Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138

Using CBT for Depression: A Case Study of a

Patient with Depressive Disorder Due to a Medical

Condition (Infertility)

Ana-Maria Vioreanu

University of Bucharest, Bucharest, Romania

Abstract

Introduction: Infertility increases the risk for psychopathology more often in women, who can

develop symptoms in mood disorders and chronic stress. Depression is one frequent

psychological consequence of this medical condition and if it’s not being addressed accordingly,

depressive symptoms can lead to delays in the onset of medical treatment, impairments in its

outcomes and, likewise, poses a risk on the patient's mental health.

Purpose: The purpose of this case study was to disseminate a specific example of how infertility

affects mental health, offering a multidisciplinary approach from both traditional CBT and health

psychology. In addition to this, the case study presents important cultural aspects regarding

psychotherapeutic process and access to health care.

Methodology: This is a descriptive and explanatory case study where multiple quantitative data

sources have been used such as self-reported inventories: The Fertility Problem Inventory (FPI),

Beck Depression Inventory (BDI) and The Coping Inventory for Stressful Situations (CISS), in

addition to a semi-structured clinical interview.

Results: Results showed an improvement in mood, acquisition of a more adaptive thinking style,

healthy coping mechanisms and self-help strategies to support the patient post-therapy. The

contribution of cultural orientation and wellbeing-centered recommendations are being discussed.

Conclusion: The improvement of healthcare services relies on such presentations of case

studies that can shift the focus in new directions of good clinical practices.

Keywords

mental health, depressive disorder, infertility, cognitive restructuring, clinical framing, CBT

Address for correspondence:

Ana-Maria Vioreanu, PhD, University of Bucharest, Bucharest Romania.

Email: ana.vioreanu8@gmail.com

This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International

License (CC BY-NC 4.0).

©Copyright: Vioreanu, 2023

Publisher: Sciendo (De Gruyter)

DOI: https://doi.org/10.56508/mhgcj.v6i1.149

Submitted for publication: 27

September 2022

Revised: 19 December 2022

Accepted for publication:

06 January 2023

Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138

Introduction

Theoretical background

Infertility represents "the failure to establish a

clinical pregnancy after 12 months of regular,

unprotected sex or an impairment of a person's

ability to reproduce either as an individual or with

a partner." (Zegers-Hochschild, et al., 2017, p.

1795) and affects about 8-12% of couples of

reproductive age globally. Infertility has been

described as a disease of the reproductive

system, which can lead to disability by impairing

reproductive function. Thus, according to the

International Classification of Functioning,

Disability and Health, it is coded b660, with

impaired procreation function (functions

associated with fertility, pregnancy, birth and

lactation) - b6600 functions related to fertility with

impairments such as subfertility and sterility

(World Health Organization, 2001). The terms

infertility/subfertility are used interchangeably.

Infertility is experienced as a crisis situation, being

a major stressor in the life of the individual /

couple and leading to psychological distress.

Often, patients with infertility are at increased risk

for psychopathology, most often developing

symptoms in the area of anxiety, depression and

chronic stress. Women tend to be much more

psycho-emotionally affected by this medical

condition than men (Maroufizadeh, Navid, Omani-

Samani, & Amini, 2019). The main reasons for

this are related to the stigma associated with

women who cannot have children, especially in

cultures that value this aspect as a primary

purpose in life and the defining role of a woman.

Thus, women with infertility are socially isolated,

neglected, more prone to divorce and experience

a drastic decrease in self-esteem and self-worth,

which can lead to feelings of guilt and lack of

meaning in life. Depression can occur as a

consequence of infertility affecting the normal

functioning of the person and the quality of the

couple's relationship (Vioreanu, 2021).

Currently available epidemiological data

indicate that depression affects between 39.5% -

42.9% of women with infertility in Nigeria

(Awoyinka & Ohaeri, 2014), with even higher rates

in Saudi Arabia (53.8%) (Al-Homaidan, 2011) and

Ghana (62%) (Alhassan, Ziblim, & Muntaka,

2014). These areas tend to be more affected due

to various factors related to cultural beliefs,

cultural practices and customs, socio-economic

level and access to quality medical services.

However, screening for depression in women

diagnosed with infertility should be an implicit

method of investigation, as it has been shown that

depressive symptoms delay the onset of medical

treatment, affect its outcomes and pose a risk to

the patient's mental health (Oladeji & OlaOlorun,

2018).

There is a strong and growing body of

research on effective psychotherapeutic

interventions in the treatment of depression. A

recent and comprehensive meta-analysis

(Cuijpers, et al., 2021) examined the effects of

several types of psychotherapy on depression,

starting with the well-known cognitive-behavioral

therapy (CBT) and including individual

psychotherapy (IPT), behavioral activation therapy

(BAT), problem solving therapy (PST), third wave

therapies (3WT), life review therapy (LRT). The

results indicate similar effects between these

types of therapies, all of which have a

considerable efficacy rate. This facilitates patient-

centered health care, favoring the patient's

preferences for a particular type of psychotherapy.

