Presenting Problem:

NAME : CECILIA
AGE : 29 YEARS
PROBLEM : DEPRESSION

The client is a 29 year old Caucasian female who presented with

symptoms of depression. She stated that she had daily crying spells, felt sad "all the
time", had trouble sleeping at night, and was overeating. She reported that her
sleeping was disturbed in that it frequently took her several hours to fall asleep, that
some nights she could not fall asleep at all, and if she did, she slept for only a few
hours. She stated that she spent the time awake "thinking" and "worrying". She
acknowledged that some of her worries included thoughts that she was not a good
mom, and she felt that she was a problem to her husband. She reported that she
thought about her family of origin and her unsatisfactory relationship with her mother.
She stated that she thought her depression had worsened after the birth of her third
child ten months ago. During the initial intake interview, the client noted that she felt
"all right, always down". The "all right" response came out immediately, almost
automatically. After a pause, she added "always down". She revealed that she was
constantly thinking and worrying, and that she felt "like everyone is looking at me".
She denied suicidal behavior and ideations. She said it would be nice to run away
from her problems, but she added that she knew she could not do that. Cecilia'
acknowledged that depression was affecting her life in a number of ways. For one, she
reported that it was affecting her relationship with her husband and children.
Secondly, she stated that depression affected her socially because it was keeping her
from participating in family events. She reported that she felt unable to work outside
her home at this time, therefore, it was having a financial impact. She expressed
unhappiness that she was not the person she wanted to be, and she stated that her
depression was "wrecking my life".

History of the Complaint:

Cecelia reported that she sought help for post-partum depression six
months ago following the birth of her third child, Zeke. She stated that she became
depressed when she found out she was pregnant, and the depression continued to
worsen after the child's birth. During the initial months of her pregnancy, she recalled
being tired, sad, having no energy, and crying several times a week. She reported that
she felt exhausted but could not sleep. She stated that she felt like she "lost control of
her life". She acknowledged that these feelings continued after Zeke's birth. Her
gynecologist prescribed 20 mgs. of Paxil, which she continued to take for a few
months. She reported that she discontinued the medication because she did not think it
was helping her. She said that it did not work, and she felt no difference in her
depression. She also stated that she did not like taking medications. She reported no
other periods of depression in her life.

Household Composition:
The client lives with her husband, Jerome, 32, her nine year old
daughter, Larissa, (from a previous relationship), four year old son, Samuel, and ten
month old son, Zeke. The family owns a home in a residential area.
Early Development/Neurological History:
The client did not recall any problems with her birth or prenatal history.
She stated that there were no unusual events that occurred during this time. She
reported no head injuries or trauma. She acknowledged having no history of
neurological problems. She reported no problems with her developmental milestones.
Family of Origin: Cecilia's family of origin includes her younger sister, Margaret,
currently 27 years old, her younger brother, Brian, 23, her mother Alice, 52, and
father, Roger, 57. Cecilia recalls having a chaotic childhood characterized by a great
deal of stress and instability. She lived with her father, mother, and younger siblings
while growing up. She reported that her parents argued frequently, usually over her
mother's use of alcohol.
At age 11, her mother left the home and the family and was absent for
several years. The client stated that her mother was an alcoholic. Her mother would
contact the children by phone, but physically did not have contact with them during
this time. Her mother later returned to the family when the client was 16 years old,
and she is currently living back home with her husband, Roger, and son, Brian.
During the time that her mother was away, Cecilia reported that her father had to raise
the children on his own. Cecilia remembered him being very "hurt" when her mother
left. She stated that her father was always a quiet man who did not share many of his
feelings with his children. She added that he worked long hours, but made sure the
children had what they needed. His family helped out by looking in on the children
when he worked.
When Cecilia was in her teens, she was responsible for getting dinner
prepared for her siblings and doing other chores around the house. She remembered
feeling that they all had to pull together during this time. She stated that she did not
feel that her father neglected them. He was home every night and made sure they were
doing their homework and chores around the house. She rarely recalled getting
punished by her father. If she did, it usually involved losing privileges such as
sleeping over a friend's house or not being allowed to use the phone. She stated that
her father never struck her nor was he physical with her or the other children. Cecilia
said that she always felt somewhat ""distant" from her father because they never
talked much. She said she was afraid to talk to him because she did not want to get
angry around him about her mother's absence. She stated that she did not think, "he
was strong enough to handle it". She said that he never tried to talk to her or ever
asked her how she felt about taking over some of her mother's roles. Instead, she
acknowledged that they just did not communicate about the situation. She reported
that this was the way the entire family handled the situation, and that it led to
emotionally distant relationships. In her opinion, her family seemed to avoid facing
and talking about their feelings. She recalled that she and her siblings did talk about
their mother, although they did not have the same reactions about her abandonment of
them. She stated that Margaret was angry, but Brian always tried to be understanding
and not blame his mother for leaving. She remembered that he would defend her
actions and make excuses for her, which Cecilia reported as being difficult for her to
hear. She acknowledged that she was very angry with her mother when she left, and
she is still angry.
Overall, Cecilia reported that she did not have adequate communication
or high levels of emotional support from her family. Cecilia expressed that she
continued to have strong feelings of anger and resentment toward her mother after her
mother returned home to the family. This return led to significant acting out and
impulsive behaviors on Cecilia's part. For example, she became pregnant by a man
who was "unstable and irresponsible". He did not continue to be a part of her life
during the pregnancy, and he currently has no contact with their child. She broke off
the relationship when she was 19, and she chose to keep the baby and raise her on her
own. Cecilia remembered having a few serious boyfriends during and after high
school. In the past, she stated that she had dated a few young men that she described
as "bad". They seemed to be exciting, but she realized they were not really whom she
wanted to be with.
With the birth of Cecilia's daughter, she acknowledged that she settled
down and became focused and serious. For example, she went on birth control pills to
prevent another pregnancy. She also looked for a partner who was responsible and
could take care of and love both of them. She said that she found these qualities in her
husband, and she married him when she was 23. She stated that her husband is a hard
worker and a good provider; she is happy that she married him. Overall, Cecilia
viewed her childhood as emotionally unsupportive and unstable. As a teenager, she
assumed the role of a parent, which she resented. She acknowledged that she
developed strong unresolved feelings of anger toward her mother, and these feelings
continue to surface in their present relationship.

