Tyshawna identifies herself as a 35-year-old Black, Lesbian female (preferred pronouns: she/her). She presents to your outpatient mental health practice for an initial evaluation, and reports the following information:

She feels little energy, little motivation, finds little pleasure in her life, and is pessimistic about a better future for herself. Her life seems meaningless and empty. She feels worthless and guilt-ridden, but does not know why. She states that she has felt unhappy "...for as long as I can remember...since I was little." She thinks about dying "every day," but has never attempted suicide. She denies any intention or plan to self-harm. She denies use of substances.

She feels tense and nervous "all the time." She is "so anxious in the morning" that she has to force herself to leave home for work. At work, she puts on a "happy face" so everyone sees her as sociable and pleasant. Privately, though, she cannot wait to return home. She only goes out when she absolutely has to. She hates being in public places or in crowds.

Tyshawna has worked as a customer service representative at the same company for ten years. Despite consistently earning superior evaluations, she has been passed over numerous times for promotions by less qualified co-workers. She wonders if her race or sexual orientation are reasons.

She lives alone in a studio apartment and has never been married. She experienced one serious relationship, in her early twenties. That relationship ended when she discovered that her then-partner - a male - was cheating on her. She does not trust men. Although she identifies as Lesbian, she has never been in an intimate relationship with another woman.

Tyshawna is prescribed medication for hypertension and diabetes. She experiences episodic headache symptoms that have worsened recently. She describes herself as "unattractive and fat." A Mini-Mental State Exam (MMSE) reveals no obvious neurocognitive impairments. Intellectual functioning is estimated to be above average.

Tyshawna appears weepy, sad, and uncomfortable; however, she is responsive to questions, expresses motivation to "feel better," and otherwise seems to be a viable candidate for therapy.

How do you think Tyshawna's behaviours are worsening her symptoms and pessimistic thoughts? Please provide references