Stepps Case Conceptualization (10_12_15)

Running Head: JOSEPH STEIN CASE CONCEPTUALIZATION 1

Joseph Stein Case Conceptualization

Sara Eliason

Philadelphia College of Osteopathic Medicine

JOSEPH STEIN CASE CONCEPTUALIZATION 2

Case Conceptualization

Client’s Name: Joseph Stein

Evaluation Date: 9/14/15

Evaluator: Sara Eliason

Identifying Demographic Information

Joseph Stein is a 65 year old Caucasian male. Joseph has been married but is recently

widowed and is the father of two daughters. Joseph is currently retired.

Reason for Referral

Nature of Complaint

Joseph was referred to counseling by his daughter. She is concerned that Joseph has not

been himself since the death of his wife three years ago and the loss of his advertising agency

shortly thereafter. Joseph agrees that he has not been feeling himself, stating he cannot get

beyond where he is and cannot seem to move forward from his past losses. Joseph also feels as

though life has lost most of its meaning. He feels stuck at this point in his life and does not want

to continue feeling at a standstill, stating something has to change. Joseph also believes that he is

a burden to his daughters and feels they do not belong in his home caring for him. Joseph feels

that if he can change his current lifestyle, his daughters will feel less concerned with him and

will return to their own families.

History of Complaint

Prior to losing his wife, Joseph was a hardworking, family man. He explained spending

much of his time either at work or with his family. Joseph appears to have no past history of

mental illness, and has now begun feeling stalled since the death of his wife three years ago and


the loss of his advertising company two years ago. Joseph struggles daily with feeling stagnant in

his life and also feels guilt for pulling his daughters away from their families each time they visit.

Consequences of Complaint

Joseph is lacking the motivation to do daily living tasks and experiences feelings of

sadness. Joseph reports having no enjoyment from life other than seeing his family; however, his

guilt of taking his daughters away from their families is impacting his enjoyment from spending

time with them. Joseph feels it is not their place to be caring for him and he finds himself

wishing they would go home despite feeling elated to see them. Joseph has begun self-isolating

because he feels as though no one is interested in hearing about his life anymore.

Relevant History

Family History

Joseph has a healthy and caring relationship with both of his daughters. His family

consists of his daughters, Gretchen and Elizabeth, each in their thirties, their husbands, John and

Don, and one granddaughter, Jane, who is 12. He reported having a loving and caring

relationship with his late wife, Maryam. Currently, Joseph receives much support from his

daughters and sees them at least once a week, Gretchen every day. Joseph appreciates seeing

them but is beginning to feel he is a burden to them. He is concerned his daughters may lose their

current families because they are investing too much time with him. In the past, Joseph’s family

relationship was supportive and loving; he spent much of his free time raising his daughters and

spending quality time with the family, such as attending shows, markets, and various town

events. Joseph and I will discuss his family of origin in upcoming sessions and learn about the

impact his family may or may not have on his current problems. Knowing family or origin

information is helpful to know as it may reveal any biological or genetic predispositions he may


have (American Psychiatric Association (APA), 2013), uncover any learned behaviors or

thoughts, may unveil factors that contribute to his current self-concept (Bembnowska & Josko-

Ochojskha, 2015), or serve as a protective factor against developing depressive symptoms

(Ivanova & Israel, 2005).

Social Support

Joseph does not currently seek friendship with his past co-workers and did not have many

friends or hobbies in the past. Much of his social support stemmed from his family. When he did

spend time with co-workers, their discussions centered around work. Joseph is currently retired

and so he no longer feels connected to those co-workers and feels they have nothing in common

or nothing to discuss. Relying on outside social support can often times be a preventative factor

against symptoms of depression; being that Joseph is lacking social support at this time may

contribute to his current struggles (Ibrahim, Din, Ahmad, Ghazali, Said, Shahar, Ghazali, &

Razali, 2013). Although Joseph has his daughters as strong social support, he feels much guilt

around spending time with them; therefore, their support at this time is less constructive.

