Direct Practice: Case Study Analysis

Theoretical Approach

Cognitive behavioral therapy (CBT) holds that our cognitions determine our emotions, which in turn determine our behavior. Consequently, distorted cognitions lead to psychological disturbances, which lead to dysfunctional behavior. Often our dysfunctional behavior causes our cognitions to become further distorted, which in turn further exacerbates our psychological disturbance, and so on (Neenan & Dryden, 2006, p. 6). For example, imagine that Joe comes to believe that his friends no longer like him. Joe then begins to withdraw from those friends, an action which causes his friends to begin to withdraw from him, which in turn strengthens his belief that they do not like him and causes him to withdraw even more.

CBT requires a strong therapeutic alliance, one in which therapists demonstrate “warmth, empathy, caring, genuine regard, and competence” (Beck, 1995. p. 5). CBT can be divided into two main stages, the psychoeducational and the psychotherapeutic (Friedberg & McClure, 2002, p. 126). During the psychoeducational stage, therapists teach clients the cognitive model, often referred to as the A-B-C Model, wherein A represents the Activating Event, B one’s Belief about the Activating Event, and C the Emotional Consequences of that Belief. Clients here are taught that the common belief that external events (A) cause emotional reactions (C) is wrong and that instead it is the beliefs we have about those events (B) that determine our reactions.

The psychotherapeutic stage consists of both cognitive and behavioral interventions. The main cognitive intervention involves eliciting clients’ cognitions—which can be broken down into automatic thoughts (the thoughts that seem to automatically pop into our minds as we go through life) and core beliefs (our underlying and usually unconscious axioms about life)—and using a method of guided discovery to help clients evaluate these cognitions in terms of their truthfulness and usefulness and, if appropriate, to replace these cognitions with more truthful and useful ones. Behavioral interventions generally involve scheduling specific activities aimed at modifying clients’ distorted cognitions (DeRubeis, Webb, Tang, & Beck, 2010, pp. 282-283).

Client

In this paper I will assume that I am a middle school social worker working with Anna Perez, a “shy” 15-year-old who has “not been able to make friends.” Anna is “struggl[ing] to attend school” and her “schoolwork is suffering.” She used to spend most of her free time with her mother and grandmother but has started to withdraw “more and more from everyone” and now spends most of her time alone in her room.

CBT seems like an appropriate approach to use with Anna for at least five reasons. First, CBT is effective at treating children and adolescents. Hoffman, Asnaani, Vonk, Sawyer, and Fang (2012) reviewed several meta-analyses of CBT treatments and found that CBT approaches “tailored to children showed robust support for treating internalizing disorders, with benefits outweighing pharmacological approaches in mood and anxiety symptoms” (p. 436).

Second, CBT is effective at treating depression, a condition from which Anna might be suffering. Hoffman et al. (2012) found in their meta-analysis that “CBT for depression was more effective than control conditions such as waiting list or no treatment, with a medium effect size,” although it was generally not more effective than psychodynamic, problem-solving, and interpersonal approaches (p. 430).

Third, CBT is effective at treating social anxiety disorder, another condition from which Anna might be suffering. “CBT for social anxiety disorder evidenced a medium to large effect size at immediate post-treatment as compared to control or waitlist treatments, with significant maintenance and even improvement of gains at follow-up” (Hoffman etc. 430).

Fourth, CBT is effective at treating Latinos. Organista and Munoz (1996) write that there is a stigma in Latin American countries “attached to therapy” because “scarce mental health services [there] are reserved almost exclusively for psychotic patients in mental hospitals” (p. 259). They write that CBT’s “use of therapy manuals, homework assignments, and chalkboards helps Latino patients to think of therapy as more of a classroom experience” than therapy (p. 259). Although only a small number of studies testing the effectiveness of CBT on Latinos have been conducted, these studies have consistently “shown it to be effective in the reduction of depressive symptomalogy” (Gonzales-Prendes, Hindo, & Pardo, 2011, p. 379). Interian, Allen, Gara, and Escobar (2008) found “significant reductions in depressive, anxious, and somatic symptoms” among Latino clients (p. 67).

Fifth, CBT tends to be relatively brief, and given that I will be meeting with Anna during school, I will be forced to limit my time with her. Leichsenring, Hiller, Weissberg, and Leibing (2006) write that CBT tends to be “one of the briefer psychotherapeutic treatments,” generally lasting between 10 to 20 sessions (p. 235). Psychodynamic therapy, by contrast, can last for several years, and even when the psychodynamic treatment is short-term it generally lasts 16 to 30 sessions (Leichsenring et al., 2006, p. 240).

