case conceptualization

Sample Paper Case Conceptualization

Introduction to the Theoretical Model

CBT therapy focuses on thought modification and realistic evaluation, the purpose is to teach people to identify, evaluate, and modify their thoughts and beliefs (Seligman, 2005). According to Aaron Beck, father of Cognitive Therapy, therapists believe that factors such as genetic predisposition, life experiences and traumatic events contribute to the development of dysfunctional cognitions and can be the root of the problem. CBT therapy is effective in the treatment of depression, phobias, addictions, anxiety, and it is a therapy that is highly structured and time limited where the sessions last approximately 12-16 weeks, the therapist is active and directive and is able to help the clients with their thought modifications. In this type of therapy people learn to recognize and to identify the beliefs and thoughts that are associated with their emotions and behaviors, evaluate the validity of their thoughts and modify them if wrong. Since unhealthy patterns play a significant role in depression, breaking that patterns and replacing them with healthy behaviors can help in the recovery process. Cognitive behavioral therapy is a good approach for depression, because it promotes the development of positive thoughts and enhancement of self-esteem by practicing to reach their desired goals. The client learns to identify the distorted thoughts and the core beliefs that are automatic and are the cause of the negative emotions. Clients during treatment also learn how to shift those negative thoughts and come up with alternative well balance thoughts. CBT goals are to help individuals solve their problems by teaching them how to modify their distorted thinking and dysfunctional behavior.

CBT is done by exploring patterns of thinking that lead to self-destructive actions and the beliefs that direct these thoughts; people with mental illness can modify their patterns of thinking to improve their coping abilities, (Sauter, 2010). Cognitive-behavioral therapy CBT focuses on helping individuals change his or her dysfunctional emotions, behaviors or thoughts through goal-oriented, specific exercises. CBT is useful in treating patients struggling with mood disorders, depression, anxiety, substance abuse and personality disorders. The CBT therapists show the individual how to identify and challenge their beliefs, explain the cycle of behaviors and thoughts, and promote positive patterns; this is done through a flexible and realistic approach. The therapist and client work together to set goals, and develop a treatment plan, CBT is a collaborative effort between the therapist and the client, (Hollon, 2012). Cognitive-behavioral therapist’s goal is to learn what the clients want out of life (their goals) and then help their clients achieve those goals. The therapist's role is to listen, teach, and encourage, while the client's roles is to express concerns, learn, and implement the learning tools the therapist has developed alone with the clients input. By developing these curtain skills and self-awareness clients can perform better and monitor themselves, clients can shift their beliefs about themselves and about the world, (Henderson & Thompson, 2011).

Basic Client Demographics

Name: Mindy

Age: 10

Ethnicity: White/Caucasian

Gender: Female

BASIC ID model for this patient:

B = Behavior (habits, responses, reactions that can be observed). In this case Mindy isolates in her room and refuses to help with chores. Mindy spends a lot of time on the Internet and texts her friends all night long. She demonstrates decreased motivation and she has decreased sleep. her grades are declining in math and science because she is not motivated to do her homework.

A= Affect (emotions and moods such as anger, anxiety, phobias, depression loneliness, and feelings of helplessness). Mindy presents symptoms of depression since she has been sad most days of the week. she reports feelings of hopelessness, helplessness, and often cries on and off during the week. She reports difficulty with attention and concentration; S = Sensation/School (Somatic symptoms as well as perceptual motor difficulties and concerns about school failure or lack of achievement). Client reports difficulty with attention and concentration, her grades are declining in math and science because she is not motivated to do her homework.

I = Imagery (nightmares, low self-esteem, negative body image, fear of rejection, and excessive daydreaming and fantasizing). Client exhibits negative body image and poor self-esteem.

C = Cognition (Irrational thinking, difficulty setting goals, thoughts of worthlessness). Client has thoughts of worthlessness and irrational thinking since she since she makes statements such as “ I’ll never amount to anything” and “my life’s sucks”. Client reports suicide ideation

I = Interpersonal Relationships (Interaction with family, friends, peers, teachers and others). Client experiences family problems since recent divorce, increased isolation from parents

D = Drugs/Diet/Biology (can include hyperactivity, weight-control problems, drug abuse and addictions). Client experiences sleeping difficulties. She only gets five hours of sleep per night.

