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Cognitive Behavioral Therapy Case Study

Introduction to Cognitive Behavioral and Rational Emotive Behavior Therapy

In general, Rational Emotive Behavior Therapy (REBT) is one form of the broader category of Cognitive Behavioral Therapy (Westbrook & Kirk, 2005). In principle, CBT provides a clinical psychotherapeutic approach that combines the most tested and proven aspects of Freudian psychotherapy or classic psychodynamic theory with behavior and cognitive therapy (Westbrook & Kirk, 2005). Under the CBT approach, psychodynamic concepts are applied to the types of clinical issues that clearly relate to psychodynamic roots and conflicts whereas behavioral and cognitive concepts are applied to help patients change the way that they perceive and process information and self-perceptions that play roles in their presenting problems. All forms of CBT emphasize retraining the patient to question fundamental assumptions and beliefs that are part of their underlying problems (Hoffman & Smits, 2008).

The REBT approach in particular is based on the fundamental principle that all people have a natural desire to be happy and that the inability to achieve happiness is typically attributable to three main types of irrational belief: first, that the approval of others is essential; second, that the failure to be treated as one wishes by others means that they are contemptible; and third, that my inability to achieve exactly what I desire for myself is a horrible situation (Butler, Chapman, Formanc, et al., 2006). Furthermore, rigid adherence to each of these fundamental beliefs corresponds (respectively) to depression, anxiety, guilt, and shame; anger, violent rage, and passive-aggression; and to low self-esteem, self-pity, and self-loathing (Butler, Chapman, Formanc, et al., 2006).

Application to David

Basic Philosophical Assumptions and Implications for Therapeutic Practice

Most generally, cognitive behavioral therapy and rational emotive behavioral therapy are based on the philosophical assumption that many aspects of personal psychological dysfunction with which patients typically present are the result of fundamental personal beliefs that patients have internalized about themselves. For example, David has accepted the negative propositions that he is, essentially, a worthless human being who would never be able to earn the genuine admiration, much less the love, of others and that he is a "rotten" person who perpetually lets others down and who is inadequate as a man in the context of a relationship with a woman.

In the absence of specific information connecting those negative aspects of David's self-perception, a therapist would assume that experiential elements of David's formative developmental history are responsible for implanting these self-defeating assumptions about the type of person he is. Naturally, one would immediately suspect issues within his family of origin and make appropriate inquiries into the character and quality of David's relationship with his parents and siblings, especially in childhood and adolescence. In David's case, much of the therapist's initial work is already obviated by the extent to which David is already consciously aware of the specific roots of most of his internalized negative messages that account for his low self-regard. While he may not necessarily be aware that the memories he relates are specifically linked to his problems, just by virtue of his conscious recall of the events and circumstances that he has shared, David would have already saved the therapist a significant amount of time and effort making inquiries designed to elicit and identify exactly the root causes evident in his unfortunate family history.

Most Important Therapeutic Goals and the Role of the Counselor

Ordinarily, the initial therapeutic goals of a case such as David's would consist of identifying the specific root causes of the patient's low self-regard and low self-esteem (Butler, Chapman, Formanc, et al., 2006). Because David is consciously aware of them and has already provided those details in his narrative, the therapist would begin by providing David with an overview of the connection between his dysfunctional family history and his poor self-image. The therapist would explain that David's reaction to the experiences to which he was subjected within his family of origin and the explicit messages from his parents caused him to internalize the beliefs and characterizations of his mother (in particular) and that the goal of therapy would be to help David recognize the falsity of those beliefs for the express purpose of allowing him to reject those false premises so that he could eventually improve his self-regard and raise his self-esteem and his perceptions about his value as a person and his worth to others to achieve a level of self-regard that is much closer to that of a person who was never subjected to those negative characterizations and beliefs.

Specific Goals for David's Therapy

In some important respects, David's situation may be more amenable to treatment through the more general CBT approach than through the REBT form of CBT. That is because David exhibits all of the classic symptoms associated with the CBT/REBT model (i.e. depression, anxiety, guilt, and shame; anger, violent rage, and passive-aggression; and low self-esteem, self-pity, and self-loathing), but he has not expressed the foundational REBT beliefs that correspond to those symptoms other than his preoccupation with his failure or inability to achieve the approval of others. Therefore, the immediate goals for David's therapy would correspond to increasing his awareness of the specific causal connection between the explicit messages from his family of origin that he has internalized and that interfere with his ability to develop interpersonal confidence, self-worth, and a belief of self-efficacy that more accurately reflects the objective reality of his situation. More specifically, the therapist would help guide David toward an understanding that his worst beliefs about himself are functions of what he was told by his mother (in particular) rather than reflections of the truth and that it would be his goal and responsibility in therapy to consciously change his beliefs about himself by confronting the falsity of those characterizations and beliefs. That process would be directed toward the most significant themes in David's inaccurate and undeserved self-perception in the following areas of his beliefs.

The Expectation of Rejection, Fear of Others, and Guilt

David expresses the belief and the expectation that if other people recognized him for the person that he really is, they would not like him. He expresses the belief that the key to overcoming is fear of rejection by others is to achieve a professional career and a position in life that they will respect. As a therapist, it would be a goal of treatment to help David understand that it is an inaccurate premise because he is the only person who regards himself as a failure because of his current position in life and that no professional achievement will be enable him to overcome that perception until he confronts the false underlying premise and the belief. The therapist would help David recognize that many people are still completing their undergraduate degrees at 26 and that on some level, he already knows that his current academic pace is largely a function of the practical need to juggle work and school simultaneously.

Reconciling Self-Responsibility and Appropriate Blame of Others

On one hand, David recognizes that members of his family (especially his mother) treated him unfairly because he fantasizes about forcing them to confront that reality after his suicide. In the process of helping David understand why suicide would never achieve this goal and that it would only confirm the false beliefs his family may have of him, the therapist would want to help David recognize that his sentiments about his mother's responsibility for treating him badly conflict with his simultaneous feelings of guilt for being everything that she falsely believes about him. In that regard, it would be appropriate for the therapist to help David reject the false premise of his mother's that any child could ever be responsible for ruining her life. This area might be amenable to psychodynamic therapy in connection with helping David…[continue]

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