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Case Conceptualization: A Cognitive-
Behavioral Approach
Clinical Report
Cognitive Behavioral Therapy
The purpose of this report is to use a cognitive-behavioral approach with a client to develop a case conceptualization
through the assessment and treatment planning process. CBT was originally developed for clients with severe
depression in order to challenge distortions in the client’s thinking and to uncover core beliefs that many clients hold
about themselves and the world around them that may exacerbate their condition or their symptoms. CBT treatment
has been applied and found effective in treating a wide range of mental health disorders and diagnoses Treatment is
based on a conceptualization, or clinical understanding of individual clients, their thoughts and beliefs, and their
patterns of behavior. This conceptualization is based on the cognitive model which connects mood and behavior to
dysfunctional thinking.1
Emily is a fictional client developed and presented by a clinical volunteer for training
purposes to develop and apply cognitive behavioral therapy skills in the clinical setting. Emily is a 26 year old female
from India who is currently completing her PhD in sociology. She is experiencing symptoms of depression and
anxiety.
CASE CONCEPTUALIZATION
“Case conceptualization is an essential „ingredient‟ in the transition from
assessment to treatment as well as an ongoing part of the treatment process.”2
Problem List
Psychiatric Symptoms
Emily identified “general feelings of anxiety and depression,” as identified by her clinical assessment. She also
identifies difficulty concentrating. She indicated passive suicidal ideation, but reports that she has no plan or intent to
commit suicide. Client is oriented to person, place, time, and situation. Emily’s feelings of depression seem to be
focused on her perceived “hopelessness” and “doom” she associates with the completion of her PhD and academic
career. Her feelings of anxiety appear to be focused on her perceived helplessness and isolation as she is afraid to ask
for help from her advisors or discuss her situation with her parents.
Interpersonal
Emily reports difficulty saying no to people and feels a need to please and help others. For example, a friend and
colleague asked her to give a guest lecture in her class, and Emily agreed even though she did not want to. She did not
have a good experience in the lecture, and afterwards, she harbored resentment towards that friend. Emily also
reported that she feels a need to please her parents and make them proud stating that “I need to feel like I
accomplished something after al lof the hard work they put into me.” Emily’s reports indicate that she has
1
Beck, J.S. (2011). Cognitive Therapy: Basics and beyond, 2nd
ed. New York: The Guilford Press.
2
Ledley, D.R., Marx, B.P., & Heimberg, R.G. (2010). Making cognitive-behavioral therapy work: Clinical process for new practitioners,
2nd
ed. New York: The Guilford Press.
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CaseConceptualization:ACognitive-BehavioralApproach|JerryBest
externalized her locus of evaluation and relies on other people’s opinions and acceptance of her to evaluate her self-
worth.
Occupational
Emily is uncertain about the academic career path that she has chosen. After her experience in her friend’s class, she
stated, “I am not suited for teaching, but I have invested too much time and effort to change my career path, now.”
She also stated, “I feel sad when I am involved with academic work. Most of the client’s statements focused on
teaching and feeling trapped and unable to ask for help.
Academic
Emily is having difficulty completing her dissertation due to anxiety, depression, and problems with concentration.
Emily reported that she will sit at her computer for an hour in attempt to work, but will often be unable to
accomplish any progress on her dissertation. At times, she will close her computer without saving the work because
she feels that the work is not good enough. Emily reported that she needs help and direction from her advisors, but
she is afraid to approach them. She fears that their perceptions of her may negatively change. She fears that they may
not believe that she deserves her PhD.
Medical
None indicated. Emily reports access to healthcare using student insurance through the University.
Financial
None indicated. Emily reports that her parents are “well off” and “supportive.”
Housing
None indicated. Emily lives in student housing.
Legal
None indicated.
Leisure
Emily identifies her parents as a social support, but did not discuss any peers or close friendships at this time. She is
concerned that her peers appear to be excelling in the field while she is struggling to complete her dissertation.
Substance Use
Emily reports having between one and six alcoholic drinks on the weekends. She stated that she tries not to drink
when she is sad as it worsens her mood.
Mental Health Treatment
No personal or family history indicated.