When the patient's preferences and opinions are

valued, it is likely that the chosen intervention will

fit better with him, and therefore the objectives will

be achieved more accurately. This should be

controlled through access to up-to-date evidence-

based information about treatment options,

expected effects, possible risks, and realistic

management of expectations regarding the

therapeutic process. Moreover, the authors of this

study highlight an essential aspect, namely that of

maintaining the positive effects of certain

psychotherapies, at one year of follow-up. These

include CBT, BAT, PST and IPT. Other studies

reinforce the efficiency of CBT in lowering anxiety

and depression symptomatology in infertile

patients. This may happen due to the various

range of strategies and techniques that CBT

provide for the patients in order for them to

restructure irrational thought patterns and acquire

healthier and more adaptable beliefs regarding

certain adverse life events (e.g. infertility). It has

been suggested that prolonged application of CBT

in infertile patients results in significant reducing of

infertility related stress, which can lead to

successful pregnancy in some cases (Golshani et

al., 2020; Wang et al., 2022).

CBT interventions are complex and target a

wide range of symptoms exploring them

cognitively, emotionally and behaviorally. Some of

these interventions include behavioral activation,

psychoeducation, homework, cognitive

restructuring, problem solving and others.

Traditional CBT is delivered face-to-face either in

an individual or group format, but this type of

psychotherapy expanded well in virtual formats

too. For example, there are platforms or

applications where individuals can learn self-help

techniques and they can benefit from

psychoeducational programs in terms of basic

cognitive-behavioral therapy (López-López, et al.,

2019). Moreover, CBT is a practical type of

therapy helping the client to acquire life-long skills

in order to use self-help in future situations and

rely on own internal resources. Generally, CBT is

a short-term therapy ranging from about five to

twenty sessions.

Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138

Case Introduction

Patient E.C., aged 35, lives in Bucharest,

Romania where she was born and raised. She

graduated from the Faculty of Cybernetics,

Statistics and Economic Informatics, working for 8

years as a Web Developer and E-Business

specialist at a renowned company. She has been

married for 6 years and currently has no children.

Recently, she presented to the therapist with

an increase in depressive mood and a decrease

in her existential drive. Four years ago, she was

diagnosed with unspecified infertility (N97.9; ICD-

10-AM) and underwent a series of unsuccessful

medical treatments. Last year, she was diagnosed

with a depressive disorder due to another medical

condition (unspecified infertility) with a major

depressive episode (F06.32; ICD-10-CM) and

followed a treatment plan consisting of

antidepressants and individual psychotherapy.

She is currently experiencing a relapse as a result

of voluntary discontinuation of both medication

and therapy. The patient has no hereditary history

of psychiatric disorders.

With respect to patient’s psychosocial

environment, E.C. lives with her husband for six

years and she describes her relationship

satisfaction as being very good until the time they

started to attempt conceiving. After failed attempts

and treatments, the couple’s satisfaction dropped

significantly (self-reported). She is employed, but

recently started to miss work feeling impaired by

depressive symptomatology.

Clinical picture

The patient comes with accusations of

insomnia, says that she can't sleep and because

of that she is absent from work, she has no

appetite, she reports feelings of inner emptiness,

she doesn't enjoy anything around her anymore,

she feels helpless and over-blaming herself for

her inability to have a baby. She believes that her

husband will leave her at any moment, stating "It

would be better for him to leave anyway because I

can't offer him anything". She no longer keeps in

touch with her friends: "I can't stand the thought

that they can have a baby whenever they want,

and I can't". She spends a lot of time in the house,

locked in her room, trying to avoid contact with her

husband by saying that she is ashamed to even

look him in the eye. She states that she feels like

„nothing in her life is worthy” and that she „will

never be able to get over this failure”. She has

feelings of worthlessness for both her family and

society, she has retreated inwardly, she is no

longer interested in anything that is happening

around her, not even the workplace where she

used to make an effort and show commitment:

„Even my work colleagues look at my differently, I

think they feel sorry for me... that I struggle so

much with the treatments and it still doesn't

work… I don't even want to go to the office

anymore, I can't concentrate on anything anyway”.

Regarding the family and the husband, the patient

claims that they never reproached her anything,

that they supported her throughout the treatment

and that the husband is the one who insisted that

she go to therapy again. The patient states that no

matter how difficult it is for her to leave the house,

she does not want to lose her job and "to

disappoint my husband even more". All these

impairments last for more than two weeks and are

experienced daily in relation to almost all

activities. The patient has insight into the disorder

and is willing to try treatment again.

In summary, the patient's clinical picture is as

follows:

• Depressed mood

• Anhedonia

• Fatigue

• Decreased existential drive

• Insomnia

• Loss of appetite

• Decreased ability to concentrate

• Feelings of worthlessness, inadequate

excessive guilt

• Social isolation.

All these symptoms cause a clinically

significant deterioration in the areas of daily

functioning (social, professional, family).

History

Patient E.C. was born and raised in Bucharest,

being the only child of a family of doctors. She

reports that the relationship with her parents was

a good one, however quite cold and distant. Her

parents longed for her to follow the path of

medicine, and when E.C. decided that she wanted

to choose another path, both her mother and her

father tried to make her change her mind by

removing any kind of support and making

contradictory arguments. E.C. says she always

felt pressured to be the best in her chosen field, to

prove to her parents that she had made the right

choice and to make them proud of her. She is

currently in contact with both parents, but

conversations and meetings are rare and austere.

