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  • Case study: How CBT can be applied in the treatment of depression

Using CBT in the Treatment of Depression | Private Therapy Clinic

The aim of this case study is to show through the use of a client study, how cognitive behavioural therapy ( CBT ) can be applied in the treatment of depression. The patient is a woman with a 2-year history of depression connected with low self-esteem, guilt and shame. An account of the CBT treatment carried out over 12 sessions is given. Noticeable improvements on measurements of mood and hopelessness, with an improvement in social and occupational functioning were achieved.

Mary is a 26-year-old nurse, who was referred for treatment for the management of depression. She presented with a 3-year history of depression along with issues related to low self-esteem and relationship problems, she was referred by her GP after being prescribed various forms of antidepressant medication over a 2-year period, this medication did not seem to be effective.

Presenting problems

Mary’s depressive symptoms lead to her social and occupational functioning being impaired. She found it difficult to complete tasks related to her job, and had been disciplined at work even though she had previously excelled in her role. She explained that she felt somewhat uncomfortable at work and found making conversation with colleagues quite challenging. She considered herself to be ‘dull’, ‘boring’ and ‘unlikeable’, which as a result lead to her isolating herself socially. Over the course of her depression she decreased her pastimes and social activities, and started to use all her free time on her own, in bed or “attempting to catch up on tasks related to her job.”

Mary was in a relationship with Angela, who lived in Scotland with her two year old son. Angela was still married to her husband when they first met and Mary felt guilty for “ruining a marriage,” and “being involved in a same-sex relationship”, therefore, this was a part of her life that she didn’t tell people about. She explained her reason for keeping this to herself was due to a fear of people judging and rejecting her over it. She also did not feel secure in the relationship and had fears about Angela’s commitment to her although she did not want to end the relationship.

Mary has a sister who is two years older than her who also has a history of depression, she sees this sister as being a good form of support. She states that she also has a good relationship with her father although “he is not in touch with my generation” and therefore “he’s not really able to understand me”.

Mary’s mother died in a car crash when she was 10 years old. She described them as having a close relationship and found the first year after her mother’s death a particularly difficult time. Mary remembers her childhood as being a happy one where she spent lots of time with her parents, who had a good relationship with one another.

Mary has no previous history of therapy but had a good awareness of her difficulties and was willing to engage in a time-limited treatment of CBT as well as continuing to take the antidepressants which her GP prescribed.

Treatment outcome measures

Variations in levels of depression and anxiety were assessed using the Beck Depression Inventory (BDI) (Beck & Steer, 1993a), and Beck Hopelessness Inventory (BHI), (Beck & Steer, 1993b). Both the BDI and the BDI have been extensively tested for reliability and validity (Conoley, 1987; Dowd, 1992; Owen, 1992). These Measures were administered pre-therapy, mid-therapy, and post-therapy. The Improving access to Psychological Therapy service (IAPT) also recommends routine use of a combination of questionnaires, the PHQ-9 for depression, GAD-7 for anxiety, and three IAPT phobia scales (social, agoraphobia, and specific phobia) as well as the Work & social adjustment scale which assesses problems in functioning with work, home management, social leisure activities, private leisure activities, and family & relationships and therefore these measure were administered at the start of each session. Mary’s score on both phq-9 (16) and the BDI (32) indicate moderately severe depression, her GAD-7 score was 9 which translates as mild anxiety, WSAS scores for Mary were 18 which is associated with significant functional impairment. The IAPT phobia measures indicated that she would markedly avoid social situations and she would definitely avoid certain situations for fear of having a panic attack. Becks Hopelessness scale which was administered in order to help assess where she was at risk of suicide, Mary scored 17 on this scale which identifies severe hopelessness, Mary confirmed occasional thoughts of a suicidal nature however she denied any intent to act on these thoughts as she felt she would be letting everyone down.

FORMULATION

Case Conceptualisation

A cognitive case conceptualisation is a method of considering a client’s problems and issues using the cognitive model of emotional disorders (Beck, 1987). It includes beliefs (automatic thoughts, underlying assumptions, and schemas), emotional reactions, behavioural strengths and deficits, social factors that influence problems, and consideration of biological factors and maintaining cycles of the client’s difficulties. The conceptualisation, constructed with the client, can be amendment through the course of treatment and can used as a directive for any problems that arises for the client both outside of therapy and in the therapeutic relationship, it can also can act as a   “map” for the therapist (Persons, 1989).

Figure 2. The cognitive model as applied to depression (Persons, 1989).

After Mary’s initial assessment the therapist drew up a longitudinal formulation to help her consider Mary’s difficulties and plan treatment. This longitudinal formulation included the following.

Early experiences: Need to please mother, parents not socializing outside family home, loss of mother.

Core beliefs :

I am not likeable (As I’ve never had a lot of friends at any time in my life), I am not good enough and can never achieve enough (My sister and classmates were always better than me), I am a bad person (As I started a relationship with person of the same sex).

Irrational Rules/Assumptions :

‘If I date someone of the same sex, I am a bad person’, ‘If I tell my friends about my same sex relationship, they will disapprove and reject me’, ‘If I take on all the duties assigned to me at work’ (regardless of my large workload), ‘my workmates will like me, If I tell anyone that I suffer from depression, they will think that I am crazy’.

Precipitating factors :

A precipitating factor for Mary’s in her life was the start of a same sex relationship. Mary feels that people would not accept her because of this. As a result she prevented others from becoming to close to her to avoid having to reveal her secret.   This avoidance of social activity resulted in her spending more time at home by herself which precipitating her depression.

Figure 3. Formulation drawn up collaboratively with Mary based on Mooey’s (2010) depression model.

Perpetuating factors

The therapist used Mooray’s (2010), “The Six Cycles Maintenance Model” model to investigated Mary’s thoughts, feelings, behaviour and physical response (Figure 3) and collaboratively conceptualize Mary’s presenting difficulties while socializing Mary to the cognitive model by showing links between thoughts, feelings, behaviours and physical sensations. This diagram was used as a “road map” to help the therapist identify and focus on factors that are likely to be important in Mary’s depression and a rationale for the therapy interventions that the therapist would include in treatment (see figure 3).

The therapist helped Mary looked at a number of maintenance cycles which were feeding back into Mary’s difficulties, for instance when Mary is around her workmates she often has the automatic thought “Nobody likes me, I will never be able to form friendships”, as a result she becomes upset and feels rejected and goes on to isolate herself from workmates by avoiding them and having lunch on her own and therefore does not break the pattern of feeling uncomfortable around her workmates and rejected by them.

1. Negative Automatic Thoughts

As a consequence of feeling low Mary’s was having more negative automatic thoughts (NAT’S) about particular situations. These NAT’S seemed highly credible to her and came up regularly without much of her awareness. These NAT’s may have kept Mary’s negative core experiences going.

