CBT in Action : A Case Study

Dr. Nicholas Jenner is a Counseling psychologist in private practice working with individuals,couples,  groups and companies globally. Online therapy is, in my experience, effective for treating a number of major conditions. Are you having issues that you need to talk through? I have a range of plans that can help you get the help you need.  Online Therapy details : Here ……

CBT is based on the belief that thoughts, feelings, and behavior are inter-related and impact each other. Since thinking, feelings, and behavior are interconnected, treatment interventions that focus directly on specific thoughts, feelings, or behaviors are expected to impact other thoughts, feelings and behavior. The main goal of CBT is to regulate, modify, augment, or replace problematic thoughts, feelings, and/or actions so that problem behaviors, thoughts, or feelings are interrupted and, ultimately, replaced with more a functional thought-feeling-behavior pattern. One of the best ways to monitor this is with the Daily Mood Sheet. This is used to log feelings, emotions and behavior caused by a triggering event and then gives the client the chance to look at the situation in a more realistic light. Constant logging of these situations will give a firm indication of thought patterns that have lead to dysfunction. They can be used as an integral part of the therapeutic process. More on this HERE.

I often use the sheets with clients as an aid in therapy. They often find it hard to keep the log and especially to look at the situation more realistically but perseverance is the key. Those who do tend to be able to change their thought patterns over time, be able to assess when dysfunctional though patterns have an impact and are able to separate the feelings produced from their general feeling about themselves. One such case is highlighted below. The client concerned found the sheets helpful to recognise where her thought patterns were coming from.

Case Study : Patient  Jodie (name changed)
Jodie was a patient of mine from June 2011 to July 2012. She contacted me initially because she “didn’t have a minute of one day when she didn’t feel depressed”. Jodie is an IT professional attached to the US military and was stationed in Germany until just recently. Apart from her depression, she was obese, had various medical problems and was on constant medication. She has given her full consent for a part of our counseling transaction to be included here.

1. Background

Jodie came from humble roots growing up in a military family in the US with two siblings. Her mother was a neurotic who spent most of Jodie’s early life in some form of institution, leaving Jodie’s primary care to her older sister. Her father was a soldier who was often posted abroad, taking the family with him. The parents had strong religious views and were highly influenced by the “fire and brimstone” style of preaching seen in the Bible Belt at that time. For this reason, out of marriage relationships and sex were seen as the devil’s work. During our sessions, Jodie revealed that she, at the age of 42, had never even come close to a sexual experience. All of these factors contributed to Jodie’s view of herself and the world around her causing unhappiness and depression. However, a breakthrough in therapy revealed a complicated relationship between Jodie and her older sister who was apparently jealous of her younger sibling and so behaved in such a way that forced Jodie to feel inferior and subversive. The relationship turned into a love-hate roller coaster that played out over several decades. Jodie’s whole experience of being “molded” by her sister to believe that she was “no good” had created her window of reference on the world and ultimately her depression. One of the side effects of this was a severe lack of assertiveness and in her words “constant cowering down and meekness”

This had affected her in all aspects of her life and none more so than at work where she was one of a few women working in a mostly male environment.  The following excerpt from one of our counseling sessions highlights a situation following conflict at work. Jodie highlighted this on her daily sheets and wanted to discuss this. We had been looking at this problem for some time using behavioral experiments and goal setting to help her deal with the situation more effectively.

2. Presenting problem

Jodie had once told me that one of the biggest issues in her life was the lack of assertiveness that she showed whenever she felt conflict was about to happen. While this happened in all aspects of her life, it was especially bad at work where she felt dominated and subversive. We had often linked this back to her experiences growing up and behavioral trials had been unsuccessful for Jodie. She had been filling in daily sheets for some time and had highlighted one situation that had caused her to fall into deep depression afterwards. It had occurred when her boss, just in from the US greeted everyone in the office apart from Jodie. This was later (two weeks) rectified and Jodie realized that is was just an oversight on his part. However, before this happened her mind had come up with many different reasons for this and together with a number of triggers resulted in her believing that he had done it on purpose because he either disliked her or she had done something wrong. She was severely agitated upon arrival and appeared to have been crying.

