Running head: COGNITIVE CASE STUDY
Cognitive Case Study: Rachel Voss
A Conceptualization and Treatment Plan
Michelle R Miklinski
Liberty University
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COGNITIVE CASE STUDY
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Abstract
Aaron Beck’s Cognitive Behavior Therapy (CBT) is an active, structured approach used
to treat a variety of psychiatric disorders (Josefowitz & Myran, 2005). Initially developed to
treat depression cognitive therapy enables clients to correct false self-beliefs that can lead to
negative thoughts and behaviors (Rupke, Blecke, & Renfrow, 2006). Cognitive therapy proposes
that our emotions and behaviors are products of our perceptions so with training individuals will
be able to recognize, evaluate, and restructure their thinking in order to achieve a more positive
and realistic interpretation of current events. This case conceptualization and treatment plan
presents the experiences of the client and the physiological events that are occurring from a
distorted thought process stemming from past experiences with a critical father and depressive
mother. Due to the client’s ongoing treatment she is aware that automatic negative thoughts are
a reality for her, although she cannot express all maladaptive thoughts, she is aware of the
emotional state of depression, anxiety, and stress they create. An outline of the goals,
interventions, and techniques will be reviewed to examine how cognitive therapy effectively
defuses automatic thoughts by providing a tool kit that can be used to challenge and change the
client’s thoughts for the better. Finally, challenges of treatment and active interventions that are
intended to increase the client’s level of experiencing are discussed
Keywords: Aaron Beck, Cognitive Therapy, conceptualization and treatment plan,
depression, schemas, core beliefs, cognitive distortions, automatic negative thoughts.
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Cognitive Case Study: Rachel Voss
A Conceptualization and Treatment Plan
Aaron Beck’s Cognitive Behavior Therapy (CBT) is an active, structured approach used to
treat a variety of psychiatric disorders (Josefowitz & Myran, 2005). Initially developed to treat
depression cognitive therapy enables clients to correct false self-beliefs that can lead to negative
thoughts and behaviors (Rupke, Blecke, & Renfrow, 2006). Beck’s research suggests that
depression is born out of pessimism and negative thought processes in individuals who are
seeking approval from others. Beck became interested in the negative thought process of his
clients which he later named “automatic negative thoughts” (Murdock, 2009). Automatic
thoughts are brief and involuntary negative thoughts or self-statements that influence our
appraisal of personal experiences and of self concept. Early life adversity and uncontrollable
negative events become internalized and the belief that these negative events are inevitable and
are attributable to negative aspects of self promote maladaptive coping capabilities and negative
appraisal bias (Gabrys, 2011).
Automatic thoughts may be verbal, visual, or both. They are not based on reflection or
deliberation; people usually are more aware of the emotion than the thought itself and
automatically accept the thought to be true without reflection or evaluation (Murdock, 2009, p.
318). Ultimately, identifying, evaluating, and responding to automatic thoughts usually
minimize their effect, therefore Cognitive therapy proposes that our emotions and behaviors are
products of our perceptions so with training individuals will be able to recognize, evaluate, and
restructure their thinking in order to achieve a more positive and realistic interpretation of current
events. Since the subject seeking treatment is motivated toward self-development and resolution
to her issues, it is the therapist’s belief that the client will benefit from this type of therapy.
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Presenting Concerns
Rachel Voss is a 40 year old white female who is seeking counseling for severe depression,
stress, and anxiety. Rachel states that she has depressive tendencies and feels that it may be
hereditary. She feels isolated and confined while withdrawing from positive community
relationships, friendships, and family communication. She states that she is pulling away from
relationships as a defense mechanism against hurt, loss, and rejection. A fall out with a close
friend, a critical father, and a feeling of being, “stuck” in an unsatisfying lifestyle has contributed
to negative thought processes about self and others. Rachel tends to use isolation and avoidance
as a protective barrier which leads to a discouraging outlook on her future. Rachel feels that she
has passed down her depression and social isolation to her children causing a sense of guilt,
anxiety, and a lack of self-worth. Rachel recognizes that she has power in making choices but
feels helpless against her distorted view of others and of self. Rachel feels that her negative self
concept and distrust of others stem from early interactions with parents that were perceived as
judgmental and conflicting. Rachel states that she hopes coming to counseling will help her
change her perspective on her past and present experiences so that she can have a more realistic
view of life events that are not clouded with automatic negative responses. Rachel is seeking
CBT as an extension to Person-Centered therapy treatment she recently experienced.