2. Ruminations and self-attacking

Mary sometimes found herself getting locked in ruminative, self-attaching thinking cycles of how she made so many mistakes and should have done things differently along with other self-attacking thoughts related to being weak and not good enough as a person.

3. Mood/Emotion

Mary identified various emotions connected to her depression which she frequently experienced such as stress, depression, unhappiness, dejection, guilt, shame and feeling sad about feeling sad all of which feed back into the her difficulties.

4. Withdrawal and avoidance

Throughout Mary’s depression she had isolated herself from others and avoided socializing and did not allow others to become close to her. She believed that she would not enjoy activities or be able to accomplish the things she wanted to. As a result of this avoidance she was not allowing herself the opportunity to test the truth behind her negative beliefs and limited her opportunity to find enjoyment or a sense of achievement from activities.

5. Unhelpful behaviours

Mary’s attempts to improve her emotions or balance her negative beliefs included taking on excessive work loads and seeking approval from others. These behaviours made her feel better in the short term but were part of what maintained her difficulties in the long term.

6. Motivation and Physical Symptoms

Mary’s physical symptoms of depression included feeling tired, tearful, on edge and having sleeping difficulties. These physical symptoms feed back into Mary’s depression leading to even less activity and contributing to a downward spiral

Therapeutic goals

Mary stated that through therapy she would like to focus on achieving the following:

  • To disclose to her sister and friends about her relationship with Angela;
  • To feel more secure with Angela, to discuss their relationship and plans for the future;
  • To achieve better ways of managing her time, and allocate more time for leisure activities;
  • To become better at communicating with people at work and no longer take on an excessive workload; and
  • To feel more at ease in social situations particularly at work.

Treatment contract

Guidelines on the duration of treatment length suggest that most of the progress made in CBT treatment is thought to take place in the first twelve treatment sessions, and additional improvements are moderately low when treatment carries on for further sessions (Barkham & Hardy 2001). If this is the case, the duration of the CBT treatment offered should be kept within this time frame. With this in mind an initial contract of 6 sessions was agreed on which was extended for a further 6 treatment sessions.

Assessment sessions 1-3

The early sessions were spent collecting client information, building therapeutic rapport, discussing issues around confidentiality and taking baseline treatment measures (see table 3). The therapist and Mary also looked at the foundations of the CBT approach and how it might be useful, the idea of working together using a structured, and focused method, with the requirement of weekly out-of-session assignments, and the opportunity to regularly review the treatment. The meaning of core beliefs, assumptions, and NAT’s were looked at and Mary started to recognize and document a number of these, many of which the therapist and Mary planned on returning to later when completing thought Records and developing Behavioural Experiments in sessions. The therapist and Mary also constructed the cognitive case conceptualisation (Figure 2.) over the three assessment sessions drawing up maintenance cycles and getting Mary to consider what could be done to try and break out of these patterns.

Sessions 4-8

As part of her out-of-session assignments Mary completed Weekly Activity Schedules (WAS) in order to monitor the activities she was involved in for each hour of each day, and to note the amounts of pleasure and mastery (feelings of accomplishment and effectiveness) actually experienced during each activity. She assigned a percentage rating to her mood for each activity she participated in and we made the connection between her mood and the activity. It discovered that Mary’s mood was worst when she was least active. After making this discovery the therapist worked with Mary to help her come up with a list of activities that she currently enjoys or used to enjoy as well as activities that gave her a sense of achievement. The therapist used Beck’s (1987) evolutionary model of depression to explain to Mary that when people have depression these activities might not be easy to do but if there is no investment there is no return. Therefore it can be useful to plan these activities in an attempt to strike a balance between pleasure and achievement. The therapist encouraged Mary to make time for these activities several times a week and explain how scheduling something makes people more likely to commit to it and that she should try to do the activities she has planned regardless of her mood. Mary monitored the outcome of this activity scheduling by taking regular mood ratings and noticed her mood ratings improved on the days she engaged in the pleasurable activities she had planned.

Mary completed a Daily Thoughts Record (DTR), which we used to investigate her thinking patterns. At first she found it hard to recognize her “hot thoughts” (automatic thoughts that carry the strongest emotional charge) and “alternative balanced thoughts.” To overcome this difficulty the therapist suggested that Mary try to note down the thoughts and feelings that go through her mind as close to the time she is feeling the strong negative emotion as possible. Mary started to enter brief notes onto her mobile phone when she felt a strong negative emotion and would later enter the information into a thought record. The therapist helped Mary use the items she had identified on the DTR as a ‘courtroom’ to challenge her hot thoughts by looking at evidence to support the hot thought and evidence that does not support the thought and consider a more balanced alternative. One of the ‘hot thoughts’ that Mary identified was on the DTR was ‘All hell will break loose if tell anyone about my partner’. After identifying this thought the therapist helped Mary consider further what might take place if she were to disclose to her housemate Tamara about her partner Angela. The therapist asked her to think about how Tamara might respond if roles were reskilled and if Tamara was the one who disclosed the information; or how Mary would react if her friend did not choose to reveal the information to her? Mary was amazed at how her beliefs and automatic thoughts as well as the intensity of her feelings could change so much.

In session seven the therapist and Mary set up a behavioural experiment to test out what would happen if she disclosed her sexuality to her flatmate. Despite the previous work on Mary’s thoughts related to this she still believed 90% that people would reject her in some way if she disclosed her sexuality. In relation to her flatmate she believed in the worst case she would chooses to move out after the disclosure or in the best case she would start spending less time with her. An alternative belief that Mary considered was that people would be surprised at the disclosure but they would not treat her any differently which she stated she believed 10%.

Mary returned in session 8 and had revealed the truth about her relationship with Angela to her housemate who at first became angry that Mary had hid it from her. During further talks with her housemate, Mary told her about her depression, the fact that she was seeing a therapist, and her problems coping with the death of her mother. Mary was surprised by her roommate’s positive reactions and later went on to share similar information with her sister. Mary re-rated her belief that people would reject her in some way if she disclosed her sexuality as 40% and re-rated the alternative believe as 60%.

Sessions 9-12

We looked at the beliefs Mary’s held regarding how she thought others saw her. She believed that everyone she knew found her boring, and then gave an account of how someone would act if they found someone “boring.” We agreed on carrying out a behavioural experiment that could be done during her break at work. This consisted of her observing her workmates and purposely watching for any proof of them being bored by what she was saying. Before the experiment, she assigned a rating to her belief (on a scale of 0-100%). After doing the experiment, she found no definite confirmation of people being bored and she rated her belief again. The rating of her belief after the experimental belief was less (55%) than before the experiment (95%). She carried out the behavioural experiment a few times in different situations, which eventually helped her see that in fact people did not regard her as boring. As a result Mary started to engage more in conversations with her workmates and attended a social event that her colleagues invited her to outside of work.

TREATMENT OUTCOME

At the time of discharge, there were noticeable improvements in Mary’s mood, levels of hopelessness, as well as overall social and occupational functioning. Mary became able to discuss her history of depression, the relationship with her partner, and the bereavement of her mother with people in her life. She disclosed her depression to her manager, who was understanding and compassionate. He arranged to temporary decrease her workload and planned regular meetings to talk about any difficulties at work. She was able to manage her time better and included leisure activates into her week. This progress can also be seen in the scales that were administered at intake, mid-therapy and discharge (seen table 4).

Table 3. Treatment outcome measures. (Beck & Steer RA, 1993a, 1993b & 1993c; Saunders et. al, 1993), (PHQ-9, GAD-7 & WSAS; part of the IAPT Minimum data set).

The rating of depression decreased significantly over time, shifting from being in the severe depression range to being in the mild depression range (BDI: 15, PHQ-9:4). The BHI scores also improved over time, showing a decline in the intensity of hopelessness. The score on the BHI of 6 was no longer showing an indication of high psychological distress. Mary’s GAD-7 (4) and Work   and Social Adjustment Scale scores (2) also decreased to subclinical levels.

Relapse prevention

In relation to preventing set backs she has kept records of material from the therapy sessions (homework and sheets from sessions) and a relapse prevention plan and states that she looks over them at times, particularly when she is experiencing low moods or particular difficulties. This self-conducted regular review of therapy sessions may assist in increasing her chances of maintaining the improvement achieved.

The ending of therapy with Mary was carefully thought out particularly because of the losses she experienced in the past. At the start of treatment we block booked all the dates we would meet on and Mary was reminded by the therapist midway through the sessions of the date they would end therapy on, the therapist again reinstated this a number of weeks before the end. The therapist regularly checked out how Mary was feeling about ending therapy and allowed Mary the space to discuss any fears she had about ending.

This case study looked at using a cognitive behavioural approach with a client with depression. The client improved in terms of mood, hopelessness, and overall social and occupational functioning. This outcome backs up various published research findings which provide evidence for the benefit of CBT in treating depression, (Rush, Kovacs & Beck, 1981; Scott, 2001; Department of Health, 2001).

Mary stated that she views her positive outcome as being a result of a mixture of CBT and medication treatment; though, she expresses the CBT treatment as being the more beneficial. She stated that CBT had “changed her way of seeing things” and provided her with a “method or system,” allowing her to steadily sort through and resolve any difficulties she experienced. This schema modification together with the restructuring of her cognitive account of depression may reduce her risk of relapsing.

Upon receiving this referral the therapist had some initial anxiety about working with a case presenting with difficulties related to her sexuality as the therapist did not have previous experience of working with patients with this type of presentation. Another difficulty was that this was only the therapist’s second depression case she had treated and this lack of experience added further concern for the therapist initially. However the therapist found the support of supervision beneficial and quickly realised that many of the techniques she had used before could also be applied to this case.

A limitation to Mary’s treatment was that she was only offered 12 sessions of CBT due to organisational restrictions which is less than recommend dose of 16-20 weeks for moderate to severe depression, (NICE, 2007a). It may have been beneficial to offer a further four to six sessions to allow the opportunity to tackle some of Mary’s rules and assumptions and therefore reduce the risk of relapse. However evidence which is contrary to this suggests that most of the progress made in CBT treatment occurs in the first twelve sessions, and further progress is moderately low after this (Barkham & Hardy, 2001). It will have been interesting to follow-up the outcome of this case at a later date to investigate the long-term effects of the treatment.

***If you’re struggling with your mental health and think you might benefit from speaking to someone, we offer a FREE 15-MINUTE CONSULTATION with one of our specialists to help you find the best way to move forward. You can book yours  here.

About the author

Dr Becky Spelman

Dr Becky Spelman is a leading UK Psychologist who’s had great success helping her clients manage and overcome a multitude of mental illnesses.

***If you think you might benefit from speaking to someone about the issues in this article, we offer a FREE 15-MINUTE CONSULTATION with one of our specialists to help you find the best way to move forward. You can book yours here

Barkham M, & Hardy GE. (2001). Counselling and interpersonal therapies for depression: towards securing an evidence-base. British Medical Bulletin. 57, 115-32.

Beck A.T. (1987) Cognitive models of depression, Journal of Cognitive Psychotherapy: An International Quarterly , 1, 5-37.

Beck AT, Rush AJ, Shaw BF, Emery G. (1979) Cognitive therapy of depression. New York: Guilford Press.

Beck A.T, Steer RA. (1993a) Manual for the Revised Beck Depression Inventory. San Antonio, TX: Psychological Corporation,.

Beck A.T, Steer RA. (1993b) Manual for The Beck Anxiety Inventory. San Antonio, TX: Psychological Corporation.

Beck, A. T. (1967). Depression: clinical, experimental, and theoretical aspects . New York: Hoeber Medical Division, Harper & Row.

Burns, D. D. (1999). Feeling good: The new mood therapy . New York: Avon Books.

Champion, L. A., & Power, M. J. (January 01, 1995). Social and cognitive approaches to depression: towards a new synthesis. The British Journal of Clinical Psychology / the British Psychological Society, 34, 485-503.

Colman, I., Ploubidis, G. B., Wadsworth, M. E., Jones, P. B., & Croudace, T. J. (January 01, 2007). A longitudinal typology of symptoms of depression and anxiety over the life course. Biological Psychiatry, 62, 11, 1265-71.

Conoley, C. W. (1987). Review of the Beck Depression Inventory (revised edition). In J. J. Kramer & J. C. Conoley (eds.), Mental measurements yearbook, 11th edition (pp. 78- 79). Lincoln, NE: University of Nebraska Press.

Dowd, E.T. (1992). “Review of the Beck Hopelessness Scale.” Eleventh Mental Measurement Yearbook, 81-82

Moorey, S. (January 01, 2010). The Six Cycles Maintenance Model: Growing a “Vicious Flower” for Depression. Behavioural and Cognitive Psychotherapy, 38, 2, 173-184.

National Institute for Health and Clinical Excellence (2007a). ‘Depression: management of depression in primary and secondary care’. NICE website. Available at: https://guidance.nice.org.uk /CG23/quickrefguide/pdf/English ( accessed on 15 Nov 2010).

Owen, S.V. (1992) “Review of the Beck Hopelessness Scale.” Eleventh Mental Measurement Yearbook, 82-83

Rush A, Kovacs M & Beck A. (1981), Differential effects of cognitive therapy and pharmacotherapy on depressive symptoms. Journal of Affective Disorders ; 3, 221-229.

Persons J.B. (1989) Cognitive therapy in practice: A case formulation approach. New York, Norton Press.

Scott, J. (2001). Cognitive therapy for depression. British Medical Bulletin. 57 (1), 101-113.

