Psychology Counseling /Discussion questions

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Working from a cognitive therapy perspective, I began conceptualizing Elena’s case by identifying the cognitive content and cognitive processes (beliefs, ideas, thoughts, ways of thinking) that directly relate to her presenting problem. Based on my understandings of Elena’s beliefs, thoughts, and ideas, I created a working hypothesis about Elena’s presenting problems. From Elena’s intake interview, a few key statements provide clues to the relevant cognitions that are likely related to her presenting problem of feeling “moody,” “tired,” “unhappy,” and that “nothing really matters.” Specifically, Elena states: “If I stay with my family my whole life, I’ll be failure.” She also reports that “the decision has been made for me” about whether to go to college or not, and indicates that she will not be going to college. Other statements that indicate relevant cognitions include feeling “stuck in the middle” between the choices of being the “perfect daughter” by staying home to care for her mother or leaving home to go to college to study journalism. Elena relates that she feels an “obligation” to both her mother and her self, which makes it difficult to decide what to do. These statements suggest that Elena has two sets of conflicting cognitive core beliefs, which are shaping her view of herself, her relationships with her family and friends, and her future. One set of core beliefs appears to be that her family is important to her and that staying to care for her mother is an expression of this importance. The other conflicting set of beliefs appears to be the idea that in order to discover and fulfill her potential that she should seek out experiences away from her family, including attending college. Within this second set of core beliefs is the belief that if she does not fulfill her potential her life will be wasted. When I consider Elena living with these seemingly opposite sets of beliefs, it is not surprising that she feels that “nothing matters.” If both sets of beliefs are true, then Elena will either disappoint her family or be a failure in life. My working hypothesis is that Elena holds conflicting sets of emotionally laden core beliefs, which are the source of her distress and difficulty with her mood. Both sets of core beliefs are likely activated and become salient in various daily activities such as attending school, doing homework, interacting with her friends and boyfriend who are encouraging her to attend college, as well as spending time with her family. It is also my hypothesis that there are cognitive errors and unhelpful information within these core beliefs, and that they may not be as incompatible as Elena perceives. It is important for me to keep in mind that my working hypothesis must be considered tentative until I gather more information to confirm it. I will need to collect additional information in order to confirm and refine my hypotheses. Moreover, I should continually evaluate and reevaluate the utility and accuracy of my hypothesis, as I continue to collect information about Elena’s situation and presenting problems. A first step in collecting additional information related to Elena’s situation is to have her keep a thought record log between now and the next time she and I meet. In the log, I will ask Elena to record her thoughts, beliefs, and ideas that occur to her throughout the day. I will ask her to particularly focus on thoughts, beliefs, and ideas that seem to come into her mind automatically. Along with keeping track of these thoughts, I will also ask Elena to keep track of related emotions, as well as to make note of any activities or behaviors in which she is engaged at the time of the thoughts. This thought record log will help Elena and I better understand what thoughts are automatically coming to her mind, what thoughts she finds most distressing, and in what activities she is engaged when these thoughts arise. I will look for patterns in Elena’s thought record log that are consistent and inconsistent with my working hypothesis. For example, consistent with my hypothesis, I expect that Elena will record thoughts coming to mind while she attempting to do homework such as, “Why bother to do this? I am not going to go to college any way so what is the point?” I will also expect, consistent with my hypothesis, that these thoughts are laden with emotions such as feelings of sadness, hopelessness, and despair. If Elena reported thoughts and emotions that were different from or inconsistent with my hypothesis, I will need to reconceptualize the case based on this additional information and then alter or expand my working hypothesis. The benefit of using a thought record log to obtain additional information from Elena is that it also serves as a first-step intervention. By keeping the log, Elena will learn to begin to track her thoughts, which were likely automatic and unscrutinized before this activity. I will strive to create a collaborative working relationship with Elena. I will encourage her to ask questions, share her ideas and insights, as well as actively practice outside of our meetings the new cognitive change skills she is learning. In an effort to create this collaborative relationship, I will aim to be warm, empathetic, and genuine with Elena. These are important qualities in any therapeutic relationship. However, I know as a cognitive therapist that Elena is much more likely to meet her treatment goals if she experiences our relationship as positive. I will not rely solely on the strengths of the relationship to achieve therapeutic gains with Elena, however. I will carefully and selectively use cognitive interventions that are likely to address Elena’s problems. I also plan to convey to Elena the importance of her work, activities, and ideas in making changes and reaching her therapeutic goals. Specific to Elena, I may need to adapt my cognitive techniques to her mood and current difficulties. Elena currently reports feeling “pressured” and “overwhelmed.” If I did not adapt my approach, I may undermine our developing therapeutic relationship. For example, if I were initially to give Elena considerable