Employment History

After Joseph attended college, he began his own advertising agency and spent many years

perfecting and building a successful business. Joseph cared much for the company and referred

to it as his son, implying that the business was an extension of himself. Joseph also alluded that

the company was very successful and stated it was possibly the best in the tristate area. After

some time and success, Joseph decided to take the company public. Sometime after his wife’s

passing, a board of trustee’s deemed that it would be best for Joseph to step down from his

position as CEO and possibly retire. Joseph agreed and is currently retired. He feels no animosity

toward the company and believes it was the correct move for the company to move forward. It’s


important to note Joseph’s business success, education, and overall socioeconomic status as it

can sometimes be a protective factor or contributing factor to symptoms of depression

(Bembnowska &Josko-ochojska, 2015). In Joseph’s case I believe it may be a protective factor.

Medical, Psychiatric, and Substance Use History

Joseph did not discuss any past medical or mental health issues. He disclosed never

having visited a counselor. Joseph is not currently taking any medications, nor is he currently

under the care of a physician. His last visit to his primary care physician was shortly after the

death of his wife. During that visit, his clinician assessed for physical or mental health struggles

as the result of his loss and prescribed him an antidepressant, possibly Zoloft. Joseph reported

taking it for a few months but discontinued use as it did not relieve him of his feelings of grief.

Joseph reported drinking an occasional glass of wine with his meals, about once or twice a

month, but does not, and has never, used or abused alcohol or other substances. In future sessions

Joseph and I may explore further relevant medical history as well as family medical and

psychiatric histories. Knowledge of a client’s medical history may reveal feelings surrounding

health and current medical state as well as susceptibility to medical or mental health issues

(IsHak, Greenberg, Saah, Mobaraki, Fakhry, Wu, Ngor, Yu, & Cohen, 2013). Also, being aware

of any family psychiatric or medical histories may also reveal biological predispositions Joseph

may face (Maradiegue, Lyon, &Meyers, 2013). Additionally, family medical and psychiatric

histories may have an impact on a client’s thoughts and feelings around health and mental health

and may contribute to any current struggles surrounding behavioral health ((Bembnowska

&Josko-ochojska, 2015). Overall Joseph is in good physical health.

Resources and Spiritual Factors


Joseph and his wife were raised under Judaism and also raised their daughters to be

Jewish. Joseph disclosed that he is not very spiritual and does not necessarily believe in the

Jewish faith anymore. He reported attending synagogue because it was important to his wife and

important that his daughters learn Jewish values. Joseph has not attended synagogue since the

death of his wife. Joseph’s past faith practices may have played a role in protecting him from

past struggles and since he is no longer following his religion, he may be more susceptible to

symptoms of depression (Koenig, 2012).

Past and Present Coping Skills

Joseph mentioned that in the past when a problem arose, he has always been able to think

through the problem independently, and be decisive according to what is best for his family and

company. He revealed that he feels frustrated because the struggles he faces now cannot simply

be figured out and decided on, much like he has in the past. Although Joseph does not have much

peer support, he appears to have a lot of support and care from his daughters, who have

motivated him to begin attending therapy. Additionally, Joseph disclosed using work to escape

some of the struggles he faced. He reported often times working harder when he was struggling

with something and seemed to use work as a distraction to help him cope with any negative

feelings he may have had. Currently, because Joseph is retired, he can no longer use work to

distract himself and finds himself watching television most of the day to take his mind of his

losses and sad feelings. Joseph realizes the television is only a temporary fix and hopes to learn

better ways to spend his time with therapy. Often times, distraction can be a healthy means of

coping with some losses; however it seems as though Joseph has no other means of coping and

as a result continues to struggle with grief and sadness (Broderick, 2005).

Risk Assessment


Joseph reported having experienced suicidal thoughts in the past around the time he lost

his wife and business. Currently Joseph is no longer experiencing suicidal thoughts and reports

that abandoning his family is his main preventative factor. Joseph could be considered at low risk

for suicide (Jacobs, 2009). Joseph reports no homicidal ideations in the past or currently.

