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CBT Case Conceptualization and Treatment Case Conceptualization The basic premises of all CBT models are that

t cognition, emotion and behavior are reciprocally related; that perceiving and experiencing are active processes that involve both experiencing the world as it is (sensory input, essentially) and interpreting the world (meaning-making); that meaning-making is related to prior learning often social learning; that a person can learn to become aware of the interaction of cognition, emotion, and behavior; and that altering the ones that may be more directly under our control or influence cognition and behavior will impact the persons responses on all levels. Further, CBT models uniformly propose that basic or core beliefs acquired early in childhood evolve into a cognitive map of the world (schema or apperceptive mass or phenomenal field) that affects not only the information the person pays attention to (a cognitive filter, creating expectancies) but also how they explain what happens to them and others (their attributions). Core beliefs or schema are usually unquestioned underlying assumptions about the world which the person takes as givens, and may be fairly accurate, flexibly responsive to incoming information, varying with time and situation, and thus adaptive. However, maladaptive schema tend to be irrational (unscientific, illogical), to be based on incomplete or incompletely understood information, to be rigidly adhered to across situations, and to be resistant to change despite conflicting information or experience. Basic beliefs or schema are revealed by consistent patterns of cognition, behavior, and emotional response across situations. Long-standing maladaptive/irrational beliefs are evident in automatic thoughts/intermediary beliefs that form the stream of consciousness of the individual. When a person is seriously distressed, these automatic thoughts are likely to be characterized by predictable errors in interpreting experience. CBT approaches attempt to reduce the occurrence of the fundamental attribution error erroneously attributing events to global, stable, internal dispositions when they might more accurately be attributed to specific,

temporary, external factors in the situation itself as well as other errors of appraisal and prediction, using cognitive interventions, and to alter maladaptive or impractical behaviors using various behavioral interventions. What each variety of CBT attends to, and how it attempts to bring about change, varies mildly to moderately within this general description. A case conceptualization based on Becks Cognitive Therapy approach would focus on cognitions about self, world, and future, and address common cognitive errors made by individuals with the patients particular disorder/diagnosis. A formulation from this perspective should describe the patients negative cognitive triad composed of dysfunctional cognitive schema or core beliefs about self, world/others, and future along the lines of Self: I'm worthless. Im not good enough. I am damaged. World: I must not disappoint my family. People cant be trusted. The world is a threatening place. The world is unfair (and should be fair). Men are dangerous. Women will betray you. Future: Its hopeless. I will never be loved. I will never be happy. My whole life is ruined. Im stuck; its impossible to solve my dilemma. It will always be this way Intermediate beliefs may be couched as if-then statements, such as: Self: I must be perfect in order to be accepted. If something goes wrong, its all my fault. World/Others: If you dont respond to me, you must hate me. If you are not for me, you are against me. If you are angry, I cannot stand it. Future: If I dont get into Harvard, my life is ruined. If he wont marry me, Ill never be happy. Automatic thoughts are essentially stream-of-conscious, barely acknowledged but easily voiced commentary, and may consist of statements such as:

Im in trouble. I bet she/he doesnt like me. I just dont have the energy. What a witch! It figures! Im such a screw-up! Negative cognitions contribute to the persons behaviors (withdrawal, isolation, acting out, revenge-seeking, cutting, reduction in sexual activity, drinking, etc.) and emotions (sadness, guilt, depression, elation, etc.) Antecedents for these problems include social learning (Bandura) experiences that establish, contribute to, or maintain the clients beliefs. o These experiences include cultural and sub-cultural, familial, gender, peer-group, and religious learning experiences that are common to subgroups to which the client belongs, as well as individually-experienced observational learning. the persons history of stimulus-response learning via operant conditioning; their role in their family perhaps related to their birth order (Adler); the way their history has been storied within the family; their history of success and failure experiences; their medical history; what they read and how it influences them; the historical events of the time and the persons experience of those; and so forth. Another area of antecedent conditions includes the inherited characteristics of the person, including intelligence, introversionextraversion, biological contributors to their disorder (such as bipolar, OCD, psychoticism, or some forms of depression) and temperament. The final but by no means the least important area of antecedents is the persons situation or what they are actually dealing with in their life what might be coded as psychosocial stressors on Axis IV of the DSM-IV. A case formulation should identify the clients cognitive errors, and might identify all-or-none/dichotomous thinking (If I dont get straight As, I am a failure);