Current Family Relationships:

Cecilia lives with her husband of six years and their three children. Her
husband adopted her daughter from her previous relationship, and they have two
additional children together. Her husband has a small roofing business and puts in
many long hours. Cecilia is home with their children all day long. Cecilia, her
husband, and children attend family barbecues, picnics, parties, and other activities
together. They also occasionally spend time with other couples and their children. She
reported that they rarely spend time alone as a couple. Cecilia states that she would
like to do this more often. When they did have time at home together, there were
usually friends present, and this posed a problem for her. When friends were around
she stated that her husband tended to drink more, and this made her feel anxious. The
client described her husband as "wonderful, understanding, puts up with all her
problems, could not ask for a better guy", but they would get into arguments about his
drinking. She did not feel that he had a drinking problem since he drank only a few
beers and did not become intoxicated, but she would have preferred no drinking at all.
She stated that she would tell him this and that he would react negatively back to her.
She realized that these reactions to alcohol came from her past experiences with her
mother, and she acknowledged that she could not feel comfortable with her husband's
use of it. She stated that she was unable to control her fear that alcohol could ruin
their relationship.
Cecilia reported that she becomes frustrated that her husband works so
much, and they do not get to spend time alone together as often as she would like. She
complained that getting baby-sitters was a problem, and that her mother always made
excuses not to baby-sit for her. In addition, her friends that she baby-sat for rarely
offered to reciprocate. This caused some angry feelings and feelings of being taken
advantage of by them. Cecilia's husband recently hurt his back at work and had to
miss several weeks of work. As a result, they got behind on their financial obligations.
Since his recovery, he has been working longer hours to catch up with the bills. As a
result, he could not help her out with the children as much as she would have liked.
She reported that she has the roles of major caretaker and disciplinarian of the
children. In terms of discipline, she stated that she utilizes short time out periods and
loss of privileges as punishment. She reported that she is usually satisfied with the
results. She said that the two older children were not much of a problem. They were
"good kids" in comparison to her youngest who was more of a challenge. She related
that she was exhausted when she tried to keep up with him. She stated that he was too
energetic, and that he was a difficult child from the date of his conception. Cecilia
recalled being sick during her pregnancy with Zeke, which was different from her
other pregnancies. She claimed that she was on birth control pills when she became
pregnant with him. He was unplanned, and she felt drained and depressed the entire
pregnancy. She said that he changed her life from the moment he was conceived. Her
relationship with her youngest son is a considerable source of stress for her, although
she states that she loves all of her children and that she tries to be a good mother.
Cecilia acknowledged that she puts a great deal of pressure on herself to be everything
to everyone. She wants to be a good mother, daughter, sibling, wife, and friend
making everyone happy without regard for her own feelings and needs. Cecilia
reports that she wants to be a good mom to her children and a better mother than her
mom was to her. She stated that she always plans outings with the kids such as trips to
the beach, the circus, and various other places of interest. However, she reported that
she was going through the motions but was not enjoying any of these activities. She
related that because of this, she would have thoughts that she was not being a good
mother. She reported having feelings of guilt. She stated that at the present time she
does not feel that she is "emotionally there" for her children due to her current state of
depression, and this is causing her to cheat her children out of what they deserve from
her.
Cecilia reported that her relationship with her mother is a concern for
her, and that she would like it to improve. She stated that her mother drinks socially at