Assessment

Diagnostic Considerations

Given Joseph’s current state and expressed symptoms, and upon further evaluation of

Joseph’s sleep patterns, eating habits, energy level, and psychomotor functioning, Joseph may

meet a provisional diagnosis of Major Depressive Disorder (MDD) or Persistent Depressive

Disorder (PDD) (APA, 2013). In considering MDD as a diagnosis, Joseph meets three of the

needed five criteria from criterion A; depressed mood most of the day, nearly every day,

diminished pleasure or interest in almost all activities most of the day, nearly every day, and

feelings of excessive guilt. Additionally, Joseph meets all other (B-E) diagnostic features of

MDD (APA, 2013). When considering PDD, Joseph meets nearly all symptoms of PDD

including depressed mood most of the day, more often than not, for at least 2 years, the presence

of two or more depressed symptoms listed under criterion B including feeling hopeless, meeting

criteria for MDD continually over a 2 year period, and the absence of a manic or hypomanic

episode (APA, 2013).

Time frame plays a significant role in determining a diagnosis. Although Joseph

expressed the onset of symptoms beginning 3 years ago following the death of his wife, it is

important to consider normal grieving periods. During the past 3 years, Joseph has lost his wife

and his business, each warranting a significant grieving period. In order to substantiate one

diagnosis over another, I would further assess the time frame of experienced symptoms,


including a reduction or absence of symptoms during the past three years, symptoms present

before the loss of his wife, and Joseph’s self-esteem and self-concept during various points in

time. Moving forward I will assess for changes in eating or sleeping, energy level, and

psychomotor functioning to address further criteria for MDD or PDD and solidify the diagnosis.

Other diagnoses that can be considered include Agoraphobia, Social Anxiety Disorder

(SAD) and Bipolar II. One might consider Agoraphobia because Joseph reports rarely leaving his

home; however, Joseph did not express any feelings of fear or anxiety associated with leaving

the home, more a lack of motivation to do so (APA, 2013). Similarly, one could consider SAD as

to the reasons why Joseph does not leave his home, feels guilt upon spending time with his

family, and appears to be self-isolating; however, Joseph expressed no feelings of fear or anxiety

associated with entering social situations rather that he chooses not to associate with others for

feeling they lack common ground or a desire to spend time with him (APA, 2013). Similarly,

Joseph may demonstrate symptoms similar to that of Bipolar II such as experiencing a depressive

episode; however there is no indication that Joseph has experienced a hypomanic episode

recently or prior to his wife passing (APA, 2013).

Assessment Instruments

In determining a solid diagnosis for Joseph, I will consider using the Beck Depression

Inventory-II, the Beck Anxiety Inventory, the Beck Scale for Suicide Ideation, and the

Dysfunctional Attitude Scale, Form A. In the Beck Depression Inventory will be used to assess

the presence of depression, Joseph’s feelings of depression, and the extent of severity (Beck,

Steer, & Brown, 1996). The Beck Anxiety Inventory will be used to rule out the possible

diagnosis of agoraphobia and social anxiety (Beck, Epstein, Brown, & Steer, 1988). The Beck

Scale for Suicide Ideation will be used to further assess Joseph’s risk of suicide (Beck & Steer,


1991). Lastly, I will use the Dysfunctional Attitudes Scale, Form A to gain a better understanding

of what thoughts and feelings maintain Joseph’s sadness and grief (Weissman & Beck, 1978).

Comprehensive Problem List

1. Anhedonia: Joseph stated feeling like life has lost its meaning.

2. Feeling stuck: Joseph expressed feeling unable to progress and move forward from his

losses.

3. Self-Isolation: Joseph is self-isolating and only interacts with others when his daughters

come to visit. Joseph does not leave the house much.

4. Feelings of guilt in being cared for: Joseph feels guilt and shame in his daughters having

to care for him and feels they belong with their own families.

5. Lack motivation to carry out daily tasks: Joseph lacks the motivation to leave the home or

complete tasks such as getting the mail, grocery shopping, etc.

