Case formulation analysis and review of the therapeutic skills

Introduction

Exploring the intricate realm of the human psyche is not merely about diagnosing a patient; it

requires a comprehensive analysis of the numerous factors that impact a person, including

their family, personal background, social and professional relationships, and career. The

amalgamation of all these mechanisms can help us comprehend the patient's issue and

provide them with effective solutions to their outcome (Engel, 1977). In this case review, the

exploration encompasses factors such as familial dynamics, social determinants, and

professional life, and examines the multifaceted web that shapes an individual's well-being.

The analysis of the interplay of these elements uncovers the complexities of the client's

condition. Furthermore, this examination underscores the considerable influence of social

determinants on mental health, where family dynamics, social interactions, and employment

can either exacerbate or mitigate symptoms. During this journey, it will be essential to

navigate through the client's familial and social landscape, unpacking the triggers,

perpetuating factors, and protective elements that have sculpted the client’s experience.

Finally, the reflection on the therapist's essential skills that have played a pivotal role in the

virtual counseling session, enabling the client's progress toward self-discovery and healing.

Social determinants of mental health in a depression case review.

According to DSM 5 (2013), the client shows the following symptoms of depression: feeling

depressed most of the day and every day, A marked loss of interest in almost all activities

during the day and every day, a slowing down of body movements, loss of energy during the

day, feeling worthless and guilty almost every day, and reduced ability to think or concentrate

or indecisiveness almost every day. Social determinants of health must also be considered in

the study of this case. Deep understanding of this case involves examining how the
depressive symptoms of the client are affected, contributed, or sustained by the mechanisms

of family, social integration, and employment. The family represents the primary source of

emotional support for an individual to navigate life's challenges. Therefore, a robust,

constructive, and enduring familial connection fosters sound psychological well-being in the

individual (Ross, 1990). Social support helps individuals to develop coping strategies to deal

with everyday stressors, but it is imperative to consider multicultural differences that lead to

different interpretations among clients (Albrecht et al., 2003). Work is a vital contributor to

well-being and integration in the community. However, when work is accompanied by

stressful experiences, particularly in older adults, there is a significant risk of developing

symptoms of depression. It is imperative to recognize the impact of work-related stress on

mental health, and to implement measures to reduce risk and support individuals who may be

affected (Lunau et al., 2013).

In this instance, our knowledge of the client's family and social connections is limited, but it

is evident the negative impact on her depression symptoms whilst also acting as a

precipitating factor. The investigation of further links within her family and social

relationships allowed a better understanding of the root cause of her syndrome. Additionally,

it is necessary to explore client’s significant relationships, best life functioning, work task

development, professional satisfaction, financial issues and so on. The collection of these

details will be helpful to understand how the client maintains a negative cycle of thoughts,

feelings and behaviours that keep her depression and prevent her from achieving wellbeing.

Integration of the case formulation and the five conceptualization factors

The formulation is a process that goes through counselling, rather than a single event; a

consistent formulation has a thorough understanding of all the factors that subscribe to the
client's stress, as well as the factors that support the development of resilience. The adoption

of the multi-perspective model and the examination of its five factors will facilitate a

comprehensive understanding of the mechanisms that contribute to the maintenance of illness

and those that promote and nurture mental health, and at the end the formulation’s

improvement (Weerasekera, 1996).

The trigger involves a work scenario that emphasizes her uselessness thought, when a

workmate told her that she must retire. Subsequently, she experienced emotions of

worthlessness, anger, irritation, dryness, and a sense of being useless. To cope, she turned to

distractions such as watching television or consuming junk food. Their beliefs about

helplessness are based on a core framework in which the individual perceives herself as

ineffective in carrying out tasks or in comparison with others. She sees her life through the

lens of this belief. Each time she struggles to do something basic, it reinforces her feeling of

worthlessness. All her tasks are linked to her lack of competence, making it impossible to

perform even simple actions like getting out of bed or getting dressed (Beck, 2020).

Furthermore, it is important to consider the previous 2-year pharmacological treatment, with

Citalopram, as a predisposing factor; which she discontinued a couple of months ago due to

concerns with their after-effects. Citalopram is a Selective Serotonin Reuptake Inhibitor

(SSRI) and an effective treatment for mild to moderate depression. It is used in lower doses

for elderly patients. Despite its effectiveness, Citalopram may cause nausea and somnolence

(Rahola, 2001). However, some effects have been observed after discontinuation, such as

nausea, vomiting, insomnia, drowsiness, dizziness, agitation, weakness, headaches, and

decreased concentration (Bezchlibnyk-Butler et al., 2000). It will be necessary to investigate

the conditions and effects of the client’s preexisting diagnostic at the time of its onset and the

reasons behind her decision to discontinue medical treatment.

An important precipitating factor in her condition is her nearing retirement age and how this

impact on her sense of self-worth. There is a viewpoint that retirement marks the cessation of

a significant work role, leading to potential psychological distress for the retiree as they can

no longer view themselves as a productive and contributing member of society. Charles et al.

(2004) finds a negative correlation between retirement and psychological well-being; for

instance, retirees exhibit lower life satisfaction compared to workers. Also, cross-sectional

models have provided evidence linking retirement to decreased well-being and even

depression with suicidal ideation. During counselling, with the case in the studio, the

therapist must explore her work relationships, job satisfaction, the challenges she faces, and

how her career aligns with her personal fulfilment.

