Stepps Case Conceptualization (10_12_15)

Running Head: JOSEPH STEIN CASE CONCEPTUALIZATION 1
Joseph Stein Case Conceptualization
Sara Eliason
Philadelphia College of Osteopathic Medicine

JOSEPH STEIN CASE CONCEPTUALIZATION 2
Case Conceptualization
Client’s Name: Joseph Stein
Evaluation Date: 9/14/15
Evaluator: Sara Eliason
Identifying Demographic Information
Joseph Stein is a 65 year old Caucasian male. Joseph has been married but is recently
widowed and is the father of two daughters. Joseph is currently retired.
Reason for Referral
Nature of Complaint
Joseph was referred to counseling by his daughter. She is concerned that Joseph has not
been himself since the death of his wife three years ago and the loss of his advertising agency
shortly thereafter. Joseph agrees that he has not been feeling himself, stating he cannot get
beyond where he is and cannot seem to move forward from his past losses. Joseph also feels as
though life has lost most of its meaning. He feels stuck at this point in his life and does not want
to continue feeling at a standstill, stating something has to change. Joseph also believes that he is
a burden to his daughters and feels they do not belong in his home caring for him. Joseph feels
that if he can change his current lifestyle, his daughters will feel less concerned with him and
will return to their own families.
History of Complaint
Prior to losing his wife, Joseph was a hardworking, family man. He explained spending
much of his time either at work or with his family. Joseph appears to have no past history of
mental illness, and has now begun feeling stalled since the death of his wife three years ago and

the loss of his advertising company two years ago. Joseph struggles daily with feeling stagnant in
his life and also feels guilt for pulling his daughters away from their families each time they visit.
Consequences of Complaint
Joseph is lacking the motivation to do daily living tasks and experiences feelings of
sadness. Joseph reports having no enjoyment from life other than seeing his family; however, his
guilt of taking his daughters away from their families is impacting his enjoyment from spending
time with them. Joseph feels it is not their place to be caring for him and he finds himself
wishing they would go home despite feeling elated to see them. Joseph has begun self-isolating
because he feels as though no one is interested in hearing about his life anymore.
Relevant History
Family History
Joseph has a healthy and caring relationship with both of his daughters. His family
consists of his daughters, Gretchen and Elizabeth, each in their thirties, their husbands, John and
Don, and one granddaughter, Jane, who is 12. He reported having a loving and caring
relationship with his late wife, Maryam. Currently, Joseph receives much support from his
daughters and sees them at least once a week, Gretchen every day. Joseph appreciates seeing
them but is beginning to feel he is a burden to them. He is concerned his daughters may lose their
current families because they are investing too much time with him. In the past, Joseph’s family
relationship was supportive and loving; he spent much of his free time raising his daughters and
spending quality time with the family, such as attending shows, markets, and various town
events. Joseph and I will discuss his family of origin in upcoming sessions and learn about the
impact his family may or may not have on his current problems. Knowing family or origin
information is helpful to know as it may reveal any biological or genetic predispositions he may

have (American Psychiatric Association (APA), 2013), uncover any learned behaviors or
thoughts, may unveil factors that contribute to his current self-concept (Bembnowska & Josko-
Ochojskha, 2015), or serve as a protective factor against developing depressive symptoms
(Ivanova & Israel, 2005).
Social Support
Joseph does not currently seek friendship with his past co-workers and did not have many
friends or hobbies in the past. Much of his social support stemmed from his family. When he did
spend time with co-workers, their discussions centered around work. Joseph is currently retired
and so he no longer feels connected to those co-workers and feels they have nothing in common
or nothing to discuss. Relying on outside social support can often times be a preventative factor
against symptoms of depression; being that Joseph is lacking social support at this time may
contribute to his current struggles (Ibrahim, Din, Ahmad, Ghazali, Said, Shahar, Ghazali, &
Razali, 2013). Although Joseph has his daughters as strong social support, he feels much guilt
around spending time with them; therefore, their support at this time is less constructive.
Employment History
After Joseph attended college, he began his own advertising agency and spent many years
perfecting and building a successful business. Joseph cared much for the company and referred
to it as his son, implying that the business was an extension of himself. Joseph also alluded that
the company was very successful and stated it was possibly the best in the tristate area. After
some time and success, Joseph decided to take the company public. Sometime after his wife’s
passing, a board of trustee’s deemed that it would be best for Joseph to step down from his
position as CEO and possibly retire. Joseph agreed and is currently retired. He feels no animosity
toward the company and believes it was the correct move for the company to move forward. It’s

important to note Joseph’s business success, education, and overall socioeconomic status as it
can sometimes be a protective factor or contributing factor to symptoms of depression
(Bembnowska &Josko-ochojska, 2015). In Joseph’s case I believe it may be a protective factor.
Medical, Psychiatric, and Substance Use History
Joseph did not discuss any past medical or mental health issues. He disclosed never
having visited a counselor. Joseph is not currently taking any medications, nor is he currently
under the care of a physician. His last visit to his primary care physician was shortly after the
death of his wife. During that visit, his clinician assessed for physical or mental health struggles
as the result of his loss and prescribed him an antidepressant, possibly Zoloft. Joseph reported
taking it for a few months but discontinued use as it did not relieve him of his feelings of grief.
Joseph reported drinking an occasional glass of wine with his meals, about once or twice a
month, but does not, and has never, used or abused alcohol or other substances. In future sessions
Joseph and I may explore further relevant medical history as well as family medical and
psychiatric histories. Knowledge of a client’s medical history may reveal feelings surrounding
health and current medical state as well as susceptibility to medical or mental health issues
(IsHak, Greenberg, Saah, Mobaraki, Fakhry, Wu, Ngor, Yu, & Cohen, 2013). Also, being aware
of any family psychiatric or medical histories may also reveal biological predispositions Joseph
may face (Maradiegue, Lyon, &Meyers, 2013). Additionally, family medical and psychiatric
histories may have an impact on a client’s thoughts and feelings around health and mental health
and may contribute to any current struggles surrounding behavioral health ((Bembnowska
&Josko-ochojska, 2015). Overall Joseph is in good physical health.
Resources and Spiritual Factors

