Written by Danielle Fuller
April 2023
78/A+

This essay develops a formulation and appropriate treatment plan for Keiko, a 26-year-old pregnant woman seeking treatment for depression and anxiety. The formulation will use the 5Ps, a biopsychosocial model useful for capturing and connecting the client’s presenting, predisposing, precipitating, perpetuating, and protective factors. Formulation models have limitations (Joseph, 2022) but are nonetheless effective tools for clinicians to comprehensively assess a client and inform intervention choice (Johnstone, 2018). First, formulation will be conducted through the 5P model. Next, Keiko’s recommended intervention plan will be described and justified. The essay will conclude by addressing the limitations and ethical considerations of applying the recommended treatment.

Presenting Factors

Keiko’s depression presents as lowered mood, low self-esteem, decreased energy, and withdrawal. Given the comorbidity of depression and anxiety and unreported anxious symptoms of heightened worry or apprehensive expectation, treatment should target her depression with goals of improving self-value and boosting social confidence. 

Predisposing Factors

Keiko notes multiple adverse childhood experiences (ACEs). The disruption of immigrating to a foreign country at age 8 likely contributed emotional distress during formative years known to sometimes manifest as depressive symptoms (Belhadj Kouider et al., 2014; Kessler et al., 2007). She reports racial bullying and difficulty making friends as a child, both of which are known to increase feelings of isolation (Cherng, 2015) and low self-esteem (Seals & Young, 2003), which contribute to depression (Matthews et al., 2016; Sowislo, 2013). Keiko also took on primary carer duties for her terminally ill mother from age 13-15; studies associate serious illness and death of a parent with depression, particularly females taking on increased responsibility (Bifulco, 1987; Grant & Compas, 1995; Kessler & McLeod, 1984; Stein et al., 1999). Keiko has an ongoing strained relationships with her father and in-laws, who disapprove of her interracial marriage. This leaves her without a stable or supportive child-parent relationship, which can benefit mental health (Zarit & Eggebeen, 2002). 

Precipitating Factors

Keiko’s first pregnancy likely triggered her symptom onset. Perinatal hormone changes can lead to depression (Brummelte & Galea, 2010; Gavin et al., 2005), and first-time mothers are twice as likely to develop depression as those with other children (Lindblad et al., 2022). Her recent return of panic attacks after ten years likely contributes to her depression and may cause anticipatory anxiety (Coryell et al., 1988; Helbig-Lang et al., 2012). She also notes changes in her social life as her only close friend, Emily, recently gave birth and has less time for engagement. Husband David works long hours and takes business trips abroad, further limiting Keiko’s social interactions. These social changes likely contribute to feelings of isolation and depression (Han et al., 2018), especially in the face of panic attacks. 

Perpetuating Factors

Keiko’s self-perception likely plays a large role in symptom perpetuation. Her low self-worth appears to manifest in withdrawal from Emily when down, as she reports not wanting to burden her friend with problems. By not seeing validity in her own struggles enough to share with and seek support from others, she fuels her isolation and lack of self-worth, which can contribute further to depression (Cherng, 2015; Matthews et al., 2016; Seals & Young, 2003; Sowislo, 2013). Lack of parental support likely exacerbates Keiko’s symptoms as she looks forward to the upcoming demands of parenthood (Chavis, 2016). Additionally, David’s work-related absences and reduced contact with Emily may perpetuate her symptoms, as lack of social connection can feed depression (Han et al., 2018). 

Protective Factors

Keiko reports a strong and supportive marriage, which correlates with general wellbeing (Roberson et al., 2018). Her friendship with Emily is also characterized by care and support, and the shared experience of motherhood can improve mental health (Marino et al., 2016). Keiko reports receiving comfort from her dog, which aligns with research findings that pets can improve mental health (Hawkins et al., 2021). She also demonstrates a sense of rationality by articulating understanding that her father’s distant actions and beliefs do not represent his love for her; this ability to cognitively process life’s dualities demonstrates a capability and willingness to cognitively reevaluate existing schemas (Jokela, 2022). 

Proposed Intervention

Based upon the preceding formulation it is recommended that Keiko start short-term psychodynamic psychotherapy (STPP) to address her present depressive symptoms, which is similar to traditional psychotherapy but with the added elements of time-limitation and goal-setting. STPP has been shown to be effective for depression in adults through many reviews and meta-analyses, statistically performing as well as other time-limited methods such as cognitive-behavioral therapy (CBT) and showing dramatic superiority over control situations (e.g., no treatment; Caselli et al., 2023; Driessen et al., 2010; Julien & O’Connor, 2017). Many of her predisposing and perpetuating depressive factors seem not to be fueled by a serious psychological disorder but rather by the personality and worldview she developed in childhood, which makes psychodynamic therapy appropriate. However, depression in perinatal and postnatal periods is a serious health concern with the capacity to develop into a chronic psychological disorder (Gavin, 2005; Wilken et al., 2020), making a time-limited approach useful to address it with urgency and intention before it progresses.