Regarding the relationship with her husband,

the patient states that this is the only authentic

relationship in her life and that he has always

supported her in all circumstances. E.C. has no

close friends, the only social contacts being at

work. She is not used to going on holiday too

often because she is busy most of the time. She

has been maintaining a leadership position for

approximately 4 years, in which she invests many

personal resources of time and energy. She

considers the job to be her greatest achievement,

wanting to add to the list the birth of a child. She

considers herself a determined, active, ambitious

person, with a desire to lead, emotionally

inhibited, chooses to keep her feelings for her.

She has no history of somatic or psychological

disorders pre-infertility.

Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138

The patient's lifestyle was mostly characterized

by the inconsistency of a stable schedule, with

extra work hours, infrequent breaks, working

under time pressure, maintaining a long vicious

position on the chair, working at the computer,

poor diet characterized by food rich in saturated

fats and sugars, eating on the run, without setting

a time for meals or sleep. Also, poor sleep

hygiene followed by excessive caffeine

consumption contributed to the maladaptive

lifestyle, a marked maintaining factor for the

patient's clinical picture.

The patient's internal resources and strengths

consist of intelligence, ambition to succeed,

conscientiousness, resilience to challenges and

determination. She also declares herself a faithful

and family-oriented person, being characterized

by stability in life, both personally and

professionally.

Purpose

The purpose of this case study was to

disseminate a specific example of how infertility

affects mental health, offering a multidisciplinary

approach from both traditional CBT and health

psychology. In addition to this, the case study

presents important cultural aspects regarding

psychotherapeutic process and access to health

care. This case study serves as an academic

shaped tool designated to illustrate, as clear as

possible, a way of putting theoretical benchmarks

into practice.

Methodology

Assessment

For the assessment part, EC completed three

questionnaires: The Fertility Problem Inventory

(FPI) (Newton et al., 1999) where she scored 160

which indicates moderate infertility-related stress,

Beck Depression Inventory (BDI) (Beck et al.,

1961) EC scored 31 which indicates severe

depression and on The Coping Inventory for

Stressful Situations (CISS) (Endler & Parker,

1990a) she obtained 38 on the emotional coping

subscale indicating the coping style she uses

frequently. The instruments have been translated

in Romanian language by a team of specialists

using reverse translation.

Case Conceptualization

The approach to this case will be based on

cognitive-behavioral therapy, as its success rate

in the treatment of depression has been proven

(Thimm et al., 2014; Twomey et al., 2017; López-

López et al., 2019 ). Therefore, the models of

conceptualization of the case will be detached

from the cognitive-behavioral area. According to

Beck and Dozois (2008), in general, the

depressed person has a negative image of

himself, the world and the future (also called the

cognitive triad of depression). The content is

negative because it is fueled by distortions in

thinking, respectively by distorted automatic

thoughts that exacerbate depressive symptoms.

Cognitive intervention is therefore an essential

step towards improving clinical manifestations.

One of the most used models in

conceptualizing depression is the stress-

vulnerability model, which is an etiopathogenetic

model in the general conceptualization of a case

in cognitive-behavioral therapy. Research

indicates its effective use in explaining depression

(Colodro-Conde, et al., 2018). According to the

stress-vulnerability model, life events that come

with a certain level of stress (in the case of the

E.C. patient the diagnosis of infertility) interacts

with the levels of biological or psychological

vulnerability of the person (i.e. inability to achieve

an important life goal such as having children) and

can lead to the onset of psychopathology

(depression). The clinical picture is subsequently

described multidimensional in terms of emotional

state, biological manifestations, dysfunctional

behaviors and cognitions (automatic thoughts)

(David, 2017).

In order for the intervention plan to be built as

efficiently as possible and for the benefit of the

client, it is important that after the clinical

evaluation, a list of issues be drawn up to be

addressed, each problem separately. For the

case-specific clinical conceptualization in

cognitive-behavioral therapy, the most used

model indicated by the literature is the ABC

cognitive model (Beck, 1976; Ellis, 1962). The

basic assumption of this model is that it is not the

life event itself that affects us, but the way we

interpret it. The ABC model consists of the

following elements:

• The activating event (A) - which can be an

external situation (events in everyday life) or an

internal situation (emotions, thoughts, behaviors);

• Beliefs (B) - the person's beliefs / cognitions

in relation to the activating life event;

• Consequences (C) - the consequences of

cognitive processing of the activating event that

may manifest at the bio-physiological, emotional

and / or behavioral level.

After the start of the therapeutic intervention, to

these elements are added two more, learned and

practiced in therapy, namely disputing (D), which

involves the restructuring of dysfunctional

cognitions, and the effective assimilation (E) of

adaptive cognitions instead of maladaptive ones

(David, 2017).