Joseph and his wife were raised under Judaism and also raised their daughters to be
Jewish. Joseph disclosed that he is not very spiritual and does not necessarily believe in the
Jewish faith anymore. He reported attending synagogue because it was important to his wife and
important that his daughters learn Jewish values. Joseph has not attended synagogue since the
death of his wife. Joseph’s past faith practices may have played a role in protecting him from
past struggles and since he is no longer following his religion, he may be more susceptible to
symptoms of depression (Koenig, 2012).
Past and Present Coping Skills
Joseph mentioned that in the past when a problem arose, he has always been able to think
through the problem independently, and be decisive according to what is best for his family and
company. He revealed that he feels frustrated because the struggles he faces now cannot simply
be figured out and decided on, much like he has in the past. Although Joseph does not have much
peer support, he appears to have a lot of support and care from his daughters, who have
motivated him to begin attending therapy. Additionally, Joseph disclosed using work to escape
some of the struggles he faced. He reported often times working harder when he was struggling
with something and seemed to use work as a distraction to help him cope with any negative
feelings he may have had. Currently, because Joseph is retired, he can no longer use work to
distract himself and finds himself watching television most of the day to take his mind of his
losses and sad feelings. Joseph realizes the television is only a temporary fix and hopes to learn
better ways to spend his time with therapy. Often times, distraction can be a healthy means of
coping with some losses; however it seems as though Joseph has no other means of coping and
as a result continues to struggle with grief and sadness (Broderick, 2005).
Risk Assessment

Joseph reported having experienced suicidal thoughts in the past around the time he lost
his wife and business. Currently Joseph is no longer experiencing suicidal thoughts and reports
that abandoning his family is his main preventative factor. Joseph could be considered at low risk
for suicide (Jacobs, 2009). Joseph reports no homicidal ideations in the past or currently.
Assessment
Diagnostic Considerations
Given Joseph’s current state and expressed symptoms, and upon further evaluation of
Joseph’s sleep patterns, eating habits, energy level, and psychomotor functioning, Joseph may
meet a provisional diagnosis of Major Depressive Disorder (MDD) or Persistent Depressive
Disorder (PDD) (APA, 2013). In considering MDD as a diagnosis, Joseph meets three of the
needed five criteria from criterion A; depressed mood most of the day, nearly every day,
diminished pleasure or interest in almost all activities most of the day, nearly every day, and
feelings of excessive guilt. Additionally, Joseph meets all other (B-E) diagnostic features of
MDD (APA, 2013). When considering PDD, Joseph meets nearly all symptoms of PDD
including depressed mood most of the day, more often than not, for at least 2 years, the presence
of two or more depressed symptoms listed under criterion B including feeling hopeless, meeting
criteria for MDD continually over a 2 year period, and the absence of a manic or hypomanic
episode (APA, 2013).
Time frame plays a significant role in determining a diagnosis. Although Joseph
expressed the onset of symptoms beginning 3 years ago following the death of his wife, it is
important to consider normal grieving periods. During the past 3 years, Joseph has lost his wife
and his business, each warranting a significant grieving period. In order to substantiate one
diagnosis over another, I would further assess the time frame of experienced symptoms,

including a reduction or absence of symptoms during the past three years, symptoms present
before the loss of his wife, and Joseph’s self-esteem and self-concept during various points in
time. Moving forward I will assess for changes in eating or sleeping, energy level, and
psychomotor functioning to address further criteria for MDD or PDD and solidify the diagnosis.
Other diagnoses that can be considered include Agoraphobia, Social Anxiety Disorder
(SAD) and Bipolar II. One might consider Agoraphobia because Joseph reports rarely leaving his
home; however, Joseph did not express any feelings of fear or anxiety associated with leaving
the home, more a lack of motivation to do so (APA, 2013). Similarly, one could consider SAD as
to the reasons why Joseph does not leave his home, feels guilt upon spending time with his
family, and appears to be self-isolating; however, Joseph expressed no feelings of fear or anxiety
associated with entering social situations rather that he chooses not to associate with others for
feeling they lack common ground or a desire to spend time with him (APA, 2013). Similarly,
Joseph may demonstrate symptoms similar to that of Bipolar II such as experiencing a depressive
episode; however there is no indication that Joseph has experienced a hypomanic episode
recently or prior to his wife passing (APA, 2013).
Assessment Instruments
In determining a solid diagnosis for Joseph, I will consider using the Beck Depression
Inventory-II, the Beck Anxiety Inventory, the Beck Scale for Suicide Ideation, and the
Dysfunctional Attitude Scale, Form A. In the Beck Depression Inventory will be used to assess
the presence of depression, Joseph’s feelings of depression, and the extent of severity (Beck,
Steer, & Brown, 1996). The Beck Anxiety Inventory will be used to rule out the possible
diagnosis of agoraphobia and social anxiety (Beck, Epstein, Brown, & Steer, 1988). The Beck
Scale for Suicide Ideation will be used to further assess Joseph’s risk of suicide (Beck & Steer,

1991). Lastly, I will use the Dysfunctional Attitudes Scale, Form A to gain a better understanding
of what thoughts and feelings maintain Joseph’s sadness and grief (Weissman & Beck, 1978).
Comprehensive Problem List
1. Anhedonia: Joseph stated feeling like life has lost its meaning.
2. Feeling stuck: Joseph expressed feeling unable to progress and move forward from his
losses.
3. Self-Isolation: Joseph is self-isolating and only interacts with others when his daughters
come to visit. Joseph does not leave the house much.
4. Feelings of guilt in being cared for: Joseph feels guilt and shame in his daughters having
to care for him and feels they belong with their own families.
5. Lack motivation to carry out daily tasks: Joseph lacks the motivation to leave the home or
complete tasks such as getting the mail, grocery shopping, etc.
Case Conceptualization
Predisposing Factors
Assessing for Joseph’s family history and past experiences will provide insight as to
where he may have developed possible thought processes, behavior patterns, values, and beliefs
that may have lead him to feeling depressed, self-isolate, and feelings of guilt around being cared
for (Maradiegue & Meyers, 2013). It is possible that Joseph was raised in a family that valued
independence, hard work, and immediate family. As a result, Joseph may feel that coping with
his losses is something he must learn to do alone, leading him to self-isolate and feel guilt around
being cared for. Additionally, because Joseph values family, he focused all of his energy on them
and was successful at fostering a family life. Currently, Joseph still values his family but also
believes that his daughters have new immediate families they must care for and possibly that