Case Conceptualization

Predisposing Factors

Assessing for Joseph’s family history and past experiences will provide insight as to

where he may have developed possible thought processes, behavior patterns, values, and beliefs

that may have lead him to feeling depressed, self-isolate, and feelings of guilt around being cared

for (Maradiegue & Meyers, 2013). It is possible that Joseph was raised in a family that valued

independence, hard work, and immediate family. As a result, Joseph may feel that coping with

his losses is something he must learn to do alone, leading him to self-isolate and feel guilt around

being cared for. Additionally, because Joseph values family, he focused all of his energy on them

and was successful at fostering a family life. Currently, Joseph still values his family but also

believes that his daughters have new immediate families they must care for and possibly that


those new nuclear families are more important. Joseph feels his daughters should be taking care

of their own children and husbands, as he did when he was raising children. Joseph wishing his

daughters would leave and be with their own families may currently make him feel as though he

has not only lost his wife but his whole family. Joseph is not only mourning the loss of his wife,

but of losing his nuclear family and business, possible the two most important things to him.

Such learned values of independence, hard work, and family have left Joseph feeling lost without

work or family, have lead him to self-isolate in order to cope, and feel shame in taking his

daughters from their families.

Joseph’s religious values may also play a role in his self-isolating behavior and guilt

surrounding being cared for by his daughters. In traditional Jewish culture, the man is the head of

the household and is considered the provider and decision maker (Jewish, 2014). It is also not

uncommon for Jewish culture to embrace hard work and traditional gender roles (Jewish, 2014).

It is possible that as the result of Joseph’s religious values that he learned the importance of

caring for his family and not being cared for by anyone. This may also contribute to his feelings

of guilt around his daughter's coming to care for him and feeling as though his struggles are

something he must suffer with in silence. It also may have led to some of Joseph’s current

learned coping styles, which may have caused him to have a difficult time in coping with his

losses.

Joseph’s learned coping skills may also lead him to feel unable to move forward, self-

isolate, and feel he is a burden to his daughters. Joseph discussed often times when facing a

problem, he would take the time to think about the situation, weigh the benefits and negative

consequences, and make a decision based on what was best for his family and business, leaving

out any self-bias or emotional reasoning. An example of this is when Joseph willingly retired


because he realized it was best for the business since he was no longer contributing; not thinking

about the consequences it may have on him socially and financially. In coping with his loss,

Joseph recognizes that this is not a situation in which he can just decide to change. He may also

be having a tough time coping because in the past he based all his decisions on his family and the

business and now that he feels he has lost each of them he has no motivation to act or begin to

make changes to his currently lifestyle; leaving him stuck in a state he was left in at the time of

his losses, unable to move forward. It is possible that Joseph learned his coping patterns from his

own father or family who may have emphasized the importance of hard work, family, or

traditional gender roles of having a male breadwinner (Seiffge-Krenke & Pakalniskiene, 2011).

Joseph may also have been raised in a family in which his feelings were often times not

attended to, invalidated, or ignored altogether. Joseph may have learned that feelings were not

meant to be talked about, or possibly that as a male, he should not discuss feelings, again

embracing traditional gender roles (Gottschalk & Keatinge, 1993). As a result, Joseph learned

that people have no desire to discuss feelings or that his feelings did not matter. It is also possible

that Joseph has never been forced to confront his emotions or to fully experience them as his

family may have suppressed them or taught him to ignore them. Now that Joseph has neither his

family nor his business to distract him from his feelings, he is forced to sit with and ruminate on

his feelings. Also, his belief that he cannot share his feelings and decisions with others may have

impacted him in such a way that he only discussed business with others. Now that he feels he has

lost components of both, Joseph now feels he has nothing important to say or discuss and in turn

feels that he has no reason to speak with anyone. Additionally, Joseph feels that people should

have no interest or desire to speak with him. This would then explain why Joseph is self-isolating


and feels as though no one has the interest in spending time with him or seeing him, including

his family.

Precipitating Factors

Two apparent precipitating factors of Joseph’s current struggles were the death of his

wife and loss of his business. As a result of such losses, it is expected that Joseph would

experience a grieving period for both losses; however, because Joseph’s coping styles have

caused him to focus primarily on his family and business, he has had a difficult time moving

forward from the losses and he has no outlet to release his feelings.

Joseph’s daughters coming to visit him may also serve as a precipitating factor. When

Joseph’s daughters come, he begins to think about all the things he did with his family as he was

raising his daughters, and feels they should be doing those same things with their families. He

then begins to feel the shame and guilt he expressed for them being around as he believes they

should not be taking care of him but should instead be with their families. He may also begin to

think that no one wants to spend time with him because he has nothing to offer or contribute to

conversation or interactions. This too may lead to Joseph feeling bad about his daughters

spending time with him as he feels they could be doing so much more with their time.

