A Case of Depression: Introducing David

Jeanne C. Watson
University of Toronto
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A brief overview of the client, David, is presented. David participated in a

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short-term emotion-focused therapy for the treatment of depression. In this

paper the clients presenting problems and history are described to provide
a context for the brief excerpt that follows. The excerpt is taken from his first
session of psychotherapy and was used by the four different therapists to
develop a case formulation illuminating their specific orientation so that
these could be contrasted and compared.
Keywords: depression, EFT, case formulation, self-criticism

David was in his fifties when he came to therapy because he was de-
pressed. He noted that he had been suffering from depression since the age of
10 when his mother became bedridden and unable to function around the
house. The first time he had sought help for depression was 5 years earlier
when he separated from his wife. During that period of being alone his
depression lifted and he began to enjoy life more, making friends, and attend-
ing social functions. Two months after the separation David reconciled with
his wife, who was distraught after he left and actively pursued him. His
depression recurred 2 years after he reconciled with his wife and was quite
severe by the time he entered therapy for the second time.
David was diagnosed pretherapy with major depressive disorder on Axis
I (Spitzer, Williams, Gibbon, & First, 1995), no diagnosis on Axis II and III;
problems with primary support group; discord with spouse, siblings, and
daughter-in-law; and occupational problems, characterized by job dissatisfac-
tion on Axis IV. On Axis V, his General Assessment of Functioning (GAF)
score was 58 and he had a score of 20 on the Beck Depression Inventory
(Beck, Ward, Mendelson, & Erbaugh, 1961) at the beginning of therapy.

Jeanne C. Watson, Department of Adult Education & Counselling Psychology, Ontario

Institute for Studies in Education, University of Toronto.
Correspondence concerning this article should be addressed to Jeanne C. Watson,
Department of Adult Education & Counselling Psychology, 252 Bloor Street West, Toronto,
Ontario, M5S 1V6 Canada. E-mail: jeanne.watson@utoronto.ca

52
Journal of Psychotherapy Integration 2010 American Psychological Association
2010, Vol. 20, No. 1, 5258 1053-0479/10/$12.00 DOI: 10.1037/a0018889
 A Case of Depression: Introducing David 53

PRESENTING PROBLEMS

In terms of his presenting problems, David reported three areas of

difficulty: first dissatisfaction with his career; second, interpersonal difficul-
ties; and third, problems in his marriage. With respect to his career, David
had difficulty setting goals, as well as starting and completing projects. He
felt he had lost his ambition and was no longer excited and engaged in his
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work. He felt socially isolated working from home as a consultant and

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missed the structure of his previous job and interaction with colleagues and
students. David felt his work was too detail oriented and had begun to
think he had chosen the wrong career path, choosing his work more to
please his mother than himself.
David reported interpersonal difficulties with other people in his life
including family members. He was fearful of authority figures and was
worried about other peoples approval. He felt that he was more irritable
than usual, which made it hard to get along with people at work. In
addition to his work difficulties he felt disconnected from his family of
origin, having lost touch with his siblings and was experiencing conflict in
his relationship with his daughter-in-law. He was concerned that the con-
flict with his daughter-in-law would impact negatively on his relationship
with his son and grandchild, with whom he wanted to maintain close ties.
His other significant area of concern was his marriage. He experienced his
wife as cold, critical, and withdrawn. He was fearful of her rages and had
become more and more emotionally disengaged from the relationship over the
months prior to entering therapy. He blamed himself for the difficulties in his
marriage attributing the problems to his laziness and depression. He thought
if he could be different he and his wife might get along better. In the meantime
he yearned for a warmer, kinder, more loving relationship.