Mechanisms
Occupational
Emily is pursuing a PhD in sociology on an academic career track. She is currently struggling to complete her
dissertation and having serious doubts about her career choice. Specifically, she is unable to make progress at this time
towards the completion of her dissertation. Emily identified that she needs to go to her advisors to seek guidance in
order to be successful moving forward with her dissertation; but is unable to do so at this time. She fears that asking
for help will negatively change her advisors’ opinions of her and would be bothersome to her advisors. Emily’s
believes that she should not/cannot ask for help is exacerbating her anxiety and depressive thoughts about work.
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Core Belief
• I am not in control.
• I am not worthy.
Intermediate Beliefs
• I must please my parents.
• I must please my advisors.
• I must succeed to prove my worth to others.
Family Issues
Emily reports that her family is a very good support network, but she feels that she is unable to reach out to them at
this time. Emily believes that because of the nature of her situation, her parents would be disappointed with her.
Emily indicated that she is continuing on with school in order to please her parents. The role strain (family vs.
academics) is causing increased anxiety for Emily.
Precipitants
Origins
Many international students experience culture shock and confusion about role expectations due to social differences
between Asian cultures and the American culture as well as alienation and separation from their family.3
Additionally,
Emily believes she is unable to approach her family for support because she fears displeasing her parents. Cultural
research has identified the traditional collectivist values of many Asian Indians and Asian cultures. For females, this
collectivist attitude emphasizes their duty of service to family and society.
3
Constantine, M.G., Kinaichi, M., Okazaki, S., Gainor, K.A., & Baden, A.L. (2005). A qualitative investigation of the cultural
adjustment experiences of Asian international college women. Cultural Diversity & Ethnic Minority Psychology, 11(2), 162-175.
Situation
•Emily sits to work
on her dissertation
for 2 hours, but
turns off her
computer without
saving her work
because she feels
that her work is
not good enough.
Automatic Thought
•I am not good
enough.
•I will never figure
this out.
•I am failing. This is
embarassing.
•There is no
solution.
Emotional and
Behavioral Response
•Anxiety
•Sadness
•Hopelessness
•Helplessness
•Avoidance of
work
•Avoidance of
advisors
•Isolating from
family
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CaseConceptualization:ACognitive-BehavioralApproach|JerryBest
Treatment Plan
MRN: #1656202 Client Name: Emily Gupta Date of Assessment: 10-08-2013
DOB: 12-05-1986 (Age: 26) Sex: F Treatment Plan Date: 11-08-2013
Contact
Information
Address: 4573 S. Providence Rd.
Columbia, MO 98765
Phone: 573-888-888
573-666-7890
Diagnostic
Information
Axis I: 309.28 Adjustment Disorder
With mixed anxiety and
depressed mood
Axis II: V71.09 No Diagnosis
Axis III:
None
Axis IV:
Problems with primary support group
Problems related to the social environment
Educational problems
Occupational problems
Axis V/GAF:
60
Emily is experiencing depressive moods and symptoms of anxiety at this time. Her symptoms seem to be related to
educational and occupational domains; however, she is experiencing some isolation from her support systems (family
and friends). Emily’s symptoms are moderate, but manageable at this time. However, she is having some interference
in her functioning at school and at work.
Emily feels isolated from her family as she is unable go to them for help or guidance. She is also unable to seek
guidance from her advisors at the university. She is concerned that their views of her may change negatively or that
she may displease them. Emily is going through a difficult life transition at this time which appears to be stirring up
emotional responses related to her dissertation and her career path. However, these emotional responses do not meet
criteria for other diagnoses.
Strengths: Barriers/Threats:
Family support
Spirituality
Motivation to change
Subject knowledge
Transferrable skills
Uncertainty about her career
Negative thoughts (depression, defeat, hopelessness)
Perceived isolation from family support
Other Agencies Involved Service Coordination Plan
None N/A
Medication Dosage Frequency Indication
None N/A N/A N/A
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Goal : Emily will engage in weekly cognitive-behavioral treatment for a total of 12
weeks.
Date:
11/08/2013
Objectives: Date
Established:
Review
Date:
Status:
1. Emily will attend all scheduled appointments and will
responsibly notify the therapist if she is unable to attend
any appointment.
11/08/2013
2. Emily will participate in the planning of her course of
treatment by selecting treatment goals and objectives she
can achieve.
