Patient identification and reason for consultation
The patient is a 44-year-old married male with two children.
Although training has existed for a few years now, he has lived exclusively on his intellectual activity (books, statements, collaborations in the media, etc.).
She has no family history of mental illness.
She suffered a brief anxiety episode that had occurred about twenty years earlier, which resolved rapidly after being treated with anxiolytics.
Few weeks before going to the clinic, trust your wife an extramatrical relationship.
It then begins a period of difficult coexistence, in which both value different possibilities and by which the patient begins therapy.
Finally, a couple months later, his wife decided to resign.
From that moment on, although initially it seems more relieved, it begins to suffer a deep discontentment, a more passive behavior and creative work is paralyzed; however, it continues to meet the original commitments related to the work.
The state of sadness, grief and despair then becomes the object of consultation.
Although the patient is well aware of this by his training in laws, it is explained that all the information provided will be treated with confidentiality that requires professional secrecy.
Evaluation strategies
The evaluation strategies used were unstructured clinical interview, self-reports and the following self-reports, common in the literature in which CA has been the treatment of choice:
Beck Depression Inventory - II: The BDI-II (Beck, Steer and Brown, 1996) is the last version of the Beck inventory.
In this case, we used the Spanish version with clinical and non-clinical samples (Sanz, García-Vera, Espinosa, Fortín y Vázquez, 2003 and Sanz, Perdigón).
Acceptance and Action Questionnaire: El AAQ (dresses et al., 2004) is a measure of the degree of avoidance experience, conceptualized from the model of Accepthly, 1999 Strromiso Therapy.
Acceptable internal consistency indexes (Cronbachs alpha = .74), temporal stability (rxx = .71) were obtained in the Spanish version adapted to English, and clinical validity was tested with general samples.
Automatic Thought Questionnaire: The ATQ (Hol and Kendall, 1980) is a 30-item questionnaire designed to measure the frequency of negative automatic thoughts (self-directed negative thoughts).
The Spanish adaptation of the THA used is that of Cano-García and Rodríguez- Franco (2002) that maintains the four-dimensional structure (negative self-concept, inappropriate here, poor fit and author).
State-Trait Anxiety Inventory: The STAI-R / STAIE is a measure of anxiety in both trait and state aspects.
In this case, the Spanish version was used (Spielberger, Gorsuch and Lushene, 1982).
Environmental Reward Observation Scale: The EROS (Armento and Hopko, 2007) is a brief 10-item instrument developed to obtain an objective self-assessment of the degree to which the environment is reinforcing.
A high score is associated with an increase in behaviors and positive affect as a result of reinforcing experiences from the environment.
The scale has good internal consistency (Cronbach's alpha = .85) and good test-retest reliability (rxx = .85).
There are also data on its construct validity (correlations with the Pleasant Events Schedule and the BDI).
The version used in this study was adapted to Spanish established by Pérez-Álvarez (2010).
Behavioral Activation for Depression Scale: The BADS (Kanter, Mulick, Busch, Berlin and Martell, 2007) is a 25-item questionnaire designed to measure four basic dimensions of work activity Avitation,
The version used in this case is the adaptation to Spanish made by a graduate student and Pérez-Álvarez (publication student).
Patients scores on the scales were as follows: BDI-II = 32 (severe depression); AAQ = 39 (medium-high avoidance); ATQ total = 44 (high self-injury attitude); ATQI = 18 (high risk; low self-treatment;
The same tests were applied again after the intervention, in the follow-up phase.
The clinical interview served to know the most relevant aspects of the case and propose the functional analysis.
In addition, it was the most important method to determine the state of the patient at the time of consultation and also to assess its evolution throughout therapy.
Together with the patient, a score of 0 to 10 was established in each session to determine the weekly mood.
Although it is possible that this type of estimates are biased by subjectivity, they provide quick and simple information that is very useful for the clinician; in addition, they are also commonly used in the assessment of known chronic pain or anxiety stimuli.
Finally, the patient was asked to develop self-reports that reflected daily activities and mood associated with each of them.
However, patients only perform this task for a single day.
Nor was it used diaries or emails that were suggested as an alternative to the records.
Case report
The main problem behaviors appeared progressively, although in a short period of time.
Approximately one week after the separation from her wife, her schedule began to change, and the patient started to bed and get up increasingly later.
At the same time, he suffered more severe insomnia and the little sleep he achieved was accompanied by nightmares.
A weight loss of ten kilos was also initiated, although it is true that this process is partly explained by the decrease in two weeks in the problem with a flu that lasted close to it.
At the same time, the patient’s self-affirmations became increasingly negative (“my life has no horizon”, “I lost what gave meaning to all my efforts: my family, my children,” I endured more integrity).
At the cognitive level, there were other problematic manifestations that accompanied this process, such as his obsive memory of the guilty chain of his previous life, feelings of guilt and the statement that he would have to suffer some kind of errors.
In the same vein he commented that his life was lately pure appearance, and that many years before he had to find out a series of “internal problems”, although no one had warned him.
Different problems were also observed in the social sphere.
General social contacts were illustrative, but relatives and those who were obliged to work remained.
However, when he was with his parents, he said his true mood to avoid suffering.
Most of these problems intensified every time he talked to his former partner about divorce proceedings and agreements.
Continued reproach for economic issues and for the education of children who have had in common emerged in the conversations.
When his older daughter (10 years) also questioned the reasons for separation.
It is also necessary to point out in this case that, although the erbalizations of discomfort were very intense (and coherently, it reflected the depression scores of the BDI-II or the ATQ), there was a lot of collaboration between the works.
The patient mentioned that he was unable to tolerate this rhythm, although he continued to do so and, judging by the results, all tasks were performed with great efficacy.
I understood the contradiction between what I said I felt and what I did, but I could not explain why.
However, it is also true that activities related to the creation of a new work were interposed and that the patient was not able to challenge them; in fact, he did not encounter them indefinitely.
He also lived in an ambivalent way the possibility of resorting to medication because although, on the one hand, he felt sick, on the other hand feared to depend on it and, in general, when he was more serene, he believed that
In order to explain why the patient was increasingly depressed even though he continued to develop intense activity and always acted responsibly with his obligations —something in principle contradictory with the usual depressive processes— his functional state justified.
This functional analysis was outlined, in its general lines, from that proposed by the authors of the CA to account for the beginning and, fundamentally, the maintenance of the depressive situation (Jacobson et al., 2001).
From this analysis it was hypothesized that, at first, the triggering element of the depressive state was clearly identified with the process of residence, less contact with the place of loss associated with it (economic breakdown, etc).
This situation had triggered a series of typical responses of the depressive condition (insomnia, negative thoughts — “nothing makes sense” “how I have been able to quote so many errors”—thinkability passed, guilty life).
However, the most interesting thing was to observe that this type of response was perpetuated by a series of avoidance patterns that were permeated by the various activities that he carried out (travels in media, maintenance, etc.).
That is, although the patient complained of being obliged to carry out all these activities, this justified him not to dive into creative work such as writing his books.
At the same time, his negative rumination, his insomnia, his lack of strength, his feelings of incompetence and his fear toward the man-woman relations, pushed him no longer to focus on creation.
Therefore, as predicted by the CA model, the depressive situation caused certain symptoms, but could also be seen as a behavior that maintained the situation itself.
Certainly, the publication of a new book could be gratifying in the long term, but in the short term it required him to have an important job of introduction, to work alone and to contact his feelings.
Similarly, returning to friends and redoing their social network, and even re-emergeting a new relationship with their partners, could be an acquaintance, but at that moment they remembered what they had lost.
In summary, the hypothesis raised was that the avoidance that involved the development of many work activities, along with the same depressive symptoms, favored an immediate negative reinforcement (to escape from unpleasant feelings more and more difficult to access).
Treatment
Choosing treatment
Based on the functional analysis, it was estimated that CA was the treatment of choice.
Of the two possible intervention protocols, that of AC (Martell et al., 2001) and that of TACD (Lejuez et al., 2001), the first one appeared to be especially relevant in this case.
Specifically, the protocol of CA: (1) emphasizes the role of negative reinforcement in the maintenance of depressive states; (2) there is also use of a broader set of strategies and not only the progressive incorporation of anxiety symptoms, subject who also reports similar empirical evidence
Application of treatment
From the functional analysis the objectives of the treatment were determined and its application began.
The following objectives were considered: (a) Behaviour to activate: (1) Maintain fixed schedules (to go to bed, raise up, and work at home) Behaving an active mindset for at least five months (seeing a week), Behaving a story last night; (1) Going up to staying up to last night; Behaving help; Behaving up to last night; Behaving up to stay
In order to carry out this intervention plan, first, the functional analysis was explained and the reasons were justified for positive and active behaviors, justified by the fact of leaving a difficult situation and having a close relationship with friends, how they could be reduced.
It must be understood that the creative activity had configured the life of this patient and the rest of his work was based on this vocation.
As suggested by the CA model, the achievement of these objectives has to be gradually established, as the depressive situation is difficult to undo.
Furthermore, given that coping with the activities indicated cannot be expected to produce a rapid relief of the depressive state, on the contrary, it was essential that a commitment be given to maintaining this attitude for longer periods.
As typical of the CA intervention, behaviors to activate and activate or moderate once incorporated into the treatment remained permanent.
The application phase of the CA therapy itself lasted seven months (over 22 sessions), after a previous month that served as an evaluation period (5 sessions), somewhat longer than usual to establish the functional circumstances of the detail subject.
Just after the end of treatment, 5 more and more distant follow-up sessions were scheduled (the first two with an interval of fifteen days between each other, then the following after twenty days, one month and one month).
In the latter, self-activation was repeated. Relapse prevention was carried out and the need to continue conducting an observation similar to the one shown in the consultation (functional analysis) was explained.
The schedule of the sessions can be seen in Table 1.
As suggested by the CR, the incorporation of the strategies and objectives indicated was progressive, and thus appears in the table.
During the process of implementation of therapy there were some parones, motivated both by holiday periods and the need to meet their labor obligations outside the place of residence.
Although initially it was dubitative, commitment to tasks and correction of some strategies facilitated the inclusion of the following elements.
As the mood and the confidence of the patient were settled after several months, the latest incorporations of behaviors turned out to be more simple (e.g., neglecting the content of depressive reserves) and focused on self-esteem.
Factors related to the therapist
The sessions were conducted by a single therapist, author of this article.
The therapist completed his degree in 1992, held a Master's degree in Clinical and Health Psychology from 1992 to 1994 and PhDed in 1997.
He is in possession of the Title of Specialist Psychologist in Clinical Psychology and Psychologist Specialist in Psychotherapy (EFPA).
The sessions were conducted in the private consultation of the therapist.
The therapeutic relationship could be considered good.
The patient showed adherence to treatment and tried to comply with the prescriptions.
However, at the beginning of the intervention the recommended records were not completed.
It is important to note that the patient had had negative experiences with psychiatrists and that this circumstance could affect his initial confidence in any therapeutic process.
Later on, the patient recorded books of his own to the therapist and was willing to come more frequently when indicated because he was found to be less conscious and because he gave adequate continuity to treatment.
The therapist showed interest in the books and commented on them in session.
The patient's cultural activities were genuinely interesting for the therapist, which probably occurred during the course of therapy.
The patient did not cancel the scheduled appointments and always informed in time if he was forced to change them.
He also attended follow-up sessions despite being distant over time.
Study design
The case reported here corresponds to an AB design.
Although this type of design does not make it possible to determine with complete certainty that the changes only obey the application of CA therapy, it can be mentioned that during the intervention there were no major changes in family, work or contextual information.
Data analysis
In order to obtain measures to contrast the possible change by the intervention, the follow-up repeated the administration of all self-reported measures applied during the baseline.
On the other hand, since the patient did not complete the self-reports prescribed at the beginning of the intervention, it was necessary to resort to other strategies to assess the effectiveness of the therapy.
Specifically, the therapist estimated, along with the patient, the mood during the week (with a score range from 0 to 10).
In addition, compliance with tasks aimed at intervention (conducts to activate and conducts to moderate) was recorded.
Given the nature of these measures, it has been considered that the presentation of the results in visual format would be clearer.
Figure 1 shows the differences between pre- and post-treatment measures for each self-medication applied.
Figure 2 presents integrated data from the mood assessment scale throughout therapy and follow-up (five months later) along with the compliance (number) of the tasks to be performed weekly by patient to reduce the amount of medication prescribed per session.
Effectiveness and efficiency of the intervention
The results of the intervention can be verified by observing the notable differences between most self-report scores before and after the intervention phase (see Figure 1).
In the BDI-II, it went from a score of 32 (severe depression) to 9 (absence of depression).
In the AAQ, the change occurred from a score of 39 to a score of 30.
In this case, it should be taken into account that in the Spanish adaptation of the instrument the mean score in the general population (non-clinical) is 34.61 (SD = 5.43) (contact, 2004).
In the THA the general score went from 44 to 33, and in the four dimensions: (1) Self-concept of Self-Report 14; (2) Indeproches of Persons 19 to 15; (3) Poor adjustment from 3 to 4
In the STAI there was a significant change in the two dimensions of the instrument, going from 41 to 20 in state anxiety, and from 39 to 24 in trait anxiety, which means going from Pn 95 to 55 in the first case.
In the ROS there was another significant change from the initial 21 points to 31.
In the original test the average for the general male population is 29.61 (SD = 4.20) (Armento and Hopko, 2007).
Finally, in the first dimension of the BADS (Activation) the patient went from 19 points to 25, in the second dimension (Avoidance/Rumsia) from 19 to 15th, and in the fourth dimension (Deterioration)
In this case, the average values reported by Pérez-Álvarez (Assignment of publication) for each subscale are 21.369) (DT = 8.93), 14.55 (DT = 6.67), 16.37 (DT = 0.001).
Figure 2 shows the notable changes in mood and compliance with both the activation of objective behaviors and the extinction of avoidance patterns detected.
Although it is difficult to determine the magnitude of these changes, particularly at the beginning of the treatment, because the intervention had to start without achieving the desired stability at baseline, the visual appreciation of the graph invites significant consequences.
This relationship corresponds to the one proposed by the CA model, which argues that the progressive disappearance of avoidance behaviors and the cessation of reinforcement of depressive behaviors leads to an improvement in the mood over time.
Along with these measures, it can be noted that the patient expressed his satisfaction with the therapy and reported being fully recovered.
He said it was clear that he had arrived at the time of discharge and was willing to provide further information if required for longer-term follow-ups, as was the case in fact.
Since I had never stopped working or interacting with other people, these comments are an important criterion for their improvement.
The intervention method of CA, which emphasizes the importance of assimilating the functional analysis and, therefore, of understanding the relationship between the performance of certain activities and the mood state seems to be better if this last phase of treatment is maintained just like this.
1.
Correspondence address: Jorge Mairal e-mail: jbarraca@ucjc.edu
Manuscript received: 03/09/2009 Revision received: 01/10/2009 Accepted: 28/10/2010
