SOCW 6121 Week 3 CBT Case Conceptualization Example

One Morning, Five Parts and a Return to Bed: A CBT Case Conceptualization of a Laid-Off Press Operator That Traces How the Thought "No One Hires a Man My Age" Feeds Shame, Fatigue and Withdrawal, Explains Why the Pattern Persists and States What the Formulation Predicts

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Walden University

SOCW 6121: Advanced Clinical Practice II

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Month Day, Year

One Morning, Five Parts and a Return to Bed: A CBT Case Conceptualization of a Laid-Off Press Operator That Traces How the Thought "No One Hires a Man My Age" Feeds Shame, Fatigue and Withdrawal, Explains Why the Pattern Persists and States What the Formulation Predicts

The Five-Part Model Applied

The conceptualization uses the five-part model associated with Padesky and set out in Greenberger and Padesky (2016), which places a person's thoughts, moods, physical reactions and behaviors inside the environment in which they occur, with each area influencing the others. Table 1 lays out one typical weekday morning for Dale, the composite client assessed in Week 1.

Table 1

Five-Part Model of One Weekday Morning

Arrows in the original diagram run in both directions between each pair of areas; the environment surrounds the other four.

How the Areas Feed One Another

On a typical morning the sequence begins in the environment. His wife's departure leaves the house empty, and the sight of the brochure prompts the thought that no one will hire him. That thought produces shame, and shame brings the heaviness and fatigue he describes in his shoulders and legs. Feeling tired and ashamed, he returns to bed. Returning to bed then confirms the original thought: by ten o'clock the morning has gone, he has done nothing toward a job, and the evidence seems to show that he is indeed someone who will not be hired. The cycle closes, and the next morning starts in the same place.

Kuyken et al. (2008) describe case conceptualization in cognitive therapy as moving from description, which sets out what happens, toward explanation, which accounts for why a pattern persists, and they argue that the process should be collaborative, with the client's own words and theories at its center. The five-part table is the descriptive level. The sections below move to explanation.

Why the Pattern Persists

Three features keep the cycle going. The first is avoidance. Returning to bed relieves shame in the short term, because there is no one to face and nothing to fail at, and that relief makes it more likely he will return to bed again. Avoiding the brochure works the same way. The second is the absence of disconfirming evidence. Because he does not apply for anything, he never learns whether his belief that no one will hire him is accurate, and the belief therefore goes untested. The third is the loss of activities that once gave him a sense of competence and connection, including the breakfast with former coworkers and helping at the union hall. Without them, the only evidence about his worth comes from the empty house.

A deeper belief may underlie the surface thought. In conversation, Dale said that "a man who doesn't work isn't worth much." Beck (2020) distinguishes automatic thoughts, which arise in specific situations, from intermediate beliefs and core beliefs, which are broader rules and convictions about oneself. The thought about not being hired is automatic; the statement about a man who does not work sounds like a rule. If so, it explains why the layoff hit him harder than the loss of income alone would suggest, and why the shame is so persistent.

His Strengths in the Formulation

Dale's strengths belong in the conceptualization because they mark places where the cycle is already weaker. He still helps his son with car repairs, and on those afternoons his mood rating drops to about 4. That suggests the cycle depends on idleness and isolation, not on an unchangeable view of himself. He is also honest about his patterns: he named the return to bed himself in session two. And he values his family enough to attend sessions he was unsure about. Kuyken et al. (2008) argue that including strengths in a conceptualization helps clients see themselves as more than their difficulties and gives the worker resources to build on.

What the Formulation Predicts

If the formulation is right, three things should follow. First, on mornings when Dale has a planned reason to leave the house before his wife's shift ends, his mood rating should be lower and he should be less likely to return to bed, because the environment that triggers the cycle has changed. Second, if he takes one small step toward the certificate, such as calling the college with a question, the belief that no one will hire him should weaken somewhat, because he will have some disconfirming evidence. Third, if he rejoins one group activity, such as the union breakfast, his ratings on that day and the next should improve. If none of these changes produce any shift in mood, the formulation may be missing a factor, such as the effects of the workplace accident or of evening drinking, and should be revised with him.

References

Beck, J. S. (2020). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford Press.

Greenberger, D., & Padesky, C. A. (2016). Mind over mood: Change how you feel by changing the way you think (2nd ed.). Guilford Press.

Kuyken, W., Padesky, C. A., & Dudley, R. (2008). The science and practice of case conceptualization. Behavioural and Cognitive Psychotherapy, 36(6), 757-768. https://doi.org/10.1017/S1352465808004815