Treatment History: Client and mother stated this is her first time in counseling and has not been seen before at any other place.

Summary of Presenting Problem for the Patient : Client was brought to therapy by her mother. Her mother states client has been having problems since her divorce, which happened six months ago. Client lives with her mother and feels very sad and depressed since her parents got divorced. Client is reportedly sad most days of the week. She reports feelings of hopelessness, helplessness, and often cries on and off during the week. Client has a markedly diminished interest or pleasure in all or almost all activities most of the day, nearly every day since she isolates in her room and refuses to help out with chores. Her grades have been declining and she is not motivated to do her homework. Client reports poor sleep, since she is only getting five hours of sleep per night, but denies going for days without sleep. Client exhibits loss of energy since she does not feel like doing anything during the day. Client experiences feelings of worthlessness since she make statements like “ my life sucks, no one really cares about me and I’ll never amount to anything”. Client reports diminished ability to think or concentrate nearly everyday and reports suicidal ideation without a specific plan. The symptoms markedly interfere with social and occupational functioning, since she is not motivated to do anything, she experiences feelings of hopelessness, her grades declined, she is isolating and had suicidal thoughts.

DSM V Diagnosis

Diagnosis: Major Depressive Disorder

296.23 (F32.2)

-Lasts at least 2 weeks

Change in previous functioning

At least 5 symptoms (one being depressed mood or loss of interest)

1.      Depressed mood most of the day nearly every day.

2.      Markedly diminished interest of pleasure in almost all activities most of the day nearly every day. 

3.      Insomnia nearly everyday

4.      Feelings of worthlessness

5.      Diminished ability to think or concentrate nearly everyday

6.      Reoccurring thoughts of suicide

Summary of Client Background

Family History: Client is the only child going to elementary school. Her parents are divorced and she currently lives with her mom. She is able to see her dad only on weekends. Client states she has a good relationship with her grandparents and other relatives such as cousins and uncles and sees them about twice a month. Client mentioned that she has a very nice family and they are all very close. Client states that she had a very nice relationship with her parents when they were still married and the style of the client’s parents discipline was democrative-authoritarian where they were firm in setting boundaries and limits and responsive to children needs (Sommers-Flanagan, 2014).

Birth Order: Client is the only child. Pampered and depends so much on adults because she has not learned to do things on her own.

Family Atmosphere: Client describes the family as a warm and nurturing. She says they were all very close and supportive.

Developmental stage of this child: Mindy is at the Preadolescence Concrete Stage (7-11).

Children during the stage need explicit examples, learning aids and directions but cannot draw a map of the same route, because they have difficulty with abstract reasoning. Children at this stage can have conversation skills and do reversible thinking. They are less egocentric and can understand the views of others, they are able to see rules as more changeable and have a greater capacity for concentration, attention and memory (Henderson & Thompson, 2011). The positives in this case are that Mindy can do reversible thinking, can appreciate views of others, she can move towards logical thought, and has a greater capacity for concentration, attention and memory. The cognitive errors that might occur at this stage that can influence therapy are that since Mindy is the only child, she can still have an egocentric personality and may not be able to appreciate the views of others. She might also have difficulty with abstract reasoning.

Developmental Problems: Mother denies developmental problems.

Education: Client is currently attending to elementary school.

Social History: Client is social and has friends. Mother stated that the client texts her friends all night long, but rejects invitations because she does not feel like going out or doing anything.

Medical Problems: Mother denies medical problems and mentioned client has always been healthy and never had any medical conditions. Mother says that she feels so sad right now and not motivated to do anything.

Spirituality: Client is Catholic, but not going to Church lately because of client’s mood.

Cultural Issues: no cultural issues were apparent in therapy with this client. Client is Caucasian decent.

Recent Stressors: Divorce of her parents.

Psychiatric Hospitalizations: Mother says client has never been hospitalized for psychiatric reasons.

Suicidal Attempts or self-harm behaviors: No suicidal attempts, but in the session client reported that she sometimes thinks about suicide but she clearly denied a plan. Seriousness of intent was evaluated and parents have been notified that their child is at risk for suicide and prevention actions have been recommended. A psychiatric evaluation was recommended for the client to determine the need of medication that in this case can help her reduce the symptoms. A medical referral was also recommended for the client so the doctor can conduct a medical history and physical exam in order to rule out illnesses or medications that might be causing symptoms.

