CBT Case Discussion
Brittany Case Study (Corey, 2017)
Brittany is a 16-year-old girl of mixed Caucasian and African American descent. Her family has recently moved from a large, diverse, metropolitan area to a small mid-western town. According to her mother and father, Brittany did not respond well to the move.
Prior to the move, Brittany’s parents reported that she was a very well-behaved child who did well in school and participated in extracurricular sports. She was an active member of the student council and worked after school at a coffee shop in the local mall to save money for college. Brittany dreamed of becoming a veterinarian. However, all of this changed when she arrived at her new school. She has only been in school 3 months and is already failing chemistry and shows no interest in after school activities. She was kicked off the track team after only two practices for arguing with the coach. She has been suspended once for fighting with another student and sent to detention 14 times for speaking disrespectfully to her teachers and disrupting class. Of great concern to Brittany’s mother is that Brittany has recently dyed her hair pink and pierced her lip. Brittany’s father is concerned because she is generally disagreeable at home, refuses to do her chores, and has not completed a homework assignment in 3 weeks. Brittany’s parents brought her to counseling because they are at a loss for how to control her behavior. They hope that therapy can help Brittany change back to her “old self.”
Psychiatric History
Dr. Bailey Works with Brittany from a Cognitive Behavioral Perspective:
When I greeted Brittany in the waiting room, she was sitting on the couch with her back turned toward her parents. Her parents were eager to speak with me alone. Although I value their input and would make time to speak with them at a later time, I was clear that this particular session belonged to Brittany. In hearing this, Brittany smirked at her parents and quickly walked into my office. When I asked Brittany how she felt about coming to counseling, she replied, “Well, at least it is better than having to talk to them!” as she rolled her eyes in the direction of the waiting room.
In talking with Brittany, several themes of her life became clear. One of these themes involved her contention that her parents had already changed her life quite drastically by moving her across the country to a new school. In this setting, none of the other students resembled her in terms of ethnicity, interests, or sophistication. She had no intention of “changing back” to her “old self” just to please them. The next issue Brittany mentioned was that she found her new school “too easy,” and her teachers to be “closed-minded,” and therefore not worth listening to or respecting. Third, Brittany mentioned that she deeply missed her friends from home and felt that her new peers were unable to accept her because she was so different from them in her upbringing, culture, and beliefs. She finally noted that she was the only biracial student in her grade and that she felt alone and isolated. When I asked her about her behavioral outbursts at school, Brittany articulately explained that she feels she is responding appropriately to an impossible situation. She was clear that she did not care if her peers, teachers, and parents felt she was acting out because none of them would ever accept her. However, she agreed to participate in therapy because she “didn’t like feeling sad and bitter all the time” and wanted to work on getting in less trouble at school. Although Brittany was tired of detention, she was adamant that she had no desire to work on her behavior at home because she felt her parents deserved what they got for moving her in the first place.
Ideally, I believed it would be helpful for Brittany to work on creating a more positive relationship with her parents from a developmental psychopathology perspective. At the same time, I realized that Brittany was a teenage girl working on the important task of individuation and was appropriately focused on asserting her own identity within her family context. Hence, some familial discord at this point in time was to be expected. As such, Brittany and I agreed that we would focus on her school-related goals during our time together. Brittany was very clear that we would discuss her parents only if it pertained to school and as she felt it was necessary to vent about how they “complicated her life” and “misunderstood her.” I agreed to her boundary, but also let her know that I was open to talking about her relationship with her parents if that was something she would like to explore, but that this was not an expectation of therapy. It was her choice.
Some of Brittany’s ideas, feelings, and actions are considered age-appropriate tasks of adolescent identity development, such as experimentation with social roles and personal appearance. It was also clear that Brittany’s attitude and behavior in her new environment were clearly disrupting her functioning in key developmental areas, namely, her school performance and social interactions. As a CBT therapist, I was acutely aware of Brittany’s use of “absolute” terms in her language as she described her circumstances. Her account of her life was filled with many overt and covert “musts” and “shoulds” as well as a good deal of “all or nothing” thinking. Brittany held several fixed, maladaptive beliefs, or cognitive distortions, about her new environment. These distortions caused angry and sad feelings that, in turn, directly affected her behavior. As her cognitive behavioral therapist, I was very interested in working with Brittany in changing her maladaptive thoughts, feelings, and behaviors into more constructive beliefs, sentiments, and actions.
The first cognitive behavioral technique Brittany and I used together was learning to identify and label her cognitive distortions. For example, after two counseling sessions Brittany was able to tell me that her belief that “none of her peers would ever accept her” contained two types of cognitive distortions: all-or-nothing thinking and jumping to conclusions. In her next session, Brittany learned that she could dispute her self-defeating thoughts through examining the evidence that supports them. For example, although Brittany feared social rejection, she was able to realize that she really did not have any factual evidence to support her unrealistic fear that every student in the school would reject her both currently and in the future. Brittany playfully admitted that she didn’t have a crystal ball and could not foresee the future and that perhaps, some day, some other student might actually want to be her friend.
Once Brittany learned to identify and accurately label her cognitive distortions, we began to reframe her inaccurate beliefs and responses into more helpful, adaptive thoughts and actions. For example, Brittany was able to take her existing, maladaptive belief that all of the teachers at her school were “closed-minded” and “not worth listening to” and modify these convictions in ways that were more in line with her goal of not getting in trouble. Brittany now listens to her teachers and evaluates whether or not they are closed-minded before she decides whether or not to speak disrespectfully to them. Over time spent in therapy, Brittany found that she actually felt better about herself when her thoughts, actions, and feelings were geared toward helping her be successful rather than geared toward maladaptive behaviors that led to undesirable outcomes like detention and being grounded. Over the last 2 months, Brittany has only served three detentions.