Central focus areas of STPP include unconscious processing, impacts of psychosocial development, and reenactment of past events and emotions (Messer, 2001). These should greatly benefit Keiko, whose psychosocial development was likely stunted in youth due to immigration, bullying, and social isolation. These experiences during formative years shaped Keiko’s personality, relation to the world, self-worth, and ability to build social connections, and STPP allows her to explore how these ACEs established or influenced her underlying emotional and behavioral patterns. Similarly, she needs to address the impact of losing her mother young before she becomes a mother herself, to reduce the likelihood that unresolved emotions and worries about parent-child relationships create adverse mental health outcomes for herself or her child (Wilken et al., 2020). While CBT is at least as effective at addressing depression, its focus on the present (Van Bilsen, 2018)) disregards the significant impact Keiko’s past likely plays on the current behaviors perpetuating her depressive symptoms and is therefore not recommended. 

Another key part of STPP is its emphasis on building a strong relationship between the client and therapist (Driessen et al., 2010). Given Keiko’s difficulties in building connections and opening up to others, this heavy focus on the establishment of a strong, supportive relationship should help balance her triangle of person, the interconnected triad of one’s relationships with those in their past, those in their present, and transference with their therapist (Malan, 1976). Keiko’s triangle of person is strongly influenced by current relations (e.g., lack of social group, absent friend and partner, strained parental relations) and childhood relations (e.g., bullying, dying mother, lack of friends), so the creation of a safe and reliable therapist relationship should let her reframe her social self-image, practice opening up to others, and build self-esteem in ways she’s unable to in other relationships (Kohlenberg, 1999). This aspect of STPP is a primary benefit over use of CBT in Keiko’s case, as CBT does not place a focus on the client-therapist relationship (Van Bilsen, 2018) and may be perceived by a socially-stunted Keiko as yet further evidence that she is only deserving of emotionally-unavailable relationships. 

This treatment should be conducted weekly for the maximum-recommended 25 weeks (Messer, 2001) to apply the benefits of time-limited therapy while also spanning the remainder of Keiko’s pregnancy. A preliminary goal should be set to build her social support network to reduce postnatal isolation, a time known for increased feelings of isolation (Adlington, 2023), which can be measured weekly by logging her intentional socializations. Another goal should be to increase expression of her own needs, wants, and opinions to improve self-esteem and protect against isolation in postnatal caring responsibilities. Instances of self-advocacy should be logged and discussed in each session. Successful achievement of these goals would be either a quantitative increase in social interactions and self-expressions over the treatment and/or qualitative expression of improved self-worth and deeper connections with those in her social circle. That said, as the first two sessions should be dedicated to broadening the therapist’s understanding of Keiko, establishing the client-therapist relationship, and agreeing upon the goals of the therapy, adjustments to this plan should be considered and implemented before the third session as needed.

Limitations and Ethical Considerations

While a very good fit for Keiko, STPP does come with some limitations and ethical considerations. While the large number of sessions is recommended to support her during an increased period of vulnerability, it would be costly if immediate support is not available through the NHS. Additionally, psychodynamic therapy relies on the client’s willingness to explore deep-seeded issues and face past trauma; if Keiko is unable or unwilling to do this, STPP will be less effective. This would be even more likely if Keiko is matched with a native, white therapist, representative of the authority she shied away from in childhood. It would therefore be more ethical and beneficial to match her with a therapist who shares her experience of childhood immigration to lessen Keiko’s fear of opening up about those experiences (Raja, 2016). A third limitation is psychotherapy’s reliance on subjective interpretation by the therapist; if this formulation is missing critical information about Keiko or improperly values social support and self-esteem over her other experiences, STPP could be misguided. Similarly, it is ethically questionable that this formulation and intervention have been created by a white person who cannot empathize with Keiko’s experience as a racial minority; however, this is at least partially alleviated by my own experience with immigration, parental tension in an interracial partnership, and personal struggle with self-value. Lastly, the time-limitation may not be enough for Keiko to unpack and reframe two decades of experience, or stave off postpartum depression. Routine psychodynamic therapy sessions may benefit Keiko in the long term, but this should not be suggested until STPP is complete to prevent lowering the urgency induced by time-limited therapies.

