01 - Appendix B. Beck Institute Case WriteUp Summa

Appendix B. Beck Institute Case Write‑Up: Summary and Conceptualization

PART ONE: INTAKE INFORMATION Identifying Information at Intake Age: 56 Gender Identity and Sexual Orientation: Male, heterosexual Cultural Heritage: American with European heritage Religious/Spiritual Orientation: Belongs to the Unitarian Church; was not attending church at intake Living Environment: Small apartment in large city; lives alone Employment Status: Unemployed Socioeconomic Status: Middle class Chief Complaint, Major Symptoms, Mental Status, and Diagnosis Chief Complaint: Abe sought treatment for severe depressive symptoms and moderate anxiety. Major Symptoms Emotional: Feelings of depression, anxiety, pessimism, and some guilt; lack of pleasure and interest Cognitive: Trouble making decisions, trouble concentrating Behavioral: Avoidance (not cleaning up at home, looking for a job, or doing errands), social isolation (stopped going to church, spent less time with family, stopped seeing friends) Physiological: Heaviness in body, significant fatigue, low libido, difficulty relaxing, decreased appetite APPENDIX B Beck Institute Case Write‑Up SUMMARY AND CONCEPTUALIZATION See beckinstitute.org/CBTresources.

Mental Status: Abe appeared to be quite depressed. His clothes were somewhat wrinkled; he didn’t stand or sit up straight, made little eye contact, and didn’t smile throughout the evaluation. His movements were a little slow. His speech was normal. He showed little affect other than depression. His thought process was intact. His sensorium, cognition, insight, and judgment were within normal limits. He was able to fully participate in treatment. Diagnosis (from the Diagnostic and Statistical Manual of Mental Disorders or the International Statistical Classification of Diseases and Related Health Problems): Major depressive disorder, single episode, severe, with anxious distress. No personality disorder but mild obsessive–­compulsive personality disorder features. Current Psychiatric Medications, Adherence, and Side Effects; Concurrent Treatment Abe was not taking psychiatric medication and was not receiving any treatment for his depression. Current Significant Relationships Although Abe had withdrawn somewhat from his family, his relationship with his two grown children and four school-­age grandchildren were good. He sometimes visited them or attended his grandchildren’s sporting events. He had a great deal of conflict with his ex-wife and had completely withdrawn from his two male friends. He was relatively close to one cousin and less so to one brother. He saw and spoke to his other brother and his mother infrequently and didn’t feel close to them. PART TWO: HISTORICAL INFORMATION Best Lifetime Functioning (Including Strengths, Assets, and Resources) Abe was at his best when he finished high school, got a job, and moved into an apartment with a friend. This period lasted for about 6 years. He did well on the job, got along well with his supervisor and coworkers, socialized often with good friends, exercised and kept himself in good shape, and started saving money for the future. He was a good problem solver, resourceful and resilient. He was respectful to others and pleasant to be around, often helping family and friends without being asked. He was hardworking, both at work and around the house. He saw himself as competent, in control, reliable, and responsible. He viewed others and his world as basically benign. His future seemed bright to him. He also functioned highly after this time, though he had more stress in his life after he married and had children. Appendix B

History of Present Illness Abe developed depressive and anxious symptoms 2½ years ago. His symptoms gradually worsened and turned into a major depressive episode about 2 years ago. Since that time, symptoms of depression and anxiety have remained consistently elevated without any periods of remission. History of Psychiatric, Psychological, or Substance Use Problems and Impact on Functioning Abe became quite anxious about 2½ years ago when his supervisor changed his job responsibilities and provided him with inadequate training. He began to perceive himself as failing on the job and became depressed. His depression increased significantly when he lost his job 6 months later. He withdrew into himself and stopped many activities: helping around the house, doing yard work and errands, and seeing his friends. His wife then became highly critical, and his depression became severe. He had not had any problems with alcohol or other substances. History of Psychiatric, Psychological, or Substance Abuse Treatment, Type, Level of Care, and Response Abe and his wife had had three joint outpatient marital counseling sessions with a social worker about 2 years ago; Abe reported it did not help. He reported no other previous treatment. Developmental History (Relevant Learning, Emotional, and Physical Development) Abe had no relevant difficulties in his physical or emotional development or in his school performance. Personal, Social, Educational, and Vocational History Abe was the oldest of three sons. His father abandoned the family when Abe was 11 years old, and he never saw his father again. His mother then developed unrealistically high expectations for him, criticizing him severely for not consistently getting his younger brothers to do homework and for not cleaning up their apartment while she was at work. He had some conflict with his younger brothers who didn’t like him “bossing” them around. Abe always had a few good friends at school or in the neighborhood. After his father left, he developed a closer relationship with his maternal uncle and later with several of his coaches. Abe was an average student and a very good athlete. His highest level of education was a high school diploma. Abe started working in the construction industry in high school and had just a few jobs in the industry between graduation and when he became depressed. He worked his way up in customer service until he became a supervisor. He got along well with his bosses, supervisors, and coworkers and had always received excellent evaluations until his most recent supervisor.