11/08/2013 11/08/2013 Achieved
3. Emily will participate in therapy homework throughout
her course of treatment. Emily agrees to actively
participate in selecting and evaluating homework
assignments. Emily agrees to complete at least 90% of
homework assignments.
11/08/2013
4. Therapist will provide orientation information for
cognitive-behavioral treatment and introduce Emily to
CBT therapy. Emily and the therapist will develop a case
conceptualization together.
11/08/2013 11/22/2013 Achieved
5. Therapist will provide psychoeducation to inform Emily
about the symptoms she is experiencing and relating
them to her experiences. Emily will work to identify
ways that her symptoms are related to her thoughts and
feelings. Therapist and Emily will work together to
identify automatic thoughts and deeper beliefs.
Goal: Emily wants “to be more motivated and productive” in working toward her
dissertation.
Date:
11/08/2013
Objectives: Date
Established:
Review
Date:
Status:
1. Emily will develop thought records identifying automatic
thoughts which are affecting her mood and anxiety levels.
Therapist will model the completion of records in
therapy, and Emily will complete thought records as
assigned for homework.
11/08/2013
2. In therapy, Emily will work with therapist to identify
intermediate and core beliefs on a more global level that
may be causing negative or distorted automatic thoughts.
11/08/2013
3. Emily will work in therapy to develop skills for boundary
setting and assertiveness in order to better manage her
goal of completing her dissertation.
11/08/2013
4. Emily will show mastery of identifying and evaluating
automatic thoughts. Emily will learn to modify
dysfunctional thoughts on her own.
11/08/2013
5. Emily will complete a pro and con list in order to
identify what she perceives as benefits and risks of
approaching her advisors about her educational concerns.
11/08/2013
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6. Emily will develop a script of items she needs to discuss
with her advisors and role play this in therapy using her
assertiveness skills she will develop in therapy.
11/08/2013
7. Emily will schedule a meeting to meet with her advisors.
Emily will attend this meeting and use her skills in order
to effectively seek guidance from her advisors.
11/08/2013
Client Signature: Date:
Guardian Signature: Date:
Therapist Signature: Date:
Problem Analysis
o
Situation
Emily sits down to work on her
dissertation. She is struggling to
complete her dissertation.
Automatic Thoughts
“This is embarrassing.”
“I can’t do this.”
“There is no solution.”
“I am a fake.”
“[If I go to my advisors,] it would
have negative consequences… it
will change what kind of student
Emotional Response
Sadness
Anxiety
“Doomed”
Self-Doubt
Frustration
Behavioral Response
After two hours of work, Emily
turns off her computer without
saving her work because she believes
it is not worth saving.
Physiological Response
Increased anxiety and heart rate.
Crying.
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Dysfunctional Behaviors
Isolating from her family: Emily is not able to approach her parents at this time to discuss her problems.
Not seeking help: Emily knows that she needs to meet with her advisors, but is unable to do so at this point.
Emily will not be able to progress successfully without direction and advisement.
Inattention: Emily is unable to focus on her dissertation and is becoming distracted when she does attempt to
complete her dissertation.
Turning off the computer: In this experience, Emily reported that she was unable to complete her
dissertation and that she deleted (did not save) two hours of work. She will not be able to complete the
dissertation if she does not save her completed work.
Cognitive Distortions
Emily believes that she will be a bother to her advisors if she asks for help.
Emily believes that her advisors will think less of her if she asks for help.
Emily thinks that her parents will be disappointed with her because she is having second thoughts about
being an academic.
Emily thinks that her future career is hopeless.
Emily’s distortions seem to have a theme of seeking approval and satisfying others.
Therapeutic Strategies
Assertiveness Skill building: Emily could benefit from building assertiveness skills to improve her boundaries
with peers.
Identifying and recording automatic thoughts: Emily will practice and master identifying automatic thoughts
and evaluating these thoughts using evidence.
Monitoring moods and behavior: monitor how automatic thoughts may effect mood and behavior.
Role play: practice approaching her advisors and parents about this situation.
Meeting: set up a meeting with Emily and her parents
Problem Solving: explore solutions to her perceived career problem without changing her course of
education.