those new nuclear families are more important. Joseph feels his daughters should be taking care
of their own children and husbands, as he did when he was raising children. Joseph wishing his
daughters would leave and be with their own families may currently make him feel as though he
has not only lost his wife but his whole family. Joseph is not only mourning the loss of his wife,
but of losing his nuclear family and business, possible the two most important things to him.
Such learned values of independence, hard work, and family have left Joseph feeling lost without
work or family, have lead him to self-isolate in order to cope, and feel shame in taking his
daughters from their families.
Joseph’s religious values may also play a role in his self-isolating behavior and guilt
surrounding being cared for by his daughters. In traditional Jewish culture, the man is the head of
the household and is considered the provider and decision maker (Jewish, 2014). It is also not
uncommon for Jewish culture to embrace hard work and traditional gender roles (Jewish, 2014).
It is possible that as the result of Joseph’s religious values that he learned the importance of
caring for his family and not being cared for by anyone. This may also contribute to his feelings
of guilt around his daughter's coming to care for him and feeling as though his struggles are
something he must suffer with in silence. It also may have led to some of Joseph’s current
learned coping styles, which may have caused him to have a difficult time in coping with his
losses.
Joseph’s learned coping skills may also lead him to feel unable to move forward, self-
isolate, and feel he is a burden to his daughters. Joseph discussed often times when facing a
problem, he would take the time to think about the situation, weigh the benefits and negative
consequences, and make a decision based on what was best for his family and business, leaving
out any self-bias or emotional reasoning. An example of this is when Joseph willingly retired

because he realized it was best for the business since he was no longer contributing; not thinking
about the consequences it may have on him socially and financially. In coping with his loss,
Joseph recognizes that this is not a situation in which he can just decide to change. He may also
be having a tough time coping because in the past he based all his decisions on his family and the
business and now that he feels he has lost each of them he has no motivation to act or begin to
make changes to his currently lifestyle; leaving him stuck in a state he was left in at the time of
his losses, unable to move forward. It is possible that Joseph learned his coping patterns from his
own father or family who may have emphasized the importance of hard work, family, or
traditional gender roles of having a male breadwinner (Seiffge-Krenke & Pakalniskiene, 2011).
Joseph may also have been raised in a family in which his feelings were often times not
attended to, invalidated, or ignored altogether. Joseph may have learned that feelings were not
meant to be talked about, or possibly that as a male, he should not discuss feelings, again
embracing traditional gender roles (Gottschalk & Keatinge, 1993). As a result, Joseph learned
that people have no desire to discuss feelings or that his feelings did not matter. It is also possible
that Joseph has never been forced to confront his emotions or to fully experience them as his
family may have suppressed them or taught him to ignore them. Now that Joseph has neither his
family nor his business to distract him from his feelings, he is forced to sit with and ruminate on
his feelings. Also, his belief that he cannot share his feelings and decisions with others may have
impacted him in such a way that he only discussed business with others. Now that he feels he has
lost components of both, Joseph now feels he has nothing important to say or discuss and in turn
feels that he has no reason to speak with anyone. Additionally, Joseph feels that people should
have no interest or desire to speak with him. This would then explain why Joseph is self-isolating

and feels as though no one has the interest in spending time with him or seeing him, including
his family.
Precipitating Factors
Two apparent precipitating factors of Joseph’s current struggles were the death of his
wife and loss of his business. As a result of such losses, it is expected that Joseph would
experience a grieving period for both losses; however, because Joseph’s coping styles have
caused him to focus primarily on his family and business, he has had a difficult time moving
forward from the losses and he has no outlet to release his feelings.
Joseph’s daughters coming to visit him may also serve as a precipitating factor. When
Joseph’s daughters come, he begins to think about all the things he did with his family as he was
raising his daughters, and feels they should be doing those same things with their families. He
then begins to feel the shame and guilt he expressed for them being around as he believes they
should not be taking care of him but should instead be with their families. He may also begin to
think that no one wants to spend time with him because he has nothing to offer or contribute to
conversation or interactions. This too may lead to Joseph feeling bad about his daughters
spending time with him as he feels they could be doing so much more with their time.
Joseph also mentioned that meeting with others that he once worked with sometimes
makes him feel as though he has nothing to contribute to conversation. Joseph stated that he had
primarily discussed work and family with his colleagues. Meeting with colleagues now may
force Joseph to re-experience his losses as often times they will talk to him about the current
state of the business or ask about his family. During such conversations Joseph may begin to
miss his business and think about how his family is not what it once was. This may reignite
Joseph’s feelings of mourning and sadness surrounding his losses while also leaving him no

outlet or distraction to cope and deal with such feelings. Joseph is again forced to think about and
sit with his feelings and feel conflicted about sharing or discussing them as he has learned that he
must cope alone. As a result, Joseph self isolates because he does not want to be forced to think
about or discuss the loss of his business and family, and also feels he needs to address his
feelings alone.
Maintaining Factors
Joseph’s coping style, automatic thoughts, and possible core beliefs may have lead him to
maintain an inability to move forward from his losses. For example, Joseph is used to distracting
himself from his emotions or problems that he cannot figure out quickly or alone. He no longer
has the business or a family to raise to distract him from his feelings of grief and sadness.
Currently Joseph resorts to the television to distract him, but that’s only a temporary solution.
Joseph’s lack of distractions in his life have left him unable to cope with his losses, thus leaving
him feeling stuck and unable to move forward as he has no other means of coping. If Joseph
could utilize other coping strategies, he may be able to fully experience his feelings around the
loss of his wife and business and begin to move forward.
Joseph also revealed some automatic thoughts throughout the session that may reflect his
core beliefs. Joseph stated that when his daughters come to care for him or visit with him that he
feels he is a burden on them and that they don’t belong there. His thoughts reflect his values of a
nuclear family but also may indicate a deeper core belief that he is unworthy of love and being
caring for. Joseph also stated that no one wants to speak with him or is interested in anything he
has to say since he does not want to discuss business or family as it brings up negative feelings
for him. Although this may also express Joseph’s values of hard work and family, it also reflects
a core belief that he is unworthy of focus, attention, or relationships with peers and co-workers.

