Case Study:

Mary is a 24 year old Irish woman with a diagnosis of paranoid schizophrenia. She
lives with her mother alone as her father died five years ago from cancer, she is
currently unemployed. She was first admitted to hospital four years ago whilst
studying arts at her local university. She became concerned that other classmates were
reading her thoughts and copying her ideas. Her course work deteriorated and she
became increasingly suspicious, irritable and secretive. Her behaviour became so
unmanageable at the university that she was asked to take a year off from the course.
Her behaviour and symptoms continued to worsen whilst she was living at home with
her family. Following a suicide attempt Mary was eventually admitted to the local
psychiatric hospital under a section of the 2001 Mental Health Act. During her stay
Mary expressed the view that she was profoundly sad about her life and the lost
opportunities due to her illness. After six months admission Mary recovered well and
returned home, however, after being symptom free for eight months she stopped
taking her medication. She felt the medication dulled her thinking process and
personality. Mary eventually became suspicious again and her mood began to
deteriorate. She was again involuntarily admitted to the psychiatric hospital after
trying to strangle her mother because she said voices had told her that she was
stealing her thoughts. Although she again made a good recovery after taking
medication, the voices have remained, although she understands that they are not real,
she continues to still feel sad about her current situation.

In relation to a therapeutic approach discussed in this module, discuss the underlining

principles of that approach and how the use of those principles would aid Mary’s
recovery and guide the nursing care.

Have to follow theses guidelines!!

• Introduction to assignment
• Discussion on the importance of the therapeutic relationship when using a
therapeutic approach
• Discussion around the principles of the therapeutic approach chosen
• Discussion on the rational for choosing the approach for this case study
• Discussion on the need for collaboration between nurse and client in order to
understand needs.
• Discussion on apply the therapeutic approach to the nursing process
• Discussion on care planning as a collaborative approach.
• Discussion on applying the therapeutic approach to the recovery model.
• Discussion on relating the approach to relevant policy, guidelines and research
on schizophrenia.
• Conclusion to the assignment

Introduction
I will be using Cognitive behavioural therapy (CBT) a psychological treatment, which
is a therapeutic approach to aid Mary’s recovery and guide her nursing care. This will
include using CBT to do an assessment of Mary, a plan of her care, implementation of
therapy and an evaluation of Mary’s care plan. I will explain what schizophrenia is.

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Additionally I will give a short summary of paranoid schizophrenia. Subsequently I
will outline how I could use the nursing process to care for Mary.
Schizophrenia is a complex disorder which affects one per cent of individuals
worldwide mostly in the age group 15-35 years. Schizophrenia is a psychotic disorder
that affects your mind and its contact with reality Kerkhof, Kingdon, and Turkington,
(2008). Paranoid schizophrenia is a subtype of schizophrenia. Paranoid schizophrenia
is diagnosed when an individual experiences a variety of symptoms and signs. These
include auditory hallucinations (hearing voices), delusions (false thoughts) such as
Mary believing that people were stealing her thoughts, violence, suicidal behavior,
showing less interest than before, behaving differently from normal (Barker, 2009).
Mary showed all of the above symptoms. Recovery is possible with effective
treatment allowing clients to continue a healthier life. According to Read, Mosher and
Bentall, 2004 delusions and hallucinations are reactions to life events and
circumstances such as the failure of a relationship. According to the case study
Mary’s main issue is feeling sad about her current situation. This may indicate a
possibility of reactive depression, if her mood is not addressed.

Researchers have suggested the common occurrence of depression among patients

who have a diagnosis of schizophrenia Addington and Addington, (1992). Together
schizophrenia and low mood may increase suffering and suicide risk Shriqui,
Christian, Nasrallah, Henry (1995) and has been connected with higher rates of
relapse and rehospitalisation Herz, Melville (1980) ;Becker (1988) hopelessness
Drake and Cotton, 1986 and poor psychosocial skills Glazer, Prusoff, Williams
(1981). Distinguishing depressive syndromes among patients with schizophrenia is
challenging Bleuler (1950); Jeste, Heaton, Paulsen, Ercoli, Harris, Heaton, (1996).
However, the negative effects of depression on people with schizophrenia may
identify comorbid disorders which are largely significant for proper treatment and
improved outcome.