Psychotropic Medications: Mother denies any history of psychotropic medications. Mother says client has never taken any. However, client was referred to a psychiatrist for a psychiatric evaluation and to determine the need of medication.

Substance use: Client stated she has never used drugs and does not drink.

Legal problems: Client is not experiencing any legal problems at this time.

History of Brain Injury: None

Presentation of patient in the office session: Client is oriented to person, place and time, the content of her thoughts are linear, and her speech is within the normal limits, coherent with normal rate not pressured and not lethargic. Client accompanied by her mother and her mood is sad and quiet. Client did not interact with office staff and other in the waiting area. Her personal grooming and hygiene is not so good, since she appears somewhat dirty, hair not brushed and gives the impression that she has not taken a shower in a few days. Client is dressed appropriately and according to the season. Client can normally walk. Her mood is really sad and appears tearful. Client cries when she talks about her situation. Client’s thoughts are clear and concise and her judgment is fair. Patient denied current plan of suicide and denied urge to self-harm. Patient has no prior suicide attempts, has contracted for safety and she has protective factors and she is future oriented.

Treatment Conceptualization: The client has been experiencing depression due to the divorce of her parents six months ago. The treatment approach to this client will be based on the cognitive behavioral therapy (CBT) perspective, because it can help the client in identifying unhealthy thoughts and behaviors and correct them by applying different skills to stop the problem. It will also help the client in developing effective coping skills. The client exhibits faulty assumptions and misconceptions about herself, the world and the future (cognitive triad). Client has a negative evaluation of the world and feels that the world is falling apart. She feels worthless since she has the irrational belief that she’ll never amount to anything and feels helpless since she says that no one cares about her. She sees herself as a failure since she constantly says her life sucks. The client is hopeless and has a negative evaluation of the future by thinking that nothing will ever get better. Due to the irrationality of these beliefs the clients has not been able to move on with her life. CBT can help the client identify the distortive negative thinking and come up with alternative balanced thoughts. CBT therapy focuses on thought modification and realistic evaluation which purpose is to teach people to identify, evaluate, and modify their thoughts and beliefs (Seligman, 2005).

The treatment plan will consist of:

Problem List

1. Depressive thoughts. Client reports depressive thoughts. Client believes she is worthless, (negative evaluation of self). Client believes the world is unfair and sucks (negative evaluation of the world). Client believes nothing will get better (negative evaluation of the future).

2.Social isolation. Spends most of the time in her room, she is not interested in any activities and rejects invitations from friends and family.

3. Procrastination and lack of self-discipline. Client is experiencing academic problems. Her grades are declining; she is not motivated to do homework and refuses to do her chores.

4. Difficulty sleeping. Client reports difficulty sleeping. She only sleeps five hours per night, and denied going for days without sleep.

Assessment. Administer the Beck Depression Inventory (BDI) to evaluate and monitor depression.

Psychoeducation. Educate client about CBT rationale, problems and procedures by the use of stories, demonstrations and life examples. Client will get an understanding of the CBT process and how the automatic thoughts and their associated emotional disturbances can be modified by the practice of CBT.

Identifying Automatic Thoughts and Core Beliefs. Help client develop awareness of her automatic thoughts and core beliefs and through the examination of those automatic thoughts the therapist will help the client come up with alternative balanced thoughts. Client will learn how to challenge thoughts that interfere with functioning.

CBT Techniques and Homework. Utilize CBT techniques such as the downward arrow to uncover underlying core beliefs, cognitive self-monitoring so the client learns to track her distorted thinking, Socratic questioning to encourage deep thought and help challenge maladaptive thoughts, distinguishing thoughts from facts, generating alternative interpretations and also Activity Scheduling to help the client engaging in more pleasant activities. Therapist will also employ Meichenbaum Self-Instructional Training to work on the client’s inner speech and Cognitive Rehearsal so the client gets to practice the new skills learned.

Homework will be given to the client for the practice of the new skills learned and probably journaling to review that together and find the negative thought patterns and educate the client on how these thought patterns can impact behavior.

Safety Plan. Design a safety plan the client can easily access. The safety plans includes the following actions: Recognize warning signs (Thoughts, images, situations, moods, behaviors indicating that a crisis may be developing). Use of coping skills, Socialize with others and with people who offer support, contact family members or friends who may help to resolve a crisis, contact health professionals, agencies or crisis hotlines (give client a list of resources).

