CBT and Solution-Focused Therapy: Case Conceptualization

Introduction to Case Conceptualization

This paper presents two counseling case conceptualizations, each applying a distinct therapeutic framework to a specific clinical concern. The first case examines Cognitive Behavioral Therapy (CBT) as it applies to suicide risk and stress. The second case examines Solution-Focused Brief Therapy (SFBT) as it applies to drug and alcohol addiction. Each case is analyzed in terms of areas of concern, presenting symptoms, the client's pathway to the current mental state, therapeutic goals and expected outcomes, specific interventions, and the role of the counselor.

Case One: CBT for Suicide and Stress

Areas of Concern: Suicide and Stress

Stress has been found to play a major role in suicide risk, mental disorders, and mood swings. Stress is a term most people use synonymously with negative experiences in life. Negative life events that confer risks of depression, suicidal thoughts, and suicidal behavior include interpersonal, traumatic childhood, and occupational events. Trauma — most notably childhood trauma — has important short-term and long-term effects on suicidal behavior risks. In particular, child abuse (physical, emotional, and sexual), parental mental illness, parental death, and witnessing domestic violence in childhood have all been connected to acute suicidal behavior over long intervals.

Interpersonal life events are also known to increase suicidal behavior risks. The death of a spouse or parent, serious conflict with a colleague, and social exit events (such as a child running away from home) have been connected to suicide attempts by adults, while parental separation and relationship break-ups have been associated with suicide among young adults and adolescents. The interpersonal events considered most essential to suicidal behavior appear to be those involving conflict or loss within current interpersonal relationships, rather than simple social isolation (Cornette & Busch, 2016).

How the Client Arrived at This Mental State

The foundation of the CBT model for suicidal thoughts and behaviors was formed by A. T. Beck's cognitive triad. In Beck's view, suicidal patients suffering from depression perceive themselves as inadequate, defective, diseased, or deprived — and therefore undesirable and worthless. They perceive others as unsupportive and rejecting, demanding too much of them. They perceive their future as hopeless, believing they lack the internal or external resources needed to solve their problems. This defective sense of self contributes to a passive approach to problem-solving; they stop trying to resolve their difficulties, hoping for an automatic solution. Since they believe no one cares about them and that their problems are overwhelming, they give up. Without the support of others or personal coping skills, they conclude that there can never be any future (Matthews, 2013).

Symptoms, Goals, and Interventions in CBT

Symptoms of Stress and Depression

The following symptoms characterize stress-related depression relevant to this case:

Feelings of hopelessness and helplessness. A bleak outlook — the belief that things can never improve and that nothing can be done to change one's situation.

Loss of interest in everyday activities. Lack of interest in past hobbies, social activities, pastimes, or sex; loss of the ability to feel pleasure and joy.

Changes in appetite or weight. Significant weight gain or weight loss — a change of up to 5% of body weight per month.

Changes in sleep patterns. Either insomnia (especially waking in the early hours) or sleeping too much (hypersomnia).

Irritability or anger. Feeling restless, agitated, or even violent; a low tolerance level and short temper.

Energy loss. Feeling sluggish, fatigued, and physically drained; small tasks may become exhausting and take much longer to complete.

Self-hate. Strong feelings of guilt and worthlessness; harsh self-criticism for any perceived mistakes or faults.

Recklessness. Engaging in escapist behaviors such as compulsive gambling, substance abuse, reckless driving, or dangerous sports.

Lack of concentration. Difficulty staying focused, making decisions, or remembering important details.

Unexplained pains and aches. Increasing physical complaints such as back pain, headache, stomach pain, and aching muscles.

Warning Signs of Suicide

In addition to depressive symptoms, the following behavioral warning signs of suicide are relevant (American Foundation for Suicide Prevention, 2016):

Increased alcohol or drug use; searching for means to cause self-harm (including online); withdrawing from activities; acting recklessly; avoiding friends and family; sleeping too little or too much; calling or visiting people to say goodbye; giving away prized possessions; and increased aggression.

Therapeutic Goals and Expected Outcomes

Suggested NOC Labels: Depression Control, Cognitive Ability, Impulse Control, Distorted Thought Control, Suicide Self-Restraint, Self-Mutilation Restraint, and Will to Live.

Client Outcomes: The client does not harm themselves; expresses reduced anxiety and control over hallucinations; communicates thoughts and expresses anger appropriately; does not access harmful objects; and relinquishes access to harmful objects.

Specific Interventions and Nursing Rationales

Suggested NIC Labels: Anxiety Reduction, Coping Enhancement, Crisis Intervention, Suicide Prevention, and Surveillance.

1. Establish a therapeutic relationship with the client. Research demonstrates the significance of this relationship in the detection and prevention of suicide.

2. Observe, document, and report the client's potential for suicide. Behaviors such as poor social adjustment, impulsivity, and mood disorders are linked to suicide attempts, particularly in adolescents.

3. Be alert for warning signs of suicide, including verbalizations such as "I can't continue," "Nothing means anything to me anymore," or "I would have been better off dead"; becoming withdrawn or depressed; behaving recklessly; arranging affairs and giving away valued possessions; showing distinct changes in behavior, appearance, or attitude; abusing alcohol or drugs; and experiencing a major life change or loss. Suicide is rarely a spontaneous decision — in the days and hours preceding it, there are almost always warning signs and clues (Befrienders International, 2001).

4. Evaluate suicidal ideation when the client's history includes alcohol and drug abuse, depression, other mental disorders, a prior suicide attempt, recent unemployment, recent separation or divorce, recent bereavement, or chronic pain (Nursing Interventions and Rationales, 2015).

Role of the Counselor in CBT

The therapist's roles in CBT-SP involve providing education to both the patient and the family during the early stage of treatment. The first task is explaining the nature of suicidal behavior, the role that depression plays, and why it is important to secure potentially dangerous objects. The therapist also explains the principles and goals of CBT-SP to the patient and family. Parents may help provide their perspective on the sequence of events leading up to a crisis and may contribute to developing and implementing safety plans. Although parents contribute to the chain analysis and safety planning, the clinician works with the young patient to determine which parental contributions are genuinely useful in improving the patient's understanding of the chain of events and enhancing safety. Ultimately, the adolescent's own perspective on the sequence of events is considered most essential (Stanley et al., 2010).

Case Two: Solution-Focused Therapy for Addiction

Areas of Concern: Confusion, Uncertainty, and Addiction

Addiction to any activity or substance is among the most complex areas of psychiatric health. Treating addiction can be quite difficult, and there are many controversies surrounding its primary causes and the most effective treatment approaches. Persons experiencing addiction to alcohol or drugs often find mental health services essential for overcoming their addiction.

How the Client Arrived at This Mental State

Biological, social, physiological, and psychological factors are all important determinants of whether a person will abuse drugs or alcohol. A family history of substance abuse makes an individual more prone to addiction, and certain social factors — such as ease of availability and peer pressure — increase the likelihood of developing drug or alcohol addiction. Additionally, once a person begins heavy substance use, physiological changes occur and physical dependence develops, requiring continuous use to avoid withdrawal symptoms.

Some families have a higher incidence of alcoholism, though not every child of an addicted parent becomes addicted; the degree to which alcoholism is genetic has remained a subject of debate. Some researchers have searched for an alcoholism or addiction gene, and some note that observing a parent drink as a way of managing stress may increase the likelihood that a child will resort to the same coping mechanism. According to some studies, genes that influence a person's response to alcohol may account for more than half of the risk of developing alcoholism — with some genes raising risk and others potentially reducing it.