Case Study CBT Laura S

Student Number 130039386
Theoretical Models in Counselling Psychology PS3504
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Case report of an individual therapy case using CBT
Student Number : 130039386
Word Count : 2,729

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CONTENTS
Section 1: Theoretical framework and Rationale
Pages 3-4
Section 2: Psychological Assessment and Case formulation
Pages 5-7
Section 3: Content of therapy and techniques employed
Pages 8-10
Section 4 : Evaluation, learning and reflection
Page 11
Linking this case study to the Ethos of Counselling Psychology
Page 12
References
Pages 13-15

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Section 1: Theoretical framework
Cognitive behavioural therapy (CBT) is an integration of Ellis’ (1996) rational emotive
behaviour therapy (REBT) and Becks’ (1976) cognitive therapy.
Central to REBT theory and practice is the ABC framework which offers a simple
explanation of understanding the client’s feelings, thoughts and behaviours (Wolfe, 2007).
‘A’ is the activating event. ‘C’ is the emotional or behavioural consequence that follows
from ‘A’. ‘B’ is the person’s belief (most likely unhealthy beliefs for a client seeking CBT)
about the event (A) and it is the belief that creates the emotional or behavioural consequence
(C). Ellis (1996) postulates that we all have the ability to change our cognitions, emotions
and behaviour by choosing to examine and challenge the irrational beliefs (B) we hold about
an event (A). One way in which the client’s irrational beliefs can be challenged is to get them
to conduct behavioural experiments either collaboratively with the therapist or individually
by setting ‘homework’. The aim of this is to test the accuracy of the client’s beliefs (Hollon &
DiGiuseppe, 2011).
Beck (1976) proposed that emotional disorders are manifested at the ‘surface level’ by
negative automatic thoughts (NAT’s). An example of an NAT could be “I will not pass this
interview”. An underlying assumption is then created (Bartlett, 1932), “If I do not pass this
interview, then I am stupid”. Negative Core beliefs arise from these thoughts and are
accepted as internal truths about the self which in turn may alter the way they construe the
world and what the future holds for them. Enabling clients to ‘Capture’ NAT’s before they
turn into core beliefs is fundamental to CBT and essential for cognitive change (Trower et al,
2011).
Although CBT has been proven to be effective with the treatment of mental illness,
the generic nature of CBT does not allow the counsellor to target specific difficulties of the

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patient (Gaag, 2014).Therefore I must be careful when discussing the formulation with Jenny
as there may not be time to work on some specific difficulties that she may bring to the table.
Rationale
I chose to employ a CBT framework for intervention because it is a short-term, focused
therapy (Fennell, 1989), has collaborative nature, and it is highly structured and directive
(Beck, 1964). I believe this would apply well to Jenny as her life appears to be lacking
structure and guidance. Cognitive-behavioural techniques have helped alleviate ‘worry’ in a
relatively short amount of time (Wells, 1995) by teaching the necessary adaptive and
functional skills to guide one through everyday life.
I also chose to use CBT as Jenny was adopting social and job related cognitive
distortions that caused her to worry about the future. CBT will aim to modify Jenny’s
thinking and belief system (Beck, 1995) through making her aware of how her avoidance of
work manifested itself cognitively, behaviourally and physiologically. A change in cognition
may positively alter the way Jenny thinks about herself and the world around her which will
in turn change her behaviour, the way she feels and her thought patterns (Greenberger and
Padesky, 1995).

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Section 2: Psychological assessment
Referral
Jenny was referred to a counselling psychology service by her GP, which offers Solution
Focused Brief Therapy in an NHS primary care setting. The referral stated that Jenny has
been on sick leave from work for 6 weeks and was experiencing bouts of low mood and
disinterest in normal activities like socialising. The client requested the counselling herself as
she felt she was not “coping well with her life”. The service offers a maximum of twelve,
fifty minute sessions and I have supervision once a fortnight for two and a half hours.
Bibliographical information and family history
Jenny is a 23 year-old, single, White-British female and lives at home with her parents and
younger sister. Last year, Jenny graduated from University and went travelling for 3 months
before commencing her job as a civil servant. Jenny was brought up in a “traditional family
who had very clear set values and expectations”. She described an isolated childhood and still
continues to feel “ignored” at home. Despite not being close to her parents, Jenny relies
heavily on them to complete tasks for her such as cooking at mealtimes as she gets little sleep
and therefore has no energy. She explained that she has always wanted to be an artist but her
parents ignored this wish of hers.
Therapist’s initial impressions
Jenny’s manner was polite, however I sensed that she felt anxious as she spoke in an
undertone. I began the session by introducing myself and explaining issues of
confidentiality. The latter was important to Jenny as she expressed concern about her parents
finding out. She was reassured when I explained that a breach of confidentiality would be

