ࡱ> ]_\ /bjbj .dee'xx$ACCCCCC8!CCX&&&A&A&&:},p{/ -n0R!z!!(&CC&!x :  Cognitive-Behavioral Case Formulation and Treatment Plan Example Cognitive-Behavioral Case Formulation Client Name: Ms. Date: Identifying Information: middle-aged female, married with two children Mental Status Examination She appeared neatly dressed in an outfit, which was age-appropriate. She was alert and oriented to person, place, and time. The client made every effort to be open and honest. Furthermore, she maintained a cooperative attitude toward the examiner. Her mood and affect were depressed and anxious. Speech was coherent and relevant. There were no signs of a formal thought disorder as observed. Memory was intact as observed. Insight was estimated as fair to good. Problem List 1. Feeling angry, resentful, anxious (Include score on BAI at intake (Thoughts -She knew we were going to be late and deliberately stayed in the closet -She runs this house -I might as well not be married (Behaviors -yelled at daughter and husband -stomach tensed up (Recent Situations -late for school and daughter was hiding in the closet -daughter refused to go to bed -husband went upstairs to play with model trains 2. Feeling depressed, helpless (Include score on BDI at intake (Thoughts -She doesnt care about what Im going through -She doesnt care about what I need -He leaves me with all the responsibility and doesnt care (Behaviors -blamed daughter and husband (Recent Situations -late for school and daughter was hiding in the closet -daughter refused to go to bed -husband went upstairs to play with model trains 3. Lack of effective communication skills (Thoughts -She knew we were late and deliberately stayed in the closet -He deliberately leaves me with all of the work (Emotions -angry -resentful -anxious (Behaviors -anger outbursts with daughter and husband -attempted to bottle up feelings about husband, which resulted in shouting match between them (Recent Situations -late for school and daughter was hiding in the closet -husband went upstairs to play with model trains 4. Lack of patience (Thoughts -Shes a self-centered brat -Shes a tyrant -She doesnt care about what I need -She doesnt care about what Im going through (Emotions -depressed -helpless -anxious (Behaviors -yelled at daughter; blamed daughter (Recent Situations -late for school and daughter was hiding in closet -daughter refused to go to bed Diagnosis Axis I: R/O Generalized Anxiety Disorder R/O Major Depressive Disorder V61.10 Partner Relational Problem V61.20 Parent-Child Relational Problem Axis II: V71.09 No Diagnosis Axis III: None Axis IV: None Axis V: GAF = 60 (current) Working Hypothesis (*integrate information gathered in additional sessions) (Core Beliefs about self, others, world, and future Self - I need to be in control I am unlovable Others - Other people frustrate my efforts to be in control Other people do not care about me or care about what I need World - *include information gathered in additional sessions Future - *include information gathered in additional sessions Precipitants (*Include information gathered in additional sessions) ((For example, client decided to begin therapy after having a serious fight with husband, in which she made him leave the house for the night) ((For example, client decided to begin therapy after hitting her daughter during one of her anger outbursts) Activating Situations (getting daughter ready for school (doing household chores (running behind schedule Origins *Include information gathered in additional sessions including family history (relationships with father, mother, siblings during childhood and adulthood) and past experiences concerning clients difficulties Strengths and Assets (*as per information gathered in additional sessions) (Ability to work collaboratively with therapist (Good relationship with infant daughter (Willingness to work; willingness to change (Strong connection to husband prior to experiencing problems Cognitive Conceptualization Diagram Patient Name: Ms. J Diagnosis-Axis I: R/O Generalized Anxiety Disorder Date: March 25, 2003 R/O Major Depressive Disorder V61.10 Partner Relational Problem V61.20 Parent-Child Relational Problem Diagnosis-Axis II: V71.09 No Diagnosis Relevant Childhood Data *Include information gathered in additional sessions ( Core Belief(s) I need to be in control I am unlovable( Intermediate Belief(s) If my daughter doesnt obey me, I am not in control/she doesnt love me If my husband doesnt do what I want him to do, I am not in control/he doesnt love me( Compensatory Strategy(ies) Anger outbursts, place blame on others, and avoid immediate expression of feelings to husband( ( ( Situation 1 Daughter hides in closet, which causes them to be late to school Situation 2 Daughter refuses to go to bed Situation 3 Husband spends night playing with model trains( ( ( Automatic Thought Shes a self-centered brat, she runs this house, and she doesnt care about what Im going throughAutomatic Thought Shes becoming a tyrant, she runs this house, and she doesnt care about what I needAutomatic Thought I might as well not be married, he deliberately leaves me with all the work, and he doesnt care about me( ( ( Meaning of Thought I am not in control I am unlovableMeaning of Thought I am not in control I am unlovableMeaning of Thought I am not in control I am unlovable( ( ( Emotion(s) Angry Worried Emotion(s) Angry Feeling on edgeEmotion(s) Angry Resentful( ( ( Behavior(s) Yelled at daughter Behavior(s) Yelled at daughterBehavior(s) Yelled at husband Cognitive-Behavioral Treatment Plan Client Name: Ms. Date: Identifying Information: middle-aged female, married with two children Treatment Goals (Reduce physical symptoms of anxiety and depression (measured via BAI & BDI) (Reduce anger outbursts (measured via personal report) (Improve ability to effectively communicate thoughts/feelings (measured via personal report and positive data log) (Reduce negative automatic thoughts (measured via daily thought record) (Modify core beliefs of need for control (measured via core belief worksheet) (Acquire relapse prevention skills (measured directly) Treatment Modality (Initial individual cognitive-behavioral therapy (Followed by family therapy Treatment Frequency (Initial weekly individual cognitive-behavioral therapy (Followed by weekly family therapy Treatment Duration (Initial 10-12 sessions of individual cognitive-behavioral therapy (Followed by 3-5 sessions of family therapy Treatment Interventions 1. Assessment (Administer cognitive, behavioral, and interpersonal assessments including the Leahy Anxiety Checklist for Patients (Administer tests and other evaluations including the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) (Evaluate suicidal risk (Evaluate need for medication 2. Socialization to Treatment (Inform client of diagnosis (Provide relevant, informative handouts on his/her disorder in particular and cognitive-behavioral therapy in general (Teach client structure of cognitive-behavioral therapy sessions (Inform client of connection between thought, emotions, and behaviors (Provide rationale for therapeutic interventions 3. Cognitive Restructuring (Assist client in identifying and evaluating automatic thoughts, intermediate beliefs, and core beliefs (daily thought record) (Assist client in generating alternative, more adaptive thoughts and beliefs positive data log, core belief worksheet 4. Relaxation Training (Inform client that anxious thoughts and emotions are more likely to occur when physiologically aroused (Teach relaxation techniques including progressive muscle relaxation, breathing relaxation, guided imagery, and meditation (Discourage client from the use of stimulants including caffeine (Encourage client to engage in regular exercise 5. Marital/Family Interventions (Teach family members to attend to, label, and reinforce positives in each other (Teach positive assertiveness (Teach communication skills including active listening and clarifying feelings (Teach time-out procedures as well as self-instructions for anger Adjunct Therapy (Pharmacotherapy is an option, if Ms. J does not respond to initial individual cognitive- behavioral therapy Obstacles 1. Difficulty distinguishing thoughts from emotions (Predicts interference with use of daily thought record to identify and evaluate automatic thoughts, emotions, and maintaining behaviors 2. Short temper, anger outbursts (Predicts noncompliance with new homework assignments involving activities, which present a cognitive or behavioral challenge 3. 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