Cognitive-Behavioral Case Formulation
and Treatment Plan Example
Cognitive-Behavioral Case Formulation
Client Name: Ms.
Date:
Identifying Information: middle-aged female, married with two children
Mental Status Examination
She appeared neatly dressed in an outfit, which was age-appropriate. She was alert and
oriented to person, place, and time. The client made eery effort to !e open and honest.
"urthermore, she maintained a cooperatie attitude toward the e#aminer. $er mood and
affect were depressed and an#ious. Speech was coherent and releant. There were no
signs of a formal thought disorder as o!sered. Memory was intact as o!sered. Insight
was estimated as fair to good.
Problem List
%. "eeling angry, resentful, an#ious
Include score on &'I at inta(e
Thoughts
-)She (new we were going to !e late and deli!erately stayed in the closet*
-)She runs this house*
-)I might as well not !e married*
&ehaiors
-yelled at daughter and hus!and
-stomach tensed up
+ecent Situations
-late for school and daughter was hiding in the closet
-daughter refused to go to !ed
-hus!and went upstairs to play with model trains
,. "eeling depressed, helpless
Include score on &DI at inta(e
Thoughts
-)She doesn-t care a!out what I-m going through*
-)She doesn-t care a!out what I need*
-)$e leaes me with all the responsi!ility and doesn-t care*
&ehaiors
-!lamed daughter and hus!and
+ecent Situations
-late for school and daughter was hiding in the closet
-daughter refused to go to !ed
-hus!and went upstairs to play with model trains
.. /ac( of effectie communication s(ills
Thoughts
-)She (new we were late and deli!erately stayed in the closet*
-)$e deli!erately leaes me with all of the wor(*
0motions
-angry
-resentful
-an#ious
&ehaiors
-anger out!ursts with daughter and hus!and
-attempted to !ottle up feelings a!out hus!and, which resulted in shouting
match !etween them
+ecent Situations
-late for school and daughter was hiding in the closet
-hus!and went upstairs to play with model trains
1. /ac( of patience
Thoughts
-)She-s a self-centered !rat*
-)She-s a tyrant*
-)She doesn-t care a!out what I need*
-)She doesn-t care a!out what I-m going through*
0motions
-depressed
-helpless
-an#ious
&ehaiors
-yelled at daughter2 !lamed daughter
+ecent Situations
-late for school and daughter was hiding in closet
-daughter refused to go to !ed
Diagnosis
'#is I: +34 5enerali6ed 'n#iety Disorder
+34 Ma7or Depressie Disorder
89%.%: ;artner +elational ;ro!lem
89%.,: ;arent-Child +elational ;ro!lem
'#is II: 8<%.:= No Diagnosis
'#is III: None
'#is I8: None
'#is 8: 5'" > 9: ?current@
Woring !"pothesis ?Aintegrate information gathered in additional sessions@
Core &eliefs a!out self, others, world, and future
%. Self - )I need to !e in control*
)I am unloa!le*
,. 4thers - )4ther people frustrate my efforts to !e in control*
)4ther people do not care a!out me or care a!out what I need*
.. Borld - Ainclude information gathered in additional sessions
1. "uture - Ainclude information gathered in additional sessions
Pre#ipitants ?AInclude information gathered in additional sessions@
?"or e#ample, client decided to !egin therapy after haing a serious fight with
hus!and, in which she made him leae the house for the night@
?"or e#ample, client decided to !egin therapy after hitting her daughter during
one of her anger out!ursts@
$#tivating Situations
getting daughter ready for school
doing household chores
running !ehind schedule
%rigins
AInclude information gathered in additional sessions including family history
?relationships with father, mother, si!lings during childhood and adulthood@ and past
e#periences concerning client-s difficulties
Strengths and $ssets ?Aas per information gathered in additional sessions@
'!ility to wor( colla!oratiely with therapist
5ood relationship with infant daughter
Billingness to wor(2 willingness to change
Strong connection to hus!and prior to e#periencing pro!lems
Cognitive Con#eptuali&ation Diagram
;atient Name: Ms. C Diagnosis-'#is I: +34 5enerali6ed 'n#iety Disorder
Date: March ,D, ,::. +34 Ma7or Depressie Disorder
89%.%: ;artner +elational ;ro!lem
89%.,: ;arent-Child +elational ;ro!lem
Diagnosis-'#is II: 8<%.:= No Diagnosis
'elevant Childhood Data
AInclude information gathered in additional sessions
Core Belie()s*
)I need to !e in control*
)I am unloa!le*
+ntermediate Belie()s*
)If my daughter doesn-t o!ey me, I am not in control3she doesn-t loe me*
)If my hus!and doesn-t do what I want him to do, I am not in control3he doesn-t loe me*
Compensator" Strateg")ies*
'nger out!ursts, place !lame on others, and
aoid immediate e#pression of feelings to hus!and
Situation ,
Daughter hides in closet,
which causes them to !e
late to school
Situation -
Daughter refuses
to go to !ed
Situation .
