Case Vignette:

Ms. A, a 27-year-old single female, medical resident doing her post-graduation in Dermat,
presented to the psychiatry OPD with the following concerns. She reported experiencing a
range of emotional and behavioral symptoms that have been impacting her daily life for the
past six months. She often feels fatigued and emotionally drained during most of her days
without minimal activity which is the first thing that she noticed was not okay with her. She
describes her mood as persistently low, with intermittent periods of intense sadness and
hopelessness. Her sleep patterns have been disrupted, leading to difficulty falling asleep and
frequent early morning awakenings and she has lost interest in academic pursuits and hobbies
she once enjoyed, including research work.
She feels as though she has lost the motivation to perform her medical duties, and she often
feels overwhelmed by the demands of her residency program.
She often engages in negative self-talk and often describes herself as a "failure" and
"incompetent” and experiences persistent ruminations about past mistakes in patient care,
intensifying her feelings of hopelessness. She has been having bouts of anxiety more so when
she is expected to meet deadlines as she is unable to meet the expectations of her course and
mentions she has noticed her concentration and decision-making difficulties hinder her
academic and clinical performance significantly. The constant mistakes and the repercussions
to them and the perceived criticism have led to social withdrawal, and she avoids interactions
with colleagues and friends and she expressed concerns about being perceived as inadequate
by her peers and mentors, which has further contributed to her distress.

She mentions that she has always done well even in her undergraduate course and feels a
constant pressure to excel along with this the responsibility for patient care has been acting as
a significant stressor. She underwent a recent breakup, leaving her with a compounding sense
of isolation.

There is a history of substance use, however, occasional. No other relevant medical history of
significant past history.

There has been an initial session that included an intake history and where
the therapist has already presented the overall model of behavioral activation and sent the
client home with reading materials. Case conceptualization is important as an evidence-based
process in behavioral activation and in other empirically supported treatments. The therapist
presents the case conceptualization according to events that have occurred in the client's life
over the past week and it is made relevant to the client's own experience. The patient will also
be introduced to concepts that are important in behavioral activation such as acting from the
outside in rather than the inside out and how to follow goal-dependent rather than mood-
dependent behaviors

Therapist: Good evening, Miss A, it's good to see you again. Last week, we discussed in
depth your history, and if you remember I talked about what behavioral activation is and how
it may help you in your situation. I also gave you some paperwork to take home and read. Did
you have a chance to look that over?

Miss. A: Yeah I was able to look it over but I’m not sure if I went super in-depth on it or not.
Therapist: That's great! I didn't intend for you to go super in-depth on it however did it make
sense to you how it fits with your life and how we're gonna proceed in terms of using
activation as a way to help you with your depression?

Miss. A: Yeah I think in a general sense it did make sense to me

Therapist: Alright, what were your immediate thoughts? Or, did you have any confusion on
reading about it?

Miss. A: It seemed like a little obvious to me, it may not be the right word but something like,
guess a part of it for me was like if I could just start doing these things I would!

Therapist: Absolutely I mean if it was as simple as just doing it you

Miss. A: Not that great, yeah.

Therapist: Anything different than what we had discussed the last time? What was the
toughest thing for you over the last one week?

Miss A: I had a seminar planned for the week and a previous pending one for which I was
asked to meet with the staff and discuss the necessary details. I guess this would be it.
Therapist: So, you had a meeting scheduled and a seminar due and then you didn’t make it to
them, yeah? How often does this happen?

Miss A: Well, I missed the one I had scheduled this week and then the one scheduled the
week before. And for the upcoming one, my staff has been trying to get us to meet atleast
once in a week but I have been missing about half of those meetings.

Therapist: So, when you didn't attend those, how did that make you feel?

Miss A: It made me feel like I'm not pulling my weight like I'm failing at my responsibilities.

Therapist: It sounds like it had an impact on your self-esteem. When you felt like you were
failing, did that affect your mood?

Miss A: Yeah, definitely. It made me feel really down and even more stressed.

Therapist: So, not attending these meetings and seminars led to feelings of failure and stress,
which in turn affected your mood negatively. And how about your motivation to engage in
other activities or responsibilities?

Miss A: I guess it made me even less motivated to do anything else. I felt overwhelmed by the
things I should be doing.
Therapist: This is starting to form a pattern that is relevant to our discussions earlier. It's not
just about doing activities; it's about understanding the relationship between your behaviors,
your thoughts and feelings. Let's map it out. When you miss these meetings and seminars
(Behavior), you start feeling like a failure (Emotion), and that contributes to your low mood
and lack of motivation (Mood/Behavior).

Miss A: I can see that, it's like a cycle.

Therapist: Exactly, it's a cycle that can keep you trapped wherever you are. What we will
collectively try to do is to break this cycle. The idea is that by changing your behavior, you
can influence your emotions and thoughts in a more positive direction. Instead of waiting for
your mood to improve, you start to act in a way that aligns with your goals and values, even
if it's just small steps. In this way, we act from the "outside in" rather than waiting for your
mood to improve from the "inside out."

Miss A: I get it, so it's about doing things that matter to me, even if I don't initially feel like
doing them.

Therapist: That's right. We'll work together to set specific, achievable goals and develop an
action plan to get you started. Remember, it's okay if it feels challenging at first, but we'll
take it one step at a time. You may not presently feel as though you are able to get much done
or that you are always tired and lack motivation. You also may be waiting to feel better or
think more positively before you become more active and start participating in activities that
once brought you pleasure. As you know, however, getting yourself to feel better is not an
easy thing to do. Therefore, we’d like you to try something different. The idea of the
treatment we are about to begin is that your thoughts and feelings are affected by your
interactions with others and your overall quality of life. So, we believe that for you to have
more positive thoughts and to feel better, you must first become more active and put yourself
into more positive situations. Although this will be quite difficult right now, it will become
easier as more and more positive experiences occur. The treatment requires you to work hard,
and I understand that you may be questioning your ability to make changes at this time in
your life, but I will help you through this process, and we will work at a pace at which you
feel comfortable.

Miss A: Thanks for explaining it to me. I'm willing to give it a try.