Application

My work with Anna can be broken down into five main components: building a rapport with her, identifying her presenting problem, teaching her the cognitive model, helping her to modify her distorted cognitions, and having her to engage in activities which will further modify her distorted cognitions.

Building Rapport
It is essential that I build a good rapport with Anna. I need to prove to her that I care about her and that she can trust me. As I will explain later, given her cultural background, this task is especially important. Building a good rapport with Anna might be challenging if she is referred to me by her teachers or parents. To be more specific, if Anna sees me as someone who has been forced on her, she might resent that she has to see me and might not want to open up to me. If this is the case, I will need to spend some more building her trust and showing her that she, and not just her teachers or parents, can benefit from our time together.

Identifying the Presenting Problem
I need to ascertain Anna’s presenting problem. Her teachers and parents paint the picture of a depressed young woman, but I need to get her side of the story. My hope is that Anna will quickly articulate the nature of her struggle. If she is reticent, I will have to determine if she is incapable of expressing her emotions. Some individuals, especially young people, lack this ability, and if Anna falls into this category, I might ask her “to draw [or] role play...to describe the problem,” or I might employ techniques such as “feeling flash cards, unfinished sentences, or feeling games” (Vernon, 2004 p. 93).

If it turns out that Anna simply does not want to share her struggle with me, I will need to spend more time building our rapport. I might also try creative ways to help her open up. Friedberg and McClure provide numerous creative methods—e.g., the talk-show method, in which the therapist pretends to interview the client—meant to help the client “find the ‘distance’” needed to become more comfortable sharing (p. 91). I might also have her take an inventory such as the Children’s Depression Inventory (CDI), Multidimensional Anxiety Scale for Children (MASC), or Revised Children’s Manifest Anxiety Scale (RCMAS) (Friedberg & McClure, 2002, p. 89).

For the remainder of this paper, I will assume that Anna is suffering from depression, and I will explain how I will treat her by using a CBT model developed by Munoz and Miranda (2000). Rossello and Bernal (1999) used this model to individually treat depressed adolescents in Puerto Rico and found that it significantly reduced their symptoms when compared to individuals on a wait-list (p. 734). Shrink, Kaplinski, and Gudmundsen (2009) used this model to individually treat depressed adolescents in the United States and found similar results (p. 113).

Psychoeducation
As soon as possible, I will begin teaching Anna the cognitive model and show her that by modifying some of her beliefs she might be able to mitigate her depression. A creative approach might be needed here. Parsons (2009) gives an example of asking a teenage client to imagine that her little brother is in bed at night when he hears a noise; the client understands that hearing the noise (Activating Event) will be followed by the boy feeling afraid (Emotional Consequence), because he will believe there is a monster in his closet (Belief) (pp. 34-36). Parsons (2009) then asks his client to imagine that the Activating Event is the same—the boy is in bed at night and hears a noise—except that now it is Christmas Eve (p. 37). The client immediately recognizes that now the boy will experience a different Consequence—he will now feel excited—because he now has a different Belief—that the noise he heard is Santa Claus—even though the Activating Event is exactly the same (p. 37).

Once Anna understands the cognitive model, we will begin exploring how certain cognitions (cognitions that are constructive, necessary, and positive) help us achieve our goals, while other cognitions (those that are destructive, unnecessary, and negative) prevent us from achieving our goals (Munoz and Miranda, 2000, pp. 10-11). We will also explore different cognitive distortions, e.g., all-or-nothing thinking (seeing everything in black-or-white terms) and jumping to conclusions (making assumptions without sufficient evidence) (Munoz and Miranda, 2000, pp. 11-12).

Psychotherapy: Cognitive Interventions
I next want to help Anna identify and evaluate her automatic thoughts. When Anna tells me about a situation in which she felt depressed, I will ask, “What was going through your mind just then?” (Beck, 1995, p. 81). Once I have elicited an automatic thought from Anna, I will ask the following three questions:

How much do you believe this thought now (0-100%)?

How does this thought make you feel (emotionally)?

How strong (0-100%) is [this emotion]? (Beck, 1995, p. 81)

I will work with Anna to evaluate those thoughts which she holds with a high level of certainty and which are causing a significant amount of psychological disturbance (Beck, 1995, p. 107). The evaluation process involves the therapeutic use of Socratic questioning, a process in which the therapist asks the client a series of questions about their thoughts with the purpose of examining the evidence for each thought, considering alternative explanations for the evidence, considering the effect of believing the thought, the effect of not believing the thought, and deciding whether the thought should be retained (Beck, 1995, p. 109).