Additionally, because Joseph invested much of his time in raising his family and building a
successful business, he may have attributed all his self-worth to the business and the family.
Now that Joseph believes he has no business or family, he may also feel he has no self-worth.
This further indicates a core belief of feeling worthless or unworthy of love. Similarly, his
feelings of worthlessness may have led to his behaviors of self-isolation, feelings of guilt about
spending time with others, and feeling unable to cope and progress from this state of profound
loss.
Theoretical Models
Cognitive Theory: Joseph’s current symptoms and struggles can be addressed through the
application of cognitive behavioral theory (CBT) and some of the models used to explain CBT.
One CBT model that may be applied to Joseph’s current problems may be cognitive theory.
Developed by Aaron Beck (1983), cognitive theory considers a person’s thoughts and their effect
on their behaviors and feelings. Beck (1983) theorized that an individual responds to stimuli
through thoughts about the stimuli or event, the automatic thoughts, and in turn has a feeling or
sensation associated with the thoughts that would then cause the person to act or behave. A
person’s automatic thoughts stem from their core beliefs about themselves and their
surroundings, self-concept (Beck, 1983). Sometimes an individual’s automatic thoughts can be
cognitive distortions, or skewed thoughts surrounding an event or stimuli (Beck, 1983). Core
beliefs stem from reinforcements a person has received throughout their lifetime that have lead
them to solidify their thoughts as true accurate representations of themselves and the social world
they act in (Beck, 1983).
Joseph stated many automatic thoughts such as my daughters don’t belong here, life has
lost its meaning, I have nothing to contribute to conversation, which may reflect a core belief of

feeling worthless. Joseph valued his business and family immensely, in which he ascribed all his
life worth and meaning to. Now that Joseph feels he has lost his business and family, he is
beginning to feel as though he is worthless and that life has lost its meaning. As a result of
feeling worthless, Joseph thinks that his daughters should not want to spend time with him, that
his co-workers should not care to speak with him, and that there is no reason for him to socialize
or to leave the home. Joseph’s feelings of worthlessness have eradicated his motivation to
progress through life, socialize, and do activities of daily living.
Social Cognitive Theory: Another CBT model that is applicable to Joseph’s current struggles is
the social cognitive theory. In social cognitive theory, an individual develops thought processes,
affective reactions, and behaviors through the modeling of others (Bandura, 1989). The model
also considers many biopsychosocial and sociocultural factors that affect behavior and the
development of a person’s self-concept, including significant life events (Bandura, 1989).
Bandura (1989) postulated that modeling plus biopsychosocial factors can shape the
development of language, means of communicating, social mores and practices, affective
attitudes, and values. Modeling, or observational learning, is when a person views another
person’s behavior and the reinforcement that follows, and decides to act similarly to receive the
same reinforcement (Bandura, 1989). Bandura (1989) further elaborates that an individual does
not simply mimic in social learning but that the above factors impact a person’s decision to feel,
think, or act a certain way based on the perceived reinforcements another individual may or may
not have received by emoting, thinking, or acting similarly.
Bandura’s social cognitive theory can be applied to Joseph as the vehicle for which he
learned some of his values, beliefs, and core belief. Joseph may have learned through the
modeling and reinforcement of his family members to value traditional gender roles,

independence, hard work, and the importance of family relationships. Joseph’s learned values
impact his current automatic thoughts around being undeserving of social interactions and self-
worth without family or work. This has reinforced a core belief of being worthless and has lead
him to begin self-isolating and feeling as though his life has no purpose. Joseph may have also
learned his coping style of distraction through modeling and observation of family members.
Similarly, Joseph may have learned that dealing with problems through work distractions is
helpful and so he was unable to develop other coping mechanisms in which he must experience
his problems and work through them. Now that Joseph has no work to distract him, he has no
means of coping with the loss of his wife resulting in him feeling stuck and unable to move
forward.
Protective Factors and Strengths
Joseph has many strengths and protective factors that will be useful in therapy moving
forward. Joseph is a good problem solver, can be diligent and focused, and is decisive, as he
discussed in his coping strategies. Joseph is ambitious and hardworking as reflected by his
successful business. Joseph also has a strong family relationship and support system that will
help him to make changes and accomplish goals.
Diagnostic Impressions
Disorders: Major Depressive Disorder, Mild, 296.21 or Persistent Depressive Disorder, with
persistent major depressive episode, 300.4 (each provisional) (APA, 2013).
Medical Problems: Joseph did not report any current medical problems that might impact
treatment or the development of his problems.
GAF: Current: 57 Best in the past year: 61

Joseph’s current GAF could be considered a 57 as he is experiencing moderate difficulty
in both social and work functioning and expressed a flat/depressed affect throughout session
(APA, 2000). Being that Joseph is retired, work functioning should be considered his tasks in
caring for his home or being employed as a homemaker. Joseph’s best GAF in the past year can
be considered a 61 as he has experienced more mild difficulty in the past year concerning work
and social functioning and can be considered to have meaningful interpersonal relationships with
his daughters and their families (APA, 2000).
Emotional Symptoms: depressed mood most of the day, nearly every day, diminished pleasure
or interest in almost all activities most of the day, nearly every day, and feelings of excessive
guilt.
Cognitive Symptoms: beliefs surrounding worthlessness, beliefs that others should not want to
spend time with him or be interested in him, thoughts that daily living activities are no longer
worth performing or accomplishing.
Behavioral Symptoms: social isolation, avoidance of leaving the home, avoidance of
accomplishing daily living tasks, ruminating behaviors, and inactivity around the home.
Treatment Plan
General Treatment Goals
1. Reduce excessive stress/guilt surrounding visiting with family and friends.
2. Increase activity inside and outside of the home.
3. Increase social support beyond family members.
4. Increase self-esteem and self-concept.
Treatment Strategy and Sequence of Treatment Components

