Case Vignette Assignment 2022

INTRODUCTION
Case Vignette
The study aims to present a cognitive therapy intervention to a patient involved
with a case of attempted suicide. The intervention is based on general principles of
cognitive therapy.
The patient Sally is a 47-year-old female alcoholic and drug addict who had been
rehabilitated earlier but has often relapsed into her drug routines. Recently she
overdosed on antidepressant medication with a moderate degree of suicidal intent
following a drug and alcohol relapse and a disagreement with her boyfriend Mark
who is a major confidant of hers. After feeling depressed for several weeks, she
relapsed again on alcohol and then overdosed on heroine. Feeling hopeless, she felt
the need to talk to someone about her relapse. Not being able to speak to her
boyfriend due to their last misunderstanding, she spoke to his sister who was also
close to her albeit in confidence asking her not to reveal the incidence to her
brother (Sally’s’ boyfriend). Marks’ sister however broke the trust and told her
brother and instead of keep in the matter to himself, Mark took it upon him to
rebuke Sally saying she could never do anything right. Sally felt bad about the
incident for it seemed to her that she had just ruined her chances of getting back in
his good books. In a way she also felt Mark was right about her not being able to do
anything right. In a moment of depressive fit she swallowed a whole handful of anti-
depressant pills feeling like a helpless addict who deserved to die. Knowing that the
overdose would lead to health complications, she called a friend to take her to the
hospital. After she was cleared she was sent to a psychiatrist and eventually
admitted to an inpatient dual-diagnosis program where she stayed for 2 weeks.
Diagnosis
Sally was diagnosed with major a major affective disorder, and depression that was
recurrent and severe. Sally is also heroine dependent and a chronic alcohol abuser.
Her affective disorder meant that she had problems with her relationships, and had
the tendency to be consumed by overwhelming feelings of shame and guilt. Added
to this was the continual feeling of helplessness. She was recommended for
cognitive therapy intervention.
The questions to be addressed through the proposed intervention include the
following:
What are the automatic thoughts and core beliefs that were activated just prior to
the individual's suicide attempt?
What specific cognitive and behavioral techniques could be taught to the patient
with the goal of decreasing suicidal thoughts and preventing future suicide
attempts?

Addressing the Case
Social History
Sally had a history of sexual abuse haven been taken advantage of by her uncle at
the tender age of 11. This made her depressive in her early years. She had once
been married before she met Mark who proved to be more understanding. She
made the point that the emptiness she experienced in her first marriage got her to
experiment with drugs until she was stuck on heroine. After her divorce her drug
addiction got the better part of her draining her physically emotionally and
financially until Mark came along. Mark appeared to understand and for a while she
was able to get off drug addiction and also able to find some financial stability with
his help. However Mark soon turned out to be domineering and controlling. She said
she felt, he was trying to hold her to ‘impossible standards’ for helping her find her
feet again. Relations between them soon got violent with Mark beating her oft, yet
she could not find the will to leave this ‘savior’. While in pain she also felt she
deserved to be treated roughly. This however did not prevent intense feelings of
loneliness and depression that forced her into her initial suicide attempt. Her money
was coming from Mark and he often took the prerogative not to give her if he felt
she was not ‘good enough’ to have it. The overwhelming feeling of being soo out of
control in her life left her haunted constantly with suicidal thoughts.
Early Sessions (Sessions 1-4)
The first three sessions lasted for 5 days during which Sally was on admission in the
hospital. From the fourth session Sally had left the hospital and was at home until
the tenth session.
From the beginning we set out the goals for the therapy according to normal
practice in cognitive therapy [ CITATION Bec76 \l 1033 ]. The set goals included:
identifying the summation of events that led up to the suicide attempt; defining
specific goal for therapy and everyday living; fighting suicidal thoughts and
behavior, feelings of depression, and beliefs about the hopelessness of her situation
by adopting an active, problem-solving orientation-this involved educating Sally
about the cognitive model, and providing relevant literature for her; referring Sally
to a social worker to develop a plan for separating her from her abusive
relationship with Mark. The plan her also included obtaining a restraining order;
developing a safety plan.

The First Session (Introducing Sally to the Cognitive Model)
In the first session, time was taken to orientate Sally with the cognitive model, there
was also the need to give her convenient room to tell her story including the
relevant history that led up to her suicidal behavior and orientation. At this stage it
was at first difficult for Sally to maintain concentration. She had been betrayed
before by Marks sister and there was a tinge of the element of distrust, at several
points in her discourse, she maintained oft that she will rather not go into details. A
skilled counsellor must be gentle in these sort of situations and ensure that they
communicate trust to the patient. The skills of active listening [ CITATION Ega131 \l
1033 ] came in handy. The right gestures, appropriate bodily contacts in a relaxed
demeanor. While being intimated with the cognitive model she often asked if the
things she was saying were being recorded or were going to be published, clearly
she had trust issues. It was important that Sally felt that her personal interests were
put in the fore and that she was not the subject of some ‘clinical experiment’.
These problems were overcome and Sally was able to open up.
The Second Session (Terminating Harmful Relationships)
In the second session, we focused on Sally’s last relationship with Mark. His
highhanded approach to ensure that she was fully rehabilitated had turned violent
and abusive so much so that it led her to suicide attempts. This was given priority.
When asked if she wanted to remain in the relationship, she could not come clear
which gave the impression that she was dependent on it in certain way, however
the overall sadness about the relationship could also not be missed. In a way she
felt she deserved the rough treatment due to her reckless ways but clearly she was
not convenient with the abuse. Her dependence could be attributed to deep seated
fears that she could not find someone better than Mark due her own inherent
problems that would turn other people off. The unfortunate history of being raped
by her own uncle at an early age could be blamed for this. Several literature have
linked a rather complex relationship between child sexual abuse and adversative
mental health consequences. The effects were strongest for drug and alcohol
dependence and bulimia [ CITATION AIF13 \l 1033 ] . The patterns of drug and
alcohol dependence were clearly noted in Sally.
To tackle her unhealthy dependence on the relationship, Sally was asked to recall
the things that really made happy supposing Mark was not around, surprisingly she
was able to name a number of things. Through the session Sally was able to see
exactly how she could be happy without Mark and that she did not deserve to be
treated roughly.
The Third Session (Developing coping Strategies)
Sally was ready to terminate her relationship with Mark by the third session. We
concluded together that getting a restraining order against Mark would be in her
best interest to ensure that she was safe