Integration of Feminist and Cognitive Therapy In Intervention With Women With Depressed Feelings By: Sheila Lynn Kaltenberger A Practicum Report Submitted to the Faculty of Graduate Studies rn Partial Fulfillment of the Requirements for The Degree of Master of Social Work University of Manitoba @ August,2002 nationare n*t \a$ona.ubrav 3få""t1å.å" Acquisitions and Acquisitions et BibiiographicServices servicesbibliographiques 395 Wellington Street 395, rue Wellington Ottawa Ol.l KlA ON4 Ottawa ON KIA 0N4 Ganacla Ganada Yout frl€ vouo réláffi our frlo Notte nilércnæ The author has granted a non- L'auteur a accordé une licence non exclusive licence allowing the exclusive permettant à la National Library of Canada to Bibliothèque nationale du Canada de reproduce, loan, distribute or sell reproduire, prêter, distribuer ou copies of this thesis in microform, vendre des copies de cette thèse sous paper or electronic formats. la forme de microfiche/ñln, de reproduction sur papier ou sur format électronique. 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Neither the droit d'auteur qui protège cette thèse. thesis nor substantial extracts from it Ni la thèse ni des ortraits substantiels may be printed or otherwise de celle-ci ne doivent êüe imprimés reproduced without the author's ou autrement reproduits sâns son permission. autorisation. 0-612-76975-5 Canad'ä THE TINIVERSITY OF MANITOBA FACULTY OF GRADUATE STUDIES ***** COPYRIGHT PERMISSION PAGE Integration of Feminist and Cognitive Therapy in Intervention with Women with Depressed Feelings BY Sheila Lynn Kaltenberger A ThesisÆracticum submitted to the Faculty of Graduate Studies of The University of Manitoba in partial fulfillment of the requirements of the degree of MASTER OF SOCIAL WORK SHEILA LYNN KALTENBERGER @2002 Permission has been granted to the Library of The University of Manitoba to lend or sell copies of this thesis/practicum, to the National Library of Canada to microfilm this thesis and to lend or sell copies of the film, and to University Microfilm Inc. to publish an abstract of this thesisþracticum. The author reserves other publication rights, and neither this thesisþracticum nor extensive extracts from it may be printed or otherwise reproduced without the author's written permission. Acknowledgements I dedicate this work to the memory of my Granny, wilhelminne Ferwoen Kretchmer, who taught me the love of reading and through her own "self ' education and determination, instilled in me the value of education. Your evening stories about the hardships of living with family violence, leaving an unhealthy relationship, working in the packing orchards with children to suppod, and having people judge you negatively for your survival decisions, left a lasting impression. They made for fascinating stories as a child, but as a mature woman and a clinician I "get it" now Granny. Thank-you for passing on your knowledge to this generation. I would like to acknowledge my appreciation of Dr. Diane Hebert-Murphy for being my faculty advisor and an excellent mentor. I have grown so much in my clinical and writing skills and I can't thank-you enough. A big thank you also goes to Dr. Karen Dyck for my "on site" supervision and invasion of her office. My dream of doing my practicum rurally would not have happened without you! Thanks to Dr. Brenda Bacon for completing my practicum committee with her mental health expertise. I would like to express appreciation to Patrick Tarnopolski, Sharon Edmundson and the Interlake Community Mental Health Team who approved and supported my practicum from the Interlake Regional Health Authority. I would also like to credit the Selkirk Mental Health Centre's librarian, Loma Weiss who operates the best kept secret in clinical research, for all your help. A heartfelt thank-you to all my colleagues/friends for their continued support, their books/articles and belief that I would complete this, especially the North Rural Unit of Winnipeg Child and Family Services (East Area philosophy lives on!). To all the women I have worked with through the years and the women in my personal life, thank-you for sharing your feelings and struggles with me. you have inspired this practicum. Sincere gratitude to the six women who participated in and supported this practicum, you helped make it happen. My heartfelt thanks goes to my soul mate and husband Brian for his encouragement, support and patient editing. You are my steadfast rock that upholds me in my accomplishments and I love you. To mymom: Thank-you for your pride in me and being here to see me through. You are a model of women's caring. Rest in peace and the secure knowledge that you did good ma! AtsSTRACT This practicum explored the usefulness of an integration of feminist