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discussed with her first. As she noticeably became more comfortable with the environment
we began to establish a rapport and I was pleased she was able to discuss her difficulties
openly. Jenny was tearful for part of the sessions as she believes that therapy is her “last
resort” in terms of her going back to work.
Presenting problems
Jenny said that she started to experience feelings of low mood and isolation when she got
back from travelling. She feels anxious and paranoid around her boss and work colleagues,
and believes they are often critical of her. She finds herself spending a lot of time ruminating
about things that have been said to her. She says she has developed a “fear” of going back to
work. These problems could be maintained by her parents as they reaffirm her negative
beliefs about herself. As she is living “under their roof”, she feels that she has little control
over her immediate environment and therefore is reliant on them. Due to her perceptions of
what her work colleagues say to her, Jenny is finding it difficult to build relationships.
Jenny also explained how she had been experiencing somatic sensations when confronted
with people at work such as uncontrollable sweating. She found these experiences extremely
unnerving and has avoided them by not being at work.
Case formulation
I employed Clark and Wells’ cognitive model of social phobia (1995) and ‘The five aspects
formulation model’ (Greenberger & Padesky,1995) to focus on the relationship between
Jenny’s difficulties at work and her cognitions and behaviours.
It appears that Jenny’s negative thoughts about what her colleagues think of her leads
to the negative expectation she has prior to any interactions at work (Clark and Wells, 1995).
It may be this expectation that leads Jenny to have negative interpretations of her colleague’s
responses which could be why she finds herself ruminating over them. Therefore, Jenny may

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not be able to focus her attention on how her colleagues are actually behaving towards her
(Pineles & Mineka, 2005). It could well be that her colleagues are acting in a positive manner
e.g. offering her constructive feedback as opposed to criticism. This sequence of events is
potentially linked to her avoidance of work.
Clark and Wells’ model explained the ineffectiveness of exposure work alone in
treating individuals who had a fear of social situations (Butler et al, 1984). This made me
conscious of what techniques I would use in therapy with Jenny. Furthermore, their findings
were specific to ‘socially anxious individuals’, and so cannot be ascribed to a pattern of
Jenny’s low mood and disinterest in normal activities.
The five aspects formulation model can help to identify a link between her
experiences at work in terms of her thoughts, moods, behaviours and physical reactions.
Jenny’s negative thoughts about the comments her work colleagues make bring about the
uncontrollable sweating sensations which leads to her avoiding work and as a result, feeling
down about not being able to go in. This model would suggest that one can target any of
these aspects and it will have a positive direct impact on the other related issues.
Therapeutic goals
Collaboratively, we set the following goals:
 Challenging her thoughts and restructuring her core beliefs and negative expectations
(cognitive intervention) so that she is able to go to work and build relationships.
 To explore preventative and coping techniques using a behavioural intervention like
activity scheduling.

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Section 3: Content of therapy and techniques employed
Sessions 1-4
The first intervention session was used to share and discuss the formulation and to complete
some Psycho-education on the CBT model explaining the way in which her thoughts,
feelings, physical sensations and behaviours link up (Padesky,1990). I asked Jenny to identify
a situation she found difficult and complete a five aspects model of her own. Jenny found it
difficult to identify her thoughts on her own and so, through Socratic questioning (Padesky,
1993), we were able to uncover the thoughts that were present in that situation. It seemed that
Jenny had initially struggled to grasp the cognitive aspects of the model but by working
collaboratively, Jenny was able to experience some sense of achievement.
We began to explore the use of thought records (Greenberger & Padesky,1995). We
were able to uncover negative thoughts and fears that were present when her colleagues
criticised her work. Jenny remembers feeling ‘stupid’ and thought that her colleagues were
probably thinking the same about her. When we looked at the evidence that did not support
this thought, she came to the realisation that she isn’t stupid as she had achieved a 1st class
degree at University. She then suggested that maybe she just wasn’t strong at performing that
particular task, and thought about seeking help for it next time. It was possible that this was a
turning point for Jenny.
Sessions 5-8
Jenny started to bring in her own ideas to the sessions such as wanting to create a plan for
getting herself back to work. I believe that this seemed important because it meant that she
was starting to take control of what she wanted in the session which may have been an
important first step in her taking control outside of the session. However, I explained that