Therefore, in this case, the activating event is

represented by the diagnosis of infertility (A), and

the consequences consist in altering the

emotional state (C) (depressive symptoms), with

response to the physical one (fatigue, social

isolation). Beliefs (B) are found in the way in

which patient E.C. interpreted the situation, that is

through dysfunctional thoughts:

Mental Health: Global Challenges Journal

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• Global evaluation: “It would be better to leave

anyway because I can't offer him anything” - the

tendency to evaluate in global terms, starting only

from a few isolated behaviors or situations;

• Intolerance of frustration: "I can't stand the

thought that they can have a baby whenever they

want and I can't" - E.C. considers it unacceptable

that she cannot fulfill an important wish, which

sets her apart from her friends; this triggered

negative emotions and behaviors (C) such as

loneliness and exclusion, absenteeism from work,

avoidance of social contacts;

• Global assessment and catastrophizing “I feel

that nothing in my life is worth it, I will never be

able to get over this failure” - maximizing the

importance of an event with an emphasis on its

negative side; these distortions have led to

hopelessness, lack of self-worth and diminished

meaning in life;

• Arbitrary inference: “Even my work

colleagues look at me differently, I think they feel

sorry for me... that I struggle so much with the

treatments and it still doesn't work… I don't even

want to go to the office anymore, I can't

concentrate on anything anyway”- leading to

concentration hypoprosexia, slowness in

expressing ideas and feelings of alienation

generated by self-perceived differentiation

between oneself and others;

• Overgeneralization and rigid thinking, in

absolutist terms: “I struggled for so many years

with IVF treatment and it didn't work, why would

this (psychotherapy) work? It's a waste of time,

only a child could save me. ”- E.C. tends to draw a

generally valid conclusion based on a single

event, which leads to a loss of confidence and

positive expectations; E.C. categorizes the

experience of having a child as an essential

condition for her psychological well-being and

meaning in life, failing to consider other

possibilities and, therefore, adopting a rigid

thinking style that prevents her from adapting to

the situation.

With that being said, the way in which the

patient perceived the triggering event and the

thoughts that she attributed to it were the reason

why the depressive symptoms were installed and

maintained.

In order to keep a holistic presentation of this

case, a clinical classification was also made. This

classification may help clinicians analyze the case

on multiple levels, hence outlining and improving

the intervention plan centered on the patient’s

psychological needs.

According to the Diagnostic and Statistical

Manual of Mental Disorders, fifth edition (DSM-5),

depressive disorder due to another medical

condition has five diagnostic criteria, as follows:

A. A prominent and persistent period of

depressed mood or pleasure / interest significantly

diminished for all or almost all activities;

B. There is evidence from history, physical

examination or laboratory findings that the

disorder is a direct pathophysiological

consequence of another medical condition;

C. The disorder is not better explained by

another mental disorder (e.g. adjustment disorder,

in which the stressor is a serious medical

condition);

D. The disturbance does not occur exclusively

during a delirium;

E. The disorder causes clinically significant

distress or impairment in social, professional, or

other important areas of functioning (American

Psychiatric Association, 2013).

Patient E.C. meets all the diagnostic criteria

listed above.

The diagnostic code of the International

Classification of Diseases, tenth edition with

clinical modifications (ICD-10-CM) is F06.32 -

mood disorder due to a known physiological

condition, with major depressive episodes (World

Health Organization , 2002).

The classification in the International

Classification of Functioning, Disability and Health

(ICF) refers to the areas of functionality affected

by somatic pathology and psychopathology.

Patient E.C. has the following moderate and

severe impairments:

• b130 - energy and impulse functions: b1300

energy level (severe impairment); b1301

motivation (severe impairment); b1302 appetite

(severe impairment);

• b134 - sleep functions: b1342 sleep

maintenance (moderate impairment) and b1343

sleep quality (severe impairment);

• b140 - attention functions: b1400 sustaining

attention (moderate impairment);

• b152 - emotional functions: b1521 emotion

regulation (severe impairment); b1522 range of

emotion (severe impairment);

• b160 - thinking functions: b1600 pace of

thought (moderate impairment);

• b660 - procreation functions: b6600 fertility-

related functions (severe impairment) (World

Health Organization, 2001).

Results

Table 1. Inventories scores pre and post

intervention.

INSTRUMEN

INITIAL

ASSESSMEN

POST-

TREATMENT

ASSESSMEN

FPI

160

100

BDI

CISS

38 (emotional

coping

subscale)

34 (task-

oriented

coping

subscale)

Mental Health: Global Challenges Journal

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Sessions of treatment

The intervention for patient E.C. was

multimodal, starting with individual

psychotherapy based on cognitive-behavioral

therapy initially with a standard 12-session

plan, antidepressive medication (the patient

resumed imipramine) and additional couple

counseling offered by IVF clinic. This aspect

could represent an important aid in the

outcomes of treatment. The main objectives

of this case study are:

• Drawing up the list of problems and

addressing the main emotional issues;

• Normalizing diagnoses (both infertility and

depression) and consolidating hope;

• Strengthening self-esteem and psychological

flexibility by disputing distorted thoughts;

• Encouraging social reintegration and

looking for alternatives;

• Developing and implementing a balanced

lifestyle.

Sessions 1-4

The focus in these sessions was on psycho-

education about psychological disorder

(depression) and somatic condition

(infertility) noting essential aspects such as

risk factors, maintaining and protective

factors, the maladaptive effect of negative and

distorted cognitions on mood and, also, goal

setting. The main objective for this module

was to explore the cognitive and affective

valences of the patient, together with the

collection of essential data from the life

history (personal, professional, medical). The

assessment tools were administered and the

list of problems was made. The patient was

presented with the advantages and

disadvantages of the therapeutic process, the

possible obstacles she may encounter, the

manner in which it is carried out, the expected

results and what will happen at the end of

psychotherapy. She also found out the

benefits of and how therapeutic counseling

can enhance the course of medical treatment

for infertility. In addition, she learned how to

set goals for herself and how homework can

facilitate this process. By the end of third

sessions, EC was able to: use self-monitoring

tools such as Dysfunctional Thought Record

(DTR) to assess her thoughts, add her own

tasks for homework and summarize the

therapy session.