Joseph also mentioned that meeting with others that he once worked with sometimes

makes him feel as though he has nothing to contribute to conversation. Joseph stated that he had

primarily discussed work and family with his colleagues. Meeting with colleagues now may

force Joseph to re-experience his losses as often times they will talk to him about the current

state of the business or ask about his family. During such conversations Joseph may begin to

miss his business and think about how his family is not what it once was. This may reignite

Joseph’s feelings of mourning and sadness surrounding his losses while also leaving him no


outlet or distraction to cope and deal with such feelings. Joseph is again forced to think about and

sit with his feelings and feel conflicted about sharing or discussing them as he has learned that he

must cope alone. As a result, Joseph self isolates because he does not want to be forced to think

about or discuss the loss of his business and family, and also feels he needs to address his

feelings alone.

Maintaining Factors

Joseph’s coping style, automatic thoughts, and possible core beliefs may have lead him to

maintain an inability to move forward from his losses. For example, Joseph is used to distracting

himself from his emotions or problems that he cannot figure out quickly or alone. He no longer

has the business or a family to raise to distract him from his feelings of grief and sadness.

Currently Joseph resorts to the television to distract him, but that’s only a temporary solution.

Joseph’s lack of distractions in his life have left him unable to cope with his losses, thus leaving

him feeling stuck and unable to move forward as he has no other means of coping. If Joseph

could utilize other coping strategies, he may be able to fully experience his feelings around the

loss of his wife and business and begin to move forward.

Joseph also revealed some automatic thoughts throughout the session that may reflect his

core beliefs. Joseph stated that when his daughters come to care for him or visit with him that he

feels he is a burden on them and that they don’t belong there. His thoughts reflect his values of a

nuclear family but also may indicate a deeper core belief that he is unworthy of love and being

caring for. Joseph also stated that no one wants to speak with him or is interested in anything he

has to say since he does not want to discuss business or family as it brings up negative feelings

for him. Although this may also express Joseph’s values of hard work and family, it also reflects

a core belief that he is unworthy of focus, attention, or relationships with peers and co-workers.


Additionally, because Joseph invested much of his time in raising his family and building a

successful business, he may have attributed all his self-worth to the business and the family.

Now that Joseph believes he has no business or family, he may also feel he has no self-worth.

This further indicates a core belief of feeling worthless or unworthy of love. Similarly, his

feelings of worthlessness may have led to his behaviors of self-isolation, feelings of guilt about

spending time with others, and feeling unable to cope and progress from this state of profound

loss.

Theoretical Models

Cognitive Theory: Joseph’s current symptoms and struggles can be addressed through the

application of cognitive behavioral theory (CBT) and some of the models used to explain CBT.

One CBT model that may be applied to Joseph’s current problems may be cognitive theory.

Developed by Aaron Beck (1983), cognitive theory considers a person’s thoughts and their effect

on their behaviors and feelings. Beck (1983) theorized that an individual responds to stimuli

through thoughts about the stimuli or event, the automatic thoughts, and in turn has a feeling or

sensation associated with the thoughts that would then cause the person to act or behave. A

person’s automatic thoughts stem from their core beliefs about themselves and their

surroundings, self-concept (Beck, 1983). Sometimes an individual’s automatic thoughts can be

cognitive distortions, or skewed thoughts surrounding an event or stimuli (Beck, 1983). Core

beliefs stem from reinforcements a person has received throughout their lifetime that have lead

them to solidify their thoughts as true accurate representations of themselves and the social world

they act in (Beck, 1983).

Joseph stated many automatic thoughts such as my daughters don’t belong here, life has

lost its meaning, I have nothing to contribute to conversation, which may reflect a core belief of


feeling worthless. Joseph valued his business and family immensely, in which he ascribed all his

life worth and meaning to. Now that Joseph feels he has lost his business and family, he is

beginning to feel as though he is worthless and that life has lost its meaning. As a result of

feeling worthless, Joseph thinks that his daughters should not want to spend time with him, that

his co-workers should not care to speak with him, and that there is no reason for him to socialize

or to leave the home. Joseph’s feelings of worthlessness have eradicated his motivation to

progress through life, socialize, and do activities of daily living.