Joseph’s treatment plan will consist of 3 phases in order to address his perceived
problems and current goals. The first phase will address Joseph’s lack of motivation and sources
of meaning. During this time Joseph and I will work toward increasing his activity in the home,
increasing his activity outside of the home, and begin to reach out or create social support
outside of his family. This will help to create a stronger social group and decrease some of his
guilt around spending time with his daughters. The first phase will also allow for Joseph and I to
build a stronger therapeutic bond which will be helpful in moving forward in other phases and
addressing deeper problems. The second phase will focus on Joseph’s self-esteem and self-
concept that contribute to his feelings of depression. In doing so, I hope to further motivate
Joseph to meet others and increase activity while also addressing his unhelpful thoughts that
without his job and family his life has no purpose. The third and final phase will concentrate on
Joseph’s current coping mechanisms and aim to develop other coping styles and sources to avoid
feelings of depression currently and in the future. The third phase will also consist of planning in
order to prevent future depressive symptoms.
Planned Interventions
Phase 1: Identifying other Sources of Life Meaning/ Decrease Anhedonia
CBT to increase motivation and decrease isolating behaviors utilizes helpful cognitive
interventions. Joseph will begin to set small goals toward leaving the home and doing more
activities in his home. This may be an ongoing process with Joseph and we will continue to set
small goals and accomplish activities as treatment continues and progresses across phases.
During this phase, I will attempt to develop trust and a therapeutic alliance with Joseph by
setting and accomplishing small goals. A strong alliance will be supportive in addressing
Joseph’s self-concept and coping strategies in the next two phases. The phase will consist of 2

parts, addressing in home activity in and out of home activity/socialization, and may be a
continual process that Joseph and I address throughout treatment.
Goal 1: Self-Isolation and Increased Activity Treatment
Treatment Rationale: Cognitive theory postulates that a person’s thoughts and feelings
around a behavior impact their performance of behaviors (Beck, 1983). Joseph has begun feeling
that his life has no meaning or purpose. Currently, Joseph’s thoughts around performing tasks of
daily living are that, someone else, one of his daughters, will just do it or take care of it. As a
result, Joseph does not see a need to perform tasks and does not do them. If Joseph perceived
everyday household activities such as cooking, cleaning, and retrieving the mail, as important
responsibilities that only he could accomplish, then it is possible that Joseph will find small
meaning in such activities. Joseph could treat running his home like running a business. As a
result, Joseph may begin to find small meaning in his life and feel less worthless as he has
responsibilities that need to be tended to. Additionally, performing task around the home are low
risk activities for Joseph in which he feels confident he can accomplish. By setting and
accomplishing low risk, smaller goals, Joseph can also begin to build his confidence and also
build trust in the process of therapy.
Intervention: Cognitive restructuring surrounding Joseph’s ability and need to perform
tasks of daily living may increase his feelings of self-worth (Hunt, Schloss, Moonat, Poulos, &
Wieland, 2007). In session, Joseph can document a daily thought record, do some reframing, and
behavioral experiments to challenge his thoughts that daily living tasks are not necessary, and
that he has no purpose. During this time, Joseph may also begin to become more aware of his
automatic thoughts about himself and uncover his core belief of feeling worthless without family
or occupational responsibilities (Hunt et al., 2007). Joseph uncovering his core belief on his own

will be helpful for upcoming phases where we can begin to challenge his automatic thoughts and
core beliefs.
Joseph can do some behavioral experiments such as getting the mail or cooking a meal
for his daughter rather than her cooking for him. In doing so, he can challenge the thought that
the tasks are not useful or important and that he is capable of doing them. He may also uncover
his daughter’s thoughts about him performing such tasks and gain some social reinforcements.
Joseph may also keep a daily thought record in order to monitor his feelings around performing
behaviors before, during, and after performing a task of daily living. As a result, Joseph may be
able to see how his thoughts are impacting his behavior and he may reframe such thoughts to feel
that the tasks are more useful and necessary. A daily thought record will also help Joseph to
monitor and identify his feelings that result from his thoughts about such behaviors and feelings
associated with thinking and believing that he is worthless. In session, Joseph and I can evaluate
is daily thought records and monitor an increase in positive thoughts and feelings surrounding
accomplishing household responsibilities.
Assessment Tools: Joseph can complete the Hamilton Rating Scale for Depression
(Hamilton, 1960) and the Carroll Depression Scales-Revised (Carroll, 1998) to monitor a
decrease in depressed symptoms both before and after an increase in activity resulting from
cognitive restructuring.
Goal 2: Identify interests and develop activity plan
Treatment Rationale: In order to give Joseph some motivation for leaving the home and
develop additional life purpose, Joseph and I can explore some hobbies or enjoyed activities.
Behavioral models postulate that when an individual does not receive enough positive
reinforcement from life, they may experience symptoms of depression and anhedonia (Beck

1983). By identifying Joseph’s interests and exploring options or activities in which Joseph
might derive pleasure from, we can begin to plan out how to performing those activities, similar
to how we explored Joseph’s daily living tasks. In doing so, Joseph will receive positive
reinforcement from the tasks he enjoys and begin to alleviate his symptoms of anhedonia. This
may also give Joseph some additional responsibilities and relationships that he can extract
meaning from and consequently decrease his thoughts and feelings of worthlessness.
Interventions: Joseph and I will use behavioral activation (Skinner, 1953) in order to
develop plans and methods for leaving the home and becoming a part of enjoyable and
interesting activities. Joseph and I will complete assessments to determine what interests he may
enjoy.
Assessment Tools: Joseph and I will complete a Self-Direct Search 5th Edition (SDS) to
uncover Joseph’s interests and tasks he might be good at or enjoy (Holland & Messer, 2013).
Joseph and I may also do a Personal Values Card Sort (Miller, Baca, Matthews, & Wilbourne,
2001) exercise to explore his values and how they relate to tasks and activities he may be
interested in. To monitor his feelings of pleasure Joseph can complete the Pleasant Activities
Schedule (Heiby, 1983) and Frequency of Self-Reinforcement Questionnaire (MacPhillamy &
Lewinsohn, 1982)
Phase 2: Depression Treatment
The second phase will aim to increase Joseph’s self-esteem and self-concept, challenge
his feelings of worthlessness, and increase the quality of his social interactions. We will consider
Joseph’s values as it contributes to his poor self-concept and work toward finding meaning and
purpose in Joseph’s life again without his business or wife. We will do so by addressing Joseph’s