Beck Institute Case Write‑Up

Medical History and Limitations Abe had a few sports-­related injuries in high school but nothing major. His health was relatively good, except for moderately high blood pressure, which he developed in his late forties. He didn’t have any physical limitations. Current Nonpsychiatric Medications, Treatment, Adherence, and Side Effects Abe was taking Vasotec, 10 mg, 2 × per day, with full adherence to treat high blood pressure. He had no significant side effects. He was not receiving any other treatment. PART THREE: THE COGNITIVE CONCEPTUALIZATION DIAGRAM (CCD) See pages 44–54. PART FOUR: THE CASE CONCEPTUALIZATION SUMMARY History of Current Illness, Precipitants, and Life Stressors The first occurrence of Abe’s psychiatric symptoms began 2½ years ago when Abe began to display mild depressive and anxious symptoms. The precipitant was difficulty at work; his new supervisor had significantly changed his job responsibilities, and Abe experienced great difficulty in performing his job competently. He began to withdraw from other people, including his wife, and started spending much of the time when he was home sitting on the couch. His symptoms steadily worsened and increased significantly when he lost his job and his wife divorced him, about 2 years ago. His functioning steadily declined after that. At intake, he was spending most of his time sitting on the couch, watching television, and surfing the web. Maintaining Factors Highly negative interpretations of his experience, attentional bias (noticing everything he wasn’t doing or wasn’t doing well), lack of structure in his day, continuing unemployment, avoidance and inactivity, social withdrawal, tendency to stay in his apartment and not go out, increased self-­criticism, deterioration of problem-­solving skills, negative memories, rumination over perceived current and past failures, and worry about the future. Values and Aspirations Family, autonomy, and productivity were very important to Abe. He aspired to rebuild his life, to recapture his sense of competence and ability to get things done, to get back to work, to become financially stable, to reengage in activities he had abandoned, and to give back to others. Appendix B

Narrative Summary, Incorporating Historical Information, Precipitants, Maintaining Factors, and Cognitive Conceptualization Diagram Information For most of his life, Abe demonstrated many strengths, positive qualities, and internal resources. For many years he had had a successful work history, marriage, and family. He had always aspired to be a good person, someone who was competent and reliable and helpful to others. He valued hard work and commitment. His strongly held values led to adaptive behavioral patterns of holding high expectations for himself, working hard, solving his problems independently, and being responsible. His corresponding intermediate beliefs were “If I have high expectations and work hard, I’ll be okay. I should solve problems myself. I should be responsible.” His core beliefs about the self were that he was reasonably effective and competent, likeable, and worthwhile. He saw other people and his world as basically neutral or benign. His automatic thoughts, for the most part, were realistic and adaptive. But the meaning Abe put to certain adverse childhood experiences made him vulnerable to having his negative beliefs activated later in life. His father left the family permanently when Abe was 11 years old, which led him to believe that his world was at least somewhat unpredictable. His mother criticized him for failing to reach her unreasonably high expectations. Not realizing her standards were unreasonable, Abe began to see himself as not fully competent. But these two beliefs weren’t rock solid. Abe believed that much of his world was still relatively predictable and that he was competent in other ways, especially in sports. As an adult, when Abe began to struggle on the job, he became anxious, fearing that he wouldn’t be able to live up to his deeply held values of being responsible, competent, and productive. The anxiety led to worry, which caused difficulties in concentration and problem solving, and his work suffered. He started to view himself and his experiences in a highly negative way and developed symptoms of depression. His core belief of incompetence/ failure became activated, and he began to see himself as somewhat helpless and out of control. His negative assumptions surfaced: “If I try to do hard things, I’ll fail”; “If I ask for help, people will see how incompetent I am.” So, he began to engage in dysfunctional coping strategies, primarily avoidance. These coping strategies helped maintain his depression. Failing to be as productive as he thought he should be and avoiding asking for help and support from others, along with harsh criticism from his wife for not helping around the house, also contributed to the onset of his depression. He interpreted his symptoms of depression (e.g., avoidance, difficulty concentrating and making decisions, and fatigue) as additional signs of incompetence. Once he became depressed, he interpreted many of his experiences through the lens of his core belief of incompetence or failure. Three of these situations are noted at the bottom of the Cognitive Conceptualization Diagram. Once Abe became depressed, he started to view other people differently. He feared that they would be critical of him, and he withdrew socially. Historically, he had seen his world as potentially unpredictable. After losing his job and his wife blindsiding him, he began to view his world as less safe (especially financially), less stable, and less predictable.

