case conceptualization group therapy CBT and psychodynamics

Abstract
This case conceptualization covers a weekly outpatient relationships group consisting of fifteen members, ages 25-50. All group members have been formally diagnosed with Generalized Anxiety Disorder and/or Depression, and some with more than one clinical disorder. Additionally, all members have attended this group for at least six months, most of whom attend regularly on a weekly basis. The case conceptualization includes background information on the clients, behavioral observations, clinical interpretations, and diagnostic impressions based on the DSM-5. A treatment plan and interventions for the clients are grounded in two primary theoretical orientations including cognitive behavioral therapy (CBT) and psychodynamics. A summary of the treatment, including client reactions, plus future recommendations are also provided. Ethical issues and quandaries are presented in accordance with the American Counseling Association (ACA) Code of Ethics. Finally, limitations and supervision needs are discussed in light of scope of counseling practice.
Background: Presenting Problem
Clients’ Biopsychosocial History
Of the fifteen group attendees, seven are female and eight are male. All have been in treatment for at least six months and have received formal diagnoses using clinical assessments by a referring psychologist or psychiatrist. Six of the clients have been diagnosed with Depression. Five have been diagnosed with Generalized Anxiety Disorder. Four have been diagnosed with both Depression and Generalized Anxiety Disorder. Moreover, three of the clients have been diagnosed with substance use disorder.
In terms of ethnic backgrounds, five of the clients are white, one is East Asian, one is South Asian, two are African American, four are Latino, and two are of mixed heritage. Their ages are between 25 and 40, and they are from diverse socioeconomic backgrounds and levels of educational attainment with three of the clients holding advanced degrees, and seven with undergraduate degrees. Religious affiliations are important to ten of the fifteen group members. Of those nine who affirm the importance of religion in their lives, five identify as Christian/Protestant, two as Catholic, one as Jewish, and one as Muslim. Of the other six group members who do not cite religion as being important in their lives, three claimed that they had some kind of spiritual practice or belief system that was not part of organized religion, and the other three claimed to be either agnostic or atheist.
Behavioral Observations
Using a mental status exam (University of Nevada, Reno, 2020), formal observations and assessment methods were used to provide an overview of client functioning. Specific sections of the mental status exam given include the following. First, general physical observations related to the clients’ appearance, manner of dress, and mannerisms were made, followed by observations of speech patterns, and interactions with others in the group. Second, thinking patterns and cognitive-emotional states are assessed based on the content of the client’s speech, including expressions of emotion, whether the client is more focused on the past or on the future, the client’s judgments and clarity, and level of self-awareness or insight. Because of the diversity of the clients comprising the group, behavioral observations reflect individual differences. Given their dedication to attending regular meetings, all of the group members are actively engaged in the group and cooperative with regards to keeping to the group regulations such as refraining from judgment or interruption.
Clinical Interpretations
Based on clinical observations of the clients comprising the group, the clinical interpretations reflect the formal appraisal of client performance in the group in conjunction with valid assessments that lead to formal diagnoses. Using a combination of cognitive-behavioral therapy and psychoanalysis allows for nuanced clinical interpretations that account for the intricacies and idiosyncrasies of an individual’s upbringing, social climate, educational attainment, job status, gender, and other variables. “Part of the counselor’s job is to decide which theoretical approach is a good fit with the client’s needs, and then use that approach to finish the case conceptualization,” (“Clinical Thinking Skills,” n.d., p. 31). Therefore, the clinical interpretations for individual clients will vary depending on the formal diagnoses of each client and individual client needs with regards to therapeutic interventions.
Diagnostic Impressions
The mental and behavioral health team contributes to diagnostic impressions, based on the results of formal assessments such as the GAD-7 and GAD-2, which are valid instruments used to assess clients for generalized anxiety disorder (Plummer, Manea, Trepel, et al., 2016). Comorbidity (particularly with GAD and MDD) was evident among group members. However, the tools used to assess clients may have varying degrees of sensitivity. As Van Loo, Schoevers, Kendler, et al., (2015) point out, a low threshold for diagnosing major depressive disorder is more likely to lead to a comorbidity diagnosis for a client. While the DSM-V does not offer guidelines for classifying patients as being mild, moderate, or severe, the clinician may discriminate between depression severity among patients with the diagnosis (Tolentino & Schmidt, 2018). It is also worth noting the various “overlapping mechanisms” in generalized anxiety disorder and major depressive disorder,” especially with regard to negative emotion generation (MacNamara, Kotov & Hajcak, 2016, p. 275). Differential diagnoses involved screening clients according to the DSM-5 guidelines as follows.