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before creating any plan I wanted to carry on focusing the therapy on her thoughts about
particular situations.
Now that we had formed a strong therapeutic alliance, it felt like the right time to
delve a bit deeper into Jenny’s belief systems using the downward arrow technique (Beck,
1979). This was used in order to identify some of Jenny’s ‘core beliefs.’ She discussed her
fear of being criticised and judged by her work colleagues. This often lead her to feeling
upset, paranoid and rejected. As a result, we identified a key core belief as “I am stupid”. The
aim of exploring Jenny’s thought processes here was to try and encourage Jenny to be able to
see herself in a more realistic light and so having both strengths and weaknesses. I explained
that if her thoughts about herself changed, she would be able to alter her thoughts in specific
situations that could be effecting her relationships (Beck,1967). She would no longer have as
many thoughts with the theme of “I am stupid”. Instead, for example, when she made
mistakes, she would think “I am not good at this”.
CBT has been criticised for denying the importance of the client’s past
(Weishaar,1993). However, if there were no time limit, I would have liked to explore the fact
that since a young age, Jenny could remember the way her parents had made her feel
“inferior”.
Sessions 9-12
In order to help Jenny to get out of the house more and to acquire some independence, we
completed an Activity Schedule (behavioural intervention suggested by Farmer and
Chapman, 2008) and then tried to schedule in some activities for Jenny to do. Jenny was
more open to taking part in activities in her home such as cooking a meal for her family
which gave her a sense of achievement.

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I then tried to expose Jenny to her fear of feeling paranoid and rejected through role-
play. The aim of this was so that we could prepare an action plan (Greenberger & Padesky,
1995) for Jenny that suggested ways in which she could respond to different types of
criticisms. One way that I taught Jenny to do this was by asking her what would be the worst
thing that might happen to her if for example, she was confronted by her colleagues. We then
made a list of all the negative things that they may think of her. Jenny’s first thought was
“I’m stupid” which I noticed she had written down on her thought records. We discussed her
thought record again, specifically concentrating on the evidence that did not support that
thought.
On leaving therapy, Jenny reported feeling in a better mood and more positive about
the future as she felt that she could finally speak to someone about her difficulties. She also
felt a little bit more in control of identifying her thoughts and cognitions. We reviewed the
tools that worked best for her in terms of overcoming worries about work in the hope that she
can continue to utilise them beyond the therapy room.

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Section 4: Evaluation, difficulties and reflection
On reflection, I wonder whether I could have used the CBT model in a more flexible manner
in a way which was tailored to all of Jenny’s needs. I felt like I took quite a directive role and
I could have used more of the time in a client-led fashion, allowing for some sessions to be
more exploratory and non-directive. My supervisor suggested that I should let Jenny lead part
of a session for herself using Socratic questions to guide her. However, Jenny expressed that
she would rather concentrate on making an action plan relating to work. Although Jenny took
initiative to help herself early on, I thought that it might have been better to revert to working
cognitively and then return to the activity schedule later on. Perhaps, using a more pluralistic
approach (Cooper & McLeod, 2007) by employing some techniques from other perspectives
could have contributed towards the strengthening of the therapeutic relationship and towards
guiding the client in making discoveries for herself.
Furthermore, one of the regular concerns I had for Jenny was that she was always
going back to a household she was not comfortable in. Perhaps it may have been helpful to
have part of the case formulation based around family dynamics and belief systems and how
this impacts on the client (Cockx, 2010). However, Jenny specifically expressed that she
wanted to focus on getting back to work. To try and overcome this issue, I was advised to
include familial activities in her activity schedule e.g. cooking a meal for her family. Jenny
was able to do this which not only gave her a sense of achievement in regards to cooking but
also that she was able to ‘socialise’ with her family.

