Olivia Campbell
APPIC Match Number: 23181/AAPI ID: 9166662625
Treatment Summary and Case Formulation
Client is a 13-year-old Black, cisgender, female. She is in the 8th grade at XYZ Middle School
and reports feeling “most attracted to girls”. Client presented to intake and initial sessions
oriented to time, place, person and event. She demonstrated normal speech and thought processes
and was dressed in an age- and weather-appropriate manner. She presented with a calm and
euthymic mood, with a guarded affect.
Presenting Problem: Client presented for initial intake with her maternal grandfather due to
concern for anxiety and depression. Client and grandfather endorsed symptoms of anxiety such
as social avoidance, somatic complaints when feeling nervous (racing heart, sweaty palms,
stomachaches), sleep disruptions and performance anxiety related to school and athletic events.
Client also stated she is “scared of dying” and is preoccupied with her health. Client and
grandfather also endorsed depressive symptoms such as frequent tearfulness, nighttime sadness,
and loss of interest in previously-enjoyed activities. Additionally, her grandfather reported that
client will often have “anger outbursts that come out of nowhere” in which she yells at her
family members. Per Client’s report, these symptoms began about two years ago following the
death of her mother.
Family History: Client lives at home with her maternal grandmother and grandfather and 17year-old sister. Her grandparents are both small business owners and identified as upper-middle
class. Client has no contact with her biological father and has not since she was a toddler.
Client explained that her mother died two years ago in a car accident in which she was under the
influence of alcohol, and crashed into a tree. Client’s mother was “in and out” of her life due to
reported opioid addiction. As such, Client and her older sister have lived with grandparents more
often than not, even when her mother was alive. Client added that she has a close relationship
with her maternal aunts, uncles and cousins and spends a considerable amount of time with her
family.
Social History: Client reported that she is a “pretty social person” with a large group of friends.
She spends a considerable amount of time with her friends, especially on the weekends and
reports feeling satisfied in her social relationships. She stated that some members of her peer
group have recently begun experimenting with marijuana which has made her uncomfortable due
to her mother’s history of drug abuse.
She reported feeling anxious when meeting new people and in large groups she often feels
“scared to talk” and is typically more reserved. She noted that her hands shake in social
situations. Client and grandfather explained that she has had issues with ordering her own food at
restaurants, asking for help in public and talking to strangers since early childhood. Grandfather
stated he is pushing her to be more socially interactive (such as with ordering her own food) and
he has noticed her slowly "come out of her shell".
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Olivia Campbell
APPIC Match Number: 23181/AAPI ID: 9166662625
Regarding peer victimization, Client stated that other students have teased her due to her hair,
style of dress and dark skin. Of note, Client lives in a predominantly white neighborhood and
states there are only three other Black students in her grade.
Client is on her middle school basketball team and enjoys spending time with her teammates.
However, Client reports experiencing significant anxiety before games and during practices,
especially when running individual drills and awaiting feedback from her coach.
Academic History: Client is currently in the 8th grade at a predominantly white public middle
school. She reports earning mostly As and Bs, with Cs in her Chinese and social studies classes.
She states her grades are lower in these courses because she does not like her teachers. She also
stated she tends to feel too anxious to ask questions during class or in front of other classmates
and asks teachers for help privately.
In terms of behavioral issues, Client’s grandfather stated she has recently received disciplinary
measures for arguing with other students in class and leaving the classroom without permission.
When asked about these incidents, Client stated that the disagreements were not her fault, as they
occurred when peers were “being racist” toward her and that she leaves class when she feels she
is “about to have an anxiety attack”.
Generally speaking, Client reports having a good relationship with most of her teachers and her
guidance counselor, with whom she visits when she is feeling anxious. She stated she would like
to be an engineer or doctor when she is older.
Medical and Psychological History: Client reported having mild asthma that tends to worsen
when she is feeling nervous. She denied any other previous illnesses or injuries and is in good
health. Her grandfather reported a family history of diabetes and heart disease.
She has not previously received therapy, nor does she have any mental health diagnoses.
Regarding her family’s psychological history, she has a maternal history of addiction, but no
other identified diagnoses. Her older sister is currently in therapy to work through grief related to
their mom’s death. Client’s grandfather stated that Client’s mother’s unexpected death was “hard
on everyone, especially the girls” and that the family is “getting through it the best that [they]
can”.
Client endorsed feeling anxious most days, notably in social situations. She also experiences
nighttime anxiety with racing thoughts that make it difficult for her to fall asleep. She endorsed
occasional nighttime awakenings due to anxiety. Client stated she tries to "push through"
anxiety as she wants to continue to do well at school and be socially engaged.
She also reported feeling sad most days, for about 40% of the day, typically when she is alone
and especially at night before bed. She stated that when she is sad, she stays in her room and
does not feel like leaving home or being around others.
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Olivia Campbell
APPIC Match Number: 23181/AAPI ID: 9166662625
Client’s grandpa reported that she struggles with anger and gets in frequent disagreements with
grandmother, typically over small household-related matters. Client notices that she "gets mad
really easily". When Client feels angry, she tends to isolate herself in her room and yell at others,
but denies any physical aggression.
