CBT Case Conceptualizaton

1. Cognitive Therapy, 2007 CBT Case Conceptualizaton

2. You receive a call… John S. asks you to call back to talk about his 25 year old son. Knowing this alone, what thoughts run through your mind?

3. Case formulation begins with the first contact. • The first contact prompts the therapist’s automatic thoughts and underlying assumptions. • If you capture these as they occur, you can treat them as hypotheses worth testing. • This is the same process we ask our clients to engage in.

4. What are your ATs and assumptions?

5. How would your automatic thoughts and assumptions be different if… • John S. asks you to call him back about his 15 year old son…?

6. How would your automatic thoughts and assumptions be different if… • John S. asks you to call him back about his 15 year old son…? • About his 35 year old son?

7. How would your automatic thoughts and assumptions be different if… • John S. asks you to call him back about his 15 year old son…? • About his 35 year old son…? • About his 25 year old daughter…?

8. How would your automatic thoughts and assumptions be different if… • John S. asks you to call him back about his 15 year old son…? • About his 35 year old son…? • About his 25 year old daughter…? • You guessed it… about his 15 or 35 year old daughter?

9. How would your automatic thoughts and assumptions be different if… • Jane S. asks you to call her back about her 25 year old son? • About her 15 year old son…? • About her 35 year old son…? • About her 25 year old daughter…? • About her 15 or 35 year old daughter?

10. John S. has called about his 25 year old son. • You call him back, and he asks to make an appointment for his son. • What questions, automatic thoughts, & assumptions go through your mind?

11. What else are you assuming about John and his son? • Cultural identity • Religious identity • Age • Marital status • Personality traits • Where do those assumptions come from?

12. Although he doesn’t say more than is needed to make an appointment for his son, John sounds like your typical American businessman, who probably is exasperated by his son’s lack of accomplishment.

13. What are your ATs and assumptions?

14. How would your automatic thoughts and assumptions be different if… • John sounded African American? • John sounded Latino? • John sounded Eastern European (German, Polish, Hungarian…)? • John sounded like an Eastern Indian or Pakastani? • John sounded Asian? • Etc…

15. How would your automatic thoughts and assumptions be different if… • John sounded uneducated? • John sounded extremely educated? • John had a speech impediment? • John called via TTD? • John contacted you via email rather than phone?

16. John sounds like your typical client in terms of demographic variables. • He sounds like a person of average or better intelligence. • The conversation proceeds as most of your first contacts go, and you make an appointment to meet with John’s son the following evening.

17. John only said, “I think he needs help, and he’s said he would like to talk with someone.” • Based on what you know so far, what are you expecting his son to be like?

18. Craig is on time for his appointment. As he walks in, you note his appearance. He is dressed in jeans, a music group tee, tennis shoes, and a hooded sweatshirt, with the hood pulled up over his head. Although it is still summer, he is also wearing a close-fitting cap. He slouches as he walks with you to your office.

19. What are your ATs and assumptions?

20. How would your automatic thoughts and assumptions be different if… • Craig were a teenager dressed the same way? • Craig were 35 and dressed the same way? • Craig were female and dressed the same way? • Craig arrived dressed in a suit? • Craig arrived dressed in dirty clothes. • Craig arrived dressed inappropriately for the weather?

21. Craig smiles pleasantly and hesitates until you indicate where he should sit. • He tells you the following: • 1. He has Ankylosing Spondylitis (AS) • Stop and notice, catch and record your spontaneous thoughts and feelings. • Begin recording Craig’s possible automatic thoughts and core beliefs.

22. Craig smiles pleasantly and hesitates until you indicate where he should sit. • He tells you the following: • 1. He has Ankylosing Spondylitis (AS) • 2. He lost a long-time job and thus has no health insurance. (Notice, catch, record…) • Record Craig’s possible ATs and core beliefs.

23. Craig smiles pleasantly and hesitates until you indicate where he should sit. • He tells you the following: • 1. He has AnkylosingSpondylitis (AS) • 2. He lost a long-time job and thus has no health insurance. • 3. He has chronic pain. (Notice, catch, record… record possibilities for Craig’s belief system… you get the picture.)

