Psychology Homework

Case Example:
Nancy
The art of living is more like wrestling than dancing. (Marcus
Aurelius)
n this chapter, we present a complete therapy from beginning to end.
The primary goal of this case presentation is to illustrate the assessment,
conceptualization, and intervention methods presented in the earlier
chapters; therefore, the presentation emphasizes those aspects of the
treatment. We particularly emphasize several ways the therapist uses
the individualized case formulation to guide his or her thinking and
decision making and to tailor interventions to the needs of the patient.
I
The In itia 1 Con tact
Mr. A. telephoned to discuss the possibility that I (J. B. P.) might treat
his daughter, Nancy.’ I spent about 20 minutes on the telephone with
Mr. A.; he told me how bright and talented his daughter was and described his concern about the difficulties she was having that were impeding her ability to excel at her new job at a prestigious publishing
house. He quizzed me to verify that I was competent to treat her, and
he indicated that he would pay for the treatment if I would send the
bills to him. I took note of the fact that Mr. A. took the trouble to call
to check me out and generously offered to pay for his daughter’s treatment. However, he seemed to be particularly intent on informing me
‘Mr. A. and Nancy are pseudonyms. Names and details have been modified to
protect the identity of the patient and her family.
I 205
http://dx.doi.org/10.1037/10389-007
Essential Components of Cognitive-Behavior Therapy for Depression, by J. B.
Persons, J. Davidson, and M. A. Tompkins
Copyright © 2001 American Psychological Association. All rights reserved.
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2061 COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
that his daughter had beat out many competitors to get her job at the
prestigious publisher. He repeatedly described her as especially talented
and unusually bright but did not say anything about any distress or
unhappiness she might be experiencing. These observations helped me
to establish some initial schema hypotheses about Nancy. I speculated
that she might believe that she must be especially accomplished to be
acceptable to others and that her feelings and distress were unimportant
and did not deserve attention.
The Initial Session
A couple of weeks later, Nancy called and we agreed to meet for a
consultation session. Nancy arrived on time and brought with her the
measures I had mailed her and asked her to complete before the session:
the Symptom Checklist 90 Revised (SCL-90-R; Derogatis, Lipman, &
Covi, 1973), the Beck Depression Inventory (BDI; Beck, Ward, Mendelsohn, Mock, fr Erbaugh, 1961), the Burns Anxiety Inventory (BAI;
Burns, 1998), a brief measure of substance use (a modification of the
CAGE Questionnaire; Mayfield, McLeod, & Hall, 1974), and a demographics questionnaire (see chap. 2, Individualized Case Formulation
and Treatment Planning).
My major goals in this interview were to begin to collect a problem
list, obtain information needed for diagnostic purposes, develop more
formulation hypotheses and test the ones I had already developed, establish rapport with Nancy, offer some initial treatment recommendations if possible, and-if I recommended cognitive-behavior therapy
(CBT)-give her some information about it. In addition, if we agreed
to move forward with treatment, I wanted to give her a homework
assignment before she left the office. These were ambitious goals, so I
was aware I that might not accomplish them all.
Nancy was a 25-year-old, single White woman who had recently
begun working as an editorial assistant to a well-known publisher after
graduating near the top of her class from a top undergraduate school.
She was an attractive young woman with curly dark brown hair and a
perky, engaging, almost childlike quality. She related in a frank, open,
pleasant way, and she had excellent social skills except at times she
seemed overly compliant and timid. Although Nancy presented herself
as generally cheerful, her mood shifted at several points during the interview. When she was talking about upsetting topics, particularly her
relationship difficulties, she looked distressed and was close to tears.
When I reviewed her scores on the various measures, I found that
Nancy had endorsed many of the items on the BDI. She reported that
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A Case Example: Nanry I 207
she felt sad all the time, felt discouraged about the future, felt guilty all
the time, was self-critical, cried often, had difficulty making decisions,
had difficulty getting anything done, and had early morning awakenings. Her total BDI score was 21, indicating a moderate level of depressive symptoms.
On her BAI, Nancy had endorsed feelings of anxiety and tension,
difficulty concentrating, and fear of criticism or disapproval. She reported several somatic symptoms, including palpitations, restlessners,
tight muscles, rubbery feelings in her legs, dizziness, headaches, and
fatigue. She had a total score on the BAI of 25, indicating moderate
anxiety symptoms.
On the SCL-90, Nancy endorsed symptoms similar to those described on the other inventories. On the CAGE questionnaire, Nancy
denied any concerns or problems involving alcohol use. She reported
that she drank half a glass of wine a week on average and did not use
illicit drugs.
When I asked Nancy to tell me in her own words what had brought
her in to see me, she replied “I feel trapped by my relationships.” Nancy
reported that she was particularly troubled by her relationships with her
ex-boyfriend and her roommate. The onset of her most significant dirtress was tied to her breakup, about 2 months ago with Morrison, a
young man she had dated for about 6 months. The relationship with
Morrison had been uncomfortable for her because he had obviously
been more enamoured of her than she was of him. After considerable
agonizing, Nancy had finally summoned the courage to break up with
him, but she was having difficulty making the break final. Morrison kept
calling, wanting to talk about their relationship, wanting to spend time
with her, and wanting her to be his confidante. Nancy found herseiif
feeling torn and trapped by this situation; she feared that Morrison
would be devastated if she refused to be his friend, but she realized that
maintaining such a close connection with Morrison was not fair to Pete,
her new boyfriend.
Nancy was also struggling with her new relationship with Pete. She
had repeatedly told him she “didn’t want to get serious,” but she admitted that she was fooling herself when she insisted she was not seriously involved with him. She said that she held the relationship at an
arm’s length because she feared that ”If I get involved and then I decide
he’s not the right one, I’ll want to break it off and he’ll get hurt.”
Nancy’s relationship with her roommate Connie was also a source
of tension. Nancy described Connie as someone she liked well enough,
but Connie wanted to spend much more time with Nancy than Nancy
did with her. When Nancy had recently said MU to an invitation, Connie
was visibly hurt and told her bitterly “now that you have a boyfriend,
you don’t want to spend time with me anymore.”
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208 I COGNITIVE-BEHAVIOR THERAPY F O R D E P R E S S I O N
Nancy said she felt she was “messing up” in all these relationships
and felt trapped in them. In fact, she considered ending them all, saying
“If I can’t be a perfect friend/girlfriend/roommate, I’d rather just live
alone.”
At work, Nancy reported that she had a heavy workload and always
felt behind and fearful of not meeting her boss’s expectations, which
were very high. Nancy had a major project looming, a presentation she
would make to her boss and other high-level editors presenting the
results of her reviews of several important manuscripts; she was extremely nervous about this presentation. Nancy had performed poorly
when she had made a similar presentation a few months ago; a factor
contributing to her poor performance on that occasion was that she had
been in the middle of a major relationship crisis when she was trying
to prepare the presentation. Aside from these difficulties, Nancy reported that she was doing well at her job and was well regarded by her
colleagues and superiors, several of whom had recently consulted with
her about possible collaborative projects.
At this point in the interview, I had the beginnings of a problem list:
Nancy had symptoms of depression, she had relationship difficulties, and
she had difficulties at work. Diagnostically, I had not yet completed a
full assessment. However, Nancy appeared to meet the criteria for major
depressive disorder, as described in the Diagnostic and Statistical Manual
of MentaZ Disorders (4th ed. [DSM-ZV); American Psychiatric Association,
1994). She was also anxious, although it was not clear yet whether she
met the criteria for an anxiety disorder (generalized anxiety disorder
and social phobia seemed the main possibilities).
I reviewed with Nancy the results of my assessment so far, including
my diagnostic hypotheses, indicating that I was basing my recommendations on the information I had and that things might change when I
got more information. On the basis of my view of her as having major
depression with some anxiety symptoms or an anxiety disorder, I offered
Nancy information about her treatment options and suggested that CBT
might be helpful to her (for more information about the issue of informed consent for treatment, see Pope 6 Vasquez, 1998).
I suggested to Nancy that I spend a few minutes in the session giving
her a first notion about how CBT would address her difficulties to help
her decide whether she wanted to pursue it; she agreed to this. To teach
the cognitive model (see the chap. 5 section entitled “Teach the Cognitive Model”), I mapped onto a Thought Record the situation Nancy
had described to me earlier when her roommate Connie looked hurt
when Nancy turned down Connie’s invitation to go out to dinner (see
Exhibit 7.1). I asked Nancy a short series of Socratic questions to show
her how these thoughts made her feel guilty, inadequate, and trapped
and how they could lead to behaviors of agreeing to do things with
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Teaching Nancy the Cognitive Model
Situation
(event, memory, attempt
to do something, etc.)
I turned down Connie’s
invitation; she looked hurt and
said “now that you have a
boyfriend, you don’t want to
spend time with me anymore.”
Behaviors
Urge to break
off the
rela tionship
‘9 2000 San Francisco Bay Area Center for Cognitive Therapy.