Sessions 5-8

In this module, the objectives were set around

the disputation of negative thought patterns

and finding alternatives for them, with the

aim of increasing the frequency of positive

thoughts. The main techniques used were

cognitive restructuring -

empirically/pragmatically/ logically disputing

central distorted cognitions and automatic

thoughts, positive reinforcement techniques

and behavioral activation for re-engaging the

patient in daily activities, relaxation

techniques to reduce insomnia, problem-

solving techniques and assertive training to

improve social skills, to strengthen self-

esteem and to develop healthy coping. During

the week, one of the homework EC had to do

was to monitor her mood and thoughts daily

and discuss this at the beginning of each

session, keeping a daily record of the positive

and negative thoughts she was experiencing,

identifying and addressing persistent

dysfunctional cognitions. In addition to this,

she also started journaling.

The stress inoculation training procedure

(SIT) has been used to manage the acute level

of stress related to infertility. This technique

is useful in cases where the activating event is

imminent and cannot be changed for various

reasons (such as in crisis situations). The

training is based on a series of techniques

aimed at forming adaptive and effective

coping strategies, and the techniques used

here are problem solving and assertive

training, cognitive restructuring, behavior

modification techniques (e.g. successive

approximations) and relaxation techniques

and meditation (e.g. mindfulness) (David,

2017). Taking into account that one of the

patient’s strong beliefs is religion, spiritual

techniques such as prayers have also been

inserted.

Also of great importance to patient E.C. is to

strengthen her resilience. She is about to face

other stressful life events with the resumption

of infertility treatment. The treatment itself is

a source of stress through its procedures, the

uncertainty of a favorable outcome, the

possibility of failure, the long waiting time

and the associated financial costs

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(Maroufizadeh, et al., 2018). Therefore, the

patient must be prepared to face the

challenges that will follow and also to be able

to look for and consider alternative strategies

(other possibilities such as adoption,

acceptance of a life without a child, etc.).

Some of the techniques that have been

considered here are finding and highlighting

strengths, internal resources, transforming

them into general action strategies,

metaphorical techniques and role play for

practicing the application of strengths,

decision-making techniques and process

focus, to the detriment of the result. By the

end of this module, EC managed to make the

transition from identifying and evaluating

automatic thoughts to fundamental beliefs, to

acquire new restructured thoughts and beliefs

and to actually believe them and to set a

different routine in her daily life in order to

achieve her therapy goals.

Sessions 9-12

The latter module focused on interpersonal

relationships and the growth of time spent

doing enjoyable activities, time management

and goal setting to improve mood. The role-

playing technique was used here, and as

homework, in addition to the self-monitoring

sheets, the patient had to complete tasks

focused on daily journaling about activities

that she enjoys, weekly planning of what to

do and setting clear goals along with steps to

achieve them. The patient was taught self-

help techniques to apply whenever she

needed, such as self-monitoring, self-

assessment, and self-management of

reinforcements (by preparing the environment

to reinforce desirable behavior). Further, the

therapist together with the patient worked on

therapy closure, progress has been recorded

and the patient received validation from the

therapist for this. She also received

counseling to prevent relapses. The most

important aspect here is for the patient to be

able to recognize for herself when she needs

specialist help, if the symptoms are getting

worse, and to act accordingly. After

completing the individual psychotherapy, the

patient, together with her husband, benefited

from a couple psychological counseling

program for infertility problems at the clinic

that offers medical treatment.

At the end of this module, EC received again

the instruments that she completed in the

beginning of therapy (FPI, BDI and CISS)

and the after scores supported the progress

observed during sessions: FPI - 100 indicating

a decrease in infertility-stress level, BDI - 19

mild to moderate depression, CISS - 34 for

task-oriented coping strategy, suggesting a

switch from using emotional coping strategy.

She also began to individually integrate

mindfulness exercises into everyday life along

with other relaxation techniques such as

progressive relaxation and diaphragmatic

breathing. EC reported that the skills learned

in therapy mostly helped her shape new

perspectives in thinking about her medical

condition stating that: „Even if IVF treatment

won’t be successful, that doesn’t mean it’s the

end; I have other possibilities so now I am

willing to consider them.” She also mentioned

that the improvement she was most proud

about was the reduction of negative self-talk

and returning to work being able to focus on

tasks

Discussion

Obstacles in the course of treatment

Even if EC recorded considerable progress

during therapy sessions, some complicating

factors were present, thus it’s important to

examine their origins in order to try and

overcome them. The therapist decided to

extend the psychological analysis on an

integrated human-environmental-

physiological model for the purpose of

observing how a patient’s individual

characteristics may act as obstacles in the face

of therapy objectives.

First, the most relevant literature models for

analysis will be selected. By extracting

essential information from the patient's

personal and professional history, one can

note the environments that influence her

health. For example, in order to be able to

determine which environmental aspects of

work are relevant to the patient's health,

which may be predisposing / maintaining

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factors, it is necessary to refer to models of

work psychology.