Categories: Cognitive Behavioural Therapy , Depression - By Dr Becky Spelman - March 1, 2021

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How to Write a Case Conceptualization: 10 Examples (+ PDF)

Case Conceptualization Examples

Such understanding can be developed by reading relevant records, meeting with clients face to face, and using assessments such as a mental status examination.

As you proceed, you are forming a guiding concept of who this client is, how they became who they are, and where their personal journey might be heading.

Such a guiding concept, which will shape any needed interventions, is called a case conceptualization, and we will examine various examples in this article.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is a case conceptualization or formulation, 4 things to include in your case formulation, a helpful example & model, 3 samples of case formulations, 6 templates and worksheets for counselors, relevant resources from positivepsychology.com, a take-home message.

In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

This is typically the evaluation of an individual, although you can extend the concept of case conceptualization to summarizing findings about a group or organization.

Based on the case conceptualization, recommendations can be made to improve a client’s self-care , mental status, job performance, etc (Sperry & Sperry, 2020).

Case Formulation

  • Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life . A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved.
  • Statement of the client’s core strengths . Identifying core strengths in the client’s life should help guide any recommendations, including how strengths might be used to offset limitations.
  • Statement concerning a client’s limitations or weaknesses . This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a recommendation about it.

Note: As with mental status examinations , observations in this context concerning weaknesses are not value judgments, about whether the client is a good person, etc. The observations are clinical judgments meant to guide recommendations.

  • A summary of how the strengths, limitations, and other key information about a client inform diagnosis and prognosis .

You should briefly clarify how you arrived at a given diagnosis. For example, why do you believe a personality disorder is primary, rather than a major depressive disorder?

Many clinicians provide diagnoses in formal psychiatric terms, per the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some clinicians will state a diagnosis in less formal terms that do not coincide exactly with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, formal or not, gives a clear sense of who the person is and the support they need to reach their goals.

Prognosis is a forecast about whether the client’s condition can be expected to improve, worsen, or remain stable. Prognosis can be difficult, as it often depends on unforeseeable factors. However, this should not keep you from offering a conservative opinion on a client’s expected course, provided treatment recommendations are followed.

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Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.

Background and referral information

This is a 15-year-old Haitian–American youth, referred by his mother for concerns about self-isolation, depression, and poor social skills. He reportedly moved with his mother to the United States three years ago.

He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.

His mother is very supportive and aware of his emotional–behavioral needs. The youth has been enrolled in a social skills group at school and has attended three sessions, with some reported benefit. He is agreeable to start individual counseling. He reportedly does well in school academically when he applies himself.

Limitations

Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.

He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.

Diagnostic impressions, treatment guidance, prognosis

This youth’s history, presentation on interview, and results of emotional–behavioral forms suggest some difficulty with depression, likely contributing to social isolation. As he has no prior reported history of depression, this is most likely a reaction to missing his former home and difficulty adjusting to his new school and peers.

Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.

Prognosis is favorable, with anticipated benefit apparent within 12 sessions of CBT.

How to write a case conceptualization: An outline

The following outline is necessarily general. It can be modified as needed, with points excluded or added, depending on the case.

  • Client’s gender, age, level of education, vocational status, marital status
  • Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
  • In the spirit of strengths-based assessment, consider listing the client’s strengths first, before any limitations.
  • Consider the full range of positive factors supporting the client.
  • Physical health
  • Family support
  • Financial resources
  • Capacity to work
  • Resilience or other positive personality traits
  • Emotional stability
  • Cognitive strengths, per history and testing
  • The client’s limitations or relative weaknesses should be described in a way that highlights those most needing attention or treatment.
  • Medical conditions affecting daily functioning
  • Lack of family or other social support
  • Limited financial resources
  • Inability to find or hold suitable employment
  • Substance abuse or dependence
  • Proneness to interpersonal conflict
  • Emotional–behavioral problems, including anxious or depressive symptoms
  • Cognitive deficits, per history and testing
  • Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
  • There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
  • The primary diagnosis should best encompass the client’s key symptoms or traits, best explain their behavior, or most need treatment.
  • Take care to avoid over-assigning multiple and potentially overlapping diagnoses.

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life.

  • Decide which events or factors are significant enough to include in a case conceptualization.
  • When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
  • A good timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.

Case Formulation Samples

Sample #1: Conceptualization for CBT case

This is a 35-year-old Caucasian man referred by his physician for treatment of generalized anxiety.

Strengths/supports in his case include willingness to engage in treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).

Limiting factors include relatively low stress coping skills, frequent migraines (likely stress related), and relative social isolation (partly due to some anxiety about social skills).

The client’s presentation on interview and review of medical/psychiatric records show a history of chronic worry, including frequent worries about his wife’s health and his finances. He meets criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet full criteria for panic disorder but could develop into such without preventive therapy.

Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing .

Prognosis is good, given the evidence for efficacy of CBT for anxiety disorders generally (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

Sample #2: Conceptualization for DBT case

This 51-year-old Haitian–American woman is self-referred for depressive symptoms, including reported moods of “rage,” “sadness,” and “emptiness.” She says that many of her difficulties involve family, friends, and coworkers who regularly “disrespect” her and “plot against her behind her back.”

Her current psychiatrist has diagnosed her with personality disorder with borderline features, but she doubts the accuracy of this diagnosis.

Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.

Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.

The client’s presentation on interview, review of medical/psychiatric records, and results of MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.

The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.

Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.

Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.

Sample #3: Conceptualization in a family therapy case

This 45-year-old African-American woman was initially referred for individual therapy for “rapid mood swings” and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

The client’s husband (50 years old) and son (25 years old, living with parents) were interviewed separately and together. When interviewed separately, her husband and son each indicated the client’s alcohol intake was “out of control,” and that she was consuming about six alcoholic beverages throughout the day, sometimes more.

Her husband and son each said the client was often too tired for household duties by the evening and often had rapid shifts in mood from happy to angry to “crying in her room.”

On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.

On interview with the three family members, each acknowledged that the instances above were occurring at home, although father and son tended to blame most of the problems, including son’s difficulty maintaining employment, on the client and her drinking.

Strengths/supports in the family include a willingness of each member to engage in family sessions, awareness of supportive resources such as assistance for son’s job search, and a willingness by all to examine and reduce alcohol use by all family members as needed.

Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.

The family dynamic can be conceptualized in this case through a DBT lens.

From this perspective, problems develop within the family when the environment is experienced by one or more members as invalidating and unsupportive. DBT skills with a nonjudgmental focus, active listening to others, reflecting each other’s feelings, and tolerance of distress in the moment should help to develop an environment that supports all family members and facilitates effective communication.

It appears that all family members in this case would benefit from engaging in the above DBT skills, to support and communicate with one another.

Prognosis is guardedly optimistic if family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).

Introduction to case conceptualization – Thomas Field

The following worksheets can be used for case conceptualization and planning.