References:

Adlington, K., Vasquez, C., Pearce, E., Wilson, C. A., Nowland, R., Taylor, B. L., Spring, S., & Johnson, S. (2023). “Just snap out of it” – the experience of loneliness in women with perinatal depression: a Meta-synthesis of qualitative studies. BMC Psychiatry, 23, 110. https://doi.org/10.1186/s12888-023-04532-2 

Belhadj Kouider, E., Koglin, U., & Petermann, F. (2014) Emotional and behavioral problems in migrant children and adolescents in Europe: a systematic review. Eur Child Adolesc Psychiatry, 23, 373–391. https://doi.org/10.1007/s00787-013-0485-8 

Bifulco, A. T., Brown, G. W., & Harris, T. O. (1987). Childhood loss of parent, lack of adequate parental care and adult depression: a replication. Journal of Affective Disorders, 12(2), 115-128. https://doi.org/10.1016/0165-0327(87)90003-6 

Brummelte, S. & Galea, L. A. M. (2010). Depression during pregnancy and postpartum: Contribution of stress and ovarian hormones. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 34(5), 766-776. https://doi.org/10.1016/j.pnpbp.2009.09.006 

Caselli, I., Ielmini, M., Bellini, A., Zizolfi, D., & Callegari, C. (2023). Efficacy of short-term psychodynamic psychotherapy (STPP) in depressive disorders: A systematic review and meta-analysis. Journal of Affective Disorders, 325, 169–176. https://doi.org/10.1016/j.jad.2022.12.161 

Chambless, D. L., Hollon, S., D. (1998) Defining Empirically Supported Therapies. Journal of Consulting and Clinical Psychology, 66(1), 7–18. https://doi.org/10.1037/0022-006X.66.1.7 

Chavis, L. (2016) Mothering and anxiety: Social support and competence as mitigating factors for first-time mothers. Soc Work in Health Care, 55:6. https://doi.org/10.1080/00981389.2016.1170749 

Cherng, H. Y. S. (2015). Social isolation among racial/ethnic minority immigrant youth. Sociology Compass, 9(6), 509-518. https://doi.org/10.1111/soc4.12276 

Coryell, W., Endicott, J., Andreasen, N. C., Keller, M. B., Clayton, P. J., Hirschfeld, R. M. A., Scheftner, W. A., & Winokur, G. (1988). Depression and Panic Attacks: The Significance of Overlap as Reflected in Follow-Up and Family Study Data. Am J Psychiatry, 145:293-300. 

Driessen, E., Cuijpers, P., de Maat, S. C. M., Abbass, A. A., de Jonghe, F., & Dekker, J. J. M. (2010). The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis. Clinical Psychology Review, 30(1), 25-36. https://doi-org.ezproxy.is.ed.ac.uk/10.1016/j.cpr.2009.08.010 

Gavin, N. I., Gaynes, B. N., Lohr, K. N., Meltzer-Brody, S., Gartlehner, G., & Swinson, T. (2005). Perinatal depression: a systematic review of prevalence and incidence. Obstetrics & Gynecology, 106(5 Part 1), 1071-1083. https://doi.org/10.1097/01.AOG.0000183597.31630.db 

Grant, K. E., & Compas, B. E. (1995). Stress and anxious-depressed symptoms among adolescents: Searching for mechanisms of risk. Journal of Consulting and Clinical Psychology, 63(6), 1015–1021. https://doi.org/10.1037/0022-006X.63.6.1015 

Han, R. T., Kim, Y. B., Park, E. H., Kim, J. Y., Ryu, C., Kim, H. Y., ... & Na, H. S. (2018). Long-term isolation elicits depression and anxiety-related behaviors by reducing oxytocin-induced GABAergic transmission in central amygdala. Frontiers in molecular neuroscience, 11, 246. https://doi.org/10.3389/fnmol.2018.00246 

Hawkins, R., Hawkins, E. L., & Tip, L. (2021). “I Can’t Give Up When I Have Them to Care for”: People’s Experiences of Pets and Their Mental Health. Anthrozoös, 34(4), 543–562. https://doi.org/10.1080/08927936.2021.1914434 

Helbig-Lang, S., Lang, T., Petermann, F., & Hoyer, J. (2012). Anticipatory Anxiety as a Function of Panic Attacks and Panic-Related Self-Efficacy: Ambulatory Assessment Study in Panic Disorder. Behav and Cog Psychotherapy, 40(5), 590-604. https://doi.org/10.1017/S1352465812000057 

Johnstone, L. (2018). Psychological Formulation as an Alternative to Psychiatric Diagnosis. Journal of Humanistic Psychology, 58(1), 30–46. https://doi.org/10.1177/0022167817722230

Jokela, M. (2022). Why is cognitive ability associated with psychological distress and wellbeing? Exploring psychological, biological, and social mechanisms. Personality and Individual Differences, 192, 111592. https://doi.org/10.1016/j.paid.2022.111592 

Joseph, S. (2022). Psychological Formulation, a Critical Viewpoint: Illness Ideology in Disguise. The Journal of Humanistic Psychology, 62(5), 683–693. https://doi.org/10.1177/0022167820985411 