According to the case study, Mary is now coping with the voices as she understands
they are not real. If Mary can improve her mood, she may be able to deal better with
her current circumstances. Barker, 2009 suggests that the reason for low mood may be
stigma, lack of hope or lack of positive outcomes in life. Her low mood may be linked
to one of more of the following occurrences in her life; having a diagnosis of a mental
illness, having to take a year out of college, having lost opportunities due to her
illness and maybe the failed relationship with her mother after she tried to strangle
her. Beck 1976 suggests that it is the client’s experience that leads them to becoming
depressed. Essentially CBT tries to aid clients to explore and challenge their beliefs.
CBT is evidence based. It is acknowledged as one of the most effective evidence
based therapeutic approaches (Beck, 1979). CBT is universally used for clients who
suffer from low mood (Evans, Hollon, DeRubeis, Piasecki, Grove, Garvey & Tuason,
1992).

A collaborative therapeutic relationship is an excellent start for developing a

foundation for CBT. The rationale behind the use of the therapeutic relationship
would be to communicate to Mary that her problems would be taken seriously and
that we could address them together in therapy. As an authentic, considerate and
trusting therapeutic relationship motivates and allows the client to take control of their
situation where possible. Trust between patient and nurse is extremely significant,
particularly as clients commence to look at various core beliefs that are very difficult,

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and since these beliefs may bring up past distressing circumstances that a patient may
then think about and converse. To build a successful collaborative therapeutic
relationship it is of foremost importance to take the clients circumstances into
account. These include beliefs, educational attainment, cultural background and
character. It is vital to use the language the client understands and not medical
language. This will develop a close working relationship in order for the client to
understand CBT. In addition, it is essential that nurses treat clients with respect and
with empathy (Lam, 2008). CBT concepts include using positive thinking as a means
of recovery from mental illness. Recovery is about an internal way of change in
feelings and beliefs Young and Ensing, 1999.

Assessment
During an assessment interview, information would be gathered about Mary’s past
and problem development could be vital in order to explore what led Mary to feeling
sad. The main purpose of CBT is to help change clients perceptions to a view more
based on reality. In this way, Mary can focus on her low mood problem and solve it
rather than letting it build up to overwhelming difficulty. A plan would be formulated
by the client in collaboration with the nurse (Westbrook, Kennerley, and Kirk, 2007).
The approaches that could be used to assess Mary low mood include interviewing and
observation. Pearson, Borbasi, Walsh, (1997) suggests that the therapeutic
relationship could be implemented by engaging with clients in order to explore their
ideas.
Furthermore, it is vital to observe and participate in the therapeutic relationship in
order to see if the client’s body language matches their communication patterns
(Pearson, Borbasi, Walsh, (1997). One of the most crucial essentials in the assessment
process is interviewing the client (Blackburn, and Davidson, 1995). Most of the
information I would be obtaining from Mary during the interview would be through
questioning her. According to Tomlinson (1983) the purpose of questions are for
focusing attention on specific issues and expressing interest in clients. Barker, 2003
suggests that the clients story, hopes, fears are unique to them therefore they must be
the central process of ant therapeutic relationship. Devito, 2007 suggests that open
questions are a necessity to investigate an exact issue. My use of questions could
enable me to keep the therapy on track and encourage further communication with
Mary in order for me to gain a better understanding of her situation. Through
interviewing Mary, I could gain knowledge on Mary’s own insight into her low mood,
her coping strategies, what she thinks caused her low mood, her expected outcome. I
could monitor her non-verbal communication her eye contact, facial expression and
posture. This may allow me to see how her mood is affecting her emotions and her
behaviour.

