Case Vignette: Sarah

Sarah is a 35-year-old woman who has sought help from the psychology clinic and has been assigned
to you. On intake, she explained that she has been depressed and anxious for most of her adult life
but has recently noticed her mood worsening. She works at the university as a researcher in a highly-
productive research unit but fears that she is not coping with the demands of her job.

She explained that she grew up with a violent father who often used to beat Sarah, her younger
sister, and sometimes their mother, depending on whoever got in his way. According to Sarah, her
father could be jovial one moment and violent the next, and she learned to be very sensitive to any
signs that his mood may change. She adds that he would often put her down, and she spent her
childhood years believing that she was somehow 'not good enough' or that his violent outbursts
were her fault.

Sarah felt responsible for protecting her younger sister from her father's violent behaviour. However,
her sister is now seemingly on good terms with her parents and has been financially successful, while
Sarah is struggling financially. She explained that she believes she deserves more from life after all
the unhappiness of her childhood.

Her family struggled financially. Sarah recalls a childhood memory of dealing with a sheriff, who had
arrived to attach their possessions because her parents had accumulated debt and were out drinking
at the time. She felt deeply ashamed of her family situation.

Sarah is a single, divorced mother of two children, a son and a daughter, from two previous
marriages. She struggles financially on a single income, but her children have obtained scholarships
to attend a local private school, which gives her much relief and pride. One of her ex-husbands is
reliable in providing financial support but not the other.

Sarah explained that although she hides her true feelings from her friends and colleagues, she
continually feels on the verge of 'a breakdown'. She is terrified that she will 'lose control' in a
meeting and shout at her colleagues or burst into tears. Although she is up to date with her work and
has been very productive over the recent years, she fears she will be exposed as a fraud and lose her
job. She explained that as long as she is highly productive, she will be okay - but the trouble is that
her low mood is interfering with her ability to do her work. For example, recently, she had to walk
out of a staff meeting on the verge of tears because she was mildly criticised for some trivial work
matter.

When you ask her more about her daily life, you learn that she is sad most of the time, sleeps poorly,
has lost her appetite but maintains her body weight by drinking alcohol heavily, worries all the time
about herself and her children, is tired all of the time, has occasional suicidal thoughts but quickly
assures you that she would never try to kill herself while her children are still reliant on her. She very
occasionally harms herself by cutting her arms with a razor blade (which makes her feel better in the
short term, but contributes to her own self-loathing over the long term). She blames herself for the
problems she is having.

She generally avoids social contact and is increasingly lonely now that her children are developing
their social lives. When she socialises with other adults, she thinks they are more successful than she
is because she assumes they earn more money, have more active social lives, or are more interesting.
However, even though she is socially isolated, she reports having maintained a few close friendships
for decades. She says her friends have described her as loyal and funny, but she does not see herself
this way.
She arrives at the first session having read about cognitive therapy online and with a notebook, in
which she records points made during the session. In addition, she seems keen to do some
homework exercises during the week.

Question 1

Write a detailed case conceptualisation, drawing on an appropriate cognitive model. Be sure to

explain how the presenting problem developed and how it is maintained. Also, include reference to
the client’s strengths.

Question 2

Based on the case conceptualisation, describe how you would approach this case in therapy. Give
specific examples of the therapy goals, the overall strategies for change, and specific structured
interventions that you might use in session and/or as homework assignments. Comment on her
prognosis.