HISTORY

David grew up in rural Ontario, on a farm, the second eldest of five

children. As a child he suffered from numerous ailments including a severe
form of asthma so that he required special attention and extra care. As a
result his siblings were jealous and resentful, seeing him as the favorite
child. When he was 10, his mother became terminally ill and was confined
to bed. She died when David was 13. David expressed intense regret that
he had not attended his mothers funeral. He recalled that no one ever told
him why she had died or explained what had happened. He just knew his
mother would not be coming home the day a neighbor returned in tears
from a visit to the hospital. Davids mother had been the mainstay of the
 54 Watson

family. His father was grief stricken after his wife died, and becoming
dependent on alcohol, often left the children in the care of neighbors. As
a result of his Dads alcoholism, David assumed responsibility for his
siblings until he left home to attend university when he was 18.
David did not have a sense of family; instead, he described a lonely,
chaotic childhood. As a child he felt mistreated, ignored, and neglected.
The dominant emotions expressed at home when he was a child were fear
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and anger. As a child he was petrified of his mother and grandmother

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because of their frequent and intense expressions of anger. He recalled

frequent quarrelling between his mother and grandmother, who lived with
them. After one argument, David recalled, his grandmother smashing a pot
through the kitchen window in a fit of rage. He described his mother as
critical and withdrawn. However, until his mother became ill he dreamed
of moving to the city and becoming a successful lawyer. His life changed
dramatically after his mother became bedridden, at which time he recalled
feeling that his life became bleak and empty, and remained that way after
her death. David observed that his Dad did not contribute much leadership
to the family; instead, he behaved more like a brother.
After completing his college degree David married and had one childa
son. His work took him away from home often causing much conflict with his
wife. He was disappointed in his marriage and wished for a more loving
relationship. David had been successful in his career and had retired a few
years prior to entering therapy. He described a good relationship with his son
and recalled happy memories of camping together when his son was younger.
He was currently concerned about his relationship with his son as he found his
daughter-in-law judgmental and difficult to get along with.

TRANSCRIPT

Client (C): I am useless. It takes me forever to finish a project. I just procrastinate and
procrastinate so that things take four times longer than they should. You know after I
get a piece done then they have to be reviewed and changes made. Then another
department became involved and increased the amount of work required . . . so it has
taken a long time to get everyone on board and clarify the goals and objectives . . . .

Therapist (T): Hmm, hmm, But hang on, hang on, hang on, theres something that
I want to clarify. I mean what Im hearing was the projects is, I mean Im not sure,
it doesnt sound like youre procrastinating, it sounds like its almost the nature of
project that they kind of drag out, (Inaudible).

C: Well, Yeah, the Last one Is basically . . . .

T: But they seem to be blaming you?

C: Yeah, the last one is really, I would say its more their problem (laughs) than mine.
 A Case of Depression: Introducing David 55

T: Hmm, hmm.

C: But the first one, but the first big project I worked on, that was really me.

T: Right.

C: But there were days like even I look back, that was maybe 4 or 5 years ago, I
would sit at the computer all day and really not accomplish anything. I would make
some changes and then uh run the program and it would be wrong again. And then
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I would have to keep fixing these same problems all the time.
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T: Hmm, hmm.

C: At that stage I would sit and work at it, like now I cant even sort of sit, well,
with the latest software, Im not bad I guess I shouldnt really (Laughs) be
critical of myself, but I do, when they have a bug I fix it fairly quickly, within a
few days.

T: Hmm, hmm. So youre fixing it, but Im right in having a sense that its hard for
you; you really have to push yourself and force yourself?

C: Yeah.

T: And thats whats hard.

C: Very difficult, yeah.

T: Uh huh.

C: So but I guess the thing I find very annoying and frustrating too, is, you know,
its like I used to have some ambition like to do things and wanted to do new
services, provide new services, this type of thing . . . .

T: Hmm, hmm.

C: . . . and then I cant really uh, I dont have that, like even before I always had
goals and thought about oh I got to get this done, lets go on to something new, and
you know, it would happen but now I dont have that.

T: So somehow this spark died?

C: The spark is all gone, yeah, little things (inaudible), and you know, I would like
to do new things, and I think, you know, and I dont think as my wife says that Im
lazy, I, you know? I think Im lazy, Im a depressed person, and I cant sort of
motivate myself anymore.

T: So its not sort of a character defect or something that youre lacking . . . .

C: Exactly.

T: Its almost that youre feeling so down?