dysfunctional thoughts around himself, his worth, and his interactions and also address Joseph’s
social skills and support.
Goal 1: Decrease dysfunctional thinking
Treatment Rationale: Cognitive therapy (CT) addresses how one’s core belief impacts
their automatic thoughts, resulting feelings, and following behaviors (Beck, 1983). Sometimes
these core beliefs and automatic thoughts are dysfunctional and cause a person to feel and act in
a way that negatively impacts their wellbeing and quality of life, such as Joseph believing no one
should want to spend time with him and that he is worthless (Beck, 1983). Additionally, CT
posits that individuals can experience symptoms of depression resulting from their core beliefs
and automatic thoughts (Beck, 1983)
Intervention: Cognitive restructuring techniques, such as downward arrow techniques or
disputing thought record may help Joseph to recognize that his automatic thoughts and core
belief of feeling worthless are not true and contribute to his feelings of depression. During this
time, Joseph and I can also explore what function his automatic thoughts are serving him so he
may identify triggers and maintaining factors. Consequently, Joseph and I can begin to make
plans to avoid such triggers, learn how to cope with the triggers, and develop maintaining factors
for new thoughts and behaviors. Cognitive restructuring may also help Joseph to alleviate and
challenge his feelings of guilt around being cared for by his daughters. Similarly, cognitive
restructuring might challenge Joseph’s current self-concept and allow him to increase his self-
esteem. By increasing Joseph’s self-esteem he may feel more competent in accomplishing tasks
around his home and his interests. In doing so, he may begin to uncover internal sources of life
worth and purpose and his increased self-esteem will reveal self-worth. As a result, Joseph will
not rely on outside reinforcements, like his job, to evaluate his worth.

Assessment Tools: Joseph’s decrease in dysfunctional thinking and increase in positive
thoughts about himself and others may be monitored through the Automatic Thoughts
Questionnaire Revised (Kendall, Howard, & Hays, 1989) the Cognitive Triad Inventory
(Beckham, Leber, Watkins, Boyer, & Cook, 1986) and the Dysfunctional Attitudes Scale
(Weissman & Beck, 1978). Additionally, completing and reviewing a disputing thought record
may help to demonstrate decreased dysfunctional thinking.
Goal 2: Improve Social and Interpersonal Skills
Treatment Rationale: Social support plays a major role in the development and treatment
of depressed symptoms (Coyne, 1976). Social support reinforces positive social interactions and
if a client is not receiving positive reinforcement from social interactions, or limited social
interactions, than it is possible the client may begin experiencing symptoms of depression as the
result of limited reinforcements (Gotlib & Whiffen , 1989). Joseph’s self-isolating behaviors are
decreasing the social reinforcements he receives and contribute to his feelings of worthlessness
and symptoms of depression.
Intervention: In treatment, Joseph can begin to do assertiveness training and social skills
training to improve his social interactions and gain social reinforcements. Such reinforcements
from others will increase Joseph’s self-esteem and self-concept, will empower Joseph to become
more active and more confident, and will ultimately contribute to Joseph feeling less worthless
and depressed.
Assessment Tools: Enhancements in Joseph’s social skills can be assessed through an
Interpersonal Events Schedule (Youngren, Zeiss, & Lewinsohn, 1975) and a Social Adjustments
Scale (Paykel, Weissman, Prusoff, & Tonks, 1971) to measure and record Joseph’s cognitions
around social interactions and his ability and growth in effective social functioning.

Phase 3: DevelopCoping Skills and Relapse Prevention
The third phase will address Joseph’s current coping styles, create and develop new
helpful coping styles, and work toward planning and relapse prevention. Clients who have
experienced depression in the past are at a higher risk of developing depression (APA, 2013).
Relapse prevention is an essential part of Joseph’s ongoing treatment and we will do so by
creating safety plans and relapse prevention plans. It is also important that Joseph begin to
develop coping mechanisms other than using distraction. We will do so by enhancing adaptive
coping skills and improving Joseph’s problem solving abilities.
Goal 1: DevelopCoping Skills/Improve Problem Solving Ability
Treatment Rationale: Although distraction is often a helpful coping mechanism for
depressive symptoms, (Broderick, 2005) having only one coping mechanism to rely on can be
harmful (Galatzer-Levy, Burton, & Bonanno, 2012). In Joseph’s case is maintaining his feelings
of worthlessness and inability to cope with the loss of his wife and business. Adaptive coping
may not only enhance Joseph’s mood but can also prevent Joseph from relapsing into future
depression (Nezu, Nezu, & Perri, 1989)
Intervention: Problem solving therapy techniques will help Joseph to identify triggers
and antecedents of his current episode, decrease the impact that his symptoms has on his overall
functioning, teach him skills to cope with current problems in the future (Nezu, Nezu, & Perri
1989). Joseph can learn problem solving and coping techniques that will help him to confront his
losses resolve his feeling surrounding the loss. Improved problem solving abilities will enable
Joseph to come to terms with his losses and move forward from his feelings of grief and
depression.

Assessment Tools: To assess Joseph’s problem solving abilities and increase in coping
skills, Joseph can complete the Social Problem Solving Inventory Revised (D’Zurilla, Nezu, &
Maydeu-Olivares, 2002) and the Problem Solving Inventory (Heppner, 1988).
Goal 2: Relapse Prevention
Treatment Rationale: Creating a plan against relapse can have an impact on the
development of future depressive symptoms and relapse (Nezu, Nezu, & Perri, 1989). Safety
plans and self-care plans may increase a client’s ability to cope with stressful life situations and
inhibit depressive symptoms from reoccurring.
Interventions: In treatment, Joseph can create a safety/relapse plan by assessing his
strengths and values throughout cognitive therapy interventions and cognitive restructuring.
Joseph can identify some of his strengths and values as the result of his disputing thought
records, acceptance paradox, and the values activity. Joseph can also use his problem solving
abilities to apply his strengths to adaptive coping strategies and prevent further depressive
symptoms. During this time, Joseph and I will identify antecedents to depressive symptoms,
possible future triggers and antecedents, and barriers to following through with his recently
developed coping and problem solving skills. Through planning, Joseph can feel prepared,
confident, and empowered to cope with his current and future distress and increase his self-
esteem and self-concept.
Assessment Tools: Joseph and I will create a safety/relapse contract, which will provide
Joseph with concrete steps and methods he can use to combat depressive symptoms. The plan
will be developed through Joseph’s own self report of which skills and interests he enjoys and
feels most confident in using in the future.
Cultural Considerations

