Formulation report: A case study of Fariha- a patient with depression and mental breakdown

 

Summary

The formulation is a key component when it comes to psychological therapies, it is very crucial in such matters and it brings many benefits to the client in the therapeutic process that have direct patient engagement. Although, the supporting formulation is based on evidence and its capacity the possible interventions are limited. The empirical evidence is also low that tells about the perception of therapy towards the client. This specific case will look deeply into the formulation in the case of Fariha who has episodes of depression in the light of psychodynamic therapy. Edward has a very elicit model of psychopathology stresses, in its cognitive model he explained the importance of critically thinking about the maintenance and elicitation of anxiety, depression, and anger (Edward S. Friedman, 2008). Working with a client described in this formulation report will provide an opportunity to understand the application of mental health and counseling theory in actual cases that include interviewing the clients directly that are facing depression or stress and quote the experience we gained in this process. The implication of the research is also discussed.

Case description

Fariha (name anonymized) is a 29-year-old woman born in 1990 in Tower Hamlets, East London. Her parents had both moved to the UK as young refugees from what became Bangladesh during the liberation war’ in 1971. Fariha’s mother (Bibha, born in 1962) came to the UK with her mother following the death of Bibha’s father who had been killed during demonstrations. Fariha’s father (Farhan, born in 1955) fled with both parents to India have been in a village that was destroyed in the fighting. He moved to London in 1973 with both parents. Fariha’s parents married in 1982. She has two brothers and one sister and she is the youngest. She and her siblings were brought up as Muslims and she went to local schools in Tower Hamlets where Muslim children were in the majority. She did well at school although was at times unhappy, describing feeling rather lonely and that she was a victim of some bullying. Her mother was understood to have been depressed at times.

At 18, Fariha went to a local university to begin a degree in biological science, and it was then that she had what she thought of as a ‘breakdown’. She was very unhappy, agitated all the time, had trouble sleeping, and was too anxious to leave the house much at all. Fariha made a serious attempt on her own life and was hospitalized for two months with a diagnosis of depression. By the time she was discharged she was feeling much better – she finished her degree whilst living at home and started to work. She then married a man whom her parents had known for some years.

Presenting issues: Haynes and Williams (2003) had an analysis in which they illustrated the importance of presenting issues and they analyzed their crucibles in understanding and developing problems. Fariha presently has depression, a history of paranoia, delusions about being a bad mother that leads to unusual beliefs, suicidal and negative behavior. She feels secluded, isolated, and cut out by society and friends.

Fariha has been referred for psychotherapy by her GP. She has a history of depression and this seemed to re-emerge shortly after her recent marriage. Fariha has felt the pressure of expectations to have children – from her husband and her family. She was also aware that her parents needed help – her father had become unwell with heart disease and her mother struggled to cope with this. Fariha was very reluctant to get further help for herself, despite the prompting from her family. Given the depth of depression and her history of a previous suicide attempt, her family became very worried about her and began to discuss the idea of having her sectioned. It was at this point that Fariha agreed to see her GP and to be referred for therapy.

Assessment process:

Assessment of Fariha’s difficulties have a primary focus on the following areas

History of her depression, bullying, and difficulty with mood:

Fariha has experienced some serious depressing background that leads to her mood difficulties followed by the bullying that she faced at school. However, during childhood, she did well at school and had not experienced some significant and serious episodes of depression by then. She had a proper mental breakdown when she entered university. However, her mother was aware of her condition but no significant efforts had been made to solace her. The alarm rang when she attempted suicide and was hospitalized for two months. By then, her family was unaware to identify the triggers.

Precipitating factors:

Johnstone & Dallos, believed that (LUCY JOHNSTONE, 2013) certain life experiences may develop such beliefs and dysfunction. These beliefs include having negative assumptions about society, family, and friends. These beliefs can be triggered by some specific incidents as we see in the case of Fariha.

During early childhood, she faced bullying. Having in a strange country and fighting for identity left her alone and she receive negative comments from people around her that add fuel to fire. She grew a belief that no one understands her. As depression is responsible for developing rational thoughts that are then crowded with depression and stressed mood swings (Fennell, 2002).

The second activating event was her parent history. Her mother is a depression patient and her father is a heart patient struggling with her bad condition. She faced difficulty while coping with her identity and connecting with her parent. As a result, she secluded herself, feel isolated, and fell prey to paranoia and depression.

The third activating event extracted from the case study of Fariha is her delusional thoughts of having poor parenting in the future. Her beliefs created a hindrance in making her confident and strengthen her to fight stress. Her past traumas were vital in developing this psychotic situation. 

Current functioning.

Fariha is currently positive about her therapy. Upon the convincing of her husband and mother and considering the thoughts of having children she agreed to have sectioned by her GP. She is experiencing major difficulties but as she agreed now to see a GP there is a hope that she will settle back into a normal routine and become a healthy and productive mother.

Risk

Risk has been assessed considering her attempt at suicide and escaping home. This proved the extent of their current difficulties that also involved having concerns about risking herself.

Family

The assessment also includes focusing on her family background, structure; which includes her unhealthy parent and her relationship with her husband. It focused on the depression history of her family and how it was addressed. Fariha may feel that she is a misfit in society and the suffering her family faced will continue. This brings a surge of not having importance in society and that is why she had thoughts of escaping home.