the present time; she usually will have one to two drinks at a social function.
According to Cecilia, her mother is no longer drinking heavily. It was not known by
the client if her mother ever sought help. Although Cecilia stated that alcohol does not
seem to be the focus, she and her mother still frequently argue. Cecilia stated that her
mother was not there for her as she grew up, and she is not there for her now. She said
that her mother was selfish and did not care about her or her grandchildren like she
should. Cecilia complained that she did errands for her mother, drove her to work, and
did all that was asked of her, but that her mother did not reciprocate. According to
Cecilia, her mother made up excuses and did not help her out when asked. She
reported feeling resentful and angry, and then afterwards, she stated that she feels
guilty.
Cecilia's family of origin stays in contact with each other, but there are
frequent arguments and conflicts that she states are due to the many unresolved issues
the family still has. Cecilia's sister is married and lives in Pennsylvania. They talk
weekly and try to see each other monthly. Her brother is currently living with her
parents. She stated that she gets along with him, but also becomes angry at him when
he does not spend time with his own teenage daughter under his care. Cecilia reported
that she likes her niece and takes her shopping and does other activities with her. She
realized that she puts herself into the caretaker role with her brother's child Cecilia
had two family events that still bothered her and caused her great sadness and guilt.
One incident related to her grandmother's death. Instead of visiting her grandmother,
she went out on a date, and her grandmother died the next day. In another instance,
her father asked her to do something for him, and she refused. He had a heart attack
that evening. In both instances, she relates that she felt guilty and blamed herself for
the outcomes. She stated that she ends up helping other people out even if she does
not want to because she fears that something bad will happen to them. She
acknowledges that this reasoning has become a strong motivating force behind many
of her decisions.

Drugs, Alcohol or Other Addictive Behaviors:

Cecilia recalled going through a period of rebellion during her teens.
She related that she experimented with alcohol and drugs (mainly wine coolers and
marijuana), but quickly lost interest in them. She recalled drinking on weekends at
parties and smoking marijuana once or twice a month at the most. She began smoking
cigarettes as a teen, and has continued smoking about ten cigarettes a day. She
reported that she does have an occasional drink at a social event. Cecilia denied any
other drug use. Cecilia acknowledged that she does obtain comfort through food, and
she had put on 40 pounds while pregnant. The weight was not coming off as fast as
she would like. She recognized that she ate when she did not feel hungry, and she
tended to eat foods that were high in fat content. She stated that this was not healthy
and that she wanted to improve her eating habits to lose weight and feel better about
her.

Medical and Psychiatric History:

Cecilia reported that she had never sought psychological help prior to
now. She did not feel that she was depressed at any other time in her life. Medically,
she reported having heavy menstrual flows lasting as long as nine days. She had been
on birth control pills before her unplanned pregnancy. She states that she got pregnant
while on the pill. She said that she must be in the "1% group that it doesn't work for".
She reported no other medical conditions that she was experiencing at this time. When
this agency's psychiatrist evaluated her, she was prescribed 50 mg. of Zoloft for her
depression. She stated that she did not like the "cotton mouth" feeling she had from it,
but she reported sleeping better since she started on it. She added that she felt better
on the medication and thought it had helped decrease her depression. Some mental
health illnesses have genetic components to them and tend to reappear in a family.
Therefore, it is pertinent to ascertain a family history. Cecilia remembered an aunt on
her mother's side who was diagnosed with bipolar disorder and another aunt who was
"mentally ill". She could not specify exactly what her diagnosis was. Cecilia recalled
that her own mother often seemed "unhappy". She stated that her mother probably
also suffered from some form of depression.