One such model, which summarizes the

necessary information and captures the

relationships between internal and external

factors is the SWOT analysis (strengths /

weaknesses / opportunities / threats). While

external analysis focuses on environmental

opportunities and threats, internal analysis

helps to identify strengths and weaknesses. At

the same time, it helps to understand which of

one’s own resources and capabilities are

rather sources of competitive advantage and

which are less likely to be sources of such

advantages (Gurel & Tat, 2017). In this case,

the following can be noted:

• Strengths: ambition, conscientiousness,

taking responsibility, leadership skills;

• Weaknesses: hyperactivity, overwork,

inhibition, repression of vulnerabilities,

negative emotionality;

• Opportunities: leadership positions;

• Threats: stressful working conditions,

leadership responsibilities - making decisions

for teams of people (marked stressor), health

problems (infertility).

Furthermore, it is important to analyze the

patient's personality profile, noting the key

features that could contribute to maintaining

the psychological symptoms. Personality

traits contribute to changes in psychological

well-being when they interact with stressors.

Thus, according to Freiburg's

conceptualization model, personality can be

divided into 12 dimensions, which when

analyzed in context, can provide a better

understanding of the person's preferential,

attitudinal, and behavioral characteristics

(Fahrenberg, Hampel, & Selg, 2010). ). Most

relevant to patient E.C are:

• Life satisfaction - people with low scores for

this trait have a negative view of life events,

have low self-efficacy, tend to ruminate, and

in unfavorable conditions easily switch to

depressive mood;

• Achievement orientation - people with high

scores in this trait are characterized by

activism, dominance, competitive behavior

and tend to devote more time to the

profession than to leisure activities (interests,

passions);

• Inhibitedness - this dimension refers to

hesitant, withdrawn behavior with low desire

for verbalization. People with high scores feel

socially inhibited, make friends hard, avoid

expressing feelings, and tend to stay away

from social gatherings;

• Strain - on this dimension we find stress,

tension, exhaustion, feelings of overwork,

responsibility and time pressure;

• Emotionality - people with high scores on

this factor often face internal conflicts, are

irritable and feel asthenic or indifferent. They

have frequent mood swings, but are most

often characterized by depression or anxiety.

There is a risk of psychosomatic

exacerbations (Biehl et al., 2020).

Therefore, these traits may explain the

increased predisposition to both psychological

and somatic vulnerabilities (i.e. unspecified

infertility). A system is dysregulated if it has

certain vulnerabilities that have accumulated,

so personality traits are here predisposing and

precipitating factors to psychopathology.

Moreover, these traits can affect the course of

therapy (e.g. EC faced some issues with

keeping her journaling routine and doing her

homework, that can be partially explained by

her strain and emotionality traits).

In addition to this, an important influence in

the patient's psychopathology is found in the

meaning that she attributes to the significant

life event she is going through. Most often,

when a person is faced with an unforeseen

and imminent situation (with a negative

valence), she/he tends to wonder why this

happened to him/her. If the person's specific

attribution pattern consists of stable beliefs

over time, then the person will tend to extend

their long-term helplessness. It should be

noted that these patterns of helplessness have

been formed over time through learned beliefs

about helplessness (e.g. "whatever I do will

not change anything"). If the pattern of

attribution is rather global, the person will

tend to extend their helplessness to more than

one life situation or context. If the attributions

are internal, then the person will feel

excessively guilty and his/her self-esteem will

be considerably affected (Peterson, Maier, &

Seligman, 1993).

This is called the learned helplessness model

and was reformulated by Abramson,

Mental Health: Global Challenges Journal

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Seligman, and Teasdale (1978) as a cognitive

model of depression. In other words, patient

E.C. presents an attributive style focused on

global assessments (“I feel like nothing in my

life is worth it, I will never be able to get over

this failure”) and excessive self-blame, which

goes beyond the situation (“I can’t stand the

thought that they can have a child whenever

they want and I can't ”) generating feelings of

worthlessness and helplessness. In other

words, depression results from the patient's

tendency to attribute his or her own failure to

stable internal qualities (e.g. self-efficacy,

personal skills) and not to internal or external

situational factors (e.g. biological limitations,

lack of treatment compliance). The therapist

reported here a difficulty in assessing the

patient’s mood flow across sessions as she

didn’t show consistency in completing self-

monitoring worksheets. The main reason for

this inconsistency was that EC did not seem

to understand the way these exercises can

help her, arguing that her mood is always the

same and nothing can help her change it. The

therapist worked together with the patient on

these self-monitoring worksheets during some

therapy sessions, helping her complete them

and then challenging the thoughts that she

experienced during and after completion.

Using past experience as proof that some

strategies can actually improve her mood (for

example, when she is sharing her thoughts

and concerns with her husband who is

showing her understanding and support), EC

was able to recognize her tendency towards

feelings of helplessness and minimization of

positive aspects. As a result, she was willing

to try again with self-monitoring, this time

putting in a good effort.

Access and Barriers to Care

Combining the medical treatment for

infertility with psychotherapy can lead to an

emphasis on the financial strain. Besides the

fact that medical treatment is expensive and

long lasting, the access to it depends heavily

on the socio-economic status of the person

and also of the country she lives in. A barrier

for EC consisted of low access to infertility-

related clinics, as she lives in Romania, a non-

western, still developing country, that doesn’t

offer so many opportunities in the healthcare

industry. She found a suitable clinic in

another city, now having to bear the

transportation costs as well. This aspect can

contribute to a time conflict between medical

treatment and psychotherapy. As a result,

some therapy sessions were held online, the

therapist offering this possibility in order for

EC to complete her medical appointments

which overlapped with therapy.

Another possible barrier to care can be the

absence of psychological counseling services

in IVF clinics. It has been shown that

psychological support for both individual and

couple levels offered simultaneously with

medical treatment in IVF clinics improves

treatment success rates and overall mental

health of the patient by reducing depressive

symptoms, anxiety and stress levels

(Vioreanu, 2021). Some patients do not afford

to pay for extra therapeutic services, thus they

may struggle with finding help. Fortunately

enough, EC managed to maintain both types

of treatment, plus a couple counseling module

offered by the clinic.

End of therapy sessions and follow-up

CBT intervention has led to a reduction in

depressive symptoms as well as a change in

dysfunctional attitudes and cognitions. She

returned to work, began a reconciliation

process, and resumed infertility treatment.

Twelve individual psychotherapy sessions

were required for partial remission of

symptoms and antidepressant (tricyclic)

medication, and in the months following

treatment, the patient continued to report

improvements in depressive symptoms as

well as dysfunctional attitudes and self-image

(consolidation of progress over time is also

accentuated by the couple's psychological

counseling). The patient understood how

negative thoughts are a barrier that prevents

her from enjoying pleasant things and social

activities. She internalized her skills learned

during therapy sessions (techniques for

stopping negative thoughts to avoid

rumination). At the same time, she and her

husband were able to consider other options

in case of failure of infertility treatment,

making the decision to adopt a child. To keep

a better track of the treatment outcomes, apart

from the measures taken at the beginning and

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the end of therapy, EC also completed a

feedback sheet at the end of each session. She

self-reported how she felt during the therapy

session, if the therapeutic relationship was

optimal, she reflected on what she learned and

how well she thinks she can apply the

techniques further, in everyday life. The

therapeutic relationship followed a consistent

pattern where the patient maintained her

wellbeing.

To ensure the stability of the balance even

further, after psychotherapy, the following

was recommended:

• Building a healthy lifestyle, based on

exposure to wellbeing factors that lead to the

patient's well-being: significant people,

spending time in nature, engaging in activities

that will please the patient and help health in

general (sports, travel, music, eliminating

monotony), reducing exposure to stressors /

psychotoxic factors (such as reducing

overwork); the goal is to spend as much time

as possible in well-being;

• Creating a regular sleep schedule (sleep

disturbance can maintain mood swings): by

controlling the stimulus, relaxation

techniques;

• Maintaining the adaptive effort, in order to

mobilize energy and the existential drive

(through self-challenges, experimenting with

new, positive things, ensuring a living

environment with various conditions).

The follow-up session scheduled three months

after completion of therapy confirmed the

lasting effects of improvement over mood and

thinking patterns. The patient followed most

of the therapist’s recommendations and she

was able to reach an important decision

regarding a possible negative result of the

medical treatment (i.e. adopting a child). Her

scores on BDI and FPI remained low and

showed a slight but, important, increase on

CISS task-oriented coping subscale score.

The patient requested to continue visiting the

therapist, remaining under psychological

surveillance with a session once every three

months.

Implications of the case

This case study shows that infertility has

extensive effects on the bio-psycho-social

level, depression being the most common

psychological consequence, especially among

women. An effective intervention plan will

address all aspects of the patient's life,

analyzing key variables from the bio-

physiological, environmental and psycho-

social level. In this case, too, the environment

in which the person lives, the factors of

psychological well-being, lifestyle and social

support were evaluated. The perspective of

approaching this case adds value by

combining classical CBT with elements of

health psychology and counseling.

The psychotherapeutic intervention itself was

the main element in the management of the

clinical picture, but the patient benefited from

more than that, learning self-help strategies

and techniques that would strengthen her

long-term progress. Relying on her inner

resources such as conscientiousness and

determination (which helped her with

homework and the integration of skills

learned in therapy), faith and family spirit

(through which she solidified her resilience

by managing the challenges that followed) the

patient managed to break the vicious circle of

negative cognitions and bring back positive

cognitions accompanied by adaptive

behaviors. To all this is added the importance

of support from her husband and friends.

The effect of social support on psychological

well-being and, implicitly, on the reduction of

depressive symptoms is well documented. A

model in the literature that explains these

associations is the model of social causality

(Kaniasty & Norris, 2008) according to which

social support is even a precedent for

psychological well-being, its lack leading to

distress. Based on the relationship between

social support and stress, the model argues

that the presence of an active support network

significantly reduces the risk of depression

because it helps boost self-esteem and

decreases engagement in dysfunctional

cognitions (Zhen et al., 2018; Ren et al., 2018

). Therefore, the fact that the patient benefited

from social support from her family was an

important aid in managing depressive

symptoms.

The outcomes of this case study are in line

with past research. For example, a recent

meta-analysis suggested that CBT techniques

led to a significant reduction of depression

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rates in infertile women and to a successful

replacement of dysfunctional behaviors with

more adaptive ones (Abdollahpour et al.,

2021). Case studies across literature which

focused on delivering CBT to infertile

patients, even if scarce, suggested that

modification of cognitive distortions and

faulty core beliefs due to CBT techniques

indicated considerable improvements in

interpersonal life of the patient (Choudhary et

al., 2019). Considering the fact that current

guidelines recommend treating severe

depression with pharmacotherapy and that

research shows that the most efficient way of

treating severe depression is through a mix of

CBT and ADM (antidepressive medication),

this can also explain the favorable outcome in

EC case (Vasile, 2020; Nakagawa et al.,

2017).