Social Cognitive Theory: Another CBT model that is applicable to Joseph’s current struggles is

the social cognitive theory. In social cognitive theory, an individual develops thought processes,

affective reactions, and behaviors through the modeling of others (Bandura, 1989). The model

also considers many biopsychosocial and sociocultural factors that affect behavior and the

development of a person’s self-concept, including significant life events (Bandura, 1989).

Bandura (1989) postulated that modeling plus biopsychosocial factors can shape the

development of language, means of communicating, social mores and practices, affective

attitudes, and values. Modeling, or observational learning, is when a person views another

person’s behavior and the reinforcement that follows, and decides to act similarly to receive the

same reinforcement (Bandura, 1989). Bandura (1989) further elaborates that an individual does

not simply mimic in social learning but that the above factors impact a person’s decision to feel,

think, or act a certain way based on the perceived reinforcements another individual may or may

not have received by emoting, thinking, or acting similarly.

Bandura’s social cognitive theory can be applied to Joseph as the vehicle for which he

learned some of his values, beliefs, and core belief. Joseph may have learned through the

modeling and reinforcement of his family members to value traditional gender roles,


independence, hard work, and the importance of family relationships. Joseph’s learned values

impact his current automatic thoughts around being undeserving of social interactions and self-

worth without family or work. This has reinforced a core belief of being worthless and has lead

him to begin self-isolating and feeling as though his life has no purpose. Joseph may have also

learned his coping style of distraction through modeling and observation of family members.

Similarly, Joseph may have learned that dealing with problems through work distractions is

helpful and so he was unable to develop other coping mechanisms in which he must experience

his problems and work through them. Now that Joseph has no work to distract him, he has no

means of coping with the loss of his wife resulting in him feeling stuck and unable to move

forward.

Protective Factors and Strengths

Joseph has many strengths and protective factors that will be useful in therapy moving

forward. Joseph is a good problem solver, can be diligent and focused, and is decisive, as he

discussed in his coping strategies. Joseph is ambitious and hardworking as reflected by his

successful business. Joseph also has a strong family relationship and support system that will

help him to make changes and accomplish goals.

Diagnostic Impressions

Disorders: Major Depressive Disorder, Mild, 296.21 or Persistent Depressive Disorder, with

persistent major depressive episode, 300.4 (each provisional) (APA, 2013).

Medical Problems: Joseph did not report any current medical problems that might impact

treatment or the development of his problems.

GAF: Current: 57 Best in the past year: 61


Joseph’s current GAF could be considered a 57 as he is experiencing moderate difficulty

in both social and work functioning and expressed a flat/depressed affect throughout session

(APA, 2000). Being that Joseph is retired, work functioning should be considered his tasks in

caring for his home or being employed as a homemaker. Joseph’s best GAF in the past year can

be considered a 61 as he has experienced more mild difficulty in the past year concerning work

and social functioning and can be considered to have meaningful interpersonal relationships with

his daughters and their families (APA, 2000).

Emotional Symptoms: depressed mood most of the day, nearly every day, diminished pleasure

or interest in almost all activities most of the day, nearly every day, and feelings of excessive

guilt.

Cognitive Symptoms: beliefs surrounding worthlessness, beliefs that others should not want to

spend time with him or be interested in him, thoughts that daily living activities are no longer

worth performing or accomplishing.

Behavioral Symptoms: social isolation, avoidance of leaving the home, avoidance of

accomplishing daily living tasks, ruminating behaviors, and inactivity around the home.

