the kind of automatic beliefs Adele had that were reinforcing her sense of helplessness, both in terms of what she went through with her first husband and her frustration at not being able to help her daughter. The therapist worked closely with Adele to help her understand how these beliefs were making her feel trapped and helpless and to learn more positive coping strategies to deal with the stress she was facing. This included relaxation training, cognitive restructuring, and stress inoculation training, all of
which can be important tools in controlling the sense of helplessness that can lead to depression.
While Adele’s treatment sessions are still ongoing, she is feeling less pressured and more in control. Along with spending more time with her husband, she is also taking a more proactive role in her daughter’s treatment, including working closely with her therapists and making her daughter stick to her chemotherapy regimen. Adele continues to get depressed, but she recognizes that she has a strong support network in place and is more confident about her ability to deal with new life problems as they arise.
Analysis
Studies have long shown that adult survivors of abuse are especially vulnerable to depression. This can include childhood physical and sexual abuse as well as domestic violence, all of which can leave victims feeling as if they have no control over their lives and which can reinforce the kind of automatic thinking commonly seen in depression and anxiety. Even for women who have moved on with new relationships, the sense of helplessness can recur whenever they are faced with some new crisis (including serious health problems developing in a child). Such crises often make women feel as if they are caught in a desperate cycle of new problems that seem to sabotage their lives. Even with the support of family and friends, it is often essential that women like Adele seek out treatment as soon as possible. Not only can a trained counselor provide needed support but can also help them become more aware about how depression and abuse are often related. There are different counseling options available depending on the kind of special needs that clients might have and may include individual or group treatment sessions. The ultimate goal of such treatment is to help clients take control of their lives and learn more effective ways of coping with new life crises as they occur. Recruiting family members or friends as co-therapists can also play an important role in recovery as well as in building up the kind of support network that can make help with future depressive episodes.
Case 4: Laura
Laura is a twenty-six-year old mother who is currently pregnant with her second child. While she experienced postpartum depression after her daughter was born three years earlier, she managed to get over eventually without the need for any formal treatment. This time around, however, seems much worse. Not only is she having more severe pregnancy symptoms but her daughter is also making more demands on her time. As for her husband, he is working full time, and Laura resents that he isn’t doing what she considered to be his fair share of caring for their daughter.
Lately, she’s been feeling much more despondent and has more trouble finding the energy to do anything but sit and feel unloved. She is also eating much less than she is supposed to at this stage of her pregnancy, something that both her doctor and husband have warned her about. What makes Laura more agitated than ever is recognizing that her old postpartum symptoms seem to be returning, and the thought of having to go through what she experienced the last time is making her more upset than ever.
Her first pregnancy had required a C-section due to unexpected complications that had left her terrified for her baby. She had found the whole experience traumatic and had experienced panic attacks even after taking her baby home. The panic attacks faded with time, but the depression lasted for months, something that she was terrified of going through a second time. She also knows that she can’t take any medication while pregnant, so she is trying to “tough it out” without telling anyone what she is feeling.
This first experience with postpartum depression had left her completely unprepared since she hadn’t known much about it. Even her birthing class didn’t have any information to prepare new mothers, and there was almost nothing about it in the handouts that the nurses at the maternity ward had given her. Though she had found some information online on sites such as postpartumprogress.com, the flashbacks and other trauma symptoms she was experiencing made her feel that the depression would be even worse this time around.
Even more alarming for her were the suicidal thoughts that seemed to hit whenever she was feeling particularly vulnerable. This is what led her to talk to her doctor about what was happening. While the doctor could not prescribe antidepressant medication since she was still breastfeeding, she did refer Laura to a psychologist who often dealt with postpartum depression.