Moreover, it may identify vulnerability, precipitating and modifying factors that may
be linked to Mary’s low mood. Brown and Harris, 1978 suggest that factors such as
the loss of a parent may make a person vulnerable to depression. Her father’s death
occurred five years ago and her first admission to a psychiatric hospital was a year
later. Her father may have had a close relationship with her and his death may have
caused her to become low in mood. This may prevent Mary letting the same situation
cause her to become low in mood in the future. I would observe Mary’s behaviour for
emotional and cognitive elements of her low mood.

The process of gathering information needs to be systematic which may begin with

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some broad questions such as what is the problem? Where does it occur? When does
it happen? With whom is the problem better or not as good around? After these
questions, the nurse may follow with the ABC model, which is a useful tool for
assessment. At the beginning of the therapy, the nurse meets the client to find out her
Autonomic (A) features related to the physical effects for example is Mary tired
because of the low mood. Tyree and Gandhi, 2005 suggests that this may be
important also if the client has general aches and pains. After that, the nurse finds out
about the (B) behavior aspects of this problem. This may inform us how Mary is
coping with her low mood. Subsequently it is vital to find out Mary (C) cognitive
features related to her low mood.

Plan
According to Kinsella and Garland 2008 CBT is instruction-based therapy, which
teaches the patient to begin to think decisively and dialectically about thoughts and
behaviors arising during complicated situations. The reasoning for this is that it helps
to use the therapeutic time most efficiently. The aim of the planning stage of the
nursing process is to help to move the client toward resolution of emotional issues.
Freud suggested that clients had essentially two difficulties, whatever problems in life
they encountered, and the way they approached those problems from a thinking
perspective. Consequently nurses work toward building concrete ways of changing
behavior and thought patterns around difficulties. The end goal is to help Mary get rid
of the negative aspects of her problem from a thought, emotion, and behavior
viewpoint. The nurse may take an active part in structuring the sessions to begin with.
However, as soon as progress is being made, and clients understand the CBT
techniques they find useful, they take increasingly more responsibility for the content
of sessions. So by the end, the client feels empowered to carry on working without
assistance (Kinsella and Garland, 2008). According to Coleman, 1999 recovery is
about accepting individual responsibility.
When planning CBT with Mary we arranged what goals to implement in order to help
her to recover. These goals would be to implement a change in Mary’s low mood.
These goals need to be linked to ABC (see above). Cognitive and behavioural
approaches are designed to break the B and C elements of depression. In Mary’s
depression, her cognitive subject matter may have being the loss of her father. Goals
can be used to see if Mary mood is improving. Goals need to be SMART in order to
be appropriate for the client’s low mood (Fennell, 1999). S is for specific to meet
Mary’s needs. M is for measurable in order to be able to calculate her progress. A is
for Achievable so that Mary can make progress at activities. R is for realistic that she
can do her activities in the community. T is for Time set for the goal to be completed.
CBT incorporates several elements, including homework assignments, the behavioral
strategy of activity scheduling, graded tasks, weekly activity schedule (WAS) and
structured problem. It is vital for Nurses to work using a therapeutic alliance. This is
one of the core therapeutic techniques in CBT for low mood (Beck, 1961).
Quality and Fairness, A Health system for you, Health strategy, (2001) suggests that
by enabling goals to be client centered and by getting clients involved in their
decision making helps improve their health. Mary’s low mood problem would
become the basis for planning the content of the first few sessions. Mary may learn
techniques how to deal with her low mood. As Mary low mood improves, she may be
able to cope better with her illness. Frequently, clients during CBT would be given
homework to be finished outside of sessions in order to help to fully comprehend their
problems. This is a fundamental part of the therapy. Confronting matters in a

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controllable way helps give the individual confidence in their own capability to cope
(Beck, 1979). We could identify through using the planning how to improve her low
mood. We could look at Mary’s previous interests and this may provide us with ideas
of activities that she used to like. I would confirm what she hopes to achieve from
CBT, for example, coping could be an important issue. Effective CBT can have
beneficial effects up to several years post treatment. There is also evidence that CBT
is associated with preventing relapse for clients with depression (Kuyken , Dalgleish
and Holden (2007).