Some cultural differences to consider when carrying out treatment with Joseph include
religious differences, a generational age gap, and gender differences. In terms of Joseph’s
religion, Joseph has expressed that he was raised Jewish, while I have been raised Christian.
Both myself and Joseph have been raised under a specific religion yet no longer follow or
practice that religion. I will have to account for the past oppression and differing values that
Joseph has learned or experienced as the result of his Jewish heritage and be sure to keep those
values and lessons in mind when creating treatment plans and identifying strengths (Leighton,
2014). Additionally, our age difference may have an impact on Joseph’s perception of me as a
counselor and on my understanding of his upbringing and current problems (Minamisawa,
Suzuki, Watanabe, Imasaka, Kimura, Takeuchi, & Uchida, 2011). It important that I display
accurate empathy for Joseph to develop our alliance and instill a sense of trust and compassion
so Joseph perceives me as competent at understanding his current problems and worthy of
hearing his struggles. Similarly, Joseph being male and my being female may impact my
understanding of Joseph’s values and importance of certain gender roles and gender stereotypes
(Anderson, & Levitt, 2015). It may also cause me to overemphasize gender roles in Joseph’s
conceptualization. To avoid such misunderstanding, I will conduct the values activity with
Joseph and further explore his upbringing to gain a better understanding of what gender role he
feels are important, the extent to which he values them, and how they are currently impacting his
self-concept.
Ethical and Legal Considerations
In working with Joseph to provide counseling service, it is important to consider a variety
of American Counseling Association (ACA) ethical codes and morals before implementing
treatment. In CBT, client collaboration and autonomy is frequently emphasized and clients are

often involved in deciding how to proceed with treatment, which techniques can be
implemented, and what goals the client is comfortable working on. To comply with ACA ethics
codes and morals I will consider the autonomy and benefice morals as well as codes A.1.c, A.2.a
and A.2.b, and A.4.b concerning informed consent, confidentiality, counseling plans, and
awareness of counselor values (ACA, 2014). If Joseph feels his role in the relationship is being
devalued or ignored, then treatment plans or practices will be modified to fit Joseph’s particular
needs and requests. Additionally, in terms of providing tests and using assessment tools to
diagnose and monitor progress with Joseph, I must also consider codes C.7.a and C.7.b as well as
all the codes under section E (ACA, 2014). By considering the codes and being aware of the
consequences and risks of using such assessments, Joseph and I can be sure to use tools that are
helpful to treatment. If the time comes where the tools are updated, revised, or no longer relevant
to Joseph’s treatment, Joseph and I will agree to discontinue use. Furthermore, I will have to
consider myself and Joseph’s cultural differences as well and my own values in creating
treatment plans, goals, and implementing techniques with Joseph and consider additional codes
such as B.1.a to avoid any cultural insensitivity (ACA, 2014). If Joseph begins to feel as though
his cultural values or beliefs are being challenged by treatment than we will agree to discontinue
that particular goal, treatment method, assessment, or technique. In addition, I will want to
consider Joseph’s retirement and being cared for by his daughters. It is possible that his
daughters may pay for sessions, or need to be involved in treatment planning. I will consider
codes B.1.b, B.1.c, B.3.d, B.4.b, and B.5.c concerning respect for privacy, confidentiality, third
party payments, couples and family counseling, and release of confidential information (ACA,
2014). If Joseph’s daughters need to be informed of treatment plans, Joseph will be informed of
the risks of involving his family and reminded of his rights to privacy, limits of confidentiality as

well as provided released information. Lastly, termination procedures and completion of
treatment will have to be carried out properly and I will consider code A.11.c in deciding when
to terminate and appropriate termination procedures (ACA, 2014). If Joseph feels as though
termination is abrupt, premature, or harmful, then Joseph and I can adjust treatment plans or
extend treatment in order to terminate at a time and way that is most beneficial.

References
American Counseling Association (2014). 2014 ACA Code of Ethics. Alexandria, VA: American
Counseling Association.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental
Disorders (Fourth Edition-TR). Arlington, VA: American Psychiatric Association.
Anderson, R. S., & Levitt, D. H. (2015). Gender self-confidence and social influence: Impact on
working alliance. Journal Of Counseling & Development, 93(3), 280-288.
doi:10.1002/jcad.12026
Bandura, A. (1989). Social cognitive theory. In R. Vasta (Ed.), Annals of Child Development
Six theories of child development, 6, 1-60. Greenwich, CT: JAI Press.
Beck, A. T. (1983). Cognitive therapy of depression: New perspectives. In P.J. Clayton & J.E.
Barrett (eds) Treatment of Depression: Old Controversies and New Approaches. New
York: Raven.
Beck, A.T., Epstein, N., Brown, G., & Steer, R.A. (1988). Beck Anxiety Inventory. San Antonio,
TX: Psychological Corporation.
Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Manual for the BDI-II. San Antonio, TX:
Psychological Corporation.
Beck, A, T. & Steer, R. A. (1991). Beck Scale for Suicide Ideation. San Antonio, TX:
Psychological Corporation.