Julien, D., O’Connor, K.P. (2017) Recasting Psychodynamics into a Behavioral Framework: A Review of the Theory of Psychopathology, Treatment Efficacy, and Process of Change of the Affect Phobia Model. J of Contempry Psychotherapy 47, 1–10. https://doi.org/10.1007/s10879-016-9324-9 

Kessler, R. C., Amminger, G. P., Aguilar-Gaxiola, S., Alonso, J., Lee, S., & Üstün, T. B. (2007). Age of onset of mental disorders: a review of recent literature. Current Opinion in Psychiatry, 20(4), 359-364. https://doi.org/10.1097/YCO.0b013e32816ebc8c 

Kessler, R. C., & McLeod, J. D. (1984). Sex differences in vulnerability to undesirable life events. American Sociological Review, 49(5), 620–631. https://doi.org/10.2307/2095420 

Kohlenberg, R. J., Tsai, M., Parker, C. R., Bolling, M. Y., & Kanter, J. W. (1999). Focusing on the client-therapist interaction. Functional analytic psychotherapy: a behavioural approach. Euro Psychotherapy, 1, 15-25.

Lindblad, V., Melgaard, D., Jensen, K. L., Eidhammer, A., Westmark, S., Kragholm, K. H., & Gommesen, D. (2022). Primiparous women differ from multiparous women after early discharge regarding breastfeeding, anxiety, and insecurity: A prospective cohort study. European Journal of Midwifery, 6, 12. https://doi.org/10.18332/ejm/146897 

Malan, D. H. (1976). Toward the validation of dynamic psychotherapy : a replication / D.H. Malan. Plenum Medical Book Company.

Marino, C. “K.”, Child, B., & Campbell Krasinski, V. (2016). Sharing Experience Learned Firsthand (SELF): Self-disclosure of lived experience in mental health services and supports. Psychiatric Rehabilitation Journal, 39(2), 154–160. https://doi.org/10.1037/prj0000171 

Matthews, T., Danese, A., Wertz, J., Odgers, C. L., Ambler, A., Moffitt, T. E., & Arseneault, L. (2016). Social isolation, loneliness and depression in young adulthood: a behavioural genetic analysis. Soc Psychiatry Psychiatr Epidemiol, 51, 339–348. https://doi.org/10.1007/s00127-016-1178-7 

Messer, S. B. (2001). What Makes Brief Psychodynamic Therapy Time Efficient. Clinical Psychology (New York, N.Y.), 8(1), 5–22. https://doi.org/10.1093/clipsy.8.1.5 

Raja, A. (2016) Ethical Considerations for Therapists Working With Demographically Similar Clients, Ethics & Behavior, 26:8, 678-687. https://doi.org/10.1080/10508422.2015.1113133 

Roberson, P. N. E., Norona, J. C., Lenger, K. A., & Olmstead, S. B. (2018). How do Relationship Stability and Quality Affect Wellbeing?: Romantic Relationship Trajectories, Depressive Symptoms, and Life Satisfaction across 30 Years. Journal of Child and Family Studies, 27(7), 2171–2184. https://doi.org/10.1007/s10826-018-1052-1 

Seals, D., & Young, J. (2003). Bullying and victimization: prevalence and relationship to gender, grade level, ethnicity, self-esteem, and depression. Adolescence, 38(152). http://bdsp-ehesp.inist.fr/vibad/index.php?action=getRecordDetail&idt=307350 

Sowislo, J. F., & Orth, U. (2013). Does low self-esteem predict depression and anxiety? A meta-analysis of longitudinal studies. Psych Bulletin, 139(1), 213–240. https://doi.org/10.1037/a0028931 

Stein, J. A., Riedel, M., & Rotheram-Borus, M. J. (1999). Parentification and its impact on adolescent children of parents with AIDS. Family Process, 38(2), 193–208. https://doi.org/10.1111/j.1545-5300.1999.00193.x 

Van Bilsen, H. (2018). Cognitive Behaviour Therapy in the Real World : Back to Basics / Henck Van Bilsen. (First edition.). Taylor and Francis. https://doi.org/10.4324/9780429473128 

Wikman, A., Axfors, C., Iliadis, S. I., Cox, J., Fransson, E., & Skalkidou, A. (2020). Characteristics of women with different perinatal depression trajectories. Journal of Neuroscience Research, 98(7), 1268–1282. https://doi.org/10.1002/jnr.24390 

Zarit, S. H., & Eggebeen, D. J. (2002). Parent-child relationships in adulthood and later years. In M. H. Bornstein (Ed.), Handbook of parenting: Children and parenting. (pp. 135–161). Lawrence Erlbaum Associates Publishers.