Cognitive Behavioral Therapy In Practice

Case History

This client is a 48 year old African American female, living in her own apartment with the support of her maternal uncle and his wife. She receives Supplemental Security Income (SSI) and financial assistance from her uncle. She has two-younger sisters and a brother. She also has diabetes and high blood pressure. My client was born into a home with little love or affection. As she was growing up, client was regularly told her best wasn’t good enough and nothing she did was right. She identified being labelled as “mentally retarded” in grade school, primarily due to reports from her mother. This resulted in placement in resource classes, although her IQ is within normal range. One of her core beliefs is that she is unintelligent. She never met her father and endorses frequent abuse during childhood, but does not identify the perpetrator. Her mother signed away her parental rights to client only, when she was 13 years old and she lived for three years at the Bronx Child Inpatient group home, where she was physically abused. At the age of 16, she left the group home, dropped out of school and lived on the streets, during which time, she had two children. She states she was beaten and raped repeatedly while homeless, exacerbating her low self-esteem and lack of trust in others. She married the father of her second child and they moved to Nashville, where she attended outpatient behavioural health therapy. Client was incapable of caring for her children after her divorce and gave her maternal uncle and his wife custody of her children. She is estranged from her children because they perceive it as abandonment. This decision, although good for the children, left client with guilt and shame. She is currently working to rebuild a relationship with her children.

She sought out services for depression, auditory (mother’s voice) and visual hallucinations and panic attacks. She identifies herself as stupid, unlovable, incapable of loving someone because “I’ve never really been loved before,” angry, depressed and a burden. This client has back and leg pain, as a result of abuse sustained in childhood and while she homeless. Stressors include hearing her mother’s negative words, crowds, loud noise, negative interaction with her children and negativity from others. Client states she constantly thinks about her past and “all of the bad stuff I went through.” She endorses wanting to work on positive self-esteem and self-talk, trust and developing healthy relationships.

Cognitive-Behavioral Assessment

According to Kaczkurkin and Foa (2015), cognitive therapy is based on Beck’s cognitive-behavioural model that suggests our thoughts, feelings and behaviours work together. According to Wedding (2010) thoughts are organized in a hierarchy, each level is different related to their availability and stability. In essence, changing maladaptive thoughts can change maladaptive feelings and behaviour. In working with this client we aim to target maladaptive thoughts to affect change in her negative thoughts and behaviour.

Core Beliefs

According to Beck (2011) we develop thoughts about ourselves, others and the world around us, which shapes their core beliefs or absolute truth, fundamental basic beliefs. Cognitive Behavioral Therapy (CBT) teaches us that these beliefs begin to develop in our formative years and strengthen through our experiences (Beck, 2011). These core beliefs are not, necessarily, based on accurate information. My client believes she is worthless, as she reports, based upon the fact that her mother regularly told her she was worthless and stupid and that no one wanted to be around her. Client states she has never had anyone treat her well. She will focus on the negative thoughts and feedback from others, but discount positive feedback she receives.

Intermediate Beliefs

Core beliefs are the fundamental beliefs that are central to how we see ourselves, our world and others (Chand, Kuckel, & Huecker, 2019). These beliefs are the rules that shape the way we perceive and manage information. They directly impact the development of intermediate beliefs which are the attitudes, rules and assumptions. These intermediate beliefs influence a person’s perspective and are responsible for how a person thinks, feels and behaves, according to Chand, Kuckel, and Huecker (2019). Our thoughts dictate our feelings, which dictates our behaviour. It’s important to adapt all three to affect change. My client described being very angry once she heard about a family gathering, that no one had mentioned to her. She said that she is ALWAYS left out. She got angry and thought it was just another example of everyone leaving her out and she deserves to stay mad. In reality, she was invited, but at that time all of the details had not been finalized.

Automatic Thoughts

Automatic thoughts are spontaneous in nature and are triggered by specific situations and can be relevant to a person’s past experience (Khoury and Ammar, 2014). These thoughts are created from assumptions. My client has excessive automatic thoughts that she verbalizes regularly, no matter the subject matter. She will pick up a book and at the first difficult word will think, “I’m too dumb to know this word or to learn.” This and many other negative automatic thoughts are created as a result of her treatment as a child. She assumes she is not worthy to teach or smart enough to learn. She is unaware of the automatic thought, but it shapes her perceptions and how she experiences things in her life.