Case Conceptualization
Rachel’s schema that constructs her perceptions of self and others has developed a
maladaptive thought process stemming from past experiences with a critical father and
depressive mother. Core beliefs that have manifested from these early experiences are: “I am
second rate”; “I need acceptance and approval at all cost”; “No one likes me”; and “When I take
up someone’s time with my concerns, I am a bother”. Intermediate beliefs include: “I must be
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perfect to receive approval”; “I must have unconditional positive regard from myself and
others”; “I must be more disciplined”; “I must get nearly perfect scores to feel good about
myself”; “I must feel guilty and ashamed if I mess up”; Hurting myself is better than being hurt
by someone else first”. “People cannot be trusted”; “Women don’t like me”. There is no
indication that Rachel’s simple schema experiences have been compromised.
Due to Rachel’s ongoing treatment she is aware that automatic negative thoughts are a
reality for her, though she cannot express all maladaptive thoughts, she is aware of the emotional
state of depression, anxiety, and stress they create. For instance, in social situations anxiety is
aroused when introduced to a person or group of persons whom she does not know their
acceptance of her. Instead of thinking that a person’s initial response to her will be favorable,
her distorted thoughts immediately tend to believe: “I am not acceptable to anyone”, No one
really wants to talk to me”, “I have nothing to say”, and “Women never like me”. These
distortions seem to stem from the primal modes of loss and threat which would explain her need
to isolate and withdraw. A second example deals with automatic thoughts that may be accurate
at face value but have distorted conclusions (Murdock, 2009, p. 323) such as: “I missed an A in
biology by one point, I am second rate” or “My children are not always happy”, it must be my
fault”; primal modes of this sort are likely victim or loss generated and only lead to depression
and frustration. Finally, a third type of automatic thought may be accurate but dysfunctional
(Murdock, 2009): “When I take up someone’s time with my concerns, I am a bother”; “I am not
perfect, so I will not be loved”; “I must be more disciplined, therefore I am lazy”, these loss
modes are keeping Rachel from experiencing meaningful relationships with her friends, family,
and father in that she is reluctant to build on relationships in fear of losing them to her perceived
inadequacies. Her weak constructive mode regarding her sense of discipline is not helping her
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attain goals with her weight, children, or overwhelming lifestyle. The fact that Rachel does have
an active conscious control system is an advantage, she is conscious of her thoughts, has
attempted to hold them captive so she does not become non-functional, and is actively seeking
treatment to resolve the inaccuracies in her schemas. It has become apparent that Rachel’s lack
of self-confidence stems from early experiences in childhood, particularly in relationship with
her mother and father. Due to the perceived critical nature she experienced with her father and
the ambiguous relationship she held with her mother early schemas have been distorted.
Rachel appears to have a sociotrophic disposition which leads her to value relationships with
others. Her self-esteem is vicariously connected to the opinions of others, negative or confusing
experiences such as those from childhood have likely developed the faulty cognitive process. It
is suspected that Rachel’s protoschemas may have genetic origin since depression is thought to
be a hereditary trait passed down maternally. Also theorized is a personality trait that may be
sensitive to rejection by others, especially since a sociotrophic disposition is indicated; these
conditions suggest that the “loss” primal mode is hypersensitive and over-generalized.
Rachel’s cognitive thought process is indicative of a cognitive triad of self, world, and future
pessimistic view (Murdock, 2009). If left unchecked the over-generalized and hypersensitive
primal mode may become fully charged (resistant to change), becoming the norm where all other
information that is inconsistent with the schemas is rejected, ultimately conditioning the client to
a cognition of helplessness, unlovability, and worthlessness (Murdock, 2009). Since Rachel’s
depression is currently intermittent, it would be beneficial to remind her of healthy schemas that
have been observed since her preoccupation to distortions and perceptions are dominant. Recent
observation suggests that Rachel’s sense of responsibility is commendable; time commitments,
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work ethic, compassion and unconditional positive regard for others are among her most
admirable traits.
Before treatment, a formal comprehensive diagnostic evaluation will be preformed to assess
the need for medication. Rachel will also complete standardized self-report inventories which
may include: Beck Depression Inventory, Beck Anxiety Inventory, Automatic Thought
Questionnaire, Dysfunctional Attitude Scale, and Beck Cognitive Insight Scale.