Beck Institute Case Write‑Up

PART FIVE: TREATMENT PLAN Overall Treatment Plan The plan was to reduce Abe’s depression and anxiety, improve his functioning and social interactions, and increase positive affect. Problem List/Client’s Goals and Evidence-­Based Interventions Unemployment/get a job. Examined advantages and disadvantages of looking for similar job as before versus initially getting a different job (one that would be easier to obtain and perform), evaluated and responded to hopeless automatic thoughts (“I’ll never get a job and even if I do, I’ll probably get fired again”), problem-­solved how to update résumé and look for a job, and role-­played job interview. Avoidance/reengage in avoided activities. Scheduled specific tasks around the house to do at specific times and did behavioral experiments to test his automatic thoughts (“I won’t have enough energy to do this”; “I won’t do a good enough job on this”). Evaluated and responded to automatic thoughts (such as “Doing this will just be a drop in the bucket”). Scheduled social activities and other activities that could bring a sense of pleasure. Taught Abe to give himself credit for anything he did that was even a little difficult and keep a credit list. Social isolation/reconnect with others. Scheduled times to get together with friends and family; assessed which friend would be easiest to contact, evaluated automatic thoughts (“He won’t want to hear from me”; “He’ll be critical of me for not having a job”), discussed what to say to friend about having been out of touch, and did behavioral experiments to test interfering thoughts. Ongoing conflict with ex-wife/investigate whether improved communication skills can help/decrease sense of responsibility for divorce. Taught communication skills such as assertion and did behavioral experiments to test thoughts (“It won’t make any difference; she’ll never stop punishing me/being mad at me”). Did a pie chart of responsibility. Depressive rumination and self-­criticism/reduce depressive rumination. Provided psychoeducation about symptoms and impact of depression, evaluated beliefs about deserved criticism, evaluated positive and negative beliefs about rumination and worry, did a behavioral experiment to see impact of mindfulness of the breath, and prescribed mindfulness exercise each morning and during the day as needed. PART SIX: COURSE OF TREATMENT AND OUTCOME Therapeutic Relationship At the beginning of treatment, Abe was concerned that I might be critical of him, and he thought he should be able to overcome his problems on his own. I provided him with my view: that he had a real illness for which most people require treatment, that his difficulties stemmed from his depression Appendix B

and didn’t indicate anything negative about him as a person, and that it was a sign of strength that he was willing to see if treatment could help. He seemed to be reassured. He demonstrated a level of trust in me from the beginning; he was open about his difficulties and collaborated easily. Initially, when he reported what he had accomplished on his Action Plans, he was skeptical when I suggested that these experiences showed his positive attributes. But he was able to recognize that he, too, would see these activities in a positive light if someone else in his situation had engaged in them. Abe mostly provided positive feedback at the end of sessions. He was able to appropriately let me know when I misunderstood something he said. In summary, he was able to establish and maintain a good therapeutic relationship with me. Number and Frequency of Treatment Sessions, Length of Treatment Abe and I met weekly for 12 weeks, then every other week for 4 weeks, and then once a month for 4 months, for a total of 18 sessions over 8 months. We had standard 50-minute CBT sessions. Course of Treatment Summary I suggested, and Abe agreed, that we work first on (1) getting Abe to get out of his apartment almost every day, (2) spending more time with his family, and (3) cleaning up his apartment. Doing these things increased his sense of connectedness and his sense of control and competence (and decreased his belief that he was incompetent and somewhat out of control). (Later we worked on spending more time with friends and volunteering.) Increasing his social activities improved his social support and fulfilled his important values of close relationships and being helpful and responsible to other people. We also worked on decreasing his depressive rumination. Once he was functioning somewhat better, we worked on finding employment; he started off by doing construction for his friend’s business. Our final goal was to see if he could improve his relationship with his wife—but he could not. Measures of Progress Abe scored 18 on the PHQ-9 and 8 on the GAD-7 at intake, and his sense of well-being on a 0–10 scale was 1. I continued to monitor progress by using these three assessments at every session. At the end of treatment, his PHQ-9 score was 3, his GAD-7 score was 2, and his sense of well-being score was 7. Although he still had some days that were difficult, on more days than not, he felt much better. Outcome of Treatment Abe’s depression was almost in remission at the end of weekly treatment. He subsequently got a full-time job that he liked and did well in, was more engaged with friends and family, and felt much better. When he returned for his last monthly booster session, his depression was in full remission, and his sense of well-being had increased to an 8.

Beck Institute Case Write‑Up