mind-reading (believing that they know how others see them or that others have specific expectations of them without checking it out); overgeneralization (all men all women I always they always); selective abstraction (attending to only some of the information, and ignoring other information); catastrophizing (if I dont do XX, the family will be destroyed; if she doesnt graduate from college her life is over; if I get a C my entire future is screwed up); emotional reasoning (if I feel worthless, I must be worthless), and so forth. A case formulation will also identify the clients shoulds or musts, what Adler calls the moral imperative.

From Elliss REBT position, one would describe the clients dilemma in largely similar ways, but would present the data in A-B-C-D-E format thusly: Activating Events: These are long-term or long-standing antecedents as well as immediate precipitants of the persons maladaptive behavior or emotion. Beliefs: These are the core assumptions, rational or irrational conclusions the client draws about himself, the world, others, and the future, as indicated above. REBT pays more attention to Musts and Shoulds that cause the person to feel stuck (what Adler calls the moral imperatives) than does CT. REBT focuses on four common cognitive errors in irrational beliefs: Awfulizing, I-cant-stand-it-it is, worthlessness, and unrealistic overgeneralization. It would be awful if I did not have the respect of the men in the family, and It would be awful to have to tell people I dont want to go to college. I couldnt stand my mothers or friends disapproval or disappointment, If I was embarrassed or ashamed, I couldnt stand it. If I am not XXX, I am absolutely worthless, or If I am not a XXX, I am no kind of woman at all. Consequences: In the REBT model, consequences are essentially the persons cognitive, emotional, or behavioral symptoms or problems over drinking, withdrawal, rumination, depression, and anxiety in this case.

D and E in the REBT model are discussed under treatment in the next question. A case formulation should also identify the clients strengths and resources. Treatment Planning CBT models vary somewhat in how they elicit patterns of maladaptive beliefs/schema, automatic thoughts and behaviors, and how they approach altering maladaptive cognitions and behaviors. In general, they utilize some form of disputation, data collection, and hypothesis testing to alter cognitive errors. Behavioral methods include stimulus control, contingency management (altering reinforcement schedules), activity scheduling, role play, direct teaching of skills, and acting as if (Vaihingers as if, Kellys fixed-role / personal construct therapy). From Becks CT perspective, one method the student will likely mention is using a Daily Thought Record to track situations in which the client is most distressed or in which the client uses maladaptive coping methods. The DTR tracks the cognitions that accompany, precede or follow these situations, and the feelings that the client experiences before, during and after the situation. Then the student might mention rating the strength of the belief, and the intensity of the emotion. The DTR would also used to collect baseline data about the frequency and severity of the clients problems, and the stimulus conditions that antecede the problems. The student should also mention the use of one or more of the Beck Inventories (Beck Depression Scale, Hopelessness Scale, or Anxiety Inventory) to establish a baseline and track progress in therapy. They might also mention the Dysfunctional Attitudes Scale, or other attitude-collecting or behavior monitoring methods.

From there, the student might mention doing a situation analysis, with a focus on identifying cognitive errors. This is best accomplished by evoking emotion during the retelling/re-experiencing of a critical incident, which also evokes the cognitions that accompanied the incident, due to state dependent learning. Thus, the client might be asked to retell, as if happening in the here-and-now, critical incidents, first experiences, or most recent episodes that typify the problem. Having evoked both emotion and cognition, the student might then discuss helping the client learn to recognize and label her cognitive errors. This encourages the client to take a more scientific or logical or realistic look at the conclusions she draws and his or her underlying assumptions. Cognitive restructuring, or altering the core or intermediary beliefs, may be accomplished by thought experiments to test underlying assumptions, by developing and testing alternative hypotheses (attributions after the fact or expectancies before the fact), or by asking the client to check it out by talking with others, or by asking her to act as if the situation is different from what he or she supposes (i.e., a behavioral experiment) and find out if her predictions or assumptions are correct. Cognitive restructuring might also involve scaling or rating to break down dichotomous thinking. The student might mention activity scheduling, to alter the clients avoidant behaviors, decrease depression, or help the client regain a sense of accomplishment and thus worth. The client would first be asked to track his activities on an hourly basis over the course of several days or a week, and to also track his mood and cognitions. Then he and the therapist would assess this, and develop a plan for helping him interact more with others and approach lifes tasks more adaptively. Other early between-session assignments might involve talking about his dilemma with others in his life who are likely to be helpful breaking each task down into small steps to assure success. Social skills training or role play might be needed to help the client overcome shyness or awkwardness in general, or in specific situations. Such interventions should take into account social mores of the clients cultural background. Training in stress management or assertiveness training might also be helpful in some cases, particularly where anxiety is a facet of the clients distress.

Later treatment would focus on challenging and testing some of the clients core beliefs about self, world and others. Cognitive errors would be identified, and behavioral experiments would be planned to test the hypotheses represented by the maladaptive cognitions. The therapist would help the client develop alternative, more adaptive cognitions, and the client would be encouraged to act as if the alternative, more adaptive hypothesis were true, collecting observations to compare both the truth and the practicality of the old and new beliefs and behaviors. From an REBT perspective, treatment would be similar but involve Disputation (the D in REBTs ABCDE model). The student might talk about helping the client identify his irrational beliefs (awfulizing, I-cantstand-its, extreme negative self-evaluations, and unrealistic generalizations). The student should certainly discuss debating the irrational beliefs through active and forceful disputation, possibly helping the client to distinguish between irrational and rational beliefs, and helping him draw the connection between irrational beliefs and distress in contrast to rational beliefs and adaptive responding. The student might also talk about helping the client assess his beliefs from a practical perspective: When I say this to myself, I feel worse and behave in ways that dont work so I should stop that and instead say something that makes me feel better or act more adaptively. The use of generating alternative beliefs, thought stopping, distraction, and problem solving are common techniques in REBT. Behavioral methods mentioned might include role play, reinforcing the client (and more importantly, the client reinforcing herself) for more adaptive behavior or taking small steps toward problem solving, activity scheduling, implosion (or exposure with response prevention), and social skills training. Ultimately, the REBT student would seek to help the client acquire a new Effective philosophy (the E in the model) that would help him think more rationally about his experiences, routinely check out his assumptions, and reduce cognitive error. These should result in less emotional distress. In addition, REBT would seek to alter behaviors that contribute to and maintain the clients distress, and to help him acquire a habit of behavioral experimentation to identify irrational assumptions. Further, REBT might seek to help the client acquire some social skills that contribute to his

discomfort with members of the dominant culture, with the general culture, and with standing up for himself within his own and the dominant culture. If the client does not make progress with the treatment techniques suggested above, the student should suggest a medication evaluation, and incorporate medication adherence into the treatment plan. Cultural considerations Where there are clear cultural differences, the therapist is likely to be viewed as an outsider by the client and her family or significant other, and cultural schema may dominate both the clients cognitions and those of her family and friends. Thus, the CBT concept that the client is the expert on themselves while the therapist is an expert on the treatment seems particularly important where there are significant differences. It should be the therapist's goal to be respectful and to work within the cultural values, beliefs and customs as much as possible, and to help the client use these potent schemas to understand her situational dilemma and life, and to find a solution. Identification with ones home culture may be either overt and known to the client or subtle and something the client is less aware of. Therapy may help the client own that identification and see it as both a resource for identity formation and values clarification and as a source of conclusions about the world (attributions and expectancies) that merit testing. Case formulation should take into account cultural sources of the clients conclusions about self, world, and future. Treatment should take into account the resources of the culture such as cultural healers, and the spoken and unspoken values of the culture, and the possibilities and limitations these provide.