24. 1. He has Ankylosing Spondylitis (AS) • 2. He lost a long-time job and thus has no health insurance. • 3. He has chronic pain. • 4. He has not completed college, and has a history of “problems with homework”.

25. 1. He has Ankylosing Spondylitis (AS) • 2. He lost a long-time job and thus has no health insurance. • 3. He has chronic pain. • 4. He has not completed college, and has a history of “problems with homework”. • 5. He completed high school via an alternative school.

26. 1. He has AnkylosingSpondylitis (AS) • 2. He lost a long-time job and thus has no health insurance. • 3. He has chronic pain. • 4. He has not completed college, and has a history of “problems with homework”. • 5. He completed high school via an alternative school. • 6. He is currently employed as a manager of a printing shop, and his health insurance kicks in in 2 weeks.

27. 1. He has AnkylosingSpondylitis (AS) • 2. He lost a long-time job and thus has no health insurance. • 3. He has chronic pain. • 4. He has not completed college, and has a history of “problems with homework”. • 5. He completed high school via an alternative school. • 6. He is currently employed as a manager of a printing shop, and his health insurance kicks in in 2 weeks. • 7. He would rather be running a restaurant.

28. 1. He has AnkylosingSpondylitis (AS) • 2. He lost a long-time job and thus has no health insurance. • 3. He has chronic pain. • 4. He has not completed college, and has a history of “problems with homework”. • 5. He completed high school via an alternative school. • 6. He is currently employed as a manager of a printing shop, and his health insurance kicks in in 2 weeks. • 7. He would rather be running a restaurant. • 8. In his culinary classes at the community college, he was the only male, and the classes were not aimed at the practical and more limited culinary skills he wanted to develop.

29. 1. He has AnkylosingSpondylitis (AS) • 2. He lost a long-time job and thus has no health insurance. • 3. He has chronic pain. • 4. He has not completed college, and has a history of “problems with homework”. • 5. He completed high school via an alternative school. • 6. He is currently employed as a manager of a printing shop, and his health insurance kicks in in 2 weeks. • 7. He would rather be running a restaurant. • 8. In his culinary classes at the community college, he was the only male, and the classes were not aimed at the practical and more limited culinary skills he wanted to develop. • 9. Two of his best friends died in the last year.

30. 1. He has Ankylosing Spondylitis (AS) • 2. He lost a long-time job and thus has no health insurance. • 3. He has chronic pain. • 4. He has not completed college, and has a history of “problems with homework”. • 5. He completed high school via an alternative school. • 6. He is currently employed as a manager of a printing shop, and his health insurance kicks in in 2 weeks. • 7. He would rather be running a restaurant. • 8. In his culinary classes at the community college, he was the only male, and the classes were not aimed at the practical and more limited culinary skills he wanted to develop. • 9. Two of his best friends died in the last year. • 10 He states he tends to be withdrawn, both on the whole and more so in the past year.

31. As he talks about his issues… • He tears up talking about the loss of his friends. • He tears up talking about the pain he is in, and the fact that the HMO doctor did not believe his long-time doctor’s diagnosis, so did not initially take him seriously or provide the pain medication he needs.

32. As he talks about his issues… • He tears up talking about the loss of his friends. • He tears up talking about the pain he is in, and the fact that the HMO doctor did not believe his long-time doctor’s diagnosis, so did not initially take him seriously or provide the pain medication he needs. • He laughingly reports that running the printing business at least allows him to swear, which he enjoys hugely. • He reports that he has always been “an independent cuss”.

33. Summarize Craig’s possible automatic thoughts, conditional beliefs, core beliefs, and behavioral imperatives. • I am… • The world is… • Others are… • Therefore I must…

34. Working from Craig’s problem list and your conceptualization, arrive at a tentative diagnosis. • What diagnoses might you consider? • What is the evidence for and against each possible diagnosis? • Consider all 5 DSM-IV-TR axes in your diagnosis.

35. DSM-IV-TR 5-Axis Diagnosis • Axis I: Major syndromes, acute disorders & learning disabilities • Axis II: Personality disorders and developmental intellectual deficits • Axis III: Medical conditions • Axis IV: Psychosocial stressors • Axis V: Global Assessment of Functioning

36. Treatment Planning • Next week!