Generalized Anxiety Disorder (GAD)
Notoriously “challenging” to diagnose, GAD manifests differently for different people (Glasofer, 2019, p. 1). Primary symptoms include persistent worry that is “excessive,” difficult to manage, and which interferes with daily life for a period of at least six months (Glasofer, 2019, p. 1). To receive the formal diagnosis of GAD, the client must also exhibit at least three of the following symptoms: restlessness, fatigue, irritability, difficulty concentrating, muscle aches, and difficulty sleeping. Differential diagnoses allow the clinician to determine whether the client does not have some other related disorder, such as social anxiety disorder, an eating disorder, obsessive-compulsive disorder, or a panic disorder—some of which could co-occur with generalized anxiety disorder. Group discussions related to anxiety focused on examples of how the symptoms of GAD manifest, taking great care to show how age, gender, race, religion, and other factors might impact symptom expression. Going over the DSM-5 checklist of symptoms in the group helped those diagnosed with GAD to recognize the reason for their diagnosis and set appropriate, reasonable treatment goals. An open discussion also permitted differential diagnosis for those whose symptoms might have been related to other conditions or who may be eligible for a dual diagnosis as several of the members of this group were.
Depression
The client needs to exhibit five or more of the following symptoms over a two week period in order to be diagnosed with clinical depression: daily depressed mood, diminished interest in life activities, change in eating habits or appetite, slow thoughts and slow physical movements, fatigue, feeling worthlessness or guilt, inability to concentrate, and suicidal ideation. Some of these symptoms correspond with anxiety disorder, which is why comorbidity is common. Moreover, both GAD and MDD need to be differentiated from disorders that can also cause similar symptoms—and do need to be distinguished from the depression or anxiety caused by acute trauma or the use of alcohol or drugs.
As was the practice regarding GAD, the group leader also discussed the symptoms of depression to help members of the group reflect on the progression of their illness and monitor signs of recovery. Group members also shared their subjective impressions regarding how their mental health issues were perceived by friends, family members, and coworkers, how they first became aware of their condition, and how their diagnosis might cause them to cultivate greater self-awareness.
Treatment Plan and Interventions
Treatment plans for individuals are different from the general treatment plans given to all group members. The treatment plan is rooted in the theoretical orientations used in the group, including cognitive behavioral therapy and psychodynamic theory. An effective treatment plan includes short and long-term goals, plus various interventions designed to help the clients achieve those goals. Also, the goals are established with the means by which to assess and measure outcomes.
Relationally-based group psychotherapy “utilizes the group setting as an agent for change and pays careful attention to the three primary forces operating at all times in a therapy group: individual dynamics; interpersonal dynamics; and, group as a whole dynamics,” (American Group Psychotherapy Association, 2007, p. 3). Therefore, a treatment plan can reflect the collective goals of the group, which meets weekly in order for the individuals to achieve their specific short-term and long-term objectives. The group treatment plan and interventions parallel and synchronize with the individualized treatment plans for each client. Aspects of the plan included regular attendance of group meetings and individual counseling sessions, compliance with any prescribed medications issued by a psychiatrist, active participation in the group with evidence of fulfillment of the exercises and interventions. Group discussions also sometimes revolved around the merits of particular strategies such as meditation or breathing techniques used as part of the cognitive-behavioral therapeutic intervention.
Theoretical Orientation
The theoretical orientation combines cognitive-behavioral therapy with psychodynamics. Both cognitive-behavioral and psychodynamic theory have been systematically proven effective in group therapy, with measurable results so long as clients remain in the group (Thimm & Antonsen, 2014). In fact, cognitive-behavioral and psychodynamic theoretical orientations are frequently combined for application in outpatient group therapy sessions for those with mood disorders like depression and anxiety disorders (Suszek, Holas, Wyrzkowski, et al., 2015). Cognitive behavioral therapeutic interventions are used to help clients recognize faulty thought patterns and to change them, while psychodynamic interventions encourage clients to analyze their current state in light of past events. The goals of treatment are the same: to reduce, minimize, or eliminate symptoms, and also to improve overall functioning.
Goals and Interventions: Cognitive Behavioral Therapy and Psychodynamic
The goals established need to be attainable and measurable, allowing client and therapist to assess progress and determine the efficacy of the interventions. Both cognitive behavioral therapy and psychodynamic methods were used to help clients achieve treatment goals. The goals included negative thought stopping, reframing, a remission of depressive symptoms, the development of a toolkit for emotional self-mastery, and the reduction or elimination of persistent anxiety. More specific goals would also align with client concerns including dietary or lifestyle regulation and sleep management.
Interventions delivered through the group included psychoeducation, empowering the clients with knowledge related to their condition, triggers, and the various CBT tools they can use in their daily lives to manage difficult emotions or triggers. After psychoeducation, the clients are better situated to incorporate the specific CBT tools such as “relaxation, cognitive restructuring, and exposure,” which are presented to clients in the form of information handouts (Wolgensinger, 2015, p. 348). The psychodynamic interventions included homework assignments that are highly reflective in nature, asking clients to write about their life story or specific anecdotes from their past and then share their learning experiences with the group. Therapists leading the supportive group also work with members to explore the the meaning of their insights into past events or formative experiences. The group dynamics provide a helpful means by which members can discuss the results they have already achieved, assisting their peers in altering their approach to applying the CBT methods in their daily lives. Providing clients with a number of different interventions ensures that each person will find whatever works for them, and what helps each person to achieve goals.