Trauma History: Client denied any history of verbal, sexual or physical abuse. However, she
identified her mother’s death as a traumatic event, as well as witnessing her mother use drugs in
childhood, including an incident where she had to call 911 following her mother’s overdose.
Case Conceptualization Utilizing CBT Model:
1. Early Learning Experiences and Precipitating Factors
Though Client’s symptoms of depression and anxiety did not fully emerge until her
mother’s death, her childhood experiences contributed to the manifestation of these
symptoms, particularly as it relates to her experience of social anxiety. Client exhibits an
anxious attachment style that emerged due in part to her relationship with her mother.
Because of her mother’s addiction, she parented inconsistently and was often in and out
of Client’s life. Client could not anticipate when her mother would or would not be
attuned to her needs, thus her anxious attachment style developed.
Further, Client developed a tendency toward feeling she needs to please people or be
accepted by others due to her attempts to gain her mother’s attention. As someone with
an anxious attachment style, Client was already prone to fear abandonment and this fear
was exacerbated when her mom died unexpectedly. This resulted in further anxiety, in
both generalized and social contexts. Client is both worried about her health and safety
but also feels that she must perform well and hold herself to a certain standard for the
approval of others.
Her depressive symptoms also result from her fear of abandonment, as well as her low
self-worth, which may have developed in response to her constant questioning if she was
valued by her mother, as well as her father, who left her when she was a toddler.
This depression and anxiety is perpetuated by her grandparents’ permissive parenting
style in which they allow Client to miss school when she is feeling sad or anxious.
Further, due to the Black cultural views on emotional expression and therapy, Client feels
like she needs to suppress her emotions and “be strong”
2. Core Beliefs, Intermediate Beliefs, Maladaptive Coping Strategies, Activating
Events and Automatic Thoughts
Due to Client’s early learning experiences, she developed negative core beliefs about
herself, others and the world. Concerning the self, she holds the belief “I am flawed”. She
also believes that “people will not accept me the way that I am” and “people are critical”,
and feels “the world is unsafe”.
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Olivia Campbell
APPIC Match Number: 23181/AAPI ID: 9166662625
From these core beliefs, flow intermediate beliefs such as
o
o
o
o
o
“If people see who I really am, they will not like me”
”If I am quiet, I will fit in”
“If others like me, then I am okay”
“No one should know how I really feel”
”Showing my emotions means that I am weak”
As a result of her core and intermediate beliefs, Client engages in maladaptive coping
strategies that exacerbate her anxiety and depression. Her response to difficult situations
typically occurs through either avoidance or hypervigilance. She is avoidant not only of
social and evaluative situations and conflict, but also of identifying and expressing her
sadness and anger related to her mom’s death. Though this avoidance initially results in
reductions in anxiety and depression, it only serves to maintain and strengthen these
feelings long-term.
She also displays hypervigilance in that her response to threats culminates in anger
outbursts as well as somatic symptoms such as racing heart, stomachache and dizziness
when faced with real or perceived conflict.
Events that activate her maladaptive coping strategies and automatic thoughts are social
situations and performances, being alone, having an emotional experience of sadness,
anger or fear, and anything that reminds her of trauma related to her mother (riding in the
car, seeing friends smoke marijuana, family gatherings). During such activating events,
she experiences automatic thoughts that can also be viewed as cognitive distortions or
“thinking traps”. Her commonly employed thinking traps are mind-reading, black-andwhite thinking, fortune telling, and labeling, as evidenced by her idea that she knows
what other people are thinking about her, her tendency to view her actions as either “good
or bad” with no leniency for middle-ground, assuming that things will go badly before
they even happen and viewing herself as “dumb” or “overly-emotional”.
As a result of her core beliefs, intermediate beliefs, coping strategies and automatic
thoughts she tends to experience anger outbursts, social and emotional withdrawal,
school avoidance and a negative sense of self-worth, all of which are associated with
anxiety and depression.
Diagnostic Impressions:
Social Anxiety Disorder
Generalized Anxiety Disorder
Major Depressive Disorder, mild
Treatment Goals:
I. Long-term goal 1: Decrease symptoms of social anxiety
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Olivia Campbell
APPIC Match Number: 23181/AAPI ID: 9166662625
•
•
Short-term goal 1: Client will understand diagnosis and symptoms and how they
relate to the CBT model.
Short-term goal 2: Client will identify/challenge/replace maladaptive thoughts
• Interventions utilized to accomplish goals- Psychoeducation, thought
tracking, cognitive restructuring, role playing
II. Long-term goal 2: Decrease symptoms of depression
• Short-term goal 1: Client will understand diagnosis and symptoms and how they
relate to the CBT model.
• Short-term goal 2: Client will engage in 3-5 enjoyable activities per week
• Interventions utilized to accomplish goals- Psychoeducation, behavioral
activation, behavioral experiments
III. Long-term goal 3: Client will reduce frequency of maladaptive coping skills
• Short-term goal 1: Client will increase exposure to stressor/anxiety-inducing
stimuli
• Short-term goal 2: Client will identify/label emotions in session
• Interventions utilized to accomplish goals: worksheets (ABC, emotions
wheel), behavior homework, behavioral activation, relaxation skills
training, exposure therapy