CBT Case Conceptualization and Treatment
Case Conceptualization
The basic premises of all CBT models are
 that 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 person’s 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 Beck’s Cognitive Therapy approach
would focus on cognitions about self, world, and future, and address
common cognitive errors made by individuals with the patient’s particular
disorder/diagnosis. A formulation from this perspective should describe the
patient’s 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.
I’m not good enough.
I am damaged.
World: I must not disappoint my family.
People can’t be trusted.
The world is a threatening place.
The world is unfair (and should be fair).
Men are dangerous.
Women will betray you.
Future: It’s hopeless.
I will never be loved.
I will never be happy.
My whole life is ruined.
I’m stuck; it’s 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, it’s all my fault.
World/Others: If you don’t 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 don’t get into Harvard, my life is ruined.
If he won’t marry me, I’ll never be happy.
Automatic thoughts are essentially stream-of-conscious, barely
acknowledged but easily voiced commentary, and may consist of statements
such as:
“I’m in trouble.”
“I bet she/he doesn’t like me.”
“I just don’t have the energy.”
“What a witch!”
“It figures!”
“I’m such a screw-up!”
Negative cognitions contribute to the person’s 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 client’s 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 person’s 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 person’s 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 person’s 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 client’s cognitive errors, and might
identify
 all-or-none/dichotomous thinking (If I don’t get straight As, I am a
failure);
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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 don’t do XX, the family will be destroyed; if she
doesn’t 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 client’s “shoulds” or
“musts”, what Adler calls “the moral imperative”.
From Ellis’s REBT position, one would describe the client’s 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 person’s 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-can’t-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 don’t
want to go to college.” “I couldn’t stand my mother’s or friends’
disapproval or disappointment,” “If I was embarrassed or ashamed, I
couldn’t 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
person’s 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 client’s 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” (Vaihinger’s “as if”, Kelly’s fixed-role / personal
construct therapy).
From Beck’s 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 client’s 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 client’s 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 life’s 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 client’s cultural
background. Training in stress management or assertiveness training
might also be helpful in some cases, particularly where anxiety is a facet of
the client’s distress.
Later treatment would focus on challenging and testing some of the client’s
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 REBT’s ABCDE model). The student might talk
about helping the client identify his irrational beliefs (awfulizing, I-can’tstand-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 don’t 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 client’s 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 client’s 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 one’s 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 client’s
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.