CBT FORMULATION

Riya Gupta (23223050)

Department of Psychology

Christ (deemed to be University), Delhi NCR

MPS252N: Multicultural and diagnostic interviewing skills

Prof Aavleen Bakshi

April 11th, 2024

 Psychodiagnostic Formulation

Index patient Mr. SV, 22 years old male, currently in his 4th year of pursuing BA LLB

and interning at the District Court in Greater Noida, belonging to a Hindu nuclear family, hailing

from the urban region of Noida, belonging to upper middle socio-economic status, with family

history of conflicting relationship with parents, there is a lack of support from his parents, and

frequent arguments with them further contribute to his irritability, with personal history of anger

issue. I approached him for my academic purpose, the source of information was reliable,

adequate, and complete; with total duration of illness of 3 months, with an acute onset,

continuous course, deteriorating progress, with maintaining factor of Time Constraints from

Internship and Parental Conflict, with chief complaints of Overwhelming Academic Stress, Time

Management Challenges, Parental Conflict and Lack of Support, Anger Issues and Self-Harm,

Poor Study Outcome and Focus Difficulties, and Sleep Disturbances.

On MSE, reaction time was normal. Affect was observed to be liable, with rapid shifts in

response to environmental factors. Content of thought was preoccupied with academic worries

and lack of support from family. The other parameters were found to be grossly normal. Insight

was grade III.

Provisional Diagnosis- Adjustment Disorder

Differential Diagnosis- Generalized Anxiety Disorder (GAD), Major Depressive Disorder

(MDD).
 Identification of Goals

Short-term Goals

1. Build awareness in Mr. SV regarding his thinking pattern and its impact.

2. Improve Mr. SV's mental and physical well-being.

3. Improve daily functioning at home and work.

4. Help Mr. SV learn adaptive coping strategies to deal with difficult situations.

5. Optimize Mr SV’s academic performance.

6. Address Mr. SV’s time management skills.

7. Increase Mr SV’s social interaction.

8. Assist Mr. SV to Acknowledge, identify, and label emotions in different circumstances.

9. Direct Mr. SV to identify, challenge, and replace negative self-talk.

10. Decrease the number, intensity, and duration of angry outbursts, while increasing the use of

new skills for managing anger.

Long-term Goals

1. Improve SV’s time management skills.

2. Mr. SV’s cognitive reappraisal towards academic performance.

3. Improve Mr SV’s Coping Strategies for Parental Conflict.

4. Decrease the level of present conflict with parents while beginning to let

go of or resolve past conflicts with them.

5. Help Mr. SV learn Emotional regulation skills.

6. Assist Mr. SV in implementing the cognitive behavioral skills necessary to solve problems

more constructively.

7. Come to an awareness and acceptance of feelings of anger while developing control.

8. Sustain Mr. SV’s overall well-being.

9. Regular follow up.

10. Guide Mr. SV to prevent future problems.

Therapeutic Inquiry

Skills

1. Open-ended Questions:

We could use open-ended questions to explore Mr. SV's experiences, thoughts, and

emotions regarding his academic stress, time management difficulties, and conflicts with his

parents. For Example: "Can you tell me more about what a typical day looks like for you, while

balancing your internship and academic studies?"

2. Active Listening:

We can listen attentively to Mr. SV's narrative, demonstrating empathy and

understanding. While reflecting on his thoughts and feelings to show that we are engaged and

validating his experiences.

3. Behavioral Observation:

We should pay attention to Mr. SV's nonverbal cues, body language, and behaviors

during sessions to gain insights into his emotional state and interpersonal dynamics.
4. Empathic Exploration:

We should demonstrate empathy and understanding by acknowledging Mr. SV's feelings,

experiences, and challenges without judgment.

For Example: "It sounds like you're feeling really overwhelmed right now, and that's

completely understandable given everything you're dealing with."

5. Summarization and Feedback:

We could summarize key points discussed during sessions and provide feedback to

reinforce progress, validate concerns, and clarify misunderstandings.

For example: "Based on what we've discussed today, it seems like finding a balance

between your internship and studies is a top priority for you. Does that sound accurate?"

6. Clarification and Validation:

We should seek clarification and validation to ensure an accurate understanding of Mr.

SV's experiences, beliefs, and perceptions.

For Example: "I want to make sure I understand correctly. Are you saying that you feel

unsupported by your parents in managing your academic responsibilities?"

Techniques

7. Socratic questioning:

It can be a valuable technique to incorporate into therapy sessions with Mr. SV. Socratic

questioning involves gently guiding the individual to examine their thoughts, beliefs, and

assumptions critically. Here's how it can be applied in Mr. SV's case:

● Exploring Academic Stress:

 Therapist: "What evidence do you have that supports the belief that you must excel in

every aspect of your academic and professional life?"

This question prompts Mr. SV to examine the underlying assumptions driving his

academic stress and perfectionism.

● Challenging Negative Thoughts:

Therapist: "What would happen if you didn't meet your own or your parents' expectations

in one aspect of your studies?"

By asking this question, we encourage Mr. SV to consider the consequences of his beliefs

and whether they are realistic.

● Examining Time Management Beliefs:

Therapist: "How do you think your perspective on time management might change if you

viewed your schedule as flexible rather than rigid?"

This question prompts Mr. SV to reconsider his rigid approach to time management and

explore alternative perspectives.

● Addressing Parental Conflict:

Therapist: "What do you think might be motivating your parents' behavior when they

express concern about your academic performance?"

By considering his parents' perspective, Mr. SV can gain insight into the underlying

motivations behind their actions and responses.

● Exploring Coping Strategies:

Therapist: "How do you think your coping strategies might be influenced by your beliefs

about your ability to manage stress effectively?"

 This question encourages Mr. SV to reflect on the connection between his beliefs, coping

strategies, and emotional responses.

8. Cost-benefit analysis:

It is a cognitive-behavioral technique used to help individuals weigh the pros and cons of

a particular behavior or decision. In the context of therapy with Mr. SV, this technique can be

applied to explore the advantages and disadvantages of his current coping strategies, behaviors,

and thought patterns. Here's how it can be utilized:

● Identifying the Behavior or Thought Pattern.

● Listing the Pros and Cons.

● Assigning Weight to Each Factor.

● Summarizing and Comparing.

● Reflecting and Discussing.

● Exploring Alternatives.

CBT Formulation

ABC Model

A- ACTIVATING EVENT:

Increased Academic Workload, Time Constraints from Internship, and Parental Conflict.
B- BELIEFS:

● Core Beliefs- “I am not good at anything.”

● Intermediate Beliefs- “If I don't perform well academically, I'm a failure.”

- Attitude: “I need to be perfect at everything.”

- Rules: “My worth as a person is directly tied to my achievements and external

validation.”

- Assumptions: “If I am not able to handle difficult situations, I am a failure.”

● Automatic Negative Thought- “I'll never be able to manage my time effectively with this

internship. I'm going to fail. I cannot focus on my studies. No one supports me. I failed as

a son.”

C- CONSEQUENCES:

● Emotional- Anxiety, Anger, Frustration, Feelings of sadness and inadequacy.

● Behavioural- Difficulty concentrating, anger outburst, Academic performance decline,

Strained relationships with family, Social isolation, Difficulty managing daily tasks.

● Physical- Sleep disturbances, Headache.

ABC MODEL
Cognitive Distortions

Mr. SV holds maladaptive beliefs about academic success, viewing it as crucial for

self-worth and validation. Let's identify some potential cognitive distortions present in Mr. SV’s

case:

1. All-or-Nothing Thinking (Black-and-White Thinking):

Mr. SV may perceive his academic performance in extremes, viewing success as

achieving perfection and failure as anything less than perfect. He may discount the incremental

progress, leading to feelings of inadequacy and disappointment.

2.Catastrophizing:

Mr. SV may catastrophize potential outcomes, imagining the worst-case scenarios if he

doesn't meet his academic expectations. He may exaggerate the consequences of failure,

believing it would result in complete disaster or irreversible damage to his future.

3. Personalization:

Mr. SV may personalize negative outcomes, attributing academic setbacks solely to his

own shortcomings or inadequacies. He may fail to consider external factors or situational

context, leading to feelings of self-blame and guilt.

4.Emotional Reasoning:
 Mr. SV may rely on his emotions as evidence for the truth of his beliefs, assuming that

because he feels anxious or stressed about his academic performance, it must mean he's destined

to fail. He may equate his emotional experiences with objective reality, reinforcing negative

thought patterns.

5.Overgeneralization:

Mr. SV may overgeneralize from specific instances of academic struggle or failure,

applying these experiences to all aspects of his life or future prospects. He may see setbacks as

evidence of his inherent incompetence or unworthiness, rather than as temporary challenges to

overcome.

By identifying these cognitive distortions, we can work together to challenge and reframe

these irrational thought patterns.

Beck’s Cognitive Triad

Beck's cognitive triad is a key concept in cognitive therapy that highlights three areas of

negative thinking patterns: negative thoughts about the self, the world, and the future. Let's

formulate Beck's cognitive triad for Mr. SV's case:

Negative Thoughts about the Self:

Mr. SV holds negative beliefs about himself, particularly regarding his academic abilities and

worth as a person.

Examples:

"I'm a failure if I don't perform well academically."

"I'm not smart enough to handle the workload of my internship and studies simultaneously."

"I'm letting everyone down, especially my parents, by struggling with my academic

responsibilities."

Negative Thoughts about the World:

Mr. SV perceives the world, particularly the academic and familial environments, in a negative

light, viewing them as threatening or unsupportive.

Examples:

"The academic demands are too overwhelming, and I'll never be able to keep up."

"My parents don't understand the pressure I'm under, and their expectations are unrealistic."

"The world is competitive and unforgiving, and I'll never measure up to others' standards."

Negative Thoughts about the Future:

Mr. SV harbors pessimistic views about his future prospects, fearing failure and envisioning dire

consequences if he doesn't meet his academic goals.

Examples:

"If I don't excel academically, I'll never achieve my dream of becoming a successful lawyer."
"I'll end up stuck in a dead-end job and disappoint everyone who believed in me."

"My future is bleak and hopeless if I can't manage the stress and pressure of my current

situation."

By identifying and addressing these negative thinking patterns within Beck's cognitive triad, Mr.

SV and his therapist can work together to challenge and reframe his distorted beliefs, cultivate

more realistic and adaptive perspectives, and develop coping strategies to navigate academic

stressors and interpersonal challenges.

Treatment Plan

1. Psychoeducation:

● We will provide Mr. SV with information about the cognitive-behavioral model,

explaining how thoughts, feelings, and behaviors interact to maintain distress.

● Will educate him about common cognitive distortions and how they contribute to

emotional distress.

● We will discuss the role of avoidance behaviors and maladaptive coping strategies in

maintaining negative cycles.

2. Cognitive Restructuring:

● We will help Mr. SV to Identify and challenge his maladaptive beliefs about academic

success, worthiness, and self-criticism.

● We will encourage him to reframe his negative thoughts and adopt more balanced and

realistic perspectives about his abilities and achievements.

 ● We will teach him coping strategies such as thought-stopping, cognitive restructuring,

and positive self-affirmations to challenge automatic negative thoughts.

3. Behavioral Activation:

● We will collaboratively develop a structured daily schedule to improve his time

management and prioritize academic and self-care activities.

● We will use behavioral activation techniques to gradually reintroduce pleasurable and

meaningful activities into Mr. SV's routine, reducing avoidance behaviors and increasing

feelings of accomplishment.

4. Interpersonal Skills Training:

● Teach him assertiveness skills to improve communication with parents and constructively

express needs and concerns.

● Will do role-play conflict resolution strategies and problem-solving techniques to address

conflicts with his parents and enhance family communication.

● Will explore strategies for setting boundaries and managing expectations within his

familial relationships.

5. Relaxation and Stress Management:

● Will introduce relaxation techniques such as deep breathing, progressive muscle

relaxation, and mindfulness meditation to help Mr. SV manage stress and reduce

physiological arousal.
 ● Encourage him for regular physical activity and healthy lifestyle habits to promote his

overall well-being and resilience to stress.

7. Cognitive Restructuring:

● Identify Automatic Thoughts: Help Mr. SV recognize and identify automatic negative

thoughts related to academic stress, time management challenges, and conflicts with

parents.

● Challenge Negative Beliefs: Encourage Mr. SV to examine the evidence supporting his

negative beliefs and consider alternative, more balanced perspectives.

● Generate Alternative Thoughts: Assist Mr. SV in generating alternative, more adaptive

thoughts or interpretations of situations, emphasizing evidence-based reasoning and

logical analysis.

● Practice Reframing: Guide Mr. SV in reframing negative thoughts into more realistic,

helpful, and self-compassionate statements that promote resilience and problem-solving.

8. Cognitive Defusion:

● Notice Thoughts as Mental Events: Teach Mr. SV to observe his thoughts as passing

mental events rather than absolute truths, using mindfulness techniques such as

mindfulness meditation or mindful breathing.

● Create Psychological Distance: Help Mr. SV create distance from his thoughts by

labeling them as "just thoughts" or "mental chatter," rather than identifying with or being

consumed by them.
 ● Use Metaphors or Imagery: Introduce metaphors or visualization exercises to illustrate

the concept of cognitive defusion, such as imagining thoughts as leaves floating down a

stream or clouds passing by in the sky.

● Practice Acceptance: Encourage Mr. SV to practice accepting and allowing his thoughts

to come and go without judgment or resistance, fostering a sense of inner peace and

psychological flexibility.

● Integration with Mindfulness: Integrate cognitive defusion techniques with mindfulness

practices to cultivate present-moment awareness and non-reactivity to thoughts and

emotions.

9. Homework Assignments:

● Will assign homework exercises to practice cognitive restructuring, behavioral activation,

and relaxation techniques between sessions.

● Will encourage him for self-monitoring of thoughts, emotions, and behaviors to increase

awareness and identify patterns contributing to distress.

● Will review his progress and adjustments in treatment goals collaboratively based on Mr.

SV's feedback and experiences.

10. Review and Maintenance:

● Will regularly review his progress and address any challenges or barriers encountered by

him during the treatment.

● Will emphasize the importance of ongoing practice and application of learned skills in

real-life situations.
 ● Will discuss relapse prevention strategies and develop a plan for managing setbacks or

future stressors effectively.

By implementing these techniques, Mr. SV will be able to gain insight into the underlying

factors contributing to his distress and develop practical skills to manage stressors, improve

coping strategies, and enhance overall well-being. Thus, collaborative goal-setting and regular

monitoring of progress are essential for successful treatment outcomes.

Reflection

The intricacy of Mr. SV's cognitive difficulties strikes me as I think about his case and

the recommended course of therapy. It feels difficult but necessary to dissect his views into

cognitive distortions and deal with them in a multifaceted manner. I understand how crucial

defusion and cognitive restructuring are to countering his pessimistic ideas. Furthermore,

behavioral activation training that incorporates interpersonal skills training recognizes the

importance of outside variables. In spite of the difficulties, I have hope for the future. I think we

can help Mr. SV navigate his distress, build resilience, and promote good change if we are

patient, empathic, and work together.

 References

Beck, J. S. (2020). Cognitive behavior therapy (3rd ed.). Guilford Press.

CBT case formulation as therapeutic process. (2021). In Springer eBooks.

https://doi.org/10.1007/978-3-030-63587-9

Tiba, A., Drugaş, M., Sîrbu, I., Trip, S., Bora, C., Miclăuș, D., Voss, L., Sanislav, I., & Ciurescu,

D. (2023). The ABC model of positive feelings: a preliminary test. Research Square

(Research Square). https://doi.org/10.21203/rs.3.rs-3034444/v1