Goals for the Client: The goals for the client are to reduce depressive symptoms, decrease negative thoughts, increase confidence and self-esteem and teach the client skills and techniques so she is able to identify the beliefs and thoughts that are associated with her emotions and behaviors, evaluate the validity of her thoughts and modify them if wrong. By doing that the client will be aware of what is causing the problem, she will analyze her beliefs and modify them, changing the maladaptive behaviors into healthy ones. The therapist will also work with her in setting up some goals, and will help her to develop the skills she will need to make her own judgments and choices because “goals are referred to regularly assess progress” (Seligman, 2005). The therapist’s goals would differ from hers in the way that the therapist will help her by teaching the skills that are necessary to reach her goals.

At the end of the treatment the therapist would examine the progress and follow up with her to reinforce skills and continuing on modifying certain beliefs and behaviors if needed.

Therapeutic Tools:

· The downward arrow is a tool that helps to uncover underlying core beliefs (Sommers-Flanagan, 2012). This tool will be very beneficial to the client since she will be aware of her negative automatic thoughts that are causing the problem.

· Socratic Questions. Socratic questions involve deep thinking and help people examine their lives and challenging maladaptive thoughts and behavior (NCVC, 2015). This technique will benefit the client, because she will be able to find the truth for herself. Socratic questioning helps to encourage deep thought and helps challenge maladaptive thoughts, distinguishing thoughts from facts, generating alternative interpretations by asking a series of questions the client will identify the logical contradictions and the evidence that doesn’t support her thoughts.

· Meichenbaum Self-Instructional Training. Therapist will work with client on taking the client’s self-talk out of her head and work with the client in developing a more adaptive speech.

· Cognitive Rehearsal, Modeling and Role Play. The therapist will ask the client to imagine a difficult situation; next the therapist will teach and practice with the client how to cope effectively and successfully with the problem by doing role-playing. The therapist will employ modeling technique where the therapist will show the child how to do something and the child will imitate the behavior. Therapist will also employ cognitive rehearsal so the client gets to practice the new skills learned.

· Activity Scheduling. It will help to monitor behavior and to incorporate in the schedule new fun activities to help the patient socialize and become active.

Barriers to Treatment: Transportation problems, financial concerns, time unavailable due to work schedule or other obligations, length of time between initial contact and the beginning of regular sessions, parents involvement and supportiveness of treatment, conflict between parents or family members, child’s resistance and level of readiness for change. Treatment depends on the child’s willingness to learn new skills and practice them for it to be effective. For the treatment to be effective is necessary that the child commits to it. The therapist can help and advise, but cannot make the problems go away without the client’s cooperation.

Community / Outside referrals:

LeRoy Haynes Center  

The Center’s mission is to strengthen the mind and spirit of children with emotional problems, special learning, and developmental needs. The Center operates a non-public school, mental health outreach, transitional housing, and autism classrooms. Students are referred by partnered school districts as well as by the Department of Public Social Services (DPSS).

 (909) 593-2581  

1233 W. Baseline  

La Verne, CA 91750

Big Brothers Big Sisters

Big Brothers Big Sisters partners with parents/guardians, volunteers and others in the community and holds itself accountable for each child in the program achieving: Higher aspirations, greater confidence, better relationships, Avoidance of risky behaviors and Educational success. Big Brothers Big Sisters seeks to change the lives of children facing adversity between 6 and 18 years of age.

Inland Empire

8880 Benson Ave, Ste. 112

Montclair, CA 91763

[email protected]

909-763-5959

References

Henderson, D., & Thompson, C. (2011). Counseling children. (8th ed.). Belmont, Ca: Cengage Learning.

National Crime Victims Research & Treatment Center. (2015). Socratic dialogue: teaching patients to become their own cognitive therapist. Retrieved from http://academicdepartments.musc.edu/ncvc/DG Kilpatrick/Socratic Dialogue

Seligman, L. (2005). Theories of Counseling and Psychotherapy: Systems, Strategies, and Skills (2nd ed). Pearson Learning Solutions. Retrieved from http://digitalbookshelf.argosy.edu/books

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2012). Counseling and psychotherapy theories in context and practice. (2nd ed.). Hoboken, NJ: Wiley & Sons.