Follow-Up: You Continue as Brittany’s Therapist:
Brittany has made progress in identifying and reframing her cognitive distortions. However, she still remains angry with her parents for moving her family across the country and is still behaving poorly at home. Likewise, she continues to have trouble making friends with her peers. She continues to feel that she is very different from other students in terms of her beliefs, culture, and interests.
Problem List
Defiant behavior in school and at home
Poor academic performance
Poor adjustment skills
Social isolation and ineffective coping skills
Physical aggression
Problem Formulation
Brittny is exhibiting the following cognitive distortions
All-or-nothing thinking: Brittny exhibits this distortion when she stated that none of her peers would accept her, that none of the students resembles her interest and sophistication, and that all of her teachers in the school are “closed-minded”.
Personalization and Blame: Brittny is blaming everyone else but herself for her problems. She is failing to see how her behavior is adding to her problems. She blames her being moved to a new school, being of a different ethnicity, the school being too easy, and the teachers being “closed minded” as the problem and does not see her response to her held beliefs as contributing to the problem
Jumping to conclusion: Brittny assumed that her peers would not accept her, that none of the students resemble her interests or sophistication, and that her teachers are “closed minded” without any evidence to support her assumptions.
Mental filter: Brittny’s perception about reality is clouded by her negative thoughts that her peers would never accept her, that her teachers are closed minded, and that her parents have changed her life by moving her to a new environment.
Emotional Reasoning: Brittny thinks that because she is angry that her parents moved her to a new school means her parents treated her unfairly. She also thinks that her life has drastically changed after she moved to a new school. She based her perception on the fact that she did not want to move to the new school.
What cognitive behavioral techniques might be appropriate to use with Brittny as she explores her angry feelings towards her parents who want her to be her “old self”, an identity that Brittny clearly rejects?
Questioning the Evidence: One of the cognitive behavior techniques that might be appropriate to use with Brittny is questioning the evidence. This involves the therapist investigating whether the patient’s information is based on facts or assumptions (Wheeler, 2014). Brittny would be asked about what evidence she has that none of her peers would accept her and that her teachers are closed minded. The therapist will then help Brittny examine the basis of whatever statement she give as evidence.
Identifying the distortion: This method would be used to help Brittny identify her negative thoughts by asking her to write down her negative thoughts like saying none of her peers would accept her, that moving has drastically changed her life, and that her teachers are closed minded. Brittny would then be gradually encouraged to reframe her negative thoughts in a more positive way (Wheeler, 2014).
Thought Stopping: This approach would also be appropriate for Brittny. She would be encouraged to interrupt her negative stream of thoughts by loudly saying to herself “Stop It” or by stamping her fingers each time she thinks that her parents have drastically changed her life by moving her to a new school (Wheeler, 2014).
Adolescence is a time of social experimentation and identity development. How would cognitive behavior therapist determine what portion of Brittny’s feelings of “not fitting in” are consistent with her developmental stages and what portion are indicative of social skills difficulty?
There are several cognitive behavior techniques that a therapist can use to determine which feelings are consistent with her developmental stages and what portions are an indication of social skills difficulty. Role-playing with Brittny will help identify her emotions, cognitions, and behaviors (Corey, 2013). Another approach is to let Brittny do cognitive homework. This involves Brittny listing her absolutist beliefs and listing how her beliefs affect her feeling of “not fitting in” (Corey, 2013).
How would you use cognitive behavioral therapy techniques in a culturally sensitively manner to address Brittny’s feelings about being the only biracial student in her class?
The first step in using cognitive therapy technique in a culturally sensitive manner in addressing Brittny’s feelings is for the therapist to understand the core cultural values of Brittny. The therapist will then be able to help Brittny explore her values and help her modify beliefs and practices that are deemed disruptive (Corey, 2013). The psychoeducational method is one cognitive approach I would apply to address her feelings. I would provide Brittny with written materials that relate to her feelings and successful approaches in dealing with such feelings. Brittny would be more likely to participate in the treatment program if she has a better understanding of how it works (Corey, 2014). I would also use role play to help Brittny identify negative thoughts that are creating disturbances and how to address those disturbances. Rapid identification of the category into which a patient’s belief falls help guide treatment (Becks, 2011).
How might the principles from REBT be applied to the case study?
Rational emotive behavior therapy is based on the assumption that individuals contribute to their own problems by holding rigid beliefs about certain situations and that emotions, cognitions, and behavior interact significantly in affecting relationships (Corey, 2017). Brittny can be taught that her emotions are mainly based on her beliefs. REBT will be used to teach her the skills to be able to identify and dispute these unfounded beliefs. She would realize that holding to the unfounded belief that her peers would not accept her is affecting her emotions and behavior. Some of the cognitive, emotive, and behavioral techniques that can be used in applying the principles of REBT include disputing irrational beliefs, bibliotherapy, role-playing, and operant conditioning.
Outcome Measures
There are a lot of psychological tools available to measure the effectiveness of therapy. The Schwartz Outcome Scale (SOS-10) is one of the effective tool used to measure outcome in CBT. It is sensitive to psychological change. It is initiated at the first visit to establish a baseline and then measured at each weekly visit for 24 weeks. A change in the score will indicate if therapy is effective. Brittny’s progress can be measured in terms of school attendance, self-perception, peer relationships, academic performance, and relationship with parents.
References
Beck, J.S. (2011). Cognitive behavior therapy: Basic and beyond. New York, NY. The Guildford Press
Corey, G. (2017). Theory and practice of counseling and psychotherapy. Boston, MA: Cengage Learning.
Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse a how-to guide for evidence-based practice. New York, NY: Springer Publishing Company, LLC.