Beckham, E. E., Leber, W. R., Watkins, J. T., Boyer, J. L., & Cook, J. B. (1986). Development
of an instrument to measure Beck’s cognitive triad: The Cognitive Triad Inventory.
Journal of Consulting and Clinical Psychology, 54, 566-567.
Bembnowska, M., & Josko-Ochojskha, J. (2015). What causes depression in adults?.
Polish Journal Of Public Health, 125(2), 116-120. doi:10.1515/pjph-2015-0037
Broderick, P. C. (2005). Mindfulness and coping with dysphoric mood: Contrasts with
rumination and distraction. Cognitive Therapy & Research, 29(5), 501-510.
doi:10.1007/s10608-005-3888-0
Carroll, B. (1998) Carroll Depression Scales-Revised (CDS-R): Technical Manual. North
Tonawanda, NY: Multi-Health Systems.
Coyne, J. C. (1976). Toward an interactional description of depression. Psychiatry, 39, 28-40.
D’Zuriila, T. J., Nezu, A. M., & Maydeu-Olivares. (2002). Social Problem Solving
Inventory-Revised (SPSI-R): Manual. North Tonawanda, NY: Multi-Health Systems.
Galatzer-Levy, I. R., Burton, C. L., & Bonanno, G. A. (2012). Coping flexibility, potentially
traumatic life events, and resilience: A prospective study of college student adjustment.
Journal Of Social & Clinical Psychology, 31(6), 542-567.doi:10.1521/jscp.2012.31.6.542
Gotlib, I. H., & Whiffen, V. E. (1989). Stress, coping, and marital satisfaction in couples with a
depressed wife. Canadian Journal of Behavioral Science, 21, 401-418.
Gottschalk, L. A., & Keatinge, C. (1993). Influence of patient caregivers on course of patient
illness: "Expressed emotion" and alternative. Journal Of Clinical Psychology, 49(6), 898-
912.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and
Psychiatry, 23, 56-62.

Heiby, E. M. (1983). Assessment of frequency of self-reinforcement. Journal of Personality and
Social Psychology, 44, 1304-1307.
Heppner, P. P. (1988). The Problem Solving Inventory. Palo Alto, CA: Consulting Psychologist
Press.
Holland, J. L., Messer, M. A. (2013). Self-Direct Search (SDS) 5th Edition. Lutz, FL:
Psychological Assessments Resources Incorporated.
Hunt, M., Schloss, H., Moonat, S., Poulos, S., & Wieland, J. (2007). Emotional processing
versus cognitive restructuring in response to a depressing life event. Cognitive Therapy &
Research, 31(6), 833-851. doi:10.1007/s10608-007-9156-8
Ibrahim, N., Din, N. C., Ahmad, M., Ghazali, S. E., Said, Z., Shahar, S., & Razali, R. (2013).
Relationships between social support and depression, and quality of life of the elderly in
a rural community in Malaysia. Asia-Pacific Psychiatry, 559-66.doi:10.1111/appy.12068
IsHak, W., Greenberg, J., Saah, T., Mobaraki, S., Fakhry, H., Wu, Q., & Cohen, R. (2013).
Development and validation of the individual burden of illness index for major
depressive disorder (IBI-D). Administration & Policy In Mental Health & Mental Health
Services Research, 40(2), 76-86. doi:10.1007/s10488-011-0376-6
Ivanova, M. Y., & Israel, A. C. (2005). Family stability as a protective factor against the
influences of pessimistic attributional style on depression. Cognitive Therapy &
Research, 29(2), 243-251. doi:10.1007/s10608-005-3167-0
Jacobs, D., Screening for Mental Health Inc., Suicide Prevention Resource Center. (2009).
Suicide assessment five-step evaluation and triage. Education Development Center.
Retrieved from http://www.integration.samhsa.gov/images/res/SAFE_T.pdf

Jewish Online: Multi-Jewish perspectives on morals and ethics. (2014). [Online Forum]
Retrieved from
http://www.jewishvaluesonline.org/question.php?id=999&cprg=%2Fsearch.php%3Fsubc
atid%3D71
Kendall, P. C., Howard, B. L., & Hayes, R. C. (1989) Self-referent speech and psychopathology:
The balance of positive and negative thinking. Cognitive Therapy and Research, 13, 583-
598.
Koenig, H. G. (2012). Religion, spirituality, and health: The research and clinical implications.
ISRN Psychiatry, 1-33. doi:10.5402/2012/278730
Leighton, T. (2014). The therapeutics of counselling religious clients: intake and assessment.
International Journal Of Mental Health & Addiction, 12(3), 295-311.
doi:10.1007/s11469-013-9454-1
MacPhillamy, D. J., & Lewinsohn, P. M. (1982). The Pleasant Events Schedule: Studies on
reliability, validity, and scale intercorrelation. Journal of Consulting and Clinical
Psychology, 50, 363-380.
Maradiegue, A. H., Lyon, D. E., & Meyers, M. F. (2013). Using family history and health risk
behaviors to determine predictors of depressive symptoms in Central American
immigrant mothers. Nursing & Health Sciences, 15(2), 220-228. doi:10.1111/nhs.12023
Miller, W.R., Baca, J. C., Matthews, D. B., Wilbourne, P. L., (2001). University of New Mexico.
Retrieved from http://casaa.unm.edu/inst/Personal%20Values%20Card%20Sort.pdf
Minamisawa, A., Suzuki, T., Watanabe, K., Imasaka, Y., Kimura, Y., Takeuchi, H., & Uchida,
H. (2011). Patient's trust in their psychiatrist: a cross-sectional survey. European
Archives Of Psychiatry & Clinical Neuroscience, 261(8), 603-608. doi:10.1007/s00406-

011-0199-1
Nezu, A. M., Nezu, C. M., & Lombardo, E. (2004) Cognitive Behavioral Case Formulation and
Treatment Design. New York, NY: Springer Publishing Company.
Nezu, A. M., Nezu, C. M., & Perri, M. G. (1989). Problem solving therapy for depression:
Theory, research, and clinical guidelines. New York, NY: Wiley.
Paykel, E. S., Weissman, M., Prusoff, B. A., & Tonks, C. M. (1971). Dimensions of social
adjustment in depressed women. Journal of Nervous and Mental Disease, 152, 158-172.
Seiffge-Krenke, I., & Pakalniskiene, V. (2011). Who shapes whom in the family: Reciprocal
links between autonomy support in the family and parents' and adolescents' coping
behaviors. Journal Of Youth & Adolescence, 40(8), 983-995. doi:10.1007/s10964-010-
9603-9
Skinner, B. F. (1953). The science of human behavior. New York, NY: Free Press.
Weissman, A.N., & Beck, A.T. (1978). Development and validation of the Dysfunctional
Attitude Scale: A preliminary investigation, Paper presented at the annual meeting of the
Association for the Advancement of Behavior Therapy, Chicago, IL.
Youngren, M. A., Zeiss, A., & Lewinsohn, P. M. (1975). Interpersonal Events Schedule.
University of Oregon, Eugene.

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