Feelings And Behaviors Associated With Automatic Thoughts

As previously suggested, our thoughts, feelings and behaviours work together. If we change our distorted thoughts, we will likely change our feelings and behaviours, as well. Unfortunately, if we do not address the thoughts, then we will remain in the vicious cycle of negativity and distorted feelings and behaviours. According to Beal (2019), the therapist works with the client to identify maladaptive thoughts and change them to a more positive and realistic thought pattern. I usually tell my client that we are putting the negative thoughts on trial. My client believes she is unlovable because she has only had negative and abusive relationships in the past. She is estranged from her children and states her uncle and other family treat her like a child. This client will quickly state that she will never be married again, because all they want to do is abuse and take advantage of her. She automatically speaks negatively about the suggestion of a family event or visiting with any family members and frequently discusses the fact that her mother “gave me to the state of New York” when she was just 13 years old.

Self-perpetuating Cycle – Describe How Client’s Reactions And/or Interpretation Of Events Acts To Reinforce Presenting Problems

Breaking the cycle of cognitive distortions is very important to improve our thoughts and feelings. People develop a pattern of thinking, behaviour and feeling, which is self-perpetuating. Khoury and Ammar, (2014) stated we must change the pattern to break the cycle of cognitive distortions and to improve our feelings and behaviour. My client is learning to image a large stop sign when she begins to think of, or discuss her mother giving her up at 13 years of age. We also work on looking at things in the here and now and in the future, rather than continuing to focus on the negative past experiences. This client has signed up for GED classes and is excited about it.

Treatment

During CBT, the therapist and client work together to identify those maladaptive core beliefs and change patterns of thoughts, feelings and behaviour to become more positive and useful to the client and improve their life. CBT is customized to meet the need of the specific client. It is not a cookie cutter approach. I began working with this client to customize her treatment goals during our first meeting. From the initial assessment, I had a plan in place to present to her and gain her feedback to ensure it was something that would work and fit her needs. We discussed CBT and identified goals she would like to work on. The goals for this client, in her own words: Increase positive mood and develop positive self-esteem.

Goal 1: Increase positive mood

Objective 1: Client will identify and process two mood symptoms and effects on relationships per month as reported by therapist and case manager in progress notes over three months.

Objective 2: Client will identify and process increasing awareness of two triggers to mood change per month as reported by therapist and case manager in progress notes over three months.

Goal 2: Develop positive self-esteem

Objective 1: Client will identify at least two instances between each session when she was able to use learned cognitive-behavioural techniques to reduce the duration, intensity, or impact of negative self-thoughts as reported by therapist and case manager in progress notes over 3 months.

Objective 2: Client will identify at least two instances between each session when she was able to use learned cognitive-behavioural techniques to increase thoughts of positive self-worth as reported by therapist and case manager in progress notes over 3 months.

I have used cognitive restructuring with this client to assist her in identifying the cognitive distortions and the distorted core beliefs that traps her in the negative cycle. My client is able to more readily identify those negative thoughts and is working to consciously be aware of her the thoughts. She is using cognitive behavioural techniques reviewed and practice during our meetings to increase her positive thoughts of self. My client continues to struggle with past trauma, but is making progress using the cognitive behavioural techniques. Client identifies being proud of herself for thinking more positively and working to counter the unhealthy cognitions.

She has embraced meditation and thought testing to combat the distorted cognitions. My client identified meditation as her best tool. She hears her mother’s voice often repeating all of the destructive things she told client as a child. We are currently working on identifying those thoughts and consciously working to “prove them wrong” by discussing how they are not healthy or accurate in her current life. She has been very open, positive and engaged in these interventions.

References:

1. Beck, J. (2011). Cognitive Conceptualization. Cognitive behaviour therapy: basics and beyond (29-45). New York: The Guilford Press.
2. Kaczkurkin, A. & Foa, E. (2015). Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues in clinical neuroscience, 17(3), 337–346. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610618/
3. Beal, D. (2019). Cognitive behavior therapy (CBT). Salem Press Encyclopedia of Health. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=ers&AN=93871842&site=eds-live&scope=site
4. Okamoto, A., Dattilio, F., Dobson, K., & Kazantzis, N. (2019). The therapeutic relationship in cognitive–behavioral therapy: Essential features and common challenges. Practice Innovations, 4(2), 112–123. https://doi.org/10.1037/pri0000088
5. Khoury, B. & Ammar, J. (2014). Cognitive behavioral therapy for treatment of primary care patients presenting with psychological disorders. Libyan Journal of Medicine, (0), 1. https://doi.org/10.3402/ljm.v9.24186
6. Wedding, D. (2010). Current psychotherapies. The Corsini Encyclopedia of Psychology, 1-4. 
7. Chand S., Kuckel, D., & Huecker R. (2019). Cognitive Behavior Therapy (CBT). Florida: StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470241/