$us!and spends night
playing with model
trains
$utomati# Thought
)She-s a self-centered
!rat, she runs this house,
and she doesn-t care a!out
what I-m going through*
$utomati# Thought
)She-s !ecoming a tyrant,
she runs this house, and she
doesn-t care a!out what I
need*
$utomati# Thought
)I might as well not !e
married, he deli!erately
leaes me with all the
wor(, and he doesn-t
care a!out me*
Meaning o( Thought
)I am not in control*
)I am unloa!le*
Meaning o( Thought
)I am not in control*
)I am unloa!le*
Meaning o( Thought
)I am not in control*
)I am unloa!le*
Emotion)s*
'ngry
Borried
Emotion)s*
'ngry
"eeling )on edge*
Emotion)s*
'ngry
+esentful
Behavior)s*
Eelled at daughter
Behavior)s*
Eelled at daughter
Behavior)s*
Eelled at hus!and
Cognitive-Behavioral Treatment Plan
Client Name: Ms.
Date:
Identifying Information: middle-aged female, married with two children
Treatment /oals
+educe physical symptoms of an#iety and depression ?measured ia &'I F &DI@
+educe anger out!ursts ?measured ia personal report@
Improe a!ility to effectiely communicate thoughts3feelings ?measured ia personal
report and positie data log@
+educe negatie automatic thoughts ?measured ia daily thought record@
Modify core !eliefs of need for control ?measured ia core !elief wor(sheet@
'cGuire relapse preention s(ills ?measured directly@
Treatment Modalit"
Initial indiidual cognitie-!ehaioral therapy
"ollowed !y family therapy
Treatment Fre0uen#"
Initial wee(ly indiidual cognitie-!ehaioral therapy
"ollowed !y wee(ly family therapy
Treatment Duration
Initial %:-%, sessions of indiidual cognitie-!ehaioral therapy
"ollowed !y .-D sessions of family therapy
Treatment +nterventions
%. 'ssessment
'dminister cognitie, !ehaioral, and interpersonal assessments including the
/eahy 'n#iety Chec(list for ;atients
'dminister tests and other ealuations including the &ec( 'n#iety Inentory
?&'I@ and &ec( Depression Inentory ?&DI@
0aluate suicidal ris(
0aluate need for medication
,. Sociali6ation to Treatment
Inform client of diagnosis
;roide releant, informatie handouts on his3her disorder in particular and
cognitie-!ehaioral therapy in general
Teach client structure of cognitie-!ehaioral therapy sessions
Inform client of connection !etween thought, emotions, and !ehaiors
;roide rationale for therapeutic interentions
.. Cognitie +estructuring
'ssist client in identifying and ealuating automatic thoughts, intermediate
!eliefs, and core !eliefs ?daily thought record@
'ssist client in generating alternatie, more adaptie thoughts and !eliefs
positie data log, core !elief wor(sheet
1. +ela#ation Training
Inform client that an#ious thoughts and emotions are more li(ely to occur when
physiologically aroused
Teach rela#ation techniGues including progressie muscle rela#ation, !reathing
rela#ation, guided imagery, and meditation
Discourage client from the use of stimulants including caffeine
0ncourage client to engage in regular e#ercise
D. Marital3"amily Interentions
Teach family mem!ers to attend to, la!el, and reinforce posities in each other
Teach positie assertieness
Teach communication s(ills including actie listening and clarifying feelings
Teach time-out procedures as well as self-instructions for anger
$d1un#t Therap"
;harmacotherapy is an option, if Ms. C does not respond to initial indiidual cognitie-
!ehaioral therapy
%bsta#les
%. Difficulty distinguishing thoughts from emotions
;redicts interference with use of daily thought record to identify and ealuate
automatic thoughts, emotions, and maintaining !ehaiors
,. Short temper, anger out!ursts
;redicts noncompliance with new homewor( assignments inoling actiities,
which present a cognitie or !ehaioral challenge
.. ;oor time-management s(ills ?Aas per information gathered in additional sessions@
;redicts noncompliance with homewor( assignments as well as additional
conflicts with hus!and and daughter due to lac( of adeGuate time for positie
interaction and effectie communication