  • Case Conceptualization Worksheet: Individual Counseling helps counselors develop a case conceptualization for individual clients.
  • Case Conceptualization Worksheet: Couples Counseling helps counselors develop a case conceptualization for couples.
  • Case Conceptualization Worksheet: Family Counseling helps counselors develop a case conceptualization for families.
  • Case Conceptualization and Action Plan: Individual Counseling helps clients facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
  • Case Conceptualization and Action Plan: Couples Counseling helps couples facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
  • Case Conceptualization and Action Plan: Family Counseling helps families facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.

The following resources can be found in the Positive Psychology Toolkit© , and their full versions can be accessed by a subscription.

Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used to more advantage in new contexts.

Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing notable strengths of other family members. In reviewing all worksheets, each family member can gain a greater appreciation for other members’ strengths, note common or unique strengths, and determine how best to use these combined strengths to achieve family goals.

Four Front Assessment is another resource designed to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that environmental factors in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.

If you’re looking for more science-based ways to help others through CBT, check out this collection of 17 validated positive CBT tools for practitioners . Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

In helping professions, success in working with clients depends first and foremost on how well you understand them.

This understanding is crystallized in a case conceptualization.

Case conceptualization helps answer key questions. Who is this client? How did they become who they are? What supports do they need to reach their goals?

The conceptualization itself depends on gathering all pertinent data on a given case, through record review, interview, behavioral observation, questionnaires completed by the client, etc.

Once the data is assembled, the counselor, coach, or other involved professional can focus on enumerating the client’s strengths, weaknesses, and limitations.

It is also often helpful to put the client’s strengths and limitations in a timeline so you can see how they have evolved and which factors might have contributed to the emergence of others.

Based on this in-depth understanding of the client, you can then tailor specific recommendations for enhancing their strengths, overcoming their weaknesses, and reaching their particular goals.

We hope you have enjoyed this discussion of how to conceptualize cases in the helping professions and that you will find some tools for doing so useful.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

  • Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research , 36 (5), 427–440.
  • May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician , 6 (2), 62–67.
  • Sperry, L., & Sperry, J. (2020).  Case conceptualization: Mastering this competency with ease and confidence . Routledge.

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A Cognitive-Behavior Therapy Applied to a Social Anxiety Disorder and a Specific Phobia, Case Study

Contributions: AP and GT designed the protocol, administer the CBT therapy sessions, analyzed and interpreted the data, and wrote the paper.

George, a 23-year-old Greek student, was referred by a psychiatrist for treatment to a University Counseling Centre in Athens. He was diagnosed with social anxiety disorder and specific phobia situational type. He was complaining of panic attacks and severe symptoms of anxiety. These symptoms were triggered when in certain social situations and also when travelling by plane, driving a car and visiting tall buildings or high places. His symptoms lead him to avoid finding himself in such situations, to the point that it had affected his daily life. George was diagnosed with social anxiety disorder and with specific phobia, situational type (in this case acrophobia) and was given 20 individual sessions of cognitivebehavior therapy. Following therapy, and follow-up occurring one month post treatment, George no longer met the criteria for social phobia and symptoms leading to acrophobia were reduced. He demonstrated improvements in many areas including driving a car in and out of Athens and visiting tall buildings.

Introduction

Social anxiety disorder (SAD), also known as social phobia, is one of the most common anxiety disorders. Social phobia can be described as an anxiety disorder characterized by strong, persisting fear and avoidance of social situations. 1 , 2 According to DSMIV, 3 the person experiences a significant fear of showing embarrassing reactions in a social situation, of being evaluated negatively by people they are not familiar with and a desire to avoid finding themselves in the situations they fear. 4 , 5 Furthermore people with generalized social phobia have great distress in a wide range of social situations. 6 The lack of clear definition of social phobia has been reported by clinicians and researchers because features of social phobia overlap with those of other anxiety disorders such as specific panic disorder, agoraphobia and shyness. 7

According to ICD-10, 8 phobic anxiety disorders is a group of disorders in which anxiety is evoked only, or predominantly, in certain well-defined situations that are not currently dangerous. As a result these situations are characteristically avoided or endured with dread. The patient’s concern may be focused on individual symptoms like palpitations or feeling faint and is often associated with secondary fears of dying, losing control, or going mad. Contemplating entry to the phobic situation usually generates anticipatory anxiety. Phobic anxiety and depression often coexist. Whether two diagnoses, phobic anxiety and depressive episode, are needed, or only one, is determined by the time course of the two conditions and by therapeutic considerations at the time of consultation.

Prevalence of social phobia varies from 0-20%, depending on differences in the classification criteria, culture 9 , 10 and gender. 11-13 The onset of the disorder is considered to take place between the middle and late teens. 14 The NICE guidelines for social anxiety disorder, describe it as one of the most common of the anxiety disorders. Estimates of lifetime prevalence vary but according to a US study, 12% of adults in the US will have social anxiety disorder at some point in their lives, compared with estimates of around 6% for generalized anxiety disorder (GAD), 5% for panic disorder, 7% for post-traumatic stress disorder (PTSD) and 2% for obsessive-compulsive disorder. There is a significant degree of comorbidity between social anxiety disorder and other mental health problems, most notably depression (19%), substance-use disorder (17%), GAD (5%), panic disorder (6%), and PTSD (3%). 15

Social phobia is also developed and maintained by complex physiological, cognitive, and behavioral mechanisms. Biological causes of social anxiety/phobia have been reported by some researchers while others look on behavioral inhibition 16 and the effects of personality traits such as neuroticism and introversion 17 as the mediators between genetic factors and social phobia.

Apart from the biological factor, the role of cognition in the acquisition and maintenance of social anxiety/phobia is very important. The main cognitive factor is the fear of negative evaluation. 18 Beck, Emery, and Greenberg 19 associated the possibility of negative evaluation by others with beliefs of general social inadequacy, concerns about the visibility of anxiety, and preoccupation with performance or arousal. 20

Specific phobia situational type, is described as a persistent fear that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation such as public transportation, tunnels, bridges, elevators, flying, driving or enclosed places. This subtype has a bimodal age-at-onset distribution with one peak in childhood and another peak in mid-20s. 21

Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response which may take the form of a situational bound or situational predisposed panic attack. The phobic situation usually is avoided or else is endured with intense anxiety or distress. The avoidance interferes often with the person’s normal routine occupational functioning, social activities or relationships. 21 Fear of heights, or acrophobia, is one of the most frequent subtypes of specific phobia frequently associated to depression and other anxiety disorders. 22 It is one of the most prevalent phobias, affecting perhaps 1 in 20 adults. Heights often evoke fear in the general population too, and this suggests that acrophobia might actually represent the hypersensitive manifestation of an everyday, rational fear. 23

From a behavioral perspective, feared situations negatively maintain phobias. Anxiety disorders have been shown to be effectively treated using cognitive behavior therapy (CBT) and therefore to better understand and effectively treat phobias. The CBT model used in the present case, was based on Clark and Wells 24 model that places emphasis on self-focused attention as social anxiety is associated with reduced processing of external social cues. The model pays particular attention to the factors that prevent people, who suffer from social phobias, from changing their negative beliefs about the danger inherent in certain social situations.

The following case it is a good representation of this model.

Case Report

George, was a 23-year-old single, Caucasian male student in his last academic year and was referred to a University Counseling Centre in Athens. The Centre provides free of charge, treatment sessions to all University students requiring psychological support.

George was diagnosed with Social Anxiety Disorder and with Specific phobia, Situational Type i.e . acrophobia. He was living alone in Athens, as his parents live in a different region of Greece. He was an only child. When asked about his childhood, he said that he had been happy and did not report any traumatic events. He described a close relationship with both his parents and when asked, he did not report any family history of psychiatric or psychological disorders or substance abuse problems.

He complained of severe symptoms of anxiety and phobias during the last six months. He began experiencing severe heart palpitations, flushing, fear of fainting and losing control, when travelling by plane, when crossing tall bridges while driving or when being in tall buildings or high places, however he did not experience symptoms of vertigo. Additionally, he reported significant chest pain and muscle tension in feared situations. His fear of experiencing these symptoms worsened and led him to avoid these situations which made his everyday life difficult. He also experienced similar symptoms when introduced to people or meeting people for the first time. He repeatedly went to see various doctors many times in order to exclude any medical conditions. George stated that he didn’t experience any symptoms of depression, had no prior psychological or psychiatric treatment and/or medication, and had first experienced this problem in the course of the previous year.

At the time of the intake, George was in his final exams which he wanted to finish successfully, and continue his studies abroad. Due to his condition, he decided not to apply for a postgraduate degree in the United Kingdom, which he always wanted, and started looking for alternative postgraduate courses in Greece.

Assessment and treatment

George was referred by a private psychiatrist. The psychiatrist used the Mini International Neuropsychiatric Interview, 25 which is a structured interview based on DSM-IV diagnostic criteria. George met the criteria for a Social anxiety disorder. He also met the criteria for specific phobia limited-symptom, which was secondary to his social phobia. The psychiatrist suggested to George, to better help him with his current symptoms to take selective serotonin reuptake inhibitors (SSRIs). George however refused to take any medication and the psychiatrist referred him to the Counseling Centre. For the specific case we decided to give individual cognitive behavior therapy based on Clark and Wells model for Social Anxiety Disorder, 24 as referred into the NICE guidelines. 26 To better assist conceptualization and treatment and also monitor his progress, two therapists were assigned to George and two assessment measures (STAI and SPAI) were given, prior to the course of treatment, following therapy and at one month follow-up. He also had to complete a self-monitoring scale through-out the 20 weeks of treatment.

Monitoring progress measures

State-trait anxiety inventory.

The state-trait anxiety inventory (STAI), 27 the appropriate instrument for measuring anxiety in adults, differentiates between state anxiety , which represents the temporary condition and trait anxiety , which is the general condition. The STAI includes forty questions, with a range of four possible responses. In each of the two subscales scores range from 20 to 80, high scores indicating a high anxiety level. Higher scores correspond to greater anxiety.

Social Phobia and Anxiety Inventory

The Social Phobia and Anxiety Inventory (SPAI) 28 is a 45 item self-report measure that assesses cognition, physical symptoms, and avoidance/escape behavior in various situations. It includes two subscales: Social Phobia and Agoraphobia. A difference score above 60 indicates a potential phobia, and a cut off score of 80 maximizes this identification rate.

George’s pre-treatment scores were, SPAI:126, State Anxiety: 64 and Trait Anxiety: 63. The ultimate goal in each situation was to reduce the client’s level of anxiety.

Cognitive-behavior techniques such as self-monitoring, cognitive restructuring, relaxation, breathing retraining, and assertiveness training were employed to reduce anxiety and fear.

Cognitive behavior therapy techniques

Self-monitoring.

Self-monitoring refers to the systematic observation and recording of one’s own behaviors or experiences on several occasions over a period of time. 29 Self-monitoring can be used as a therapeutic intervention, because it helps the patient to evaluate his/her thoughts, emotions, and behaviors, recognize the feared situations and find appropriate solutions. Kazdin 30 states that self-monitoring can lead to dramatic changes, while Korotitsch and Nelson-Gray 29 add that although the therapeutic effects of self-monitoring may be small, they are rather immediate. George was asked to monitor his thoughts, feelings, and behaviors and record any changes.

George had to complete an Every Day Self-Monitoring Scale for 20 weeks measuring feelings of anxiety (0=no anxiety to 10= most anxiety) and phobia (0=no feelings of phobia to 10=most feelings of phobia), ( Figure 1 ).

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Every day self-monitoring scale score.

Cognitive restructuring

Beck and Emery, 19 have identified three phases in cognitive restructuring: i) identification of dysfunctional thoughts ii) modification of dysfunctional thoughts and iii) assimilation of functional thoughts. During cognitive restructuring, the client starts recognizing his/her automatic or dysfunctional thoughts and emotions that derive from this thoughts. For example, one of George’s thoughts was that: it is dangerous to drive at night , which made him feel very anxious and frightened. However, an adaptive thought could be that: that sometimes is dangerous but also a lot of times are not, due the fact that at night there is less traffic in the streets . Therefore, throughout the sessions he was taught how to substitute several automatic negative thoughts with adaptive ones. He also kept a dysfunctional thought record for 6 sessions, which he discussed with his therapist every week.

Muscle relaxation

Relaxation techniques were used for the treatment of George’s symptoms and more specifically for the physiological manifestations of anxiety and panic. 31

George was trained in breathing and muscle relaxation exercises, based on Jacobson’s technique and he was given 8 relaxation training sessions, in order to establish a sense of control over his physical symptoms. The client learned to apply brief muscle relaxation exercises in his daily life and especially every time he had to face an uncomfortable situation.

Assertiveness training

Assertiveness training can be an effective part of treatment for many conditions, such as depression, social anxiety, and problems resulting from unexpressed anger. Assertiveness training can also be useful for those who wish to improve their interpersonal skills and sense of self-respect and it is based on the idea that assertiveness is not inborn, but is a learned behavior. Although some people may seem to be more naturally assertive than others are, anyone can learn to be more assertive. In the specific case the therapists helped George figure out which interpersonal situations are problematic to him and which behaviors need the most attention. In addition, helped to identify beliefs and attitudes the client might had developed, that lead him to become too passive. The therapist used role-playing exercises as part of this assessment.