Emotions 1 Thoughts
Guilty,
inadequate,
trapped
I’m messing up
(again).
If I were a good
friend, I would go
out with her.
If I can’t be a
perfect friend and
roommate, I’d
rather just live
alone.
Responses
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210 COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
Connie that she did not want to do as well as to urges to break off the
relationship. I let her know that in therapy we would work together
to develop cognitive and behavioral coping responses that would help
her feel less guilty and inadequate in this type of situation and to handle it better. I recommended that we meet weekly, and I pointed out
that homework between sessions would be a key component of her
treatment.
Nancy indicated she wanted to try CBT, so we agreed to move forward with treatment. She indicated that she had tried Prozac in the past
and found it increased her anxiety, so she did not want to take medication at this point. I told her that I was willing to try CBT alone as a
treatment plan, but if we did not make good progress, I would want to
revisit the pharmacotherapy option; she agreed to that.
As the session came to a close, I proposed an initial homework assignment: I asked Nancy to read the first 3 chapters of David Burns’s
(1999) book Feeling Good and to let me know her reactions to it when
we met the next time. I also asked her to think about what she would
like to accomplish in her therapy and to draft a list of treatment goals
and bring it the next time. As a first step on the basis of her scores on
the BDI (21) and BAI (25), I suggested that we include on her list the
goal of reducing her symptoms of anxiety and depression. To track our
progress, I asked her to complete the BDI and BAI scales for me weekly
before the session. I asked her to come 5 minutes early for her session
and to fill out the measures, kept on clipboards in the waiting room,
and give them to me at the beginning of each session, .starting with her
next session.
As her first session came to a close, I asked Nancy for feedback about
how the session had gone. She said that she liked the idea of a treatment
approach that would teach her skills for managing her mood and solving
her relationship problems. I felt we were off to a good start.
Summary of the
Initial Session
I accomplished the goals I had set for the initial session. In particular, I
collected some important information for the initial case formulation: I
collected the beginnings of a problem list: Nancy had symptoms of anxiety and depression, she was distressed about relationship problems, and
she was having some difficulties at work. I obtained a few details about
some of the cognitive, mood, and behavioral components of Nancy’s
relationship problems and a bit of information about her work problems.
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A Case Example: Naniy I 211
Some information I obtained in the session led to a revision of the
schema hypotheses I had developed after the telephone conversation
with Nancy’s father. My initial hypothesis had been that Nancy believed
she must achieve at a high level to be accepted by others. However,
Nancy’s distress when Connie was angry at her, her difficulty breaking
off with Morrison for fear of upsetting him, and her reluctance to attach
herself to Pete for fear of disappointing him later suggested that Nancy
believed that “I must meet others’ needs to be acceptable to them” and
that “if another person is unhappy, this means I did something wrong.”
These beliefs are similar to the “self-sacrificing” schema vulnerability
described by Young ( 1999).
I noted that although Nancy was clinically depressed, she had a
bouncy, perky mode of interacting. I hypothesized that this perkiness
was a compensatory strategy that she had developed to protect others’
feelings and to hide her distress from them. Similarly, I hypothesized
that Nancy’s compliance, which made her pleasant to work with, was
also part of her mode of accommodating to others. I noted as a potential
obstacle to treatment that Nancy might have difficulty asserting herself
if she disagreed with me about something.
Ea r ly Sessions : Begin n ing
to Intervene and
Continuing to Assess
Assessment, formulation, and treatment occur in tandem through0 ut
treatment, as the therapist uses the hypothesis-testing mode of clinical
work described in chapter 1. Of course, in the initial sessions, the proportion of time spent on assessment and formulation is higher than it
is later. We attempt, in the first four sessions, to collect all the information needed for a complete psychiatric writeup, including a comprehensive problem list and a complete Cognitive-Behavioral Case Formulation and Treatment Plan (see chap. 2, Individualized Case
Formulation and Treatment Planning). While collecting this information, the therapist also begins intervening both to get the treatment
underway and to generate information based on the patient’s response
to the interventions, which feeds back to the formulation.
SESSION 2
BDI = 11
I went into the second session wanting to ask for Nancy’s response to
our initial meeting, follow up on her homework, continue to orient her
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212 1 COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
Progress Plot for Nancy
BDI BAI
25
20
E 2 15 RJ
z
0
0
E
3 * 10
5
4
3
2
1
0
Session dates
to the treatment, finish developing my problem list, begin to establish
treatment goals and, if possible, begin intervening. I also wanted to
make a new homework assignment.
Nancy came on time to the second session, and she brought a completed BDI but not a BAI. Her score on the BDI had dropped considerably (from 21 to 11). Such improvement often happens in the early
sessions of CBT (see Ilardi 6 Craighead, 1994), for reasons that are not
well understood, although the decrease in Nancy’s BDI score was unusually large.* I entered this score on the Progress Plot I had set up after
our first session (see Exhibit 7.2), and I showed her the plot and how
’1 hypothesized that one factor contributing to this large improvement was Nancy’s
wish to meet my need to be a successful therapist.
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A Case Example: Nancy I 213
we would use it to monitor her progress. I asked her to bring both a
completed BDI and a completed BAI to her next session.
I began the session by orienting Nancy to the structure of the therapy session (see the chap. 3 section entitled Orient Patient to the Structure of the Session). I suggested that we begin with a check in because
I would like to hear how things had gone during the week and any
thoughts she might have about why her BDI score was so much lower.
After the check in, I let her know that I would work with her to set an
agenda for the session and, as part of that, I wanted to get her reactioris
to our last interview and to follow up on her homework.
During the check in, Nancy reported she was feeling considerably
better because things were going more smoothly with her roommate.
When she elaborated, I learned that things were going better because
Nancy had found an apartment and planned to move out and she had
been yielding to Connie’s requests for time, so she felt less guilty. I was
glad that Nancy felt better but was sorry to hear the reasons for her
“improvement.” My working formulation suggested that Nancy felt tern –
porarily better because she had allowed her behavior to be driven by
her maladaptive belief that she was inadequate unless she did what
others wanted. The formulation also suggested that moving was (at least
in part) maladaptive avoidance behavior, resulting from Nancy’s discomfort in asserting herself with others and tolerating their negative feelings
when they were unhappy with her. Because the decision to move appeared to be a “done deal” and Nancy and I were just getting our therapy underway and had not discussed my tentative formulation in any
detail, I did not volunteer my speculations.
Next, I followed up on her homework. Nancy indicated that she hatl
read and liked the first 3 chapters of Feeling Good and that she liked the
approach Burns described. I asked her for her reaction to the previouy
week’s interview; she indicated that she felt pleased at the way we hatl
started and repeated that she liked the idea of a goal-oriented, structured
therapy.
Another homework assignment had been to draft some treatment
goals; Nancy had not done this, saying she had forgotten about this
assignment. I was surprised at this because my formulation Suggested
that Nancy held a belief such as “I must meet others’ needs”; this belief
can contribute to excellent homework compliance. However, I realized
that part of the noncompliance may have been due to my own failure
to provide sufficient structure to the task. I also realized that another
part of the formulation (Nancy’s views of her own needs as unimportant) predicted that the task of asking herself what she wanted to accomplish in therapy might be particularly difficult for her. I suggested
we spend some time in the session setting goals together; Nancy was
agreeable to this.
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214 I C 0 G NITIVE -BE HAVI 0 R THERAPY F 0 R D E PR E S S I0 N
I asked Nancy if she had any other topic she wanted to put on the
agenda for the session today. (My working formulation predicted that
this was a question that she might have difficulty answering.) Nancy
indicated that she did not have any urgent business, so I proposed that
I collect more information and we set treatment goals, to which she
agreed.
To complete my problem list, I asked for more information about
Nancy’s work difficulties. Nancy indicated that she was well liked and
well regarded at work; her problem was that she was chronically behind
and anxious about being behind. In particular, she had trouble handling
her quarterly report, a detailed summary of her assessments of all the
manuscripts she had reviewed that quarter. Nancy always felt behind
on this project and had to scramble at the last minute to put something
together. Nancy reported that most editors at her (junior) level worked
long hours, putting in lots of evenings and weekends and that she was
having trouble doing this as much as she wanted to because she found
herself agreeing to social dates with friends that she really did not want.
This information supported my hypotheses that Nancy believed that she
must meet others’ needs to be acceptable to them and that her needs
were unimportant. This information also helped me to understand how
these two beliefs contributed not only to her relationship problems but
also to her work problems (see the working hypothesis portion of
Nancy’s complete case formulation in Exhibit 7.5).
I also asked for more information about Nancy’s relationship difficulties. Nancy indicated that her major interpersonal difficulties arose
with Connie, Morrison, and Pete (she had described these in our initial
session). Nancy also found her relationship with her father to be problematic at times. She described him as unpredictable: angry one moment, warm and supportive another. Nancy’s job, although prestigious,
was low paying, so she relied on her father, who was a highly successful
businessman, to pay for extras such as therapy. Her mother had remarried and now lived on the East Coast, so Nancy had little contact with
her.