Treatment Plan

General Treatment Goals

1. Reduce excessive stress/guilt surrounding visiting with family and friends.

2. Increase activity inside and outside of the home.

3. Increase social support beyond family members.

4. Increase self-esteem and self-concept.

Treatment Strategy and Sequence of Treatment Components


Joseph’s treatment plan will consist of 3 phases in order to address his perceived

problems and current goals. The first phase will address Joseph’s lack of motivation and sources

of meaning. During this time Joseph and I will work toward increasing his activity in the home,

increasing his activity outside of the home, and begin to reach out or create social support

outside of his family. This will help to create a stronger social group and decrease some of his

guilt around spending time with his daughters. The first phase will also allow for Joseph and I to

build a stronger therapeutic bond which will be helpful in moving forward in other phases and

addressing deeper problems. The second phase will focus on Joseph’s self-esteem and self-

concept that contribute to his feelings of depression. In doing so, I hope to further motivate

Joseph to meet others and increase activity while also addressing his unhelpful thoughts that

without his job and family his life has no purpose. The third and final phase will concentrate on

Joseph’s current coping mechanisms and aim to develop other coping styles and sources to avoid

feelings of depression currently and in the future. The third phase will also consist of planning in

order to prevent future depressive symptoms.

Planned Interventions

Phase 1: Identifying other Sources of Life Meaning/ Decrease Anhedonia

CBT to increase motivation and decrease isolating behaviors utilizes helpful cognitive

interventions. Joseph will begin to set small goals toward leaving the home and doing more

activities in his home. This may be an ongoing process with Joseph and we will continue to set

small goals and accomplish activities as treatment continues and progresses across phases.

During this phase, I will attempt to develop trust and a therapeutic alliance with Joseph by

setting and accomplishing small goals. A strong alliance will be supportive in addressing

Joseph’s self-concept and coping strategies in the next two phases. The phase will consist of 2


parts, addressing in home activity in and out of home activity/socialization, and may be a

continual process that Joseph and I address throughout treatment.

Goal 1: Self-Isolation and Increased Activity Treatment

Treatment Rationale: Cognitive theory postulates that a person’s thoughts and feelings

around a behavior impact their performance of behaviors (Beck, 1983). Joseph has begun feeling

that his life has no meaning or purpose. Currently, Joseph’s thoughts around performing tasks of

daily living are that, someone else, one of his daughters, will just do it or take care of it. As a

result, Joseph does not see a need to perform tasks and does not do them. If Joseph perceived

everyday household activities such as cooking, cleaning, and retrieving the mail, as important

responsibilities that only he could accomplish, then it is possible that Joseph will find small

meaning in such activities. Joseph could treat running his home like running a business. As a

result, Joseph may begin to find small meaning in his life and feel less worthless as he has

responsibilities that need to be tended to. Additionally, performing task around the home are low

risk activities for Joseph in which he feels confident he can accomplish. By setting and

accomplishing low risk, smaller goals, Joseph can also begin to build his confidence and also

build trust in the process of therapy.

Intervention: Cognitive restructuring surrounding Joseph’s ability and need to perform

tasks of daily living may increase his feelings of self-worth (Hunt, Schloss, Moonat, Poulos, &

Wieland, 2007). In session, Joseph can document a daily thought record, do some reframing, and

behavioral experiments to challenge his thoughts that daily living tasks are not necessary, and

that he has no purpose. During this time, Joseph may also begin to become more aware of his

automatic thoughts about himself and uncover his core belief of feeling worthless without family

or occupational responsibilities (Hunt et al., 2007). Joseph uncovering his core belief on his own


will be helpful for upcoming phases where we can begin to challenge his automatic thoughts and

core beliefs.

Joseph can do some behavioral experiments such as getting the mail or cooking a meal

for his daughter rather than her cooking for him. In doing so, he can challenge the thought that

the tasks are not useful or important and that he is capable of doing them. He may also uncover

his daughter’s thoughts about him performing such tasks and gain some social reinforcements.

Joseph may also keep a daily thought record in order to monitor his feelings around performing

behaviors before, during, and after performing a task of daily living. As a result, Joseph may be

able to see how his thoughts are impacting his behavior and he may reframe such thoughts to feel

that the tasks are more useful and necessary. A daily thought record will also help Joseph to

monitor and identify his feelings that result from his thoughts about such behaviors and feelings

associated with thinking and believing that he is worthless. In session, Joseph and I can evaluate

is daily thought records and monitor an increase in positive thoughts and feelings surrounding

accomplishing household responsibilities.

Assessment Tools: Joseph can complete the Hamilton Rating Scale for Depression