Early experiences

Fariha explained her childhood negatively. She had a history of difficulties and traumatic episodes. Through sessions with GP, it has been revealed that she has high expectations about her identity. Therapy revealed how she had events when she faced difficulty in fitting in the society during school time. How due to her background and ethnicity she was bullied. Also, having a child induces fear in her as she thinks that she will be a terrible mother and the upcoming children will face the same brunt of society.

Psychodynamic Therapy

Fariha experienced several difficulties during her therapy including the idea of being a burden on her sick parents and husband. Also, she had an idea of not being fit for her upcoming children.

Current worries and concerns:

Fariha has a bad condition and she is currently very down and not feeling well. She reported a bad history and having “bad days” occasionally. Her major concern is having a very doubtful and negative future and that things may go down in the future.

Aims and Goals in psychodynamic therapy:

Fariha has a stern belief regarding her present condition and why her health is dropped so noticeably. She is also terrified that it may happen again. The main goal of the therapy is to find the roots of why she is having such deep depression and stress; also, what factors will make her vulnerable in the future. Fariha wants to be better and able to handle future problems and she wants them to be addressed early to save her from happening again. It was mutually agreed that she would have to focus on some strategies and practices that will play a vital role in improving her condition. Precisely, her family and husband want her to be ready to accept and handle children without having any mood difficulties.

Fariha’s goals regarding therapy were very much in line with the aims and goals of the formulation. Particularly, in being able to cope with stress, being society compatible, and being a good and healthy mother. This can only be achieved by understanding the pattern and mechanism of her present problem.

Method:   

Studies suggest that there is a debate and controversy about the validity and reliability of formulation (Kuyken, 2003). However, there is evidence that proved the effectiveness of psychodynamic therapy (American psychological association, 2010).

Psychodynamic therapy aims to evaluate external and internal factors that are responsible for triggering the present condition. The GP will complete a precisely demographic questionnaire, Symptoms rating assessment, and self-report measures. As it’s a talking-based therapy a semi-structured interview is conducted. The patient corporate alongside the therapist to find out symptoms that are traced back to a daily routine that will indicate improvement. The patient is then handed over an individual record sheet to complete for each day. Patients have signed an agreement to participate in procedures with consent and research study afterward. The patient is not provided with incentives for research the patient are recruited into a research study for inclusion. Patients receive psychotherapy on weekly basis under strict supervision (Gray, 2010). 

Interview:

Although there are tools that exist that sole purpose is to evaluate the formulation quality such as the Quality of Cognitive Case Formulation Rating Scale (Kuyken W, 2005) or examining the quality of the Case Formulation for Obsessive-Compulsive Disorder scale (Zivor M, 2013). Still, there are no tools that exactly tell about the impact or effectiveness. The interview helps understand the invention phase of therapy also. The interview information has been derived from DCP, a reasonable practice guide (Society, 2011).

Such formulation and interviews are helpful for Fariha in finding out the difficulties that she was experiencing. There is also a possibility that some questions will remain semi-structured and unanswered for her but overall she will find it helpful in thinking about the future contributions she has to make to get her life back.

Best way forward

Such type of formulation is also helpful in inducing a sense of understanding of the underlying pattern of her life. Such kind of identification is the best practice in moving forward and informing the intercession.    

Help the patient in believing that she is been understood:

The psychodynamic therapy will assist the patient in discussing the issues, feelings that Fariha is hiding since her childhood. She also never wanted to be noticed in this way especially when she has a sick parent but ultimately the therapy will be helpful for her in able to get recognition.

Integration:

If we look at the case of Fariha then her childhood and her upbringing have a direct relationship with her behavioral issues and the problem lies within her childhood. It's been suggested that the symptoms as that of Fariha are seen as an issue or problem in interacting and communicating with family and friends.

Not only childhood memories can have a traumatic effect on Fariha's life but also family relationships can have problematic effects that lead to such life-risking circumstances. An economic and social factor may also be an issue in shaping her life difficulties. For instance, she moved from her homeland as a refugee. Social and systematic inequity may also be a cause of Fariha's problems.

 

 

 

 

 

 

 

 

 

 

 

Bibliography

American psycological association, 2010. Psychodynamic Psychotherapy Brings Lasting Benefits through Self-Knowledge. [Online]
Available at: https://www.apa.org/news/press/releases/2010/01/psychodynamic-therapy#:~:text=WASHINGTON%E2%80%94Psychodynamic%20psychotherapy%20is%20effective,by%20the%20American%20Psychological%20Association.

Edward S. Friedman, M. E. T. J. H. W., 2008. Cognitive and Behavioral Therapies. Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Fennell, J., 2002. Davidson on Meaning Normativity: Public or Social. Wiley online library.

Gray, E. I., 2010. Psychodynamic psychotherapy for depression: Illuminating processes of change using a time-series design. TRACE: Tennessee Research and Creative Exchange, p. 45.

Kuyken W, F. C. M. M. C. P., 2005. The reliability and quality of cognitive case formulation. Behaviour Research and Therapy. JSTOR, p. 43.

Kuyken, W. e. a., 2003. Is cognitive case formulation science or science fiction?. psycnet, p. 10.

LUCY JOHNSTONE, R. D., 2013. Formulation in Psychology and Psychotherapy. s.l.:s.n.

Society, B. P., 2011. Good practice guidelines on the use of psychological formulation.. Leicester: The British Psychological Society, Division of Clinical Psychology.

Zivor M, S. P. O. V. K. J., 2013. Formulation in cognitive behavior therapy for obsessive-compulsive disorder: aligning therapists, perceptions and practice.. Clinical Psychology: Science and Practice, p. 20.