Chapter 12: Psychiatric understandings of mental health

Case Study: Cognitive behavioural therapy

Jennie has had multiple admissions to different psychiatric units over the years, under the care of a number of different psychiatrists.  She has been diagnosed with depression and has had various different prescriptions of antidepressants, none of which seem to have completely improved the way she feels. Most of the time Jennie feels her mind is not quite her own; she has been on medication so long she has almost forgotten what it feels like not to be on it. One time, Jennie was so desperate she agreed after persuasion to have a course of ECT. It appeared to help but she hated it, and the depression came back again anyway.

These days, Jennie has a new care team. The psychiatrist wants to review her medication. He thinks the antidepressants are ineffectual and she might be advised to come off them. He wants to do this carefully but Jennie is still very anxious about what might happen without her medication. This psychiatrist doesn’t seem to dominate the team like others, and he often encourages Jennie to make the most of the expertise of other members of the team. So she has begun having appointments with a community nurse who practices CBT and is also seeing a psychologist. For the first time, professionals are asking her to tell them where she thinks her depression came from. Whether there is anything traumatic in her past. There actually is, but Jennie is not yet ready to tell anyone about her childhood. To her, these events are too painful to even consider talking about. She thinks the psychologist suspects what has happened to her, which is making her even more anxious.

What is positive about the new team’s approach? What else could they do to help Jennie?

› Possible answer

The team seem to be working quite democratically, respecting each other’s strengths and roles.  They also are committed to offering a range of treatment options for Jennie, including psychotherapies. The psychiatrist is open to thinking about medication reduction and even discontinuation, and this is in line with evidence and reported patient experience in this case. The team appear to have grasped the logic of exploring ‘what has happened to you’ rather than ‘what is wrong with you’. It does seem, however, that some of what has happened to Jennie form the worst has been her previous experiences of services, including a negative experience of ECT, which may have affected the extent to which she trusts clinicians. She doesn’t yet trust them enough to open herself up to the pain of disclosing and working through her childhood trauma. The team will have to build this trust over time, and attempt to allay Jennie’s anxieties. Reassuring Jennie that she can go at her own pace and need not disclose anything she doesn’t wish to might help. Also, making sure that Jennie appreciates that a compassionate and concretely supportive response would follow any disclosure. They may also consider a referral to a more specialised agency or support group as and when Jennie does speak more about her childhood.