Education and Job History:

Cecilia stated that she is a high school graduate. She acknowledged that
she has worked at various jobs. The most recent one was at a neighborhood
convenience store as a cashier. She reported working full time for four years and then
part time until the birth of her last child. She currently is a full time homemaker. Since
she is home, Cecilia often baby-sits for her friend, and many times does so for free.
She expressed an interest in getting trained in the field of phlebotomy or some other
kind of blood work when her children are a bit older, and she stated that she planned
to look into this in the future.

Other Agency Involvement: There were no other agencies that the client
dealt with. She stated that she had not been in treatment before. She had no
involvement with the courts or any other social service agencies.
Social Supports and Patterns of Relationships: Cecilia said her
husband recognized that she had some kind of problem, and that he was supportive of
her seeking treatment. She stated that he wanted to help her, but he did not know what
to do. She added that she talked to him about her depression, but she did not feel that
he understood what she was going through. According to her, he did want her to get
help and was accepting of her receiving counseling. She reported that he was willing
to participate if need be. She stated that she was concerned that her depression may
cause problems in their marriage if she does not get "out of it" soon. She said that she
worried that he will get tired of her being this way if it continued to last for an
extended period of time. Cecilia stated that her sister was also an advocate for her, as
she insisted that other family members reduce their demands on Cecilia. Cecilia listed
her husband, some friends, and her sister as her supports. She reported that she talked
to them and shared how she was feeling but only to a certain extent. She
acknowledged that they did not know how depressed she really was because she did
not disclose everything to them. She attempted to act more upbeat around them than
she was feeling. She related that her brother was the reason she sought counseling. He
had suggested it since he noticed that she was unhappy and angry especially in
dealings with their mother. She reports that she was resistant to his advice, but
eventually accepted that he was right.

Situational Stressors:
Cecilia acknowledged that her primary sources of stress are related to her
lack of financial resources, long hours spent caring for her children, and difficulty in
managing the behavior of her youngest child. Cecilia also stated that her mother
continued to be a cause of stress due to her lack of emotional reciprocity.

Coping Mechanisms:
Cecilia reported that she relies on five primary techniques to cope with
stress. She stated that two of these techniques are negative and she would like to
change her reliance on them. The other three coping techniques are viewed as positive
and helpful. The first negative coping mechanism Cecilia mentioned was smoking.
She stated that she smokes approximately ten cigarettes a day to help her relax. Even
though smoking was reported as effective in reducing her stress, Cecilia also stated
that she had a desire to stop smoking. The second negative coping mechanism is
eating. She admitted food was a way of dealing with stress, but she wanted to work on
changing and not resort to eating when she is stressed. The first positive coping
mechanism she relies on is exercise. She stated that she used exercise videotapes that
she worked out with for 40 minutes a day. She reported that she felt much better
mentally and physically after she exercised. She added that she wanted to lose all the
weight she gained with her last pregnancy. The second positive coping technique she
employed was seeking out the support and guidance of friends and family. She stated
that she talks to her girlfriends daily and has been sharing some of her therapy
homework assignments with them. She said that some of her friends experienced
depression also. She acknowledged that she was getting support from them, and that
she liked having other people available with which she can share information. In
addition, Cecilia was planning a visit to her cousin's for a weekend in the near future.
She stated that this would help her relax and that she would be able to get away from
some of the stress and pressure in her life. She reported that it would be a change in
her daily routine, which could be beneficial. The final positive coping method she
employed was seeking therapy. Since starting therapy, she reported feeling less
depressed. She also stated that coming to therapy and telling a stranger her problems
made her feel better.

Perception of Self and Motivation Toward Treatment:

Cecilia reported that she had no confidence in herself and that she felt
that she was at the mercy of others. She recognized that her self-concept was tied into
reactions received from those around her. She acknowledged that she had made her
role one of service to others at the cost of herself. She reported dissatisfaction with
this and wanted to change. She stated that these realizations and feelings are what
prompted her to enter into therapy.

Summary: The client is a 29-year-old Caucasian female who sought treatment for
depression. She reported that her depression began with the conception of her third
child and has continued for ten months prior to her seeking treatment. Cecilia stated
that she has never been in therapy before, but she had taken antidepressants prescribed
by her gynecologist. However, she reported that she stopped taking the medication
because she felt it was not helping her.

Review of Prior Assessments: The client reported having no prior

evaluations.