Running head: COGNITIVE THERAPY: A CASE STUDY 1
Cognitive Therapy: A Case Study of Margaret
Angelena Bertolini-Alley
Liberty University
COGNITIVE THERAPY: A CASE STUDY 2
Abstract
Cognitive Therapy is based on the belief that an individual’s maladaptive thoughts lead to
distorted perceptions of a situation and therefore negative behaviors and feelings. Cognitive
Therapy is one of the most researched and expanded upon psychological theories and has been
shown to be effective with a wide array of diagnoses and issues, including anxiety. Margaret, the
client, has distorted thoughts including she must be perfect, she is unable to make effective and
solid social connections, and she is incapable of expressing her emotions. She catastrophizes
every situation without any evidence to back up her perceived outcome. Margaret is a very
intelligent and pragmatic individual, perfect for Cognitive Therapy. Therapy will utilize
techniques that play to her strengths such as organization and logical thinking while at the same
time challenging her to learn new information and skills in order to meet her goals. While this
educational type setting may fit Margaret’s desire for knowledge, it could potentially cause an
issue when it comes to her religion. Cognitive Therapy places a great deal of emphasize on
individual control based on rational thinking. This focus removes any reliance on God or room
for value based feelings. Of all the theories, Cognitive Therapy does leave the most room for
Christian Integration, however, therefore Margaret’s therapy can incorporate her Christian
beliefs.
COGNITIVE THERAPY: A CASE STUDY 3
Case Conceptualization using Cognitive Therapy
The founder of Cognitive Theory is Aaron Beck. Contemporary psychologists include a
number of other theories under the umbrella of Cognitive Therapy, including Cognitive
Behavioral Therapy. “In fact the term Cognitive Therapy is often used as a general label for a
number of system that emphasize the role of cognition in dysfunction and intervention. Most
contemporary psychologists and theorists agree that the Cognitive Behavioral Therapy “…has
allowed for the development of unique and effective cognitive and behavioral interventions in
order to bring about symptom belief.” (Hyland & Boduszek, 2012).
In Cognitive Therapy, our perceptions of events effect our thoughts and feelings, thoughts
and feelings then lead to behavior and consequences (Murdock, 2013). The purpose of Cognitive
Therapy is too change the maladaptive thoughts, known as negative automatic thoughts, so the
behavior leads to ideal consequence of adaptation and survival (Hyland & Boduszek, 2012). “A
core task of Cognitive Therapy is the identification of maladaptive thoughts that contribute to
emotion dysregulation” (Shirk, 2001). Hyland and Boduszek (2012) described the maladaptive
process as the following:
The process of irrationally appraising one’s distorted representational automatic thoughts,
which themselves arise as a consequence of the activation of underlying dysfunctional
representational (core beliefs) and appraisal (demandingness beliefs) schematic
structures, gives rise to the development of cognitive emotional- behavioural
dysfunctioning. (p. 9).
In Cognitive Therapy the counselor helps the client become aware of the answers she seeks, the
therapist acts as a guide (Murdock, 2013). In the beginning the therapist’s role may be that of a
teacher, educating the client on the process and setting up goals for the client to reach. As the
COGNITIVE THERAPY: A CASE STUDY 4
therapy continues, the working relationship is enhanced and the client then takes the lead in their
own treatment.
Although Beck was one of the first theorists to create a manual for the treatment of
Cognitive Therapy and it is considered to be one of the most researched approaches for many
different client issues, the evidence is not as strong as one may think (Murdock, 2013). The
support also changes depending upon the problem the client is suffering from. For example, one
study by Gibbons, Fournier, Stirman, DeRubeis, Crits-Christoph, and Beck (2010), found that
when patients were treated at the Center for Cognitive Therapy (CCT) they experienced a 61%
decrease in depressive symptoms over the course of their treatment. The main concern in this
study is that CCT is not a research setting.
Murdock (2013), notes that many studies which support the efficacy of Cognitive
Therapy for anxiety disorders actually combine behavioral techniques as well. Cognitive
Behavioral Therapy, a branch of Cognitive Therapy which utilizes behavioral approaches has
been shown to be exceedingly effective for anxiety disorders (McManus, Grey, & Shafran,
2008). There were suggestions that by adding emotional regulation techniques and mindfulness
techniques could further enhance the benefits to the clients (McManus, Grey, & Shafran, 2008).