After the first few sessions, the therapist arranged for Laura’s husband to attend joint counseling to get him more involved in her treatment. Laura was reluctant about this, especially since she and her husband had been experiencing relationship problems that had been made worse by her depression, but eventually agreed. Her husband, Bob, had difficulty as well, especially since he was afraid of saying anything that might upset Laura further. As the sessions continued, both Laura and Bob learned more about postpartum depression and the triggers that were contributing to Laura’s depression as well as their relationship issues.
During the sessions, which continued even after Laura gave birth to her son, she became more open with Bob, including being able to communicate her feelings to him, something that she had been afraid to do in the past. Not only did this make her feel less alone but she and her husband also agreed to share childcare duties more evenly, which relieved some of her stress. She was also able to open up about how bad the depression had been the first time around, something she had never told him before (though he admitted to being aware of it).
While Laura still experiences occasional episodes of depression, she is much more optimistic about the future. Also, her relationship with her husband and children has improved immensely, and she has become much more socially active and is trying to get back to her regular life as much as possible. She is also determined to do something to boost awareness of postpartum depression. Along with getting in touch with the local branch of Postpartum Support International, she also helped organize a Climb Out of the Darkness walk in her community. Though it is starting out small, she is hoping to make it an annual event and to encourage more people to attend. She is also making sure that the maternity ward at her local hospital provides more comprehensive information about postpartum depression, including numbers to contact for people who want more information.
Analysis
While having a baby is often seen as a happy time for mothers, the months before and after giving birth can be extremely stressful due to the new responsibilities involved as well as the physical and emotional changes that all women go through. As a result, postpartum depression can be a common problem faced by many new mothers (see Question 15). In fact, women are far more likely to receive mental health counseling during their childbearing years than at any other time in their lives. Even though many women may be reluctant to admit to what they are experiencing (especially if they view their symptoms as being fairly mild), postpartum depression should not be left untreated, especially if the symptoms don’t seem to be going away. As postpartum depression is becoming more widely recognized, it is becoming common practice for health care professionals to screen new mothers for symptoms of depression and for hospital maternity wards to provide new parents with educational brochures on how to get help when needed. Also, though postpartum depression was once viewed as a problem that affected the mother alone, therapists now recognize that the kind of relationship mothers have with their partners and other family members can play a critical role in developing symptoms. For this reason, couples and family counseling can be extremely valuable in helping mothers deal with their symptoms and prevent relapses during later pregnancies. While women like Laura may be reluctant to speak out about what they are feeling out of fear of being considered crazy, it is only through speaking out that help becomes possible.
Case 5: Christopher
Since Christopher often regarded himself as a survivor due to the physical abuse that he endured while growing up in the foster system, it came as a surprise to him that he began experiencing symptoms of depression years later.
At twenty-four years of age, Christopher was working full time and going to school at night to finish high school. H
e was also in a good relationship though he found himself feeling more pessimistic about his future despite all the positives in his life. He certainly remembered how depressed he got as a foster child and how he would resort to drinking and whatever drugs he could get to relieve his moodiness. Though he has been clean for years, he finds himself feeling less confident about his ability to handle the adult responsibilities he thought he was prepared for. While he tries to hide his moodiness as much as possible, his girlfriend is noticing the change and how he has become more irritable and impatient. He is also losing weight since he is eating much less than usual though, again, he has been trying to keep this hidden from anyone who might notice.
To make things worse, his moodiness is affecting his relationship with his employer and coworkers, and he has recently received a negative performance review as a result. Suddenly, it seems harder than ever to keep things together, and Christopher feels that he is about to snap. But it was only after his girlfriend, Beth, noticed the red marks on his hands (he had been punching walls in his apartment to relieve stress) that he finally opened up to her about what was happening to him.
Not only was Beth sympathetic (which he hadn’t been expecting) but she was also candid about her own fight with depression years earlier and urged Christopher to attend treatment at the same place she had attended. Given his past experience with youth counselors while he was still in the foster system, Christopher was convinced that treatment would be a waste of time. Still, with all the setbacks in his life recently, he was afraid that his relationship with Beth would end if he didn’t at least give it a try.
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