Clinical sessions

George completed 20 individual, 50 min therapy sessions that took place within a period of 5 months. During the first session the rationale of the cognitive-behavioral treatment was analyzed and special emphasis was given to educate the patient on Social Anxiety disorder and Specific phobias. An introduction was made to the role that automatic thoughts play in our cognitions and helped him to recognize automatic negative thoughts and feelings. A self-monitoring diary of anxiety was given to him as homework. Emphasis was also given to establishing good rapport and collaboration in the therapeutic relationship. During the second session, George narrated stressful life events and reported specific cases in which the anxiety symptoms increased. He was also taught how to identify the three phases of cognitive restructuring and was given the dysfunctional thought record as homework. The third session was based on teaching him breathing exercises and muscle relaxation. Relaxation techniques were taught by a different therapist, with expertise in stress management and relaxation techniques. George was given 8 such sessions, each lasting 20 minutes while he also practiced the sessions daily at home and completed a Daily-form for progress monitoring.

Sessions 4 to 9 were devoted to ways of challenging dysfunctional thoughts by resorting to adaptive responses. At first we tried to recognize negative automatic thoughts during specific situations and record George’s mood in that situation. After recognizing George’s negative thoughts, emotions and behaviors, we worked on the evidence that supported these thoughts.

The next three sessions (10-12) were devoted to teach him assertiveness skills to learn to socialize with people more effectively. We explored what assertiveness meant for George, what prevented him from being assertive and what were the differences between assertive, submissive and aggressive behavior, which he found really helpful and role-playing exercises were initiated to exercise these skills.

Sessions 13-20 were devoted identifying anxiety provoking situations which were hierarchically classified according to the degree of anxiety they produced. An example is shown in Table 1 . Exposure to feared situations was performed by facing in vivo each level of the hierarchy and gradually practice each step, until he was confident enough to go on to the next.

Fear hierarchy for visiting tall buildings.

Accordingly, situations such as driving, crossing bridges etc were also explored.

During the last session, George referred to overcoming challenging experiences, such as meeting new people, visiting friends living in tall apartment buildings and crossing two high bridges, while driving to visit his parents in a different part of Greece. He effectively challenged his cognitions in all relevant situations and utilized muscle relaxation and breathing exercises to control feelings of anxiety. Last session was also devoted to discuss relapse prevention, ways to avoid it and how to overcome past failures and difficulties. Finally, we discussed how he could modify and apply the skills and techniques that he had learned, in his daily routine.

The post-treatment scores of STAI and SPAI obtained by George at termination indicated an improvement. The Social Phobia score dropped to 100, the Anxiety State score was 41 and the Trait score was 42.

During the follow-up session one month later, George talked about his improvement, he mentioned that his progress continued and that he was not experiencing any of the averse symptoms of the past, while driving, visiting tall buildings/bridges and meeting new people. He continued the relaxation and the cognitive restructuring exercises. The STAI & SPAI scales were administered again. The assessment revealed maintenance of gains in terms of reduced anxiety and fear symptoms with State anxiety score: 38, Trait anxiety score: 39 and SPAI score: 77 ( Figure 2 ).

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STAI and SPAI Scores.

Treatment implications

In the present clinical case, George attended 20 individual sessions of CBT, in order to reduce his anxiety levels and phobias and learn how to monitor his progress in his daily life. His anxiety levels were reduced in social situations and also he managed to overcome his fear of heights in specific provoking situations. His progress was inevitable which was confirmed by the anxiety scores of the STAI and SPAI. The follow-up session that took place a month later, showed that his progress was sustained. The Every Day Self-Monitoring Scale during the 20 weeks period, showed a gradual reduction in self monitoring feelings of anxiety and phobias ( Figure 1 ).

However although we based our CBT model on Clark and Wells model for Social Anxiety, we had certain variations from the original model. For example, the Clark and Wells model suggests, that individual therapy for social anxiety disorder should consist of up to 14 sessions of 90 minutes’ duration over approximately 4 months. In our case study, the duration of each session lasted 50 minutes and we gave 20 sessions of individual therapy to our client over a period of 5 months, thus trying to tailor our client’s needs and requirements for treatment.

A good rapport was developed with George and that helped the entire treatment process. Working on a list of feared hierarchies in combination with relaxation training skills, George was able to manifest his high level anxiety visiting tall buildings, crossing tall bridges etc. Furthermore, the fact that George learned to identify his automatic thoughts, helped him to reduce his unpleasant feelings by alternating his thoughts. Role-playing exercises in order to acquire assertiveness training skills helped him in relation to meeting new people. It is also worth mentioning that George was motivated and completed his CBT homework every week, something that helped the therapeutic outcome.

Conclusions: recommendations to clinicians and students

Cognitive behavioral therapy is very effective in treating anxiety. It is a structured intervention that follows a general framework that is modified for each individual. For the successful treatment of social phobia, the cognitive behavior therapy must be thorough and comprehensive. Sometimes is needed to use combinations of techniques, like in this case we used traditional CBT techniques in combination with assertiveness skills training. Collaboration with other specialists is also advised for ultimate results, as in this case two therapists were involved, one main therapist and one specialist on stress management techniques. The cognitive-behavior therapist is important to adapt the session, on the basis of his/her client’s needs, for example in the case of George we used exposure based techniques and although the Counseling center offers a maximum of 6 therapeutic sessions, in the case of George we decided on 20 sessions, in order to fully accommodate his problem. It is also very important for the therapist to explain the rationale behind each CBT session and help the patient understand each session’s agenda up to the point he/she feels comfortable to set their own agenda during the session. However, despite the therapist’s best efforts, the patient often hesitates to carry out the everyday homework, thus sometimes delaying the therapeutic progress. Therefore, the good rapport established with the patient will almost certainly add greatly to his/her adherence during the treatment.

Therapist-client relationship, play a fundamental role in the therapy process. It is important for the client to trust the therapist and feel comfortable within the therapy context. Creating a safe and empathetic environment is important from the first therapy session. Furthermore as CBT is directive, a strong therapeutic alliance is necessary to allow the client to feel safe engaging in this type of therapy. It is also important to mention that therapists need to refer to the widely accepted guidelines and recommendations for treating Social anxiety disorders and specific phobias, from widely accepted national institutes, such as the National Institute for Health and Care Excellence that covers both pharmaceutical and psychotherapeutic approaches. However, it is necessary sometimes to tailor-made therapy around client’s needs, as each case must be seen individually . There are too many manuals on CBT and there is the danger for the therapist to work in such a program that can lose creativity, individual thought, imagination and contact with the client. The crucial role of any therapeutic intervention, is not only to help people to acquire the techniques, but to feel comfortable to apply them daily in situations they feel discomfort.