Once we have evaluated some of Anna’s automatic thoughts, we might evaluate some of her core beliefs. One way to elicit core beliefs is to use the downward arrow technique. I would use this technique on an automatic thought I suspected might “be directly stemming from a dysfunctional belief” (Beck, 1995, p. 145). I would then ask Anna “for the meaning of this cognition, assuming the automatic thought were true” and continue doing so until we “uncovered” a core belief (Beck, 1995, p. 145). I will use the same process for evaluating core beliefs as I used for evaluating automatic thoughts.

Psychotherapy: Behavioral Interventions
I eventually want to teach Anna that one way to fight depression is to engage in self-care activities, that is, activities she finds “pleasant, rewarding, or inspiring” (Rossello & Bernal, 1999, p. 736). I then want to show her how to devise a self-care plan, emphasizing that an effective plan “entails setting reasonable goals, focusing on positive actions, and planning rewards” (Rossello & Bernal, 1999, p. 736).

I will also spend some time encouraging Anna to have strong relationships with others. Having strong relationships is so important because the stronger one’s relationships, “the easier it will be to face difficult situations and overcome depression” (Rossello & Bernal, 1999, p. 736). Being assertive—as opposed to being passive or being aggressive—is needed to maintain strong relationships, and, as explained in more detail in the Cultural Competence section, I will teach her how to be more assertive (Rossello & Bernal, 1999, p. 736).

Psychotherapy: Homework Assignments
I will give Anna different homework assignments throughout our time together. I will list just a few examples here. After I teach her the cognitive model, I will ask her to begin filling out a Daily Mood Scale every night. Doing this will help us to see if our sessions are mitigating her depression (Munoz and Miranda, 2000, p. 8). After I teach her the importance of self-care, I will ask her to start completing a List of Pleasant Activities to help her become aware of the self-care activities she engages in (Munoz and Miranda, 2000, p. 29). Soon after that I will ask her to complete a Personal Contract in which she plans to perform an activity from the List of Pleasant Activities (Munoz and Miranda, 2000, p. 38).

Cultural Competence

My treatment of Anna needs to be individualized, meaning I need to tailor my approach to her individual needs and values. Nonetheless, given that Anna is from Argentina and does not seem to be entirely acculturated into American culture, I should be mindful of the Latino values of personalismo, familismo, and respeto.

Personalismo requires the therapist to “demonstrate genuine interest in the client, rather than focusing on procedures” (Gonzales-Prendes, Hindo, & Pardo, 2011, p. 382). Organista and Munoz (1996) write that “taking time to engage in self-disclosure and small talk, or platica,” builds confianza, or trust” (p. 260). They advise therapists to begin “the first session with platica, in which therapist and patient share background information about where they are from, their families, work that they have done, and so on” (p. 260). In order to emphasize similarities, a “non-Latino therapist could share an experience of being ‘different’ or of moving from one city to another” (Organista & Munoz, 1996, p. 260). Related to the value of personalismo, “being able to ‘get things off one’s chest’ (desahogo) is a commonly described benefit of psychotherapy” among Latino clients, and Anna might need to be given this opportunity during especially stressful times (Interian, Allen, Gara, & Escobar, 2008, p. 72)

Familismo “conveys the centrality of the family as a source of loyalty, support, and identity” (Gonzales-Prendes, Hindo, & Pardo, 2011, p. 382). This “sense of loyalty means that family interests are often placed above individual interests” (Gonzales-Prendes, Hindo, & Pardo, 2011, p. 382). Given familismo, it follows that I might be ineffective if I appeal mainly to Anna’s “self-interest as a motivation to change” and not “the impact on [her] family” (Gonzales-Prendes, Hindo, & Pardo, 2011, p. 382). Familismo might be preventing Anna from engaging in self-care activities that would help her. For such cases, Interian, Allen, Gara, and Escobar (2008) suggest reframing such activities as “necessary for the family, given that improving [her] depression would lead to better family functioning” (p. 70).

Respeto refers to the respect owed each family member. Latino families tend to be hierarchical, with “the father assum[ing] the predominant role, followed by the mother, and then the children” (Gonzales-Prendes, Hindo, & Pardo, 2011, p. 382). Largely because of respeto, Latinos, especially women, have “a tendency to guardar, or hold in anger, rather than express it to spouses, family members, and others with whom they are upset” (Organista & Munoz, 1996, p. 262). Consequently, Anna might especially benefit from learning to be more assertive. This can best be accomplished by teaching her, perhaps through role-playing exercises, how to be assertive while remaining respectful—for example, by teaching her to preface assertive statements with the phrase “With all due respect” (e.g., “With all due respect, Senor, would you please not yell at me when you want to talk to me about my work?”) (Organista & Munoz, 1996, p. 263).

