Case Conceptualization

By
Ayesha Kashif
 Background
• In the 1960s, Aaron T. Beck, observed that
during his analytical sessions, his patients
tended to have an internal dialogue going on
in their minds, almost as if they were talking
to themselves.
• However, they would only report a fraction of
this kind of thinking to him. Therefore free
association failed to elicit them
 Background
• For example, in a therapy session the client
might be thinking to him/ herself: “The
therapist hasn’t said much today. I wonder if
he’s annoyed with me?” These thoughts might
make the client feel slightly anxious or
perhaps annoyed.
 Background
• He or she could then respond to this thought
with a further thought: “He’s probably tired,
or perhaps I haven’t been talking about the
most important things.” The second thought
might change how the client was feeling.
 Background
• Thus the basic theme underlying depression,
anxiety was not withholding emotions like
anger but was negative bias in cognitive
processing.
 Background
• Beck realized that the link between thoughts
and feelings was very important. He invented
the term automatic thoughts to describe
emotion-filled thoughts that might pop up in
the mind. Beck found that people weren’t
always fully aware of such thoughts, but could
learn to identify and report them.
 Basic Concepts
• Schema a cognitive structure.
• An idiosyncratic and biased manner in which
an individual views himself or others
• Habitual ways in which you see things (Leahy,
2003)
• Constructs used to classify, interpret, evaluate
and assign meanings to events (Dryden &
Golden, 1986)
 Basic Concepts
• A schema may be latent at any time and is
activated by certain kinds of circumstances
such as those analogous to the original
experience
• Or in reaction to a series of nonspecific
traumatic experiences which surpass an
individual’s coping ability
 Basic Concepts
• Two types of informational content at schema
Level
1) Beliefs are unconditional self – relevant
statements/ truths about self/world e.g. “I
am a failure” “This world is a rotten place”
 Basic Concepts
2) Assumptions represent contingencies
between events & self appraisals and are
expressed as if – then statements e.g. “If I am
not social, no one will know I am a loser”

Schemas in normal are flexible, whereas

schemas in disorders are rigid and inflexible
 Basic Concepts

• We learn Schemas from our parents, siblings,

peers from our interaction with them or just
by watching them

• “You are quite dark and should use a fairness

cream” would activate schemas about ugliness
and dark complexion
 Basic Concepts
• “Your cousin went to LUMS why can’t you be
like him? Schema about inferiority /
incompetence

• “I am going to leave you and your father”

schemas about abandonment
 Basic Concepts
• Schema Compensation If one has a schema
about a specific issue, he may try to
compensate for the vulnerability. For example

• If a husband’s schema is about being

abandoned, he may try to compensate for it
by giving in to his wife all the time
 Basic Concepts
• He would be afraid of asserting himself due to fear
of abandonment. Sometimes we stay in
relationships far beyond we need to

• If you have a schema about physical weakness, you

may try to become very strong, excel in martial arts

• If you have a schema about failure you may work

excessively hard and have a hard time relaxing
 Basic Concepts

• Schema Avoidance means that you try to

avoid facing any issue that taps into your
schema e.g. if you have a schema about failure
you may avoid by never taking up a
challenging situation or giving up too soon
 Basic Concepts
• If you have a schema about abandonment you
may avoid it by not entering into a relationship

• Other ways of schema avoidance are by

emotional escape in the form of using drugs to
dull the painful feelings, binge eating,
excessive sex
 Basic Concepts
• Depressive schemas reflect themes of loss,
failure, rejection & depletion

• Anxiety schemas reflect themes of threat,

danger & injury

• Anger schemas reflect themes of insult,

humiliation & domination
 Basic Concepts

• Negative Automatic thoughts represent

the surface cognitive features of schema
activation
• Appraisals or interpretation of events and can
be tied to particular behavioral/affective
responses
• Rapid negative thoughts that can occur
outside of the focus of immediate awareness
 Basic Concepts
• Primary NAT concerns themes of
abandonment, danger e.g. “I will be left
alone” “I am going to die”

• Secondary NAT concerns themes of

escape, neutralizing e.g. “I ‘d better not say
much” “ I must get a drink/joint”
 Basic Concepts
• Surface thought are thoughts which are
neither primary nor secondary NATs are called
surface thoughts e.g. “I will feel miserable
now”, “I am going to have panic”
 Basic Concepts
• Worry is a chain of negative affect laden thoughts
aimed at problem solving. It is predominantly a
verbally based thought process, whereas NATs can
occur on verbal as well as imaginal level (Borkovec et
al. 1983)
• Obsessions tend to be of shorter duration than
worries and are ego dystonic, whereas NATs & worries
are not ego dystonic (aspects of one's behavior or
attitudes viewed as inconsistent with one's
fundamental beliefs and personality)
 Basic Concepts
• Worry is of longer duration (9 min), less
involuntary and more realistic than obsessions
(2 min)