 56 Watson

C: Yes, thats true. And I think the other thing too is like Im sort of my worst
enemy, you know, Im very critical of myself.

T: Hmm, hmm.

C: Which isnt very good either (laughs).

T: Right, right.
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C: You know, I guess thats . . . .

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T: So when you say youre critical, youre kind of quite demanding of yourself?

C: Yes.

T: You have high expectations?

C: Yes, exactly, and I dont know, when I get into these software projects, they drag
on and on and on and on . . . .

T: Hmm, hmm.

C: . . . it just seems like the interests sort of goes as long, the longer the project goes
on, my interests or Id be, I think I become probably more depressed, and then I do
less and less work like as it goes out. And then I guess when I cant see the end of
it, its like, you know, I just get up and work, so the next day I do the same thing.

T: So hang on, am I right in saying this, its really hard for you when these projects
do drag on?

C: Yes.

T: It seems as somehow you (inaudible).

C: Yeah, exactly, yeah.

T: Uh huh.

C: But mind you, Im going to get out of the business though.

T: Hmm, hmm.

C: If I can finish this one, this last one.

T: Hmm, hmm, youve decided that?

C: Yes.

T: But that doesnt work for you?

C: And I think thats one of the problems, that Im not in the right, the right area,
 A Case of Depression: Introducing David 57

you know, like the detailed work causes, you know, isnt really my cup of tea as
whatever you want to say.

T: Right.

C: And its basically, you know, its depressing. And the other thing I think in the past
but Ive always like shorter jobs so you can sort of see some results and with these long
jobs, I mean they take, well, taking years sort of grinding away on these things.
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T: Right.
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C: And uh . . . .

T: So what youre realize these really arent a good fit for you?

C: No, no, definitely not.

T: It might be the income, but it sounds like you would prefer something thats not
quite so specific?

C: Exactly, yeah. In some things . . . .

T: And you can see you chart your progress more . . . .

C: Yeah, exactly, so if I can get them to chart it or do something that sort of

indicates that Im getting ahead, you know?

T: Hmm, hmm.

C: Now, Im just sort of like turning my wheels, like just like in a mud puddle or
something, youre just grinding away.

T: Right, and thats real hard for you?

C: It is tough, yeah, very tough.

T: What is it about that that gets you down?

C: Pardon me?

T: What is about that, that gets you down, thats spinning your wheels?

C: Well, the fact, not treating it or not seeing like the light at the end of the tunnel
or not seeing that uhm, you know, the end. Like it, I feel that this thing goes on and
on and on and on, its very depressingI mean to say the least.

T: So theres almost a sense of like youre being trapped in the tunnel?

C: Yeah, exactly, yeah, its like Im being trapped, that would be a good word.

T: Uh huh.
 58 Watson

C: And even though, its like being a box and then trying to sort of get out of the
box and then, uhm, or like I say or see the light at the end of the tunnel.

T: Uh huh.

C: Like to break out of this box and to get out of the damn thing and I seem to be
trapped.

T: It doesnt seem to be (inaudible).

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C: Pardon me?

T: Its hard enough having momentum, is that it?

C: Yeah, exactly, yeah, yeah.

T: Uh huh.

C: Now another problem too, is that you know, I work on my own, which may not
be very good either but uh . . . .

T: Hmm, hmm. You find that hard being alone?

C: Yeah, yes, and especially long term.

T: Hmm, hmm.

C: Like over a week or so, I find its a bit lonely.

T: So it is lonely, its isolating?

C: Yes, that is true. But I also do other work, I do teaching, I do instruction.

T: You enjoy that?

C: Yeah, I enjoy that. That is the best, it gets me out of the house, and uh I forget
that I am depressed or get . . . .

T: Oh, so having that contact with people kind of makes the depression easier?

C: Yes, yeah. And I guess I try harder to, like I, you know, I concentrate harder to
make sure that I do the course properly.

REFERENCES

Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for
measuring depression. Archives of General Psychiatry, 4, 561571.
Spitzer, R., Williams, J., Gibbon, M., & First, M. (1995). Structured clinical interview for
DSMIV. New York, NY: American Psychiatric Press Inc.