Implement:
Behavioral assignments using graded tasks were used to increase her daily activity
level. The primary focus was on daily living skills for example self-care. Exploration
of earlier interests and the use of an interest inventory were beneficial in stimulating
her interests and increasing the range of her activities. She may have had previous
interest in art and painting by numbers paintings may make it a easier start for her.
Learning macramé may follow this. Subsequently she may join an art group that way
she could meet other people.

Mary may implement her weekly activity schedule (WAS) in collaboration with me.
This may include a timed activity schedule for Mary (see appendix one) and may be
useful in helping her cope with the loss of structure she experienced in her life. Mary
would complete her record of activity using a blank calendar in three time blocks:
morning, afternoon and evening. The WAS would enable me to find out what Mary
was doing in her daily routine. In addition, the WAS may help to find out what
activities would give Mary enjoyment and pleasure we would focus on these. This
could be done by asking her to put the letter P beside activities that were pleasurable
for her and A for the ones she achieved. In order to increase her mood we could plan
extra activities. As Mental Health Foundation, 2007 suggests that exercise appears to
improve mood. Mary may use graded task assignment to plan her activities step by
step.
Goal achievement may take Mary a very long time. The client needs to understand the
techniques and practice them. This is the reason why I made goals with Mary and
encouraged her to practice the techniques learned.
Mynors-Wallis, Gath, Day and Baker, 2000 suggest that depressed individuals may
find social problem solving difficult. Therefore, by helping Mary to structure
problems may help her cope with her low mood. After identifying Mary low mood as
the problem Mary and I wanted to work on. We would think about ways to solve this
problem. Mary and I may write down many ways to solve the problem. This may
generate many different approaches for Mary. We could cross off solutions, which
Mary did not like. Subsequently I would plan the best solution with Mary; it may be
beneficial to list the main advantages and disadvantages of each solution. It is best to
work with clients to put in place small steps for her to start activities for example
daily grocery shopping. I would also offer Mary and her family information regarding
depression. This may help Mary and her family to be aware of the time and
determination needed in order to address the problem.

Evaluate:
The weekly activity schedule (Beck, 1984) was reviewed the activities to identify
what things improved or worsened her condition and to help Mary understand her
reactions to different events. The WAS could be particularly helpful in identifying

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how Mary’s thoughts and behavior affect each other allowing Mary to gradually
regain a sense of control over situations in her life. Achievable and pleasure ratings
were assigned to activities to evaluate the benefits of the activities and to identify
cognitive distortions that minimised her sense of accomplishment and pleasure. Mary
may be able to cope on her own after a few weeks and continue planning her weekly
activities on her own. She may no longer need to break things down into graded task
assignments.

Cognitive therapy makes use of graded tasks assignments to test out a person’s
negative thoughts Williams black book. Mary’s graded tasks assignments may help
her plan her daily activities. This may be useful to get Mary started in planned her
activities. These tasks would have to be manageable for Mary to do in the community.
When WAS, homework and graded task assignments are done continuously they may
help to gain a measure of Mary’s baseline in order to manage her current activities
and add structure to her day. It is important that support is available if relapse occurs
so that re-evaluation and management can be re-continued where possible. This
review focuses on the work done, and looks toward more work that can be done in
order to be able to create a more thinking approach to high emotions and difficult
situations. The end goal is to use thinking to unlearn and replace negative emotions,
thoughts and reactions with more positive ones.

Conclusion: CBT an effective psychological treatment for low mood, it addresses the
clients current problems. It is a therapeutic treatment, which is client centred and
recovery focused. Without treatment, symptoms of depression may last for months or
even years. A baseline is important as it allows the client and nurse to monitor
progress and to ensure CBT is working. The coping mechanism such as weekly
activity schedule may be helpful and could be used when CBT has been completed.
Therefore, the effects of CBT for clients can last even when the therapy is finished.
Problems can be understood by considering the relationship between environment,
thoughts, feelings and behaviour. The key elements of CBT include the following:
CBT is based on a combined approach between the nurse and client. There is a strong
emphasis on homework assignments and learning from experience. Clients who have
the cognitive ability to follow the thinking in CBT can show great progress and have
improved quality of life.

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