outside homework or present her with multiple cognitive change strategies, she may become overwhelmed and not experience success in therapy. This could reinforce her feelings of hopelessness and sadness. Possible feelings of discouragement or lack of concrete success may jeopardize the strength of our therapeutic relationship. Thus, I will break down therapy tasks and homework activities into small steps so that Elena can feel a sense of accomplishment and achievement as she masters each task. My short-term goals for Elena are to focus on improving her mood and decreasing her feelings of sadness, tiredness, and unhappiness because these are the foremost presenting problems. Related to these problems, my short-term goal will be for her to begin to learn cognitive change skills so that she can monitor, track, alter, and replace the surface thoughts and ideas that are unhelpful to her. She and I will begin to examine the thoughts and ideas that elicit feelings of sadness and then modify and replace these beliefs with helpful thoughts. In terms of measuring this short-term goal, I will look for positive changes in Elena’s mood. As one way of measuring changes in her mood, I will ask her to track her mood in a thought/feeling record log. I will ask Elena to complete standardized measurements and scales that can also give us information about changes in her mood. I will also ask Elena to track behavior changes. For example, it is easier for her to do her homework? Is she engaging in more positive coping activities, like taking walks? These behavioral changes will be indicators of underlying positive cognitive changes. Moreover, I will ask Elena to track her skills and capacities to use cognitive change skills. Another indicator of goal success will be Elena’s report that she felt success in using cognitive change skills on her own outside of our therapy meetings. For long-term goals, I will plan to work toward change in Elena’s core beliefs about what it means to be a good daughter, as well as what it means to have a successful life. Over time, I will plan to address the cognitive errors that are part of her core beliefs. For example, commitment to family and helping family members can be valued and considered a successful way of life. Choosing to stay with her parents and help care for her mother does not mean that Elena is a failure, although Elena currently conceives of this option as such. Likewise, there may be ways that Elena can pursue an independent life and goals while still being committed and involved with her family. For example, perhaps there is a community college or distance learning program in which Elena can enroll, so she can be involved with her family and pursue her educational and career goals. There are likely multiple solutions and possibilities for Elena. As a cognitive therapist, it is my working hypothesis that Elena is unlikely to see or consider these solutions because of her conflicting core beliefs. Altering Elena’s core beliefs, in the same way I would aim to alter her surface thoughts and ideas in the short-term, is a critical long-term goal to ensure that Elena does not continue to struggle with feelings of sadness and hopelessness in the future. Elena’s sociocultural context is a key feature in my conceptualization of this case. The consideration of Elena’s sociocultural context is consistent with cognitive theory because all aspects of a client’s environment, including family and community, can be powerful influences in shaping cognitions and cognitive patterns. Elena is the child of first-generation Mexican immigrant parents. Her conflicting sets of core beliefs about what it means to be a good daughter and what it means to have a successful life may be consistent with this sociocultural status. On the one hand, she loves and closely identifies with her Mexican immigrant parents who as she says would consider her the perfect daughter if she just stayed at home. On the other hand, she also identifies with her peers and with Eurocentric American culture which stress autonomy and independence as part of a successful transition from adolescence to adulthood. In many ways, Elena is a typical adolescent trying to make sense of adulthood. However she may need to discover, in her transition to adulthood, a unique path that affirms both of these cultures. The challenge of finding this unique path is likely being manifested in her conflicting core beliefs and in her current presenting problems. Still, because the path is challenging to navigate does not mean it is impossible to traverse. I will need to adapt my cognitive therapeutic techniques to fully consider Elena’s sociocultural experience and context in my interventions. Moreover, as European American woman, I will seek out supervision and consultation from other professional colleagues who may be similar in cultural and ethnic background to Elena. Additionally, I will seek out resources and support for Elena from appropriate Mexican American groups or key members of the local Mexican American community. Having Elena meet with other Mexican Americans who have navigated a similar path to adulthood can give Elena new information that will help to modify and adapt her cognitions in ways that can help Elena reach her life goals. In listening to Elena and reading her case, I find myself thinking that family systems theory will also be useful in conceptualizing and intervening with Elena’s presenting problem. Although cognitive therapy does consider the environment in case conceptualization, cognitive therapy is less able to provide guidance for interventions with the client’s environment. Understanding Elena’s role in her family system, particularly given that her brother has successfully left home and her sister’s problems are causing difficulties for the family, can help in the conceptualization of this case, as well help to direct therapeutic interventions with Elena and her family. For example, family counseling and family-level interventions that include Elena, her mother, and her father may be instrumental in addressing Elena’s presenting problems and ultimately finding solutions for Elena as she transitions into adulthood.

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