To make my treatment plan culturally competent, I should also remember that Anna likely holds many traditional Roman Catholic beliefs. Organista and Munoz (1996) encourage therapists to “reinforce churchgoing and prayer as behavioral and cognitive activities, respectively, that help [clients] deal with stress and negative mood stages” (262). But they add that it is important to “explore and challenge forms of prayer that seem to lessen the probability of active problem-solving”—for example, by encouraging clients to “ask God for support in trying out new behaviors,” instead of just generically asking God to fix their problems (p. 262).

Supervision

It is difficult to know at this point exactly how I would use supervision in this case, as in the past I have mostly used supervision to help problem-solve the unexpected things that popped up during my work. I believe I would first want to use supervision to help decide what presenting problem to focus on. My suspicion is that Anna has depression, but I would want my supervisor to confirm this view. Assuming that Anna has depression, I would feel fairly confident as I began my work with Anna, largely because I would have an accessible, evidence-based curriculum to guide me.

I would also use supervision as I tried to reconcile my approach with Anna’s cultural values. Organista & Munoz (1996) make some good suggestions, but they say other things that confuse me. For example, they write that Latinos generally have difficulty learning the cognitive model and should instead be taught “the difference between ‘helpful’ thoughts, which help to reduce symptoms and initiate adaptive behaviors, and ‘unhelpful’ thoughts that do the opposite” (Organista & Munoz, 1996, p. 261). They further propose teaching the “Yes, but…” technique “in which patients are taught that much of problematic thinking amounts to ‘half-truths’ about problems that need to be made into ‘whole-truths’” (Organista & Munoz, 1996, p. 261). I have trouble understanding why Latinos would have trouble learning the cognitive model and would ask my supervisor about his experience doing CBT with Latinos. I would also ask his thoughts on the “Yes, but…” technique.

References

Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: The Guilford Press. DeRubeis, R.J., Webb, C.A., Tang, T.Z., & Beck, A.T. (2010). Cognitive therapy.

K.S. (Ed.) Handbook of cognitive-behavioral therapies (3rd ed.) (277-316). New York: Guilford Press.

Friedberg, R.D., & McClure, J.M. (2002). Clinical practice of cognitive therapy with children and adolescents: The nuts and bolts. New York: The Guilford Press.

Gonzales-Prendes, A.A., Hindo, C., & Pardo, Y. (2011). Cultural values integration in cognitive-behavioral therapy for a Latino with depression. Clinical Case Studies, 10(5), 376-394.

Hoffman, S.G., Asnaani, A., Vonk, I.J.J., Sawyer, A.T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy Research, 36(5), 427-440.

Interian, A., Allen, L.A., Gara, M.A., & Escobar, J.I. (2008). A pilot study of culturally adapted cognitive behavior therapy for Hispanics with major depression. Cognitive and Behavioral Practice, 15(1), 67-75.

Leichsenring, F., Hiller, W. Weissberg, M., & Leibing, E. (2006). Cognitive-behavioral therapy and psychodynamic psychotherapy: Techniques, efficacy, and indications. American Journal of Psychotherapy, 60(3), 233-259.

Munoz, R.F., & Miranda, J. (2000). Cognitive therapy manual for cognitive-behavioral treatment of depression. Santa Monica, CA: RAND.

Neenan, M., & Dryden, W. (2006). Cognitive therapy in a nutshell. London: Sage Publications.

Organista, K.C., & Munoz, R.F. (1996). Cognitive behavioral therapy with Latinos. Cognitive and Behavioral Practice, 3(2), 255-270.

Parsons, R.D. (2009). Thinking and acting like a cognitive school counselor. New York: Corwin.

Rossello, J., & Bernal, G. (1999). The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. Journal of Consulting and Clinical Psychology, 67(5), 734-745.

Shrink, S.R., Kaplinski, H., & Gudmundsen, G. (2009). School-based cognitive-behavioral therapy for adolescent depression. Journal of Emotional and Behavioral Disorders, 17(2), 106-117.

Vernon, A. (2004). Using cognitive behavioral techniques. In Erford, B.T. (Ed.) Professional school counseling: A handbook of theories, programs & practices (91-100). Austin: CAPS Press.