As noted above, Cognitive Therapy has been shown to be effective with both depression
and anxiety. When Cognitive Behavioral Therapy is utilized, however, clients with other
diagnosis have also shown positive effects. In particular interest to Margaret, one study by Riley,
Lee, Cooper, Fairburn, and Shafran (2007) showed that short term Cognitive Behavioral Therapy
interventions were positively correlated with a reduction in clinical perfectionism. Cognitive
Behavioral Therapy research in the area of Post-Traumatic Stress Disorder has also been
promising (McManus, Grey, & Shafran, 2008).
COGNITIVE THERAPY: A CASE STUDY 5
Of particular interest to Margaret is the notion that the Cognitive Therapy
counselor/client relationship begins as a very structured environment where the therapist is the
expert, however ends with the client solving her own problems utilizing what she has learned
Murdock, 2013). Margaret is extremely intelligent, therefore she will respect a therapist that also
comes across as professional and competent. Her independent nature, however will also coincide
well with the idea that she is in fact in charge of figuring out her own problems with the therapist
as simply a guide (Murdock, 2013). The fact that there is Cognitive Behavioral research in the
area of perfectionism, one of Margaret’s main issues, also gives credence to the appropriateness
of the approach (Riley, Lee, Cooper, Fairburn, and Shafran, 2007). Finally, and perhaps most
importantly, one of the main techniques of Cognitive Theory is social skills training (Murdock,
2013). Margaret has difficulty reaching out to others and building a support system, mainly
because she has never experienced a strong support group and does not know how to establish
one. Social skills training will help her learn how to effectively interact with others.
The primary ethical concerns surrounding Cognitive Therapy are transference,
inappropriate reactions to the client’s responses, and therapist error (Murdock, 2013). Due to
Margaret’s abrupt personality, there is a chance that the counselor could misinterpret her
responses, however choosing a well-established and competent counselor should reduce the
likelihood of that happening.
Considering Margaret is from a Western culture and has not experienced any real
discrimination in her life I do not see any cultural or gender specific issues that may hinder her
progress.
Cognitive Therapy can absolutely be used in crisis situations. Cognitive Therapy is meant
COGNITIVE THERAPY: A CASE STUDY 6
to be a short term approach and therefore results are seen pretty quickly. Murdock (2013) noted
that the client’s suffering can even be reduced in the first appointment by the use of quick
symptom relief techniques. In Cognitive Therapy and Cognitive Behavioral Therapy clients learn
how to problem solve and eventually question their own distorted automatic thoughts.
Interventions
Margaret presents with problems in every area of her life, professional, social, and
personal. Margaret is a self-focused perfectionist who sets unrealistic expectations for herself and
suffers from anxiety and depressive type symptoms when she is unable to reach those standards.
She is unable to form strong healthy connections with others because of the emotions that
accompany relationships. When she does experience emotion she has difficult regulating it, often
reacting at the extreme end of the spectrum. She is worried that if she presents herself to others
in what she perceives as the wrong way that they will react adversely.
After explaining the concept of Cognitive Therapy to Margaret, we agreed upon three
primary goals to focus on. The first goal centered around her inability to accept that she may not
reach every standard she sets for herself and how to handle the anxiety that comes along with the
negative self-evaluation that follows. Secondly Margaret is going to learn how make effective
and healthy social connections. Finally, Margaret will work on her ability to accept her emotions
and they come and regulate them appropriately.
Questioning
Questioning is perhaps the most basic, yet most effective technique in Cognitive Therapy.
It involves asking the client what they are thinking and more importantly why they are thinking
that (Murdock, 2013). Socratic thinking pushes the client to become aware of the fact that there
may be no evidence to support their distorted thought. For example, if I were to ask Margaret
COGNITIVE THERAPY: A CASE STUDY 7
what the worst thing that can happen if she fails to turn in a report with no errors and she
responds that her boss with probably demote her and find someone else that can do the job
correctly, I would quickly ask Margaret what evidence does she have that would support that
assumption? It is important for Margaret to understand that she is assuming she knows what her
boss would do without any prior experience to back up that automatic thought. In the future she
will be aware of these automatic distorted thoughts when they pop up and use the questions to
come to a more rational outcome.
Sometimes the perceived negative outcome will actually come to be and therefore the
question of how would she cope with that outcome must be discussed. The point of questioning
is not to badger the client, but in order for someone as strong minded as Margaret I will have to
confront her maladaptive automatic thoughts in order for her to become aware of the fact that she
is assuming the worst without all the facts. Questioning is structured and straightforward, there is
very little interpretation involved and I feel this technique would mold very well with Margaret’s
personality.
Emotional Regulation
Although not technically a technique in and of itself, emotional regulation is something
that is essential to Margaret’s mental well-being and progress towards her goal. Emotional
regulation begins with very basic techniques and practices which will allow Margaret to be
aware of her feeling, appropriately label what she is feeling, and then react accordingly
depending on the strength and type of emotion (Macklem, 2011). Limited knowledge of
emotions can trigger depression and anxiety, both of which Margaret shows displays symptoms.
Since Margaret is used to structure and organization, I believe a log keeping track of her positive
emotions would be beneficial. This would allow her to recognize what situations or people she
COGNITIVE THERAPY: A CASE STUDY 8
associates with positive emotions. Also documenting her emotions that cause her fear or distress
would allow her to see what situations trigger those feelings. “Interventions designed to teach
emotion regulation must include increasing positive emotions as well as addressing negative
emotions because positive emotions affect the course and duration of experiencing negative
emotions.” (Macklem, 2011, p. 113). Eventually, Margaret will be able to recognize her emotion,
label it, associate it to whatever situation she is in, and then react accordingly.
Social Skills Training
Prior to meeting Andrew’s family and breaking out of her shell a bit, Margaret’s
relationships focused around work. Actually, to call them relationships would be a stretch, she
dominated every conversation and individuals in office were afraid to even approach her.
Margret did not have a social life or support system and now that she is trying to make the
relationship work with Andrew she wants to learn how to interact appropriately. One of the core
elements of Cognitive Therapy is social skills training. True to the nature of Cognitive Therapy
education and teaching are involved, however it is in the form of role playing and coaching
(Murdock, 2013). In our sessions Margaret and I would discuss an upcoming event, perhaps a
family gathering, and actually act out the possible interactions she may encounter. I would model
for her the appropriate behavior for each possible situation and then guide her through an
example with her using the skill I just modeled. Eventually, Margaret will begin to feel less
anxious in social settings as she becomes more comfortable with her social skills, her confidence
will grow and we and continue to build on that.
Spiritual Application
The main spiritual challenge I see in Margaret’s case is her willingness to let go of
control and give her life to God. Proverbs 3:5 states “Trust in the LORD with all your heart, and
COGNITIVE THERAPY: A CASE STUDY 9
do not lean on your own understanding.” (English Standard Version). Both Margaret and
Cognitive Therapy rely on comprehending and understanding thoughts, feelings, and actions, to
surrender that power would go against everything she is comfortable doing and has done her
entire life. Integrating a Christian worldview into therapy may also cause issues for the therapist
because as Jones and Butman (2011) state: “The job of the therapist, then is to help the client
construct a story that brings a certain degree of peace and hope.” Cognitive Therapy places the
counselor in the role of a guide while the client discovers their way. In Christianity only the Holy
Spirit can guide the way and God provides peace and hope. Both Margaret and the therapist
would have to accept that they are not in control.
There have been at least 10 research studies done involving the use of prayer and
scripture in Cognitive Behavioral Therapy that show some supportive empirical evidence (Tan,
2007). Affirming Margaret’s behaviors and progress based on God’s word and not the internal
feeling of pride or my external praise would keep the focus on producing change that will not
only improve her life but more importantly serves Him. In order me as the counselor to continue
addressing Margaret’s needs from a Christian worldview I would initially focus on the empirical
studies because I know she is more likely to buy into an intervention if it has been shown to
work.
The first referral I would make to Margaret is to a Christian support group for anxiety.
There are many support groups in each state so we would be able to find one that she feels
comfortable attending. Margaret will be able to hear from other Christians struggling with
anxiety and learn how they turn to God for help, not just their therapist. A bonus is that Margaret
will have the opportunity to practice her social skills. If Margaret does not feel comfortable
enough to express her feelings in front others, she can begin by joining an online Christian
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support group for those struggling with anxiety. The same concepts apply as with the physical
group; however, Margaret would be in the emotional safety of her own home until she feels
confident enough to enter into a social setting. A third option would be to refer Margaret to a
meditation group. Meditation is no longer only an Eastern practice and is used frequently in
many therapeutic disciplines including those that fall under the umbrella of Cognitive
Behavioral. “Meditation simply means to focus one’s mind on God.” (Thomas & Sosin, 2011).