and cognitive therapy in intervention with women experiencing feelings of depression. The practicum report reviews the literature on various theories of depression. Women,s experiences of depressed feelings are examined with a strong emphasis on the environment and context within which these feelings of depression develop. Relational cultural theory was utilized to develop this understanding. The report then examines the application of a brief model of intervention based on cognitive therapy and a feminist perspective used in individual intervention with six women in a rural setting. Two in-depth case analyses and a chapter on themes that emerged from the intervention are presented to illustrate the application of an integrated cognitive/feminist model of practice. The effectiveness of this brief therapy model is discussed based on Beck Depression Inventory scores, a program questionnaire, verbal and written client feedback, and clinical observation. 111 TAEI-E OF'CONTEi\TS Page CHAPTER ONE: INTR.OÐUCTIOI\ 1 CHAPTER TWO: LITER,ATURE, REVIEW 3 Understanding and Defining Depression J Theories of Depression 7 Psychoanalyti c/P sychodynamic Theory 7 Biological factors and Genetics Theory 8 Behavioral and Cognitive Theory I Interpersonal Relatedness Theory 10 Problematic Behaviors as defined by Cognitive Therapists l1 What Happens in Cognitive Therapy? t2 Restructuring Positive Thinking - A Cognitive Techniques 13 Strengths and Lirnits of a Cognitive Model 14 Cognitive Therapy, Does it Work? Empirical Evidence t4 CHAPTER THREE: WOMEN, DEPRESSION AND RELATIONAL CULTIRAL THEORY: A F'EMINIST PERSPECTIVE 16 Historical/Structural Context and the Social Environment 16 'Women Oppression of Within Traditional Therapeutic Relationships 19 Responsibility of Caring and Maintaining Relationships Related to Gender I9 Relational Cultural Theory 20 Cognitive Therapy Challenged by a Feminist Critique 25 Re-labelling of Pathol ogzing Concepts 25 Focus on Feelings 26 Integration of Social Role Theory 2l Why Feminist Practitioners Like Aspects of Cognitive Theory 28 Intervention from a Feminist Perspective 29 Evaluating Feminist Therapy 30 Conclusion 32 CHAPTER FOUR: THE PRACTICUM SETTING 35 Practicum Objectives 35 Objectives For tndividual Therapy 35 Leaming Objectives for the Practicum 35 Clients 36 Duration of Therapy 36 Setting 36 iv Page Supervision 36 Agency Expectations 36 Exclusionary Criteria JI Clients Experiencing Crisis or Suicidal Ideation During Therapy 37 CTIAPTER F'IVE: INTERVENTION 39 Overview 39 Interventioú 39 Assessment 42 Goal Setting 44 Themes that can Be Present in'Women With Feelings of Depression 44 Loss 45 Anger 45 Shame 47 Cognitive/Feminist Techniques That Can Be Utilized 47 Assertiveness Training 47 Self-esteem Training 48 SelÊnurturing 49 Validating 49 Restructurin g/Reframing Thoughts 50 Possible Contradiction [n the Therapy Models 52 Termination 52 Evaluation 53 Beck Depression Inventory 53 Rural Setting 56 Client Summaries 57 CHAPTER SIX: TWO CASE STUDIES 63 MS. A 63 MS. B 81 CHAPTER SEVEN: THEMES/SIMII,ARTTIES FOI ND 102 IN CLINICAL OBSERVATION Difficulty Labeling Feelings and Lack of Awareness of Thoughts r02 Cognitive Difficulties 104 Social Isolation 104 Economic Status t0l Gender Socialization 108 Successful Outcome of Treatment and Client Satisfaction 110 Effect on Clinician From Clients'Evaluation rt2 PAGE CItrAPTER. EIGI{T: CONCI USION 114 Figure I BDI-II Pre-test/Post-test Scores lll vi CT{APTER ONE Introduction My primary practicum objective was to provide counselling services for women who self-identify with feelings of depression. To accomplish this I utilized an integration of cognitive and feminist therapy to facilitate the treatment of depressed feelings. For the purpose of mypracticum, depression was defined as a description of feelings, not as a diagnostic label. A feminist perspective stresses the importance of relationships and raises two main issues in understanding depressed feelings: the role of environmental/contextual factors and gender issues. Inter-relatedness and relational cultural theory were explored to help advance this understanding. This practicum is relevant to social work practice because the feelings of depression are common in the female clientele we serve. It is also typical for clients to be further pathologized when seeking help, especially when gender stereotypes, and social and environmental variables are not taken into consideration (Crowley Jack, 1991). Therefore, my second objective was to help women understand the context and environment in which their feelings of depression developed. I also strived to help clients develop healthier coping strategies for stressors, develop problem solving skills and to enhance selÊesteem. This included