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Linking this case study to the Ethos of Counselling Psychology
The importance of establishing a strong collaborative relationship in therapy is now firmly
established in CBT theory and practice (Wills, 2008). Beck (1995) stressed the need for
therapists to develop a strong TR where they can collaboratively develop therapy goals, ways
of working and homework tasks. In this case study, Jenny and I collaboratively agreed
together on what her goals were. The TR in CBT was important as it gave Jenny a sense of
responsibility for her own circumstances. Woolfe (1990) identified the significance of the TR
in Counselling psychology and that using therapeutic techniques are only useful if there is a
strong therapeutic alliance between client and therapist (Sanders, 2010).This is why it was
important that I used emotion-focused methods like role playing only when the TR was
established.
Counselling Psychology emphasises the importance of engaging with subjective
experience, values and beliefs in seeking to understand the ‘inner world’ of the client
(Strawbridge & Woolfe, 2010). Due to the nature of CBT, it generally does not allow
considerable amounts of ‘exploratory’ time and therefore, it may be difficult to fully engage
with the subjective experience of the client. However, I felt that this was paramount in
creating a strong TR with Jenny, which in turn would lead to the desired outcomes. I believe
that this was down to the non-judgemental atmosphere that I created and my appreciation
towards her life experiences (Woolfe et al, 2003), as I continuously immersed myself into
Jenny’s subjective experience of how she sees herself, the world and her future.

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References
Bartlett, F. C. (1932). Remembering. Cambridge: Cambridge University Press.
Beck, A. T. (1964). Thinking and depression: II. Theory and therapy. Archives of general
psychiatry, 10(6), 561-571.
Beck, A.T. (1967). Depression: Clinical, Experimental and Theoretical aspects. New
York: Harper Row.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York:
International Universities press.
Beck, A.T., Rush. A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression.
New York: Guilford Press.
Beck, J. S. (1995). Cognitive behaviour therapy: Basics and beyond. New York: Guilford
Press.
Butler, G., Cullington, A., Munby, M., Amies, P., & Gelder, M. (1984). Exposure and
Anxiety Management in the Treatment of Social Phobia. Journal of Consulting
and Clinical Psychology, 52(4), 642-50.
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G.Heimberg,
M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social Phobia: diagnosis,
assessment, and treatment (pp. 69–91). New York: Guilford Press.
Cockx, A. (2010). Case formulation: cognitive behavioural family therapy. In A. Grant,
M. Townsend, J. Mills & A. Cockx. Assessment and Case Formulation in
Cognitive Behavioural Therapy (2010). London: Sage.
Cooper, M., & McLeod, J. (2007). A pluralistic framework for counselling and
psychotherapy: Implications for research. Counselling and Psychotherapy
Research, 7(3), 135-143.

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Ellis, A. (1996). Better, Deeper, and More Enduring Brief Therapy: The Rational Emotive
Behavior Therapy Approach. New York: Brunner/Mazel.
Farmer, R. F., & Chapman, A. L. (2008). Behavioral interventions in cognitive behavior
therapy: Practical guidance for putting theory into action. Washington, DC:
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Fennell, M. J. V. (1989) Depression. In K. Hawton, P. M. Salkovskis, J. Kirk and D. M.
Clark (eds), Cognitive Behaviour Therapy for Psychiatric Problems. Oxford:
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Gaag, M. (2014). The efficacy of CBT for severe mental illness and the challenge of
dissemination in routine care. World Psychiatry, 13(3), 257-258.
Greenberger, D., & Padesky, C.A. (1995). Mind over mood: A cognitive therapy treatment
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Hollon, S. D., & DiGiuseppe, R. (2011). Cognitive theories of psychotherapy. In J.
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potential threat in social anxiety. Journal of Abnormal Psychology, 114, 314–318.

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Sanders, D. (2010). Cognitive and behavioural approaches. Handbook of counselling
psychology, 3, 105-129.
Strawbridge, S., & Woolfe, R. (2010). Counselling psychology: Origins, developments
and challenges. Handbook of counselling psychology, 3, 3-22.
Trower, P., Jones, J., Dryden, W., & Casey, A. (2011). Cognitive-Behavioural Counselling
in Action (2nd ed.). London: Sage.
Weisharr, M.E. (1993). Aaron T. Beck. London:Sage.
Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalized anxiety
disorder. Behavioural and cognitive psychotherapy, 23(03), 301-320.
Wills, F. (2008). Skills in Cognitive Behaviour Counselling and Psychotherapy. London:
Sage.
Woolfe, R. (1990). Counselling psychology in Britain: An idea whose time has come. The
Psychologist, 3 (12): 531-535.
Woolfe, R., Dryden, W., & Strawbridge, S. (eds) (2003). Handbook of counselling
psychology. London: Sage.
Wolfe,J.L. (2007).Rational emotive behaviour therapy (REBT). In A.B. Rochlen (ED.),
Applying counselling theories: An online case-based approach (pp.177-191).
Upper Saddle River, NJ: Pearson Prentice-Hall.

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