Moreover, a perpetuating factor, in this case, is the relationship with the partner, which

reinforces the feeling of worthlessness and incapacity to complete domestic tasks and the

possibility of not being able to contribute financially to the household. Byrne et al. (2004)

reveals in their comparative study, that within long-term relationships, depression in women

is associated with lower commitment, increased demand-withdraw interactions, reduced

constructive communication, and dissatisfaction with decision-making and childcare

distribution; then it will be necessary for the therapist to delve into the dynamics of the

relationship and any dissonance that exists within the couple to find elements that can help to

promote a healthy outcome in the client.

In addition, the protective factor is based on her friends, the group of friends appear as a

provider of optimism to overcome her depression and to move on from her reluctance to do

anything. For Thomas Aquinas (1920), the company of friends heals the soul's sorrow. In

times of pain the presence and sympathy of a friend offer solace for two reasons. Firstly, it is

like sharing a heavy burden, lightening the load of sorrow. Secondly, when friends console

each other, it demonstrates love and care, bringing pleasure that can alleviate the suffering of

the person in pain. It is vital for the therapist to be a facilitator of the client's positive

relationships to support her recovery.

Therapist skills reflection

In this virtual counselling session, the counsellor effectively demonstrates several crucial

skills that collectively contribute to the client's experience and overall therapeutic progress.

These skills are particularly vital as they aid Mary in navigating her multifaceted challenges

and feelings of depression. In this way, the boundary management in this virtual session

promotes a secure and confidential counselling relationship (Mc Leod, 2011). The counsellor

effectively manages these allegedly virtual boundaries, ensuring that Mary feels comfortable

and safe discussing her personal struggles in her current environment. Also, he expertly

structures the session, maintaining a steady and reassuring rhythm of both their speeches.

The practitioner excels the attending skill, maintaining eye contact and ensuring Mary feels

heard and valued throughout their interaction. The ability to attend is closely related to

attunement, where the therapist tunes into Mary's emotional state and the way she expresses

herself, even though a screen; for instance, as Mary discusses her challenging work situation,

he not only listens, but also recognises the frustration and sadness in her voice and

expressions. Besides, the counsellor’s empathy and responsiveness create a safe and empathic

alliance, crucial for Mary to open about her feelings of depression, irritation, and guilt.
Challenging Mary gently yet purposefully is essential, especially as she discusses her work-

related issues and her declining social life. The counselor uses this skill to encourage her to

explore her feelings and thoughts more deeply. For instance, when Mary mentions her

colleague's hurtful comment about retirement, the counselor challenges her by asking, "How

did that comment make you feel, and what thoughts does it trigger?" This empowers Mary to

delve into her emotions and thought patterns surrounding this issue.

In addition, the counselor's use of self-monitoring is crucial, as it ensures that their responses

come from a place of empathy and support. For instance, when Mary shares her struggles

with maintaining motivation and engaging in social activities, the counselor's self-monitoring

helps them provide responses that are understanding and encouraging, not critical or

accusatory.

Listening skills are paramount in a virtual setting, as they form the basis of the therapeutic

alliance, in this case, the counselor's active listening, allows Mary to feel heard and validated;

helping Mary make sense of her experiences. For example, when Mary expresses her

difficulty in finding motivation and feeling overwhelmed, the counselor invites her to explore

her personal perspective, saying: "It seems like you're experiencing a lack of motivation. Can

you share more about what might be causing these feelings?" This open-ended question

encourages Mary to reflect on her issues and gain a deeper understanding of her emotions and

challenges.

Furthermore, the counselor's use of silence as a therapeutic tool is powerful, giving Mary the

space, she needs to process her emotions and thoughts in a virtual environment, he does not

rush the conversation. During moments of silence, Mary can reflect on her declining social

life and the impact on her relationships with friends and husband. The counselor acts as a

virtual witness to Mary's experiences, providing a safe space for her to explore her emotions

and thoughts.
The summary covers significant details, like Mary's personal history and emotional triggers,

which enhances the counselling experience. The therapist recalls previous topics that Mary

shared in first place, the same way as her feelings and body language. This skill empowers

the therapist to mention these topics late in the conversation, prompting Mary to explore

whether to rediscover their emotions, reactions to situations and the union between these.

Conclusion

In conclusion, this exploration underscores the complexity of factors contributing to an

individual's mental health, highlighting the pivotal role of social determinants. By

recognizing and addressing the multifaceted aspects that influence an individual's

psychological well-being, it approaches to provide holistic and effective solutions for those

grappling with depression and similar mental health challenges. Also, in the ongoing pursuit

of mental health understanding, it is essential the continuous exploration and acknowledge

the intricate realm of human psychology in all its nuanced mechanisms.

The integration of the case formulation and the five conceptualization factors offers a

multidimensional perspective on mental health challenges, emphasizing the need for a

comprehensive understanding of individual experiences. By addressing the trigger,

predisposing, precipitating, and perpetuating factors, and acknowledging protective factors,

therapists can provide more effective and tailored support. The therapeutic journey is a

dynamic process, and it is through meticulously exploring these factors that mental health

professionals can guide clients toward self-discovery, healing, and overall well-being.

The synthesis of attending, attunement, boundary management, challenging, checking

out/clarifying, immediacy, listening, making sense, remembering, self-disclosure, self-

monitoring, structuring, using silence, and witnessing in the therapist's approach forms a

comprehensive framework that empowers the client in addressing her experiences of

depression. These skills are not merely therapeutic tools but catalysts for trust and

connection, both of which are essential components for the success of the therapeutic

alliance. This proficiency in delivering virtual counseling reflects the evolving landscape of

mental health support and its capacity to facilitate meaningful change, even in a digital realm.

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