Nancy stated that she suffered from migraine headaches about once
a month but did not have any other significant medical problems. I
collected some additional data and concluded that Nancy’s anxiety
symptoms, concern about her schoolwork, and difficulty in exam situations did not appear to meet the full DSM-IV criteria for generalized
anxiety disorder or social phobia.
Nancy’s psychiatric history showed that she had had several bouts
of anxiety and depression and had received outpatient therapy on several occasions. She had received treatment for an episode of depression
following the death of her maternal grandmother, to whom she was
close. When her grandmother died, Nancy, who was 16 years old, was
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A Case Example: Nancy I 215
extremely upset and went into the bathroom; she poured out a bottle
of aspirin, intending to take them, but did not. Nancy denied any subsequent suicidal behavior but said that at times when she was depressed,
she did entertain thoughts of suicide. When she was not acutely depressed, Nancy frequently experienced a chronic low mood and energy
state. Nancy had also been treated for panic attacks when she was 15
years old; she linked these attacks to feeling overwhelmed by pressures
from both her parents to take sides in their contentious divorce.
Nancy and I used the last part of the session to set the following
treatment goals:
1. Reduce symptoms of depression and anxiety (BDI, BAI).
2. Feel more comfortable and less pressured in relationships, less
guilty; be less dependent in relationships; be more assertive and
feel more comfortable being assertive, particularly when saying
no to others.
3. Feel less anxious about work; work longer hours on a regular
basis and be caught up at work; and finish the quarterly report
more comfortably, without so much last-minute scrambling.
We agreed on a homework plan to continue reading Feeling Good.
As we discussed Feeling Good, Nancy indicated that she liked the Thought
Record concept and she seemed to grasp it; I had given her an initial
orientation to it in the first session. So we agreed that she would fill out
the first few columns of a Thought Record for any upsetting situation
that might come up during the week, particularly one involving Connie,
Morrison, or Pete. I recommended that she spend only 15 minutes on
the Thought Record. I pointed out that because I had not spent much
time orienting her to the details of the Thought Record, she might run
into trouble but that if she did, she could bring whatever she could
complete to the session and I would help her with it.
By working with Nancy on a Thought Record before teaching activity scheduling, I was modifying the standard Beck et al. (1 979) protocol,
which suggests that the cognitive therapist use activity scheduling interventions to help the patient make behavioral changes before using
the Thought Record to promote cognitive restructuring. I began Nancy’s
therapy with cognitive interventions for several reasons. First, Nancy’s
level of day-to-day functioning was adequate; if she had been severeiy
immobilized, spending a lot of time in bed, I would have begun with
behavioral activity scheduling because individuals who are not functioning at all often cannot make good use of cognitive interventions.
Second, she had asked to learn to use the Thought Record. Third, I had
laid the groundwork for the use of the Thought Record when I used it
in our first session to teach the cognitive model. Fourth, I believed she
could benefit from it. Most decisions therapists make (e.g., whether to
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216) COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
use activity scheduling or cognitive restructuring) cannot be made on
an empirical basis. Therefore, the therapist makes decisions on the basis
of a logical rationale, relying when possible on the case formulation for
guidance, and monitors the outcome to assess whether the decision was
a good one or not.
SESSION 3
BDI = 19, BAI = 48
I entered Nancy’s scores on her Progress Plot (see Exhibit 7.2) when she
gave me her measures at the beginning of the session. It was easy for
both of us to see that her scores had gone up noticeably. When I asked
her about this during the check in, Nancy told me that she had had a
very stressful week due to lots of pressure at work; she had been behind
in her work and had had to pull an all nighter to get everything done.
I learned that this was a common problem, and we agreed to set a
treatment goal of eliminating the need to stay up all night to meet a
work deadline.
We set an agenda for the session: I recommended that we review
her homework, I let Nancy know that at some point I wanted to collect
additional background information, and then I asked Nancy what she
wanted to put on the agenda. Nancy indicated that she had started a
Thought Record on a situation with her roommate Connie that was
upsetting her, and she wanted some help with it. We agreed to begin
the session by working on the situation with Connie and to collect history if time permitted. I noted that Nancy had spoken up assertively
with me to propose an agenda item, which suggested that Nancy might
not need skills training to become more assertive; she might only need
cognitive restructuring to overcome her obstacles and barriers to exercising those skills.
Nancy’s Thought Record (see Exhibit 7.3) focused on a situation in
which Connie had asked her to go out one evening when Nancy wanted
to work. She yielded to Connie, went out, had a drink, did not get her
work done, and had a headache and felt frustrated and upset with herself in the morning. This situation was an excellent one to work on for
many reasons: It was an example of the interpersonal, work, and mood
problems that appeared on Nancy’s problem list and treatment goals,
and it seemed likely to involve the schema in my working hypothesis
that 1 had proposed were central to Nancy‘s difficulties (the need to
please others, the tendency to ignore her own needs).
Nancy had written down the situation and a good set of automatic
thoughts but no responses to the thoughts. As we looked at her Thought
Record together, I used Socratic questions to show Nancy that her negative mood states and her behaviors stemmed from her thoughts, not
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Nancy’s First Thought Record
Emotions
GuiltH pressured
Situation
(event, memory, attempt
to do something, etc.) Thoughts
If I say no, it will
hurt her feelings.
Connie asked me to go out, but
I had work to do.
Behaviors
I agreed to go.
I said no last time
she asked. I’m
going to want to
take a break
anyway.
Maybe it will be
fun.
I
Responses
Action plan:
“NO THANKS. I’VE
GOT A LOT OF
WORK TO DO.”
I HAVE A DEADLINE COMING UP,
AND I DON’T
MtNUTE
SCRAMBLE,
JUST BECAUSE I
SAY NO DOESN’T
MEAN I DON’T CARE
ABOUT CONNIE’S
FEELINGS.
so
I AM SAYING NO
BECAUSE I HAVE A
LOT OF WORK TO
DO.
IF A FRIEND
TURNED ME DOWN
BECAUSE SHE HAD
LOTS OF WORK, I
WOULDN’T SEE HER
AS UNCARING.
WANT A LASTNote. Italics indicate what Nancy wrote for her homework assignment, whereas all caps are what Nancy and her therapist wrote during the therapy
session.
L
2
4
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2181 COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
from the situation. This idea, simple though it is, is the heart of the
cognitive model and a tremendously empowering notion (because
Nancy’s problem becomes her own thoughts, not something external).
To convey this idea to Nancy, I asked her if another person in this situation could have felt differently and behaved differently in response
to Connie’s invitation to go out. Nancy agreed that another person could
have refused Connie’s invitation without feeling overwhelmingly guilty.
I asked her if she would have liked to have been able to respond differently in this situation. She hesitated a bit before agreeing that she
would have liked to have had the option to say no to Connie’s invitation
without feeling so guilty. I followed up this opening with more Socratic
questions, and the following dialogue ensued.
Therapist: “Okay, let’s see if we can work on that. I would say that
what is needed is some responses to the automatic
thoughts on this Thought Record. Let‘s see if I can help
you find some. Does that sound useful?”
Nancy: [Nods] “Yes.”
T: “Okay, good. Here’s a question for you. Imagine another
person who handles this situation differently, who responds behaviorally by saying ‘I‘d really love to go out,
it would be really fun, but I‘ve got a lot of work to do,
and I really need to stay home and get it done.’ How does
that sound?”
N: “It sounds pretty good.”
T “Okay, let’s put this down as a response-it’s a behavioral
response, so we’ll call it an ‘action plan’ in the response
column of the Thought Record, on the right. This is the
new behavior you’re shooting for. [The material Nancy
brought to the session appears in italics on the Thought
Record; material added during the session appears in all
caps; Nancy writes ’NO THANKS, I’VE GOT TO WORK.’]
Now here’s the thing we have to figure out: ’What
thoughts would that person need to have to drive or support that behavior?”’
N: “I don’t know.”
T: ”Okay, right, that may be part of why you don‘t do that
behavior! Let’s try to figure it out. Think about it a moment. What might that person be thinking?”
N: ”I guess that person would be thinking ‘I really need to
work. I’ve got a deadline coming up, and I don’t want to
have to scramble at the last minute to meet it.‘ That
would be fine. But maybe that person would be thinking
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A Case Example: Nancy I 219
’I have work to do, and I don’t care if I hurt Connie’s
feelings.’ That’s where I run into trouble.” [As I heard
this concern, I speculated that Nancy’s acute perception
of how hurtful it can be when others act in an uncaring
way stemmed from her own experience. I speculated that
her parents expected Nancy to meet their needs (e.g.,
insisting that Nancy take sides in their divorce) and did
not consider Nancy’s needs or feelings. I made a note to
test this hypothesis when I collected information about
Nancy’s family history.]
T “Yes, I can see that would be hard. Let’s look at your
answer one piece at a time. Let‘s start with the first part:
The person is holding onto the idea of how important it
is to get the work done in an orderly manner, without a
last-minute scramble. Would it be helpful to you to hold
onto those ideas?“
N: “Yes.”
T ”Okay, why don‘t you put that down in the thoughts
column [Nancy wrote ’I HAVE A DEADLINE COMING
Now you’re worried that that person might not care
about hurting Connie’s feelings and you don’t want to be
like that, is that what you’re saying?”
UP, AND I DON’T WANT A LAST-MINUTE SCRAMBLE.’]
N: ”Yes.”
T ”Okay. Let me ask you this: ’Would it be possible to care
about Connie’s feelings and still say no’? Or if you care
about her feelings, do you have to say yes.”
N: [Hesitates] ”Yes, I guess I could care and say no. Just hecause I say no doesn’t mean I don’t care.”
T “That sounds good to me. Do you believe that?”
N: “Yes, I do. [Hesitates] Some.”
T: “Right. How much? Not loo%, I guess. What percent
N: ”Maybe 50%.”
T: “Okay, fine, let’s put it down [Nancy writes this on her
Thought Record in the response column and writes 50%
next to it.] Okay, now let’s look at that. I hear you saying
it’s helpful, but we need something more here. Let me
ask you this: ‘Do you care about Connie’s feelings?’”
would you say?”
N: “Yes.”
Copyright American Psychological Association. Not for further distribution.
220 I COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
T: “Okay, let’s put that down. [Nancy wrote ’I DO CARE’ in
her response column.] If you do care, why are you saying
no to her?”
N: [Hesitates]
T: ”Do you know the answer?”
N: [Silence.]
T ”Because you have work to do. Is that right?”
N: “Yes.”
T “Okay, should we put that down?”
N: “Okay.” [With some help from her therapist to settle on
the wording, Nancy wrote ‘I AM SAYING NO BECAUSE
I HAVE A LOT OF WORK TO DO.’]
T: “So you are a person who does care about Connie’s feelings, but you are saying no to her because you’re putting
your work at the highest priority on your list of things
you plan to do on this particular evening.”
N: ”I guess SO.”
T: “This is hard for you, huh?”
N: “Yes.”
T ”Think about this: If one of your friends said no to your
invitation to go out for a drink because she puts meeting
a work deadline higher in priority on her to-do list than
spending some time with you that particular evening,
would you conclude that your friend didn’t care about
your feelings?”
N: “No. It would be okay.”
T ”So you wouldn’t view it as a callous and uncaring way
N: ”No, it would make sense to me.”
T “Okay. So do you want to put that down in the response
column? ’If a friend turned me down because she had a
lot of work to do, I wouldn’t feel she was uncaring.’
[Nancy wrote this down.] Now let me check in with you
and see how we’re doing. Imagine that when Connie
asked you out, you had these thoughts we just wrote
down instead of the ones you did have. Would these
thoughts help you to say no?”
N: “Yes, if I were having them, they would help me say no.
to treat a friend.”
Copyright American Psychological Association. Not for further distribution.
A Case Example: Nancy 1 221
But they feel strange. I don’t usually have thoughts like
these!”
T: “Right! You don’t usually have these thoughts, and you
don’t usually turn down this sort of invitation. The
thoughts you usually have are the ones in the automatic
thought column-the ones you started with. These
words in your response column are foreign territory, so
it’s going to feel strange to imagine having them. Would
you like to have thoughts like these more often? Would
you want to be able to say nu to invitations you don’t
want to accept?”
N: “Yes, I guess so.”
T ”Okay, right, how can you do this?”
N: [Silence.]
T: “Well, I would suggest that one thing we can do is to usc
Thought Records to help you strengthen the line of
thinking you need to support those behaviors. I’ll give
you a copy of this Thought Record to refer to [I made
her a copy to take with her, and I kept one for my chart].
As we do more Thought Records, we’ll develop more
ideas to help you in this type of situation. How does that
sound?”
N: [Nods and seems to like this idea.]
I suggested that Nancy set up a file folder for her therapy where she
could keep the Thought Record from today’s session and others we
would develop later. We agreed that the issue of assertiveness, especially
saying no to others, was an important one to keep working on. I suggested that she complete a Thought Record sometime during the week
when she experienced an upsetting situation, especially when she felt
pressured by a friend; she agreed to this assignment. We did not have
time to take up the agenda item of information gathering, so we agreed
to postpone it to her next session.
The intervention described here draws heavily on the strategies we
described in chapter 5 (Using the Thought Record). I used the Thought
Record both to teach the cognitive model and to promote change. I
followed the guidelines for using a Thought Record described in that
chapter: I focused on a concrete situation, and I relied heavily on Socratic questioning to help Nancy shift her thinking. I used the strategies
of asking Nancy what thoughts would be helpful in this situation and
what another person might do in this situation (see Exhibit 5.2, Quations That Promote Cognitive Restructuring).
Copyright American Psychological Association. Not for further distribution.
222 I COGNITIVE-BEHAVIOR THERAPY F O R D E P R E S S I O N
This intervention is also similar to the “old viewhew view” intervention (see Persons, 1989, p. 123). In this intervention, the therapist
lays out three of four pieces of a puzzle: the old maladaptive behavior,
the line of thinking that supports that behavior, and a proposed new
behavior. The missing piece is a line of thinking that would support the
new behavior. The therapist asks Socratic questions to help the patient
obtain the missing fourth piece of the puzzle.
SESSION 4
BDI = 16, BAI = 40
The check in revealed that Nancy had moved and was pleased to be
living alone. She had told her father how happy she was with me, and
he asked to come to see me himself. He was upset when she told him
that she did not think she would be comfortable with that. I thought it
was terrific that she could assert herself with him about this, and I told
her so. I reviewed her homework. Nancy told me that she had worked
on a Thought Record focused on a situation in which a colleague had
asked her for more help on his project than she had wanted to give.
She reported that the Thought Record had helped her give him less help
than she would have given in the past; she was pleased with this result.
Unfortunately, she did not bring in the Thought Record so we could
review it together; I asked her to bring it the next time so I could see
how she was doing.
I wanted to finish collecting information for a complete family and
social history, so I asked to put on the agenda some time for history
taking. Nancy agreed to this and asked for time to discuss an upcoming
trip to Puerto Vallarta that she was taking with her father, his new wife,
and their two children. She feared that her father and his family would
monopolize her time and that she would not be able to get any work
done on the trip, which fell at a busy point in her work schedule. This
was an excellent agenda item because it addressed Nancy’s central interpersonal problem.
Nancy was anxious about the trip and in fact had not really wanted
to go at all but had been unable to say no because her father had already
bought the ticket (without consulting her), which was quite expensive.
She feared that all her time would be spent babysitting her infant half
sister, and she would not get her work done. To address her anxiety
about getting work done during the trip, I asked Nancy if she thought
it would be helpful to work out a concrete plan for combining work
time and leisure time on the trip. She liked this idea, so I showed her
how to use an Activity Schedule form to plan her time.
Nancy quickly decided that she wanted to allocate the morning of
each weekday of the trip to work and spend the afternoon and evening
Copyright American Psychological Association. Not for further distribution.
A Case Example: Nancy I 223
with her family. She wrote out this plan on her Activity Schedule (see
Exhibit 7.4). I suggested that it might be a good idea for Nancy to let
her father know beforehand about her proposed schedule; Nancy agreed
to tell him about this, as her homework assignment. Because we would
have another session or two to prepare her for this trip and I wanted
to spend some time on history taking, I did not initiate a discussion of
the obstacles to success of her plan at that time, but I suggested that she
think about any obstacles that might interfere with the schedule and
we could address them at her next session.
We spent some time collecting her family history. Nancy had been
born in a commune. Nancy’s mother told her that she had used drugs
when she was pregnant with Nancy; Nancy remembered her mother
smoking marijuana in the car when she was picking Nancy up from
school. When Nancy was 15 years old, her parents told her that they
planned to divorce. “My mother was drunk when she told me. My father asked me if I could convince her to stay with him.” Nancy reported
that she felt good when her mother remarried when Nancy was in college ”because I felt guilty leaving her to go to college.” Nancy described
her mother as often drunk when Nancy was a child, keeping her home
from school “because she wanted me to do things with her.” She described her father as “unpredictable; he could be really nice at times,
and other times he yelled.”
This disturbing information provided some support for my earlicr
hypothesis that Nancy’s parents had placed their needs first and expected Nancy to accommodate to them. In fact, they had done this frequently, even when it caused Nancy emotional distress or threatened
her physical safety. I placed some of this information in the origins section of Nancy’s case formulation because it might explain how Nancy
learned that her needs were unimportant and that she must meet others’ needs. Nancy and I spent a short time discussing the link between
her upbringing and her tendency to be overly accommodating to others’
needs while undervaluing her own.
The Middle Phase
of Treatment
By the end of the fourth session, I had completed all of my initial a5-
sessment tasks. At this point, I wrote up a complete formulation and
treatment plan for my clinical record (see Exhibit 7.5). Nancy and I had
settled down and established a good rhythm and way of working. We
now embarked on a series of sessions in which I began working actively
to help Nancy accomplish her treatment goals.
Copyright American Psychological Association. Not for further distribution.
2241 COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
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Copyright American Psychological Association. Not for further distribution.
A Case Example: Nancy 1 225
Cognitive-Behavioral Case Formulation and Treatment Plan for Nancy
Name: Nancy
identifying Information: 25 SWF editorial assistant living with a roommate. Referred by
her father through another therapist.
Problem List:
1. Depressive symptoms. BDI = 21. Sad, discouraged about the future, guilty, selfcritical, crying, difficulty making decisions, difficulty getting anything done, EMA.
Suicidal thoughts. Typical automatic thoughts: “I’m a bad friend/girlfriend/
roommate if I don’t meet others’ needs.” Typical problem behaviors: accepting
social invitations pressed on her by others when she would rather work.
2. Anxiety symptoms. BAI = 25. Anxiety, tension, fears of criticism and disapproval,
palpitations, restlessness, tight muscles, rubbery legs, dizziness, headaches,
fatigue. Typical automatic thoughts: “I’m behind at work,” “Connie will be angry
with me if I don’t spend time with her,” “I’m not prepared for this presentation,
and 1’11 mess it up.” Typical problem behaviors: socializing with others when she
would rather work, last-minute scramble to meet work deadlines.
handled them badly. Frequently felt guilty when others wanted to spend more
time with her than she did with them, guilty about breaking up with boyfriend
Morrison: “If I don’t do what others wantheed, they’ll get hurt and it’s my
fault.” Alternated between capitulating to others’ wishes and avoiding contact
with them. Good social skills, including assertive behaviors, but frequently avoids
assertion for fear of hurting others.
4. Work difficulties. Was not working as many hours as she wantedheeded to do
well at her job. Frequent (every 2 weeks) last-minute scrambles to meet
deadlines. Unassertive (e.g., excessively deferential to others’ opinions). Typical
automatic thoughts: “I don’t know what I’m doing,” “If I don’t do it his way,
he’ll be angry.”
5. Financial stresses. Low-paying job left her dependent on her father for financial
support for therapy and other extras.
3. Relationship difficulties. Felt trapped in her relationships and believed she
Diagnosis:
Axis I: Major depressive disorder, recurrent
Axis 11: None.
Axis 111: Migraine headaches.
Axis IVC Relationship difficulties, financial stresses.
Axis VC 60
Working Hypothesis:
Schema:
(self) “I am inadequate.”
“I’m a selfish person.”
“I must meet others’ needs to be acceptable to them.”
“My feelingsheeds are unimportant.”
“I am responsible for the happiness of those I’m close to.”
(other) “Others’ needs are more important than mine.”
“Others are dependent on me for their happiness.”
“Others expect perfection and are critical when I don’t produce it.”
(world) “The world is a burdensome place.”
(future) “The future is unpromising.”
Dysthymic disorder
(con tin ued)
Copyright American Psychological Association. Not for further distribution.
226 COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
Precipitants and Activating Situations:
Precipitants: breakup with boyfriend Morrison, demanding roommate.
Activating situations: pressure from others to meet their needs, for example, from
friends/boyfriends/former boyfriends to be close, spend time together; deadlines at
work, especially quarterly report deadline.
Origins: Nancy was reared by parents who expected her to meet their needs and
disregard her own, (e.g., her mother drove her home from school after smoking
marijuana and kept Nancy home from school when her mother wanted company; her
father asked her to convince her mother not to divorce him).
Summary of the Working Hypothesis: Nancy’s beliefs that paying attention to her
needs and interests was a sign of selfishness and that others’ needs were more
deserving than hers, when activated by her interactions with her roommate, boyfriend,
and others, caused her to feel guilty, inadequate, and trapped and to give in to their
requests even when she did not want to. As a result, she felt trapped and pressured in
relationships and at times coped by withdrawing (e.g., not returning phone calls). Her
tendency to give in to others’ requests for her time caused her to have difficulty
getting her work done in a timely manner, which was anxiety provoking and
sometimes meant she had to stay up all night to meet her deadlines. Financial
problems were a result of her low-paying job coupled by her insistence on living alone
(vs. with a roommate with whom she could share expenses). Living alone was in part
Nancy’s compensatory strategy for handling her difficulty being assertive.
Strengths and Assets: bright, attractive, personable, cooperative, collaborative, many
good social skills
Treatment Plan
Goals (measures):
1. Reduce symptoms of depression and anxiety (BDI, BAI).
2. To feel more comfortable and less pressured in relationships, less guilty. To be
less dependent in relationships. To be more assertive, and to feel more
comfortable being assertive, particularly saying no to others.
3. To feel less anxious about work. To work longer hours on a regular basis, and to
be caught up at work. To be better prepared (no last-minute scrambling), and to
feel less anxious when making important presentations (e.g., on her quarterly
report). No more “all nighters” to meet work deadlines (currently doing this
twice a month). To be more assertive at work.
Modality: Individual cognitive-behavior therapy.
lnterven tions:
Frequency: Weekly.
1. Cognitive restructuring to address her views of self and others.
2. Activity scheduling to carve out time for work, to assist with saying no to others.
3. Role-plays to practice assertiveness.
Adjunct therapies: None at this time.
Obstacles:
1. Nancy’s beliefs that her needs are unimportant and that she must defer to
others’ needs may cause her to be excessively compliant in therapy and then to
feel resentful or trapped.
withdraw financial support for the therapy.
2. If Nancy’s therapy results in increased assertiveness with her father, he may
Note. SWF = single, White female; BDI = Beck Depression Inventory; EMA = early morning awakening;
BAI = Burns Anxiety Inventory; score on Axis V = Global Assessment of Functioning Scale.
Copyright American Psychological Association. Not for further distribution.
A Case Example: Nancy I 227
SESSION 5
BDI = 12, BAI = 30
Nancy reported that she had spoken to her father about her proposed
schedule for the vacation, and she felt good that he had agreed to the
plan. This, she felt, explained her lower BDI score. Nancy wanted to
work on her guilt about her interactions with her ex-boyfriend Morrison. As we negotiated the agenda for the session, I suggested another
possible agenda item: troubleshooting any obstacles that might arise
during the Puerto Vallarta trip. Nancy agreed that this was a good idea
but asked to do this in next week’s session, pointing out that the issue
with Morrison was very distressing and we had one more session before
the trip. This plan made good sense (and I noted Nancy’s good assertiveness skills in the negotiation process with me).
We began to work on the issue with Morrison. Nancy reported that
she was feeling guilty for breaking up with him, hurting him, not wanting to get back together, not wanting to be his confidante, and getting
involved with Pete after telling Morrison that she wanted to break off
with him so she could be alone. As we discussed this situation, Nancy
recalled that she had been repeatedly told by her parents that she was
“selfish” and that her view of herself as a bad friend to Morrison was
guided by the view that unless she put his needs first, she was selfish.
I suggested that we use a Thought Record to help her with this
problem, and Nancy was agreeable to this. We developed a Thought
Record focused on a recent situation in which she had spent a long time
on the telephone talking with Morrison about his feelings for her, which
caused her to feel guilty and upset in response to the automatic thought
that she was being selfish if she did not meet his needs. After I asked
her some Socratic questions, Nancy was able to write down the response
“considering my own needs in this situation does not make me a selfish
person .”
However, as we focused on the topic of Nancy’s needs, it became
clear that part of Nancy’s problem was that she spent so much time
focused on Morrison’s needs that she had not really thought about what
she wanted. I suggested that we take up that issue. To help her focus
her thinking, I asked her, “If you could set up this relationship the way
you would want it, what would it look like?” After a brief discussion,
Nancy was able to state that what she wanted was for Morrison to stop
asking her to be his girlfriend. She wanted them to try being friends.
This led to an action plan, which we wrote in the response column
of her Thought Record. Nancy agreed to ask Morrison if he would
agree to being friends and to stop asking her to be his girlfriend. I asked
her to write down this action plan before she left my office because
my formulation told me that it might be easy for her to lose track of
Copyright American Psychological Association. Not for further distribution.
228 I COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
what she wanted, especially if Morrison started pushing for his agenda
again. Her homework assignment was to call Morrison and propose a
friendship.
SESSION 6
BDI = 15, BAI = 32
Nancy arrived on time to the session, brought her measures, and reported that she had completed her homework assignment. This had
worked out well, at least in part because Morrison had realized it was
time to back off. The main agenda item for this session was the final
planning for the upcoming Puerto Vallarta trip. We spent time thinking
about any obstacles that would interfere with Nancy’s proposed plan for
managing her time on the trip. We practiced role-plays to help Nancy
handle any pressure from her family to abandon her morning study plan
or to stay up late playing cards and drinking.
SESSION 7
BDI = 17, BAI = 30
Nancy reported that she had followed through with her study plan on
the trip to Mexico and was pleased at how well it had worked. She had
experienced a bit of pressure early in the trip to give up her mornings,
but after she held the line once or twice, she did not receive any more
“arm twisting.” She was anxious about her upcoming quarterly report
and proposed this as our main agenda item for the session. It was due
in 4 weeks, and she felt behind in her work and anxious about getting
it done without major heroics at the end, as had happened last time.
I began by reviewing with Nancy how she had handled her previous
quarterly report, so I could get more detailed information about what
problems she encountered in that situation. I asked her for this information so I could develop a miniformdation-a hypothesis about the
causes of a particular instance of a particular problem-in this case, the
poor performance on the quarterly report (see chap. 2). A miniformulation describing the problems that arose with the previous quarterly
report would be helpful in planning interventions to help with the upcoming report the next time around.
Nancy reported that a major reason she did not do well on the report
(she had had to stay up all night the night before it was due and did
not do as thorough a job as she had wanted to) was that she had been
having a major relationship crisis (she was caught between two boyfriends) that had impeded her ability to focus on the project. Nancy
agreed that she was in a better position in this regard now. But carving
out time to get the report done remained a problem; she reported that
Copyright American Psychological Association. Not for further distribution.
A Case Example: Nancy I 229
she continued to “cave in” to requests from others, including colleagues
at work, to socialize or help with their projects when she needed to
carve out time to read manuscripts and complete her own report.
To address this problem, I suggested that Nancy make an Activity
Schedule to block out her work on the report over the next week (see
the graded task assignments intervention, as described in chap. 4).
Nancy agreed that this strategy had helped her in Mexico and would be
helpful again. I gave her an Activity Schedule form, and we spent the
session blocking out times during her workday, evenings, and weekends
over the next week to work only on her quarterly report, while still
allowing some time for other projects and for socializing. Her homework
plan for the week was to try to follow the schedule and to make notes
of any problems that arose so we could discuss them the next week.
As I plotted Nancy’s BDI score on the Progress Plot (see Exhibit 7.2)
at the beginning of the session, I was reminded that at this point in the
treatment Nancy’s BDI and BAI scores had not improved much from
her initial scores. I was a bit concerned about this and planned to continue to watch her scores carefully. However, I was not overly concerned
for three reasons: (a) We were having productive sessions: Nancy was
trying cognitive and behavioral interventions and finding them helpful;
(b) we had a good, collaborative working relationship; and (c) the high
scores might be a function of stress about her upcoming report, and I
hoped the scores would drop after the report, especially if Nancy managed it successfully.
SESSION 8
BDI = 15, BAI = 30
During check in, Nancy reported that the Activity Schedule had been
helpful in getting her quarterly report work done. Even though she had
had to revise it as the week went on, the Activity Schedule had helped
her stay focused on her work and gave her a bit of leverage to say 120
to activities that were not on the schedule. Because the Activity Schedule had been helpful that week, I suggested that she complete another
one for the next week. She agreed to this readily and said that she could
do this at home on her own, so we set it as a homework assignment.
We spent some time in the session working on her anxiety about
the upcoming presentation of her report to the senior editors at the firm.
Nancy reported that the last time she presented her report, her superiors
had become, to her mind, overly focused on questioning her about ccrtain minor issues, not allowing her to present the main ideas that she
had about some of the manuscripts she had reviewed. She felt that she
could have been more effective if she had been more assertive. Using a
role-play practice, we developed some tactful ways that she might assert
Copyright American Psychological Association. Not for further distribution.
2301 COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
herself in this type of situation should it arise again; Nancy made notes
about some of the strategies we developed so she could remind herself
of them as she prepared for her presentation.
I also learned that Nancy had read the previous report verbatim
rather than giving a talk based on the report. She did this in part because
she did not have time to prepare a talk. She agreed to use the Activity
Schedule form to carve out time to prepare and practice a talk based on
her quarterly report. Nancy’s homework assignment was to continue to
use the Activity Scheduling form to work on her report and to prepare
a talk based on the report.
SESSIONS 9-12
Sessions 9, 10, and 11 were spent helping Nancy with her report. Nancy
used Activity Scheduling each week to schedule her work on the project, and we did role-plays to practice refusing unwanted invitations during this time. We also worked on her difficulty speaking up assertively
to her landlord about a problem in her apartment. After we did a
Thought Record and some role-plays, Nancy was able to handle the
apartment problem successfully, which was satisfying for her.
In Session 11, Nancy announced that she had completed her report
in good time and that the presentation had gone much more smoothly
than last time. In response to this good news, Nancy’s BDI and BAI
scores showed a nice drop.
We began working on Nancy’s telephone problem: She felt trapped
by calls from Connie and others who wanted to spend 30 minutes or
more talking on the phone. Nancy reported that she did not like talking
on the phone to begin with and certainly did not want to spend 30
minutes or more of her evening talking on the phone; she preferred
spending her evenings working or with her boyfriend. We worked on
a Thought Record, tackling a situation in which she was on the phone
with Connie and wanted to get off.
When I asked for feedback about the helpfulness of the Thought
Record, Nancy admitted that the responses we developed, which focused on the logic that just because Nancy did not give Connie what
she wanted did not mean that Nancy was a selfish person, were not
very compelling. Nancy said that she believed this concept intellectually,
but she had trouble really believing it at an emotional level and using
it to guide her behavior when she was actually talking on the phone
with Connie. In the actual situation, her maladaptive schema became
activated and drove her mood and behavior.
We tackled the telephone problem again in Session 12, and we developed two responses to her negative automatic thoughts in this situation that Nancy found more compelling than the initial ones we had
Copyright American Psychological Association. Not for further distribution.
A Case Example: Nancy I 231
developed. Through a series of Socratic questions, Nancy saw that if she
did not begin to set limits on the time she spent on the phone with
Connie, she would be tempted to break off the relationship altogether
(as she had done when pressured in other relationships) and that this
was not what she wanted or what Connie wanted. Nancy found this
response particularly compelling because it reminded her that it was
in Connie’s interest for Nancy to set limits that would allow her to be
comfortable in the relationship. Nancy also saw that she was not being
completely honest and in fact was leading people on if she spent more
time with them than she wanted.
Nancy found these two concepts helpful, and we wrote them in the
response column of a Thought Record that she took home with her (see
Exhibit 7.6). A review of the formulation indicates why these notions
were particularly helpful to her: They capitalized on Nancy’s vulnerability (her concern for others’ feelings and needs), while helping her be
assertive and take care of her own needs.
Nancy’s homework assignment was to log her calls so we could determine where her problems lay and track our progress at reducing her
time on the telephone. The first time I suggested that Nancy keep a log
of phone calls, she did not complete it. When I learned this, I suggested
that we discuss it, saying,
Therapist: “Nancy, I know you usually complete your homework
and that this telephone problem is something you really
want to solve. Let’s think about what got in the way of
your doing this assignment.”
Nancy: ”I don’t know.”
T: “I don’t know either. But I think it would be good to find
out. I suggest we put this on our agenda and spend a bit
of time trying to figure it out. Would that be all right?”
When we discussed the assignment, I learned that part of the problem was therapist error; I had not followed one of the key guidelines
for making a successful homework assignment (see chap. 3, Structure
of the Therapy Session). I had not made the assignment sufficiently
explicit, and Nancy was uncertain about what information to put on
the telephone log.
However, therapist error was not the full explanation because Nancy
could have made her own decision about how to structure the log or
even called me to ask for guidance. I pointed this out; when I asked her
to speculate about why she had not done either of these things, she
responded with the following:
N: “It would never have occurred to me to call you outside
the session about a thing like this.”
Copyright American Psychological Association. Not for further distribution.
N
W
N
Thought Record on the Telephone Situation
Date
Situation
(event, memory, attempt
to do something, etc.)
On the phone with Connie,
want to get off
Behaviors
Stay on the
phone
Emotions
Trapped
Thoughts
1. If I end the
conversation
now, Connie’s
feelings will be
hurt.
2. I’m selfish not to
want to spend
time with her.
3. A few more
minutes won7
hurt.
Responses
1. I can’t be sure how
she’ll feel; this is mind
reading.
2. The fact that I don’t
give Connie what she
wants doesn’t make
me selfish.
3. I need this time to
work.
Also
If I don’t set limits that
are comfortable for me, I
will want to break off the
relationship, and this is
not what Connie nor I
want.
If I just play along with
Connie’s agenda, I’m not
being honest with her
about my feelings.
Action plan: 1’11 say,
“Connie, I wish I had
more time to talk, but
I’ve got a lot of work to
do tonight, so I’m going
to have to get off the
phone and go to work.”
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0 2000 San Francisco Bay Area Center for Cognitive Therapy.
Copyright American Psychological Association. Not for further distribution.
A Case Example: Nancy 1 233
T: “Why not?”
N: “It’s such a small thing! I’m sure you don’t want to be
bothered by little details like this!” [I speculated, on the
basis of this evidence and what I knew about her upbringing, that Nancy believed, “others don’t care about
me and aren’t willing to put out effort to meet my
needs. “1
T “I don’t? Are you sure?”
N: [Pause] “No, I guess I’m not sure.”
T: “I will tell you that I would be happy to talk with you
about this issue if you called me up. Remember, it’s partly
my fault that you don’t have this information, so that
makes it even more reasonable for you to call me about
it.”
N: “Okay” [but looking doubtful].
T: “Now let’s think about another thing: Why didn’t you
just figure something out and set up a log on your own?”
N: “I don’t know. I wasn’t sure how you wanted it done.”
T: “Okay, now this is an interesting statement. Do you see
N: [Pause] “No.”
T “Because it’s a log you are keeping to help you solve a
problem. If you set up a log that is helpful to you, it
doesn’t really matter how I wanted it done, does it?”
what’s interesting about it?”
N: “No, I guess not.”
T: “Okay, now do you see why this piece is interesting?”
N: “No, not quite” [with a quizzical expression on her face].
T: “Well, you look like you have an idea, so take a stab
N: “I’m focused again on other people’s needs, not mine.”
T “Exactly!”
at it.”
After this discussion, Nancy and I agreed on a format for the log that
was clear, explicit, and helpful to her. She came to Session 13 with a
completed log.
SESSION 13
BDI = 10, BAI = 17
During the check in, Nancy reported that she had begun to make some
headway on the phone conversation problem. She reported that the log
Copyright American Psychological Association. Not for further distribution.
234 COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
was helpful and that she kept it near the phone to remind her to complete it and of her goal to spend less time talking. The Thought Record
we had completed a couple of sessions ago (see Exhibit 7.6) continued
to be helpful. The fact that she had a lot of work to do also helped her
get off the phone. She stated that she wanted to spend the therapy
session on questions she was having about her career direction, and we
agreed to start with that issue and take up the telephone problem again
if we had time.
Before we began working on our agenda items, I proposed that in
the next session, we review Nancy’s treatment progress. I suggested that
we both think about the therapy between now and next week and
that in the next session, we review how we were doing in making
progress toward her treatment goals. A systematic review of the patient’s progress is of course central to the hypothesis-testing mode of
treatment described here. Nancy and I had been monitoring her progress weekly by reviewing of the graph of her BDI and BAI scores, but
these scores are not the whole story. It is also useful to schedule a
formal time to review progress collaboratively with the patient. Nancy
agreed to this.
When we discussed the career issue, I learned that Nancy was
spending her time working on projects that she did not find particularly
interesting, in part because she was unclear as to what areas interested
her. As I collected information about the details of her problem, we
learned that one reason Nancy had difficulty establishing her own interests was because several senior editors in various parts of the firm
had asked her to work with them. The pressure from these editors made
it hard for Nancy to ascertain what she found interesting. I proposed
that we brainstorm to develop some ideas about things Nancy could do
(e.g., individuals in her firm she could meet with) to clarify her interests
and to learn more about what opportunities might be available at her
firm.
In our brainstorming session, Nancy proposed several excellent ideas
(e.g., attend a meeting focused on professional books, an area that she
thought might interest her, and talk to a young colleague about what
he was doing in the travel books department, another potentially interesting area). She agreed to a homework plan to follow up on one of
those items during the coming week. I pointed out again, and Nancy
could see, that her views of her own needs as unimportant or invalid
and those of others as imperative and important were getting in her
way. I suggested that we take up this issue directly a bit later in her
therapy. We did not have time to take up the telephone conversation
problem, but Nancy said she would continue to work on this problem
by logging her phone calls.
Copyright American Psychological Association. Not for further distribution.
A Case Example: Nancy I 235
Review of Treatment Progress
SESSION 14
BDI = 11, BAI = 15
The check-in portion of the session revealed that Nancy had gone to the
professional books meeting, as she had agreed to do, and had kept her
phone log. We agreed to begin the session with a review of her treatment progress, as planned, and then to work more on the phone call
problem.
When we reviewed her treatment progress, Nancy and I agreed that
overall she had made some good gains but had more work to do. The
following is a list of her treatment goals and the progress she had made
on each them.
1. Symptoms of depression and anxiety. These were improved, with
Nancy’s BDI score down from 2 1 to 11, and her BAI score down
from 25 to 15.
2. Relationship difficulties: Nancy was pleased that she had been
able to change her relationship with Morrison and with her assertiveness during her Puerto Vallarta trip, in talks with her landlord, and on the telephone. However, when I asked her for a
rough figure, she reported only 60% progress on this problem. I
was surprised that this number was so low, given the accomplishments we had listed. When I questioned her about this, Nancy
reported that the evening telephone calls were still a major problem for her and that email was another problem area. These
“sticky” spots caused her to continue to feel pressured and burdened by her relationships. I was glad to have this information
because it gave me clear guidance about where we needed lo
work.
3. Work difficulties: Nancy reported that she was much more successful at handling her workload than before. She was pleased at
how she had handled her recent quarterly report and felt more
confident about handling these reports successfully in the future.
She had not stayed up all night to complete a project since early
in the therapy; this was a major accomplishment.
4. Financial difficulties: Unchanged.
I asked Nancy for feedback about what interventions had been helpful, and we made a list of them in the session. (I kept one for my own
records and she kept one.) She reported that what had helped most was
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236 I COGNITIVE-BEHAVIOR THERAPY F O R D E P R E S S I O N
scheduling activities (e.g., work), clearly establishing why setting limits
on relationships was good for the relationship, learning to use a Thought
Record, and working on being more assertive with others.
In the remainder of the session, we returned to the telephone call
problem. We reviewed her phone log and learned that although Nancy
was doing a better job of getting off the phone more quickly, she frequently did this by promising to see the person for lunch the next day,
for example; she wanted to stop doing this. To address this issue, we did
some role-plays of getting off the phone without promising lunch or
making any other commitment to see the person at a definite time. We
practiced saying “1’11 see you” instead of “let’s have lunch tomorrow.”
Nancy agreed to try doing this as her homework assignment for the
next week and to keep notes about any occasions on which she offered
a lunch date or other meeting just to get off the phone.
Coming Down the
Home Stretch
At this point in the treatment, Nancy had made some solid progress on
her treatment goals. In the next several sessions, we continued working
on the treatment goals, particularly the interpersonal issues, and began
working on her underlying schema.
SESSIONS 15-17
We used Thought Records and role-plays to continue to work on
Nancy’s phone call problem and to address other problematic interpersonal situations. We worked on email communications, which absorbed
more time than Nancy wanted. She felt compelled to write extensive
email messages to everyone who sent email to her, including a young
man she had known in high school who insisted on keeping in touch
with her but whom she did not like.
It was striking how nearly all the situations Nancy needed help with
were of the same type: She felt pressured into doing what others wanted
her to do and guilty when she did not give in to this pressure. She was
frequently unclear about what she herself wanted in the situation; when
she was aware of her preferences, she often had difficulty asking assertively for them.
We continued to use many of the interventions that Nancy had
found helpful in our previous work, introducing new ones as they were
needed. In a situation in which Nancy needed to be assertive with a
young man who was pursuing her for a lunch date, Nancy insisted that
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A Case Example: Nancy I 237
she needed to tell him in person that she had a boyfriend and did not
want to date him; when I suggested that she tell him by email, she dvmurred because this method of communicating such information seemed
rude to her. However, she found herself avoiding talking with him.
To handle this problem, I suggested that she do some contingency
contracting (see Masters, Burish, Hollon, 6 Rimm, 1987) with herself:
I suggested that she commit to tell him in person by Monday and that
if she did not, she would tell him on the phone or with an email message
on Tuesday before our session on Wednesday. Nancy liked this idea and
agreed to it (she told him in person). To solve her email problem, Nancy
used activity scheduling; she made a plan to limit her email communication to 30 minutes a day after dinner; she reported that this strategy
worked well.
Although Nancy had not reported her relationship with her father
as particularly problematic, it was not surprising that problems in interactions with him might arise. We spent part of a session working on
how upset she was about the fact that her father had agreed to help her
pay for a laptop computer but was not keeping his promise. She was
also upset about the fact that when she talked to him about how stressed
she was about her work, he was unsupportive, saying “Aren’t you in
therapy?”
We did a Thought Record to help her with these situations. Her
automatic thoughts included “He made a promise; he should keep it.”
“If he’s not planning to follow through, he shouldn’t make promises.”
“He should be more supportive when I’m upset.” After we spent some
time discussing Nancy’s father and I asked her a number of Socratic
questions to open up her perceptions of him, we developed responses
to her automatic thoughts and wrote them on a Thought Record. These
responses included “He is unreliable; that’s a fact, and it probably doesn’t
have much to do with me.” “He has a history of making promises to
others that he doesn’t keep.” “He is not good at providing emotional
support when others are upset; he’s more supportive when things are
going well.” ”This is a drag, but if I can accept it, we can have a better
relationship.” As part of her work on this issue, Nancy read chapter 6
of Feeling Good, which offers an astute account of the cognitive underpinnings of anger and some excellent strategies to help alleviate it.
SESSION 18
BDI = 8, BAI = 10
Overall, Nancy was doing well. Her relationship with her boyfriend Pete
had smoothed out, and work was going well too; in fact, she had already
begun to work on her next quarterly report and felt confident about it.
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238 1 COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
Nancy reported that her 30-minute email schedule was working well,
and she was pleased to see that even when she carried out a behavioral
experiment (see chap. 4) of sending very brief emails, her friends did
not seem offended. She had been able to ignore or delay responding to
people she did not want to communicate with; this was a big step forward for her.
I suggested that at this point in the therapy, we begin working directly on the schema that seemed to underpin Nancy’s difficulties, particularly the interpersonal problems. We had already identified that
Nancy viewed herself as selfish, and we noted that the automatic
thought “I’m selfish” had appeared repeatedly in her Thought Records.
I suggested that we spend some time working to develop and strengthen
an alternative, a less distorted view of herself, and she agreed.
I introduced the Positive Data Log, and Nancy agreed to try it. I took
some time to introduce the log carefully, using some of the strategies
illustrated in the Schema Change Methods video (Tompkins, Persons, 6
Davidson, 2000), including using the “prejudice” example borrowed
from C. Padesky (1993a) and illustrated in the video. Nancy and I chose
an alternative to “I’m selfish,” which was “I set limitskake care of my
needs in a way that is respectful of myself and others.” We spent some
time fleshing out the term respectfid ofothers; Nancy decided that by this
she meant not leading others on, being honest about what she could
offer others in a relationship, and not being maliciously hurtful or carelessly inconsiderate. We began the Positive Data Log with the following
item: Refused an invitation from Susan to go biking on Saturday (I had
already promised Pete I would go with him).
SESSIONS 19-21
Nancy’s BDI and BAI scores continued to be low, namely, in the 5-10
range on the BDI and occasionally as high as 12 on the BAI. Our focus
in this phase of her treatment consisted of working on additional
(mostly minor) difficulties that arose and reviewing the Positive Data
Log weekly. Nancy at first struggled to find items to put on her Positive
Data Log, but after I spent time with her in Sessions 19 and 20 helping
her add items to the log and overcome obstacles (e.g., “That’s too small
an event to enter-it doesn’t count”) to adding items to the log, she
found it easier to do this herself. Over time, she created the Positive
Data Log seen in Exhibit 7.7.
We also spent some time working on Nancy’s increasing feelings of
boredom at work. We followed up on some of the things she had done
to learn more about her career interests. She decided that she wanted
to ask for a change in assignments, but she had difficulty deciding which
department to ask for. To help her with this, I used a decision-making
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A Case Example: Nancy I 239
Date and time Evidence in support of alternative schema
413
414
416
Refused invite from Susan to go biking on Saturday (I had
already promised Pete)
Booked conference room at the time best for my client but
inconvenient for my colleague
Stayed home from work yesterday when sick, although it was
hard on my boss not to have me at a big meeting
0 2000 San Francisco Bay Area Center for Cognitive Therapy.
418
411 3
Asked dry cleaner to redo a blouse that had a stain they had
failed to remove
Told Pete I could have dinner with him on Thursday, not
Wednesday
Positive Data Log
Instructions: Describe your maladaptive schema and alternative schema in the space
provided. Then, write down each piece of evidence in support of your alternative
schema and the date and time when you observed the evidence. Be as specific as you
can. For example, rather than writing “Someone said something nice to me” write “Tom
said he liked the shoes I was wearing.” Remember, you are to write down all evidence
in support of the alternative schema, regardless of how small or insignificant you might
think it is.
Maladaptive schema: “I’m selfish.”
Alternative schema: “1 set limitshake care of my needs in a way that is respectful of
myself and others.
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240 I COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
strategy described by David Burns (ZOOO), in which she listed advantages
and disadvantages of two options and then used them to make her decision. Nancy decided that she wanted to ask for a transfer to the travel
section of the firm. Making this request required some assertiveness and
required fighting against her fear of selfishness because she knew that
the head of her current department would be unhappy about losing her.
We did a Thought Record and a role-play to help Nancy with this situation, which she handled successfully.
As we discussed her professional interests and career direction, we
learned that Nancy had difficulty pursuing her own interests in part
because she was encountering a certain sexism in her company. The
senior male editors, she reported, pushed her toward areas of the field
that were not interesting to her but that they believed were more suitable for women editors; it was draining to “swim upstream” continuously against them and to experience their subtle lack of support for her
interests. A Thought Record on this topic led to a new intervention, one
that involved changing the Situation column, as it were. I suggested
that to feel more supported at work, Nancy might benefit from cultivating collegial relationships with her female colleagues, particularly
senior editors who could serve as mentors and role models.
This intervention is an interesting one. Although it emerged from
the use of a Thought Record, it is not described in chapter 5 and is not
a routine Thought Record intervention. However, the intervention flows
firmly out of the cognitive-behavioral model (which states that external
events activate schema to produce problems) and Nancy’s individualized
case formulation (which states that she has difficulty in situations in
which she experiences pressure from others to meet their needs). Although most of the therapy’s interventions focused on changing the
automatic thoughts, behaviors, and schema components of Nancy’s
problems, interventions intended to change the external environment
itself were clearly consistent with cognitive theory.
A general point is that the cognitive-behavior therapist is free to
develop new interventions that are not described in any textbook. Novel
interventions, particularly if they flow from and fit the nomothetic
model and the individualized case formulation, are worth attempting.
When using them, therapists can obtain feedback from the patient and
monitor the outcome to evaluate their helpfulness.
Termination
At the end of Session 21, Nancy stated that she was doing well and felt
ready to bring her therapy to a close. I agreed that this was appropriate
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A Case Example: Nancy I 241
but suggested that we schedule a final session to review her progress,
summarize what she had accomplished and learned, and think ahead
to prepare for any potential future difficulties. Nancy agreed to this.
SESSION 22
BDI = 6, BAI = 10
We began this session by reviewing Nancy’s progress in general terms
and as it applied to her treatment goals. Overall, Nancy was pleased
with what she had accomplished in therapy.
1. Depressive and anxiety symptoms. Her BDI and BAI scores were
significantly reduced and now in the normal range.
2. Relationship difficulties: Nancy reported she felt 85 O/O improved,
but she agreed that she needed to keep working on these issues.
Her relationship with her boyfriend was more solid and comfortable, she had an easier time refusing invitations that she did
not want to accept, she handled interactions with her father more
successfully, she was more assertive and happier at work, and
she had set good limits on her phone and email communications.
Nancy felt confident that she could continue to make progress in
this area on her own; she felt that the Positive Data Log was
helping her here, and she planned to continue this intervention
after her therapy ended.
3. Work difficulties: Nancy reported that she handled her workload
much more effectively than before, and she no longer felt continually behind and anxious about it. She was meeting deadlines
without panicky last-minute efforts.
4. Financial stresses: Nancy’s increased assertiveness and productiv-.
ity at work gave her some confidence, and she planned to ask
for a raise sometime soon.
I suggested that we make a list of strategies Nancy had found helpful
in her therapy that she could keep for later reference should she need
them. The list read as follows:
1. About relationships,
I Use Thought Records. In the response column, don’t assume
others are hurt or feeling rejected when I say no.
1 Remember that saying yes all the time will only lead to grief
down the road if it is not honest and causes me to want to end
the relationship.
I I tend to see myself as selfish, but this view is not supported by
the data I collected on the Positive Data Log.
I Remember to ask myself what I want.
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242 1 COGNITIVE-BEHAVIOR THERAPY FOR DEPRESSION
I Use the Activity Schedule to block out my time the way I want
to spend it.
I When dealing with my father, remember he is more supportive
when I let him know I am doing well and less supportive when
I tell him that I am upset or unhappy.
fi Be assertive and speak up for what I want.
I When tackling big jobs, break them into parts (graded task assignments) and use the Activity Schedule to plan time to work
on them.
2. At work,
3. When upset,
At the end of the session, I reminded Nancy that depression is a
recurrent problem, and we reviewed how she would know if she needed
to return to therapy. Nancy decided that if she felt her mood sliding,
she would complete a BDI. If she scored 15 or over, she would begin to
take action on her own to feel better (using the strategies she had
learned in therapy). If she did not improve in 2 weeks, she would call
for an appointment.
Nancy and I said goodbye. I had enjoyed working with her. It was
a pleasure to see her do so well and finish up her therapy, but I would
miss seeing her. I encouraged her to call me anytime that I could be of
help in the future and to feel free to call me anytime, even if it was just
to leave a message or send me a note to let me know how she was
doing.
I Do a Thought Record and look for distortions.
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