Another important clinical implication that

derives from this case is the utility of

screening for depression in IVF clinics.

Infertility patients should be screened for

depression, stress and anxiety before starting

any medical treatment in order to assure

positive outcomes. That is because

psychological wellbeing plays an essential

part in treatment compliance and, so, CBT is

recommended to those patients who show an

altering psychological state.

As a custom note, this case has important

implications for Romanian culture and

intercultural research. Firstly, because there is

a significant paucity of studies contextualized

on Romanian society, where psychology was

negatively impacted by its outlawing during

the communist regime. Consequently,

research in this field is quite limited, also due

to the lack of validated psychological tools.

One way to move things forward is the

translation and validation of questionnaires

and tests on the Romanian population, aspect

that has been remedied in recent years (Ispas

et al., 2014).

Secondly, this case study adds on the

perspective of how different populations may

respond in the face of a similar challenge, if

compared with other case studies of infertile

patients from different cultural backgrounds.

For example, EC’s reaction in the face of

infertility diagnosis (i.e. negative, distorted

thoughts such as catastrophizing, all-or-

nothing thinking) might be partially explained

by her cultural-framed tendencies of valuing

cohesion, obligation and familism. These

values are characteristic to a collectivist

culture (Burholt et al., 2017), thus supporting

her emphasis on the importance of having

children and social comparison (e.g. „I can’t

stand the thought that they [friends and

workmates] can have a child whenever they

want and I can't”). If EC would have been

raised in a different culture, an individualistic

one, values and cultural norms could have

shaped a different thinking pattern, therefore,

she could have had a different outcome

Limitations and Strengths of the

Study

Limitations of the Study

Some limitations can be acknowledge here.

For instance, any case study is subject to

researchers’ own subjective feeling which has

been created throughout therapy sessions and

therapeutic relationship and it may influence

the way the case study is presented. Another

example is that case studies as such are

difficult to replicate due to specific, individual

and cultural characteristics. A third limitation

may be connected to the difficulty in

generalization of results to the wider

population, considering the personal note of

the case and cultural shaped influences. This

means that the conclusions drawn from this

case study may not be transferable to other

settings

Future directions

This case study highlights the importance

of psychotherapy for infertility patients and

indicates that traditional CBT has a positive

outcome on managing depression. Sure

enough, we must not overlook the fact that

this patient followed a mixed treatment plan,

combining CBT with ADM and couple

psychological counseling, contributing to

overall improvement. Changes in thought

patterns (e.g. controlling negative thoughts

and quitting overgeneralization), behavior

modification by adopting adaptive patterns

(e.g. returning to work and keeping a healthy

sleep schedule) are skills learned through

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CBT strategies and techniques that set the

patient on the right track to recovery.

For this case study, an analysis concerning

the impact of CBT and the impact of

medication was not performed. It would have

been useful to see under what percentage did

the therapy help alone, compared to

medication. Future works can add this

dimension into their assessment. Clinicians

are encouraged to use the screening of

infertility patients for depression, but also for

anxiety and stress, as these are the most

documented psychopathological

consequences of infertility (Galst, 2017). To

assure a good practice, the psychological

interventions should be applied at the

beginning, during and at the end of IVF

treatment, as it has been shown that infertility

treatment can worsen the psychological state

of the patients (cost, duration and uncertainty

of success rate) (Chu et al., 2017).

It would also be useful to look into mixed

CBT techniques and if their impact on

depressive mood can be more conclusive.

Because this case study only focused on

traditional CBT strategies, future research

could mix ACT with CBT in order to control

for any added value this might have.

Ultimately, clinicians and students could

investigate infertility patients with different

backgrounds such as other cultural origins.

This case focused on a patient born and raised

in a non-western, collectivistic country that is

considerably distinct in cultural orientation

compared to western countries. Some cultural

aspects such as rules of society, the

characteristic way of adapting, the meaning

and significance of life, traditions and beliefs

contribute to the way of evaluating and

responding in a certain life situation (for

example, coping with infertility).

To illustrate this, one study that focused on

establishing personality typologies in a

specific culture found that, in Romanian

culture, there are five types that can be

identified: the sub-controlled type (with

insufficient impulse control), the

overcontrolled type (with excessive impulse

control), the resilient type, the passive type,

and the tense type that is most prone to

irrational cognitions and maladaptive thought

patterns that could lead to psychopathology

(Sava et al., 2011). Therefore, emic

personality traits predispose an individual to

different outcomes in the face of an important

life event, changing the prognosis of a

disorder.

Conclusions

To ensure the stability of the balance even

further, after psychotherapy, it is

recommended to maintain an adaptive effort,

in order to mobilize energy and the existential

drive (through self-challenges, experimenting

with new, positive things, ensuring a living

environment with various conditions).

Concluding, the improvement of healthcare

services relies on such presentations of case

studies that can shift the focus in new

directions of good clinical practices.

Conflict of interest

The author declares that she has no conflicts

of interest.

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