Treatment Plan
Goals for Counseling
The goal of cognitive behavioral therapy is to help a person learn to recognize negative
patterns of thought, evaluate their validity, and replace them with healthier ways of thinking
(Goldberg). Distorted and dysfunctional thinking will be identified, prioritized, and addressed
by using problem-solving strategies learned in the counseling session. The goal of the client will
be to learn these strategies so they can be applied as a coping mechanism to sequester and then as
a tool to modify or remove the negative thought process. The intention will be to have the client
operate mental functioning based on reflective, constructive processes (through the use of the
conscious control system rather than primal modes of focus) whereby exchanging faulty schemas
for a more realistic and unconditional belief system that does not threaten the self-concept of the
client. Rachel’s self-enhancement primal mode must be strengthened so to elicit a more positive
self-regard.
The goals of the first session will be to: establish a relationship, set session goals, and
socialize the client (Murdock, 2009, p. 334). Socializing the client means, “to teach the client
the cognitive model” ( ie. relationship between thoughts, feelings, and behaviors) (Murdock,
2009). If immediate concerns are indicated, techniques can be administered for quick relief and
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to build confidence in the treatment process. Structured counseling sessions will include: A brief
update (mood check) of feeling from the past week compared to other weeks, what events
happened during the week that seem important, what thought process the client would like to
analyze in the session, summarize or “bridging” between the previous therapy session and the
current session by asking the client what they found important during the past session (Beck,
2012), review of homework, discussion of issues (use of techniques), devising new homework
(Murdock, 2009), summary of the session (important points), and feedback from client.
Examples of feedback would include: what was helpful about the session, what was not,
anything that bothered the client, anything the therapist didn't get right, and anything the client
would like to see changed (Beck, 2012).
Intervention
Cognitive restructuring is a general term consisting of a variety of procedures designed to
eliminate maladaptive thinking patterns and increase the frequency of constructive thoughts and
beliefs (Morris, 2005). People learn to behave in certain ways and to experience particular
feelings based on what they think is happening in the environment or on their expectations about
consequences that will occur, rather than on cues and outcomes that actually exist (Stanley,
Hersen, & Rosqvist, p. 203). By treating thoughts as hypotheses rather than facts and examining
the rationality of the thoughts, clients are asked to consider the possibility of logical "errors" in
the process of thinking (Stanley, Hersen, & Rosqvist). Common cognitive distortions include:
personalization (referencing oneself for an outcome that was not under one's control), all-or-none
thinking (thinking something is "all" bad or "all" good, with no in-between), labeling (involves a
person negatively evaluating themselves and mistakenly believing that their weaknesses dictate
who they are as a person), and overgeneralization (making a general conclusion based on one
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single experience). Other problems in thinking include mind-reading (assuming you know the
thoughts of another) and catastrophizing (the future is viewed as a disaster, other outcomes are
not even considered). When clients begin to notice thoughts that represent one or more of these
illogical patterns of thinking, they are asked to identify alternative thoughts that are more logical.
Techniques
Questioning
Socratic questioning refers to leading questions that help the client to test the validity of
their thought process. Some of the questions included are: (1) What is the evidence that makes
the thought true? (2) Is there an alternative explanation? (3) What is the worst that can happen?
What is the most realistic outcome? (4) What is the effect of my believing the automatic
thought? (5) What should I do about it? (6) What would I tell a friend if he/she was in the same
situation?
The thought record is typically used in this phase to record the client’s responses
(Murdock, 2009).
Thought Recording
The most commonly used instrument to capture thought recordings is the Dysfunctional
Thoughts Record (DTR). The counselor gives the client the DTR to take home and complete.
The client is asked to record events that lead up to an automatic negative thought, what the
thought response is, what emotions were aroused, what is the adaptive response generated, and
what was the outcome? The counselor and client will review the DTR during the next session
and evaluate the client’s responses to the automatic thoughts along with devising alternatives if
needed (Murdock, 2009).
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Behavioral Experiments
Behavioral experiments are assignments that target a specific belief; it is a task or
activity that challenges the faulty cognition and works toward altering the core belief that may
trigger the automatic negative thought. The behavioral experiment is designed to obtain new
information to aid in testing the validity of the clients' belief and replace it with a more adaptive
one (Mor & Haran, 2009, p. 269).
Graded Tasks
Graded task assignments involve taking an overwhelming situation and breaking it up
into smaller manageable pieces making it less intimidating. Structured steps are planned in order
to assure a positive outcome followed by additional steps focusing on the achievement of each
goal. The first steps should be relatively easy so the client is not overwhelmed and set up for
failure (Murdock, 2009, p. 341).