3.. Final Evaluation

Jodie was in a state that called for a clear head and thought. She is the type of person who had been known to withdraw from others when things got too much for her so I was happy that she appeared for the session. She was unusually agitated and somewhat aggressive and accusatory, something I was not used to from her.  This session turned out to be the catalyst for what I consider a successful end to therapy. Jodie in a recent communication with me cited the CBT techniques learnt in our sessions as the major reason for her change in mindset. I would evaluate the session in the following way :

  • Jodie filled in the sheets even though she couldn’t find a rational response at the time. She later stated that thought the sheets helped her focus on the issue at hand.

  • I was happy with the way I guided Jodie through the session, setting an atmosphere that facilitated conversation and relaxation.

  • The use of CBT tools ( sheets, questioning and probing) and a Rogerian style of dealing with the client were present and effective.

  • I used the good therapeutic relationship between us to give Jodie the basis for expanding on her problem.

The following is a transcript of part of the session :.

Therapist

               Client             Evaluation
Please come on in. You look   rather like you could do with some tea..would you like some? Oh, yes please, that is very kind of you. I was trying to set a   relaxed atmosphere. She was in a clear state of anxiety and this was needed  to coax her into talking.
You told me on the phone that   you have been depressed about something that happened at work. I am sorry you   have had a bad week but can you give me some more details? Well…I am going to quit the   damn job and to hell with it! This was a reaction I   was not expecting and through me off guard for a second. My usual prompts for   information were usually met with a more open response. I guessed if she was   being direct then I can prompt further.
I understand that you have had   a bad week but please tell what is going through your mind at the moment. Well, my damn boss came into  the office, said hello to everyone except me and left. What do you think is   going through my mind at the moment? If you can’t understand that then I am   leaving! This showed the severity of the problem. This was the first time she had reacted in such a  way.
I can see you are very upset   but let’s try and see if we can talk through the issue and see if we can find   another way of looking at it..would that be ok? What is there to look at ?..I   know what happened but go ahead..we still have 45 minutes. This was a sign for  me that that she was ready to look at the issue from another angle so I  decided to bring in one of the CBT tools we had been working with.
Let’s start with your sheet   entry..can you tell me what you wrote? Ok..boss ignored me..emotions..angry, worried, embarrassed. Thoughts…I am going to be fired…how will I   support myself..he always give me the cold shoulder..how did that look in   front of my colleagues. Rational response..none This helped to focus   the situation on the issue and not the emotion. My aim now was to help her   seek evidence to the contrary.
OK..Jodie that was obviously an   experience that triggered some reactions..can you remember what we said about   triggers a few sessions ago in terms of ABC ? Yes..and I tried to apply that   but it just didn’t work. I thought it was good   to revisit and consolidate part of the ABC model here.
Ok..well I understand you may   have been a bit overwhelmed by all of the reaction to the event so let’s try   and break down the reactions one by one, ok? I think that would help. It has   been a difficult week. This was the first   sign that Jodie was willing to open up.
Good..take your time with   answering and if anything is too much, we can look at it later..is that ok?   Let’s look at your first statement…I am going to get fired..do you know   this to be 100% true and how do you know this? Well..it is clear…I am the   one to go. Nobody told me this but from his actions, I can tell. I was trying here to   establish links between events and dysfunctional thinking
Interesting..so there is no   real evidence that you will be fired? I told you, damn it..it is   clear. Are you calling me stupid?
Of course not…but I just want   to look at the comment you just made…nobody has told me this. It is my impression. Here was a good  chance to introduce signs of evidence to the contrary.
But are there signs that you   will be kept on? Well, I did get a good  performance rating and my boss did say I am a valuable member of staff.
So looking at it realistically, could there be another reason he didn’t say hello? Maybe he just didn’t see me.

  7 comments for “CBT in Action : A Case Study

  1. January 29, 2013 at 9:26 pm

    When I got out of hospital a couple of years ago, my doctor wanted me to go to the CBT course. It takes 2 weeks here but I couldn’t bring myself to do it! Maybe one day I will. Hugs Paula xx

    Like

  2. The Quiet Borderline (back in hospital)
    January 31, 2013 at 9:20 pm

    Keep up the good work – very interesting.

    Like

  3. February 2, 2013 at 10:28 am

    I do not even know how I ended up here, but I thought this post
    was good. I do not know who you are but definitely you’re going to a famous blogger if you aren’t already 😉 Cheers!

    Like

  4. January 5, 2014 at 3:09 pm

    Great Blog! Thanks for the follow!

    Like

Feel Free to Comment

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: