CBT CASE FORMULATION

CBT Case Formulation

CBT Case Formulation

Identifying Data

Mrs. Smith is a 76 year old white female of Italian descent and resides in a low income housing development. Mrs. Smith is a widow who was married for fifty years. She has two brothers whom she has little contact with, and a son whom she has not seen for many years.

Mrs. Smith has been diagnosed asthma, COPD, emphysema and cataracts. She is a heavy smoker, and she claims she only drinks when she cannot deal with her depression. She has been struggling to cope ever since the death of her husband two years ago. The bereavement of her husband has caused loneliness and isolation. She has canceled many appointments because she had no one to go with her. Mrs. Smith had growing difficulty getting up in the morning, poor appetite, sadness, fatigue, social withdrawal, isolation, sleep disturbance, loss of self-worth, weight loss, and an increased use of alcohol. She was referred to counseling because of depression and isolation.

DSM

Axis 1: 296.33 Depression

Axis II: 308.82 Avoidant Personality Disorder

Axis III: 492.20 Bronchitis, obstructive chronic (COPD), without acute exacerbation

Axis IV: Death, Loss of friends, inadequate social support, Living Alone, Transportation to healthcare facility unavailable

Axis V: No Testing

Strengths and Assets

Mrs. Smith's strength is her mobility and her ability to maintain her financial responsibilities. Her biggest asset is her resident social service coordinator. She relies on her for decision making purposes.

Focal Problem

The case conceptualization of Mrs. Smith's current problems is due to depression and isolation. Mrs. Smith claims she only drinks when she is very depressed. Alcohol consumption has been a symptom. She drinks to ease her depression and low self-esteem. When she drinks she has a loss of appetite and sleep. As a result, she has excess weight loss. Because of her isolation, low self-esteem and loneliness, Mrs. Smith has cancelled several appointments with her medical counselors.

Relevant Childhood Data

Mrs. Smith states that during her early childhood her mother treated her inferior to her other siblings. She describes her mother as being very critical about everything she did. This made her feel that she could not get anything she deserved. Her two brothers were always praised for their accomplishments and spent most of their time with their father. The relationship between her father and brothers often made her feel left out and that she was not good enough. This indicates development of an inferiority complex in her childhood. She believes her teachers did not like her because they told her she was lazy and she was not going to get good grades. Her teachers seemed to confirm the view her mother had of her.

In school, she went into the company of wrong guys, and started smoking at age thirteen. Unfortunately, the friendships did not last as those friends expanded their social circle with other peers whom they thought were more exciting. At age fifteen she had to drop out of school because she was ...