What makes meditation easy is that Margaret can go to any meditation class and concentrate on
God’s presence and no one else is involved. It is a social setting; however, each person
concentrates on their own source of comfort. Not only would Margaret become closer with God,
but meditation is also beneficial for relieving physical tension in the body as well.
Taking into consideration there are many branches of Cognitive Therapy it is not difficult
to find ways in which one of the many theories is compatible with Christianity. At the beginning
Cognitive Therapy came from a place of maladaptive behavior, everyone is unhealthy in some
way and needs to work towards becoming healthy (Murdock, 2013). This is similar to the core
Christian idea that everyone is broken and a sinner, our goal is to redeem ourselves. The second
way that Cognitive Therapy lends itself to Christian integration is in its adaptability (Jones &
Butman, 2011). Cognitive Therapy is structured around measurable and objective goals and
interventions; values are not a part of the process. Therefore, Christian counselors have the
ability to integrate values into the therapy without disrupting its effectiveness and without
minimizing the importance of the Christian worldview. The third and perhaps the most important
connection between Christianity and Cognitive Therapy is that thoughts and behaviors are
connected and must remain in balance. Jones and Butman (2011) state “Even a superficial
reading of the pastoral exhortations of the New Testament epistles yields a clear theme of
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obedience in actions and in thoughts as a way to maturity.” (p. 246).
Because Cognitive Therapy is so structured and scientifically based, it can cause issues
with Christian integration. The first way Cognitive Therapy is incompatible with Christianity is
that it is individualistic. In Cognitive Therapy the client ultimately can control her behavior and
responses to outside situations by controlling their thoughts and perceptions (Murdock, 2013). As
I stated above, Christianity is not about controlling your own life, you must give up control of
your life to God in order to truly find peace and therefore a healthy life. The second area in
which Cognitive Therapy is not compatible with Christianity is their definition of truth. Jones
and Butman (2011) state that Cognitive therapists believe truth is something constructed by man.
One of Christianity’s core beliefs is that God is truth, period. Thirdly, Cognitive Therapy relies
extensively on rationality, yet there is no standard for who or what is rational (Jones & Butman,
2011). Socratic questioning, for example, challenges the client to explain the evidence behind
their perceptions and thoughts (Murdock, 2013). Let’s pretend the thought or perception
involved the existence of God, how would that line of questioning ever end? What the client
may believe is a rational perception the counselor may disagree with or vice versa, it would be a
disheartening power struggle that would eventually cause the client to disengage and possibly
question her Christian beliefs. The idea of rationality is too subjective.
Conclusion
Cognitive Therapy and the other theories that fall under the umbrella of its name will
benefit Margaret because it is information based and very logical. Margaret is solution focused
and very driven by educating herself and using her intellectual abilities. Cognitive Therapy in a
nut shell can be explained as perception affects thoughts and feelings which then affect behavior
(Murdock, 2013). Margaret may be a very intelligent and driven woman, however many of her
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thoughts and perceptions are distorted by her poor social skills and inability to regulate her
emotions. By utilizing socratic questioning, journaling, and modeling I can begin to teach
Margaret how to change those thoughts and therefore change her behavior (Macklem, 2011).
Margaret enjoys a challenge, especially an intellectual one, therefore even though it will be
difficult for her to accept that some of her perceptions are incorrect, focusing on facts to back up
the new perceptions and thoughts will interest her. I believe the most challenging goal for
Margaret will be learning to recognize and label her emotions. Until she is able to do so, she will
continue to have interpersonal issues both at work and in her personal life with Andrew
(Macklem, 2011). The techniques and interventions utilized by Cognitive Therapy practically
designed for a person like Margaret who believes life should be orderly and logical. Interestingly,
in order to reach her goals Margaret will have to recognize and accept that logical and rational
are not the same thing.
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References
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Hyland, P. & Boduszek, D. (2012). Resolving a difference between cognitive therapy and
rational emotive behaviour therapy: Towards the development of an integrated CBT
modelof psychopathology. Mental Health Review Journal, 17(2), 104-116. doi:
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Jones, S.L. & Butman, R.E. (2011). Modern psychotherapies: A comprehensive Christian
appraisal. Downers Grove, IL: InterVarsity Press.
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Psychology and Christianity, 26(2), 101-111. Retrieved from:
liberty.summon.serialsolutions.com
Thomas, J.C. & Sosin, L. (2011). Therapeutic expedition: Equipping the Christian counselor for
the journey. Nashville, TN: B&H Publishing Group.