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COMMENTS

  1. Case Examples

    Clinical Case Study: CBT for Depression in A Puerto Rican Adolescent. Challenges and Variability in Treatment Response. Depression and Anxiety, 26, 98-103. https://doi.org/10.1002/da.20457 Interpersonal Psychotherapy for Adolescents Sam, a 15-year-old adolescent

  2. PDF Case Write-Up: Summary and Conceptualization

    Cognitive: Trouble making decisions, trouble concentrating Behavioral: Avoidance (not cleaning up at home, looking for a job, or doing errands), social isolation (stopped going to church, spent less time with family, stopped seeing friends)

  3. PDF Case Example: Nancy

    2061 COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION that his daughter had beat out many competitors to get her job at the prestigious publisher. He repeatedly described her as especially talented and unusually bright but did not say anything about any distress or unhappiness she might be experiencing.

  4. Cognitive Behavior Therapy for Depression: A Case Report

    Cognitive Behavior Therapy for Depression: A Case Report Authors: Jesan Ara University of Rajshahi Abstract and Figures Depression is expected to become the most common psychiatric disorder...

  5. CBT for difficult-to-treat depression: single complex case

    The aims of this study were: (1) to illustrate the application of high dose SR-CBT in a difficult-to-treat case, including treatment decisions, therapy process and outcomes, and (2) to highlight the similarities and differences between SR-CBT and standard CBT models.

  6. Cognitive Behavioral Therapy for Depression

    Cognitive behavioral therapy (CBT) is one of the most evidence-based psychological interventions for the treatment of several psychiatric disorders such as depression, anxiety disorders, somatoform disorder, and substance use disorder. The uses are recently extended to psychotic disorders, behavioral medicine, marital discord, stressful life ...

  7. Cognitive evolutionary therapy for depression: a case study

    Cognitive evolutionary therapy for depression. CBT focuses on changing dysfunctional cognitions, thus leading to improvements in the depressive symptoms 4, 20. From this perspective, dysfunctional beliefs are seen as proximate, or immediate causes of depression. But some have argued, for example, that Beck's cognitive distortions are a ...

  8. Clinical case study: CBT for depression in a Puerto Rican adolescent

    Background: There is ample evidence of the efficacy of cognitive-behavioral therapy (CBT) for depression in adolescents, including Puerto Rican adolescents. However, there is still a high percentage of adolescents who do not respond to a standard "dose" of 12 sessions of CBT. This clinical case study explores the characteristics associated with treatment response in a Puerto Rican ...

  9. The process and delivery of CBT for depression in adults: a systematic

    Study eligibility and selection. An extended description of the methods of this review is available in the published protocol (Davies et al., 2018).Eligible studies were randomised controlled trials (RCT) including adults (⩾18 years) with a primary diagnosis of depression, in which the effectiveness of a CBT intervention during an acute phase of depression had been compared to treatment-as ...

  10. PDF CBT for Depression: AN INTEGRATED APPROACH

    CBT for Depression case studies and examples, this book marries treatment components with how to go about providing them. There is also an emphasis on trouble-shooting because not all . CBT interventions work smoothly every time; methods that generally work well can be a poor fit for particular clients. So this book explores how to provide CBT ...

  11. PDF A case study of person with depression: a cognitive behavioural case

    The cases of depression can be effectively handled using cognitive behavioural therapy (National Institute for Clinical Excellence (NICE), 2009; American Psychiatric Association, 2010; Cuijpers et al., 2013; Thase et al., 2007).

  12. The evidence base for cognitive—behavioural therapy in depression

    Evidence for the effectiveness of CBT in depression. A recent key document in this area is the Department of Health's review Treatment Choice in Psychological Therapies and Counselling (Department of Health, 2001).These guidelines summarise evidence-based information that can aid decisions about which psychological therapies are most appropriate for which patients.

  13. PDF CASE WRITE-UP EXAMPLE

    Emotional: Feelings of depression, anxiety, pessimism and some guilt; lack of pleasure and interest Cognitive: Trouble making decisions, trouble concentrating Behavioral: Avoidance (not cleaning up at home, looking for a job or doing errands), social isolation (stopped going to church, spent less time with family, stopped seeing friends)

  14. DEPRESSION AND A Clinical Case Study

    Studies that have compared CBT to anti-depressant medications have found mixed results, with some citing superior outcomes for anti-depressants alone and the combina-tion of CBT with anti-depressants when compared to CBT alone,[6] and others that have found superior outcomes with CBT alone when compared to anti-depressants alone or a combination...

  15. Case study of a client diagnosed with major depressive disorder

    Implemented treatment consisted of combined cognitive behavioral oriented psychotherapy and psychotropic medication. The Beck Depression Inventory (BDI-II) was used to assess changes in depressive symptoms. Results indicated a significant decline in depressive symptoms over the course of treatment. At the onset of treatment,

  16. Case study clinical example CBT: First session with a client with

    0:00 / 13:54 Case study example for use in teaching, aiming to demonstrate some of the triggers, thoughts, feelings and responses linked with problematic low mood. This s...

  17. Using CBT in the Treatment of Depression

    Case study: How CBT can be applied in the treatment of depression The aim of this case study is to show through the use of a client study, how cognitive behavioural therapy ( CBT) can be applied in the treatment of depression. The patient is a woman with a 2-year history of depression connected with low self-esteem, guilt and shame.

  18. Cognitive Behavior Therapy in The School Setting: A Case Study of A

    Journal of Depression and Therapy - 1(2):37-48. https: ... This case-study illustrates how CBT can be applied within primary school addressing test anxiety when the concern is not only on the level of an emerging mental health problem, but also on a specific symptom. ... this case study is an illustrative example of how small group CBT can be ...

  19. Cognitive group therapy for depressive students: The case study

    Abstract. The aims of this study were to assess whether a course of cognitive group therapy could help depressed students and to assess whether assimilation analysis offers a useful way of analysing students' progress through therapy. "Johanna" was a patient in a group that was designed for depressive students who had difficulties with ...

  20. How to Write a Case Conceptualization: 10 Examples (+ PDF)

    Sample #3: Conceptualization in a family therapy case. This 45-year-old African-American woman was initially referred for individual therapy for "rapid mood swings" and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

  21. Cognitive Behavioral Therapy for Depression Case Study

    Introduction 1.1 Depression Depression is a low, sad state, in which life seems dark and its challenges are overwhelming. It is believed that psychological stress plays a vital role in depression. People with depression often complain about feeling tired all the time and they tend to have trouble sleeping.

  22. A Cognitive-Behavior Therapy Applied to a Social Anxiety Disorder and a

    The cognitive-behavior therapist is important to adapt the session, on the basis of his/her client's needs, for example in the case of George we used exposure based techniques and although the Counseling center offers a maximum of 6 therapeutic sessions, in the case of George we decided on 20 sessions, in order to fully accommodate his problem.

  23. Case Study: Cognitive Behavioral Therapy

    Case Example: Jill, a 32-year-old Afghanistan War Veteran This case example explains how Jill's therapist used a cognitive intervention with a written worksheet as a starting point for engaging in Socratic dialogue. About this Example This is a case example for the treatment of PTSD using Cognitive Behavioral Therapy.