• Type 1 Worry is worry about external events

• Type 2 Worry is worry about occurrence of
worry
 Basic Concepts
• Metacognition A metacognitive analysis of
disorder is one in which appraisal of thought is
a central feature such as ‘Worry About
Worry”. For example “If I check the gas heater
repeatedly I will get fatigued” “If I don’t
something bad will happen”
 Basic Concepts
• Wells (2000) proposed that metacognition i.e.
cognition about cognition plays an important
role in producing emotional disorders. For
example a patient with GAD may say “worry is
harmful to my health” or “worry helps me
solve my problems”
 Cognitive Distortions
• Schemas especially when activated introduce
biases in the processing of information. These
biases are distortions that affect
interpretations of events in a way that is
consistent with the content of schemas.
• Also called interpretive biases and cognitive
errors
 Cognitive Distortions
• Jumping to Conclusions
• Making a negative interpretation or prediction
even though there is no evidence to support
their conclusion. This type of thinking is often
made when thinking about how others feel
towards us. Often divided into 2
subcategories, mind reading & fortune telling
 Cognitive Distortions
Mind Reading
You assume that you know what people think without
having sufficient evidence of their thoughts. For
example “He thinks I am a loser”.
Fortune Telling
You predict the future – that thing will get worse
or that there is danger/failure ahead. For Example
“I’ll fail that exam” or “I won’t get the job.”
 Cognitive Distortions
Arbitrary Inference
You draw a conclusion in the absence of
sufficient evidence
Selective Abstraction
Focusing on one aspect of a situation while
ignoring more important & more relevant
features
 Cognitive Distortions
Catastrophizing
You believe that what has happened or will
happen will be so awful and un bearable that
you won’t be able to stand it. For example “It
would be terrible if I failed’.
 Cognitive Distortions

Labeling
You assign global negative traits to yourself and
others. For example “I am undesirable” or “ I am
a rotten person”.
 Cognitive Distortions
• Name Calling
• Putting an extremely negative &
emotionally loaded label on
oneself/others. It is an extreme form of
magnification/minimization & also
represents gross overgeneralization
 Cognitive Distortions
Discounting Positives
You claim that the positive accomplishments you
or others attain are trivial. For example That’s
what wives are supposed to do – so it doesn't
count when she is nice to me” or those success
were easy, so they don’t matter”.
 Cognitive Distortions
Negative Filter
You focus almost exclusively in the negatives and
seldom notice the positives. For Example “Look
at all of the people who don’t like me”.
 Cognitive Distortions
Overgeneralization/ Allness &
Neverness
You perceive a global pattern of negatives on the
basis of a single incident. For Example “This
generally happens to me. I seem to fail at a lot of
things”.
 Cognitive Distortions
“Because conditions of living are intolerable they
will always be this way & I shall never have any
happiness”
Dichotomous thinking
You view events, or people, in all-or-nothing terms.
For example. “He is my ideal. I cant imagine him
doing anything wrong” or if you don’t get along
with someone “He is awful with no positive trait”.
 Cognitive Distortions
Judgment Focus
You view yourself, others, and events in terms of
black/white evaluations (good-bad or superior-
inferior) rather that simply describing, accepting
or understanding. You are continually measuring
yourself and others according to arbitrary
standards and finding that you and others fall
short.
 Cognitive Distortions
• Judgment Focus
• You are focused on the judgments of others as
well as your own judgments of yourself. For
example “I didn’t perform well in college” or
‘If I take up tennis, I won’t do well” or “Look
how successful she is . I’m not successful.”
 Cognitive Distortions
Shoulds
You interpret events in terms of how things
should be rather than simply focusing on what
is. For example “I should do well. If I don’t, then
I am a failure”.
 Cognitive Distortions
Personalizing
You attribute a disproportionate amount of the
blame for negative events to yourself and fail to
see that certain events are also caused by
others. For example “My marriage ended
because I failed”.
 Cognitive Distortions
Blaming
You focus on the other person as the source of
your negative feelings and you refuse to take
responsibility for changing yourself. For example
“She’s to blame for the way I feel now” or “My
parents caused all my problems”.
 Cognitive Distortions
Unfair Comparisons
You interpret events in terms of standards that
are unrealistic by focusing primarily on others
who do better than you and then judging
yourself inferior in the comparison. For example
“She’s more successful than I am” or “others did
better than I did on the test”.
 Cognitive Distortions
Regret Orientation
You focus on the idea that you could have done
better in the past rather than on what you could
do better now. For example “I could have had a
better job if I had tried” or “I shouldn’t have said
that”.
 Cognitive Distortions
What if?
You ask a series of questions about “what if”
something happens, and you are never satisfied
with any of the answers. For example “Yeah, but
what if I get anxious?” or “what if I can’t catch
my breath”.
 Cognitive Distortions
Emotional Reasoning
You let your feelings guide your interpretation of
reality. For Example “I feel depressed, therefore,
my marriage is not working out”.
 Cognitive Distortions
Inability to Disconfirm
You reject any evidence or arguments that might
contradict your negative thoughts. For example,
when you have the thought “I am unlovable,” You
reject as irrelevant any evidence that people like
you. Consequently your thought cannot be
refuted. Another example “That’s not the real
issue. There are deeper problems. There are
other factors”.
 Cognitive Distortions
• Phonyism when I don’t do as well as I ought
to do and they still praise and accept me I am
a real phony & will soon fall on my face &
show them how despicable I am
• Perfectionism I realize that I did fairly well
but I should have done perfectly well on a task
like this and therefore really am incompetent
 Cognitive Distortions
• Fallacy of Change
• We expect that other people will change to
suit us if we just pressure or cajole them
enough. We need to change people because
our hopes for happiness seem to depend
entirely on them
 Cognitive Distortions
• Always Being Right
• We are continually on trial to prove that our
opinions and actions are correct. Being wrong
is unthinkable and we will go to any length to
demonstrate our rightness.
 Cognitive Distortions
• For example “I don’t care how badly arguing
with me makes you feel, I am going to win this
argument no matter what because I am right”.
Winning an argument is more important than
relationships
 Cognitive Distortions
• Heaven’s Reward Fallacy