Treatment Plan Summary and Client Reactions
The treatment plan includes dedication to the group for a set period of time, along with regular individualized and/or family counseling. All clients incorporate both CBT and psychodynamic interventions into their treatment plans. Clients journal, and share a weekly progress report with the group leader and peers. Some clients become frustrated when a week or two go by without any measurable or recognizable outcomes. The group leader and peers remind the clients who feel a sort of plateau to keep working their treatment plan. Simply showing up to the group sessions is an indicator of a successful treatment plan.
Client reactions vary, and fluctuate. Some clients vacillate between elated self-confidence or optimism and their polar opposites of cynicism, depression, and hopelessness. Others seem more stagnant, albeit with sudden and unexpected bursts of clarity and epiphany leading to symptom reduction and the fulfillment of treatment goals. Clients respond well to the interventions overall, with no overt signs of rebellion or noncompliance. As expected, though, a good number of clients do resist change at various stages. Some find it difficult to incorporate the new routines into their daily lives: such as journaling or thought stopping. It helps to inform clients that the process does involve their hard work and dedication, and that their efforts will pay off.
Ethical Considerations: ACA Code of Ethics
Section A9 of the ACA (2014) Code of Ethics covers group work. One of the main ethical considerations outlined in the ACA (2014) Code of Ethics is the importance of pre-screening group members (A.9.a). All group members in this case were screened using multiple methods. The importance of screening group members prior to commencing cannot be underestimated, as a cohesive group is uniquely conducive for success. The members of the group need to have similar goals and objectives related to anxiety and depression, allowing the development of a group-oriented treatment plan in spite of the diverse individual needs. Also, screening prevents the inclusion of potentially disruptive members that could prove unsettling or even traumatic to other members of the group.
The counselor also needs to be aware of the risks involved in group therapy with regards to confidentiality and privacy agreements. Section B of the ACA (2014) Code of Ethics covers all issues relevant to confidentiality and privacy in the therapeutic relationship. When the group is formed, all members need to become aware of the importance of mutual trust, maintaining boundaries, and respecting the right of all clients to privacy. Just as no group member is ever required to share anything publicly that they do not wish to share, clients are instructed explicitly to refrain from sharing the details of the group meetings with anyone outside the group. In all group work, “counselors clearly explain the importance and parameters of confidentiality for the specific group,” (ACA, 2014, B.4.a). In this case, the clients were handed out a form that they had to sign for relevant informed consent to participate. Finally, the ACA (2014) clarifies the importance of respect for diversity in all settings, calling on the group leader to ensure a respectful environment free from micro-aggressions or more overt acts.
Limitations of Treatment and Supervision Needs
The use of CBT and psychodynamics in group therapy interventions has been well-established, especially effective with a client group with generalized anxiety disorder and depression. However, there are bound to be limitations of the treatment that need to be acknowledged and addressed. Some clients will also be taking medications through a psychiatrist, which will affect treatment goals and outcomes. Unless the group leader is a licensed psychiatrist, there will also be a need for collaborative work with other members of the healthcare team. Other limitations include the inability to know the degree to which clients are following through with treatment plan recommendations at home or outside of the group context. The counselor factors in issues related to diversity, but cannot be aware of all the pertinent variables that might impact individual responses to the treatment plan, the interventions, or to other members of the group.
Supervision is inevitable to help maintain the efficacy of a group being led by relatively inexperienced counselors or those whose areas of expertise do not closely correspond to the presenting problems of the group members. In counseling, supervision is “an intensive, interpersonally focused relationship in which one person is designated to facilitate the professional competence of one or more other persons,” (American Group Psychotherapy Association, 2007, p. 35). In this case, supervision is used at the beginning during the screening process, and also throughout the group meetings whenever issues related to differential diagnoses or assessment are called into question. Supervision was and will be needed when specific assessments are administered, to ensure that all members of the team meet the legal an dethical requirements of the ACA (2014). Similarly, all the diagnoses given to clients need to be accurate, requiring a collaborative approach that in many cases extends beyond the scope of the counselor’s clinical practice. When the ethical considerations are taken into account, supervision is used, and limitations of the treatment strategies are addressed and systematically overcome, then the counselor is in a position to help clients reach their treatment goals.
References
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American Group Psychotherapy Association (2007). Practice guidelines for group psychotherapy. Retrieved from: https://www.agpa.org/docs/default-source/practice-resources/download-full-guidelines-(pdf-format)-group-works!-evidence-on-the-effectiveness-of-group-therapy.pdf?sfvrsn=ce6385a9_2
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