Problem Solving
Depressive disorders are known to be linked with stressful life events, and clients with
depression are less likely to cope with these events in a clear, focused way (Mynors-Wallis,
2012). Problem solving is geared toward improving an individual's ability to cope with these
stressful life experiences by identifying the concern, creating a solution, evaluating the feasibility
of the alternative, implementing the alternative, and assessing the functionality of the new
approach (Murdock, 2009).
Imagery
Imagery can be used to facilitate a visual representation of an event that is causing
stress and anxiety for the client. Emotions associated with the situation can be brought out, and
cognitions examined in a non-confrontational way. If the images become threatening they can
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be controlled by the “turn-off technique” which involves a disruption in the thought process such
as a loud clapping noise or blow of a whistle (Murdock, 2009, p. 342).
Role Playing
Role playing is likened to a rehearsal of a social situation that may produce heightened
emotion for the client. Pre-set self-coaching statements can be implemented to help with the
anxiety produced by the interaction. A graded approach can be used to gently introduce the
client to the feared situation. Coaching can be implemented to help the client formulate his
words and cope with the thoughts and emotions that are elicited (Murdock, 2009).
Homework
Many of the techniques that are used in the counseling session can be used at home and
practiced as homework. Cognitive therapy is about learning new life skills to replace
dysfunctional old ones and in order to learn new skills, they must be practiced. One of the best
methods that can be practiced at home is writing down negative thoughts and trying to flip them
into positive ones. The Dysfunctional Thought Record is perfect for capturing your automatic
thoughts and is instantaneous in allowing you to see your thought, analyze it, and respond to it.
If you have difficulty finding an adequate positive response to the thought you can share your
work with your therapist and resolve it together in the next session.
Conclusion
Cognitive therapy is an effective way to defuse automatic negative thoughts. When used
for depression, cognitive therapy provides a mental tool kit that can be used to challenge and
change our thoughts for the better. Over the long term, cognitive therapy for depression can
change the way a depressed person sees the world. This therapist believes that Cognitive therapy
fits the nature of Rachel’s most pressing concerns and matches her personality in that she is
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eager to take control of her negative thought process that she feels rules over her perceptions of
life, love, and acceptance. Aware that these schemas are products of early childhood experiences
and not biological, her perspective has already changed in that she is capable of challenging and
taking those thoughts captive armed with the tools, techniques, and collaborating relationship of
the therapeutic process. Possible concerns to treatment may stem from Rachel’s cognitive
distortions in that her all or nothing thinking could contribute to relapse in her thinking pattern
especially if she believes that all her negative thoughts are going to immediately come under
submission especially since core beliefs are resistant to treatment. Rachel is going to have to
understand that although she has these thoughts, they do not label her or define her and recognize
that there are many positives in her life and her character that she can be proud of. As long as
she remains aware of her distortions, especially those that pertain to persons around her, such as
mind reading, personalization, should and must statements, she will be better able to cope with
the process of cognitive restructuring and the life long journey toward positive self-regard.
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References
Beck, J. S. (2012). What happens during a typical therapy session? Retrieved from
http://www.academyofct.org
Gabrys, R. (2011). The role of negative automatic thoughts on stress-related processes and
symptoms of depression. (Doctoral dissertation, Carleton University, Canada, 2011)
Retrieved from search.proquest.com.ezproxy.liberty.edu:2048/docview/1000440410
Goldberg, J. (2012, July). Cognitive behavioral therapy for depression. Retrieved from
http://www.webmd.com/depression
Josefowitz, N. & Myran, D. (2005). Towards a person-centered cognitive behavior therapy.
Counseling Psychology Quarterly, 18(4), 329-336.
Mor, N., & Haran, D. (2009). Cognitive-behavioral therapy for depression. The Israel journal of
psychiatry and related sciences, 46(4).
Morris, T. (2005). Cognitive Restructuring (p. 775). Thousand Oaks, CA: Sage Publications.
Murdock, N. (2009). Theories of counseling and psychotherapy: A case approach. Upper Saddle
River, NJ: Pearson.
Mynors-Wallis, L. (2012). Problem-solving treatment in general psychiatric practice. Advances
in Psychiatric Treatment, 18(6), 417-425.
Rupke, SJ, Blecke, D, & Renfrow, M. (2006). Cognitive therapy for depression. American
Family Physician, 73(1), 83-86.
Stanley, M. A., Hersen, M., & Rosqvist, J. (2005). Cognitive Restructuring. Encyclopedia of
Behavior Modification and Cognitive Behavior Therapy: Adult Clinical Applications, 1.