• We expect our sacrifice and self denial to pay

off, as if someone is keeping score. We feel
bitter when the reward doesn’t come true
 Assessment
• Formal/Informal

• Standardized Diagnostic Interview

• Clinical Assessment Interview

 Assessment
• The clinical assessment interview is informed
by CBT theoretical framework and helps in

• Identification/detailed description of the

presenting problem
 Assessment
• Cross – sectional cognitive behavioral analysis
involves detailed exploration of factors
contributing to initiation, exacerbation, &
maintenance of problem
• Triggers, thoughts, emotional, behavioral and
physiological responses.
 Assessment
• Longitudinal Analysis comprises of elicitation
of historical details that may contribute to the
understanding of the patient’s vulnerabilities
and the present situation
• Eliciting information for case
conceptualization/Formulation
• Planning/monitoring therapy
 Assessment
• Formulation is a provisional explanation or
hypothesis of how an individual comes to
present with a certain disorder or
circumstance at a particular point in time.
(Weerasekera 1996)
• A formulation is the tool used by clinicians to
relate theory to practice. Formulations can
best be understood as hypotheses to be
tested(Butler 1998)
 Assessment
• A psychotherapy case formulation is
essentially a hypothesis about the causes,
precipitants and maintaining influences of a
person’s psychological, interpersonal and
behavioral problems (Eells 1997)
 The Five Ps of CBT Formulation

1. Presenting issues
• Statement of the client’s presenting problems
in terms of emotions, thoughts and behaviors.

2. Precipitating factors
• The external and internal factors that
triggered the current presenting issues.
.
 The Five Ps of CBT Formulation
3. Perpetuating factors
• The internal and external factors that maintain
the current problems.

4. Predisposing factors
• The external and internal factors that
increased the person’s vulnerability to their
current problems.
 The Five Ps of CBT Formulation

5. Protective factors
• The person’s resilience and strengths that help
maintain emotional health ( Johnstone &
Dallos, 2006)
Structure of Assessment Interview
• Explain the structure/goal of interview
• Administer/review objective measures
• Description of current problem
• Determine cross sectional details
• Determine longitudinal details
• Check for remaining issues/feedback
• Prepare for therapy
 RELEVANT CHILDHOOD DATA
Born a sensitive and emotional child, second born among 4, parents praising sibs for achievement &
undermining Mona. Sexually molested by a neighbor at 8.
 

CORE BELIEFS
“I’m vulnerable.” ‘others are bad.” I’m bad.”
 

CONDITIONAL ASSUMPTION/ATTITUDES/RULES
“If I avoid challenges, I’ll “If I try to do difficult “If I avoid people I won’t
Be less miserable.” things, I won’t be able to.” get hurt/rejected.”
 
COPING STRATEGIES
Hypervigilant for negative Avoids doing tasks she Avoids situations in which
Emotion. Perceives will be difficult she might be asked to deal
with people esp men
.
 
SITUATION
Rape
 
AUTOMATIC THOUGHTS
“Such things only happens to bad people. God is punishing me”
 
MEANING OF A.T. MEANING OF A.T.
“My life should end” “I’M BAD.”
EMOTION BEHAVIOUR
Hopelessness/Guilt Suicidal attempt
Cross Sectional Conceptualization
• Trigger: Seeing a good looking person of opp
gender
• Intrusion: Sexual thought
• Meta Cognition: Thinking like this would make
me immoral/bad
• Appraisal of intrusion: Am I immoral/bad? If I
control my thoughts I can be ok
Cross Sectional Conceptualization
• Behavior: Try not to have thoughts, avoid
looking at good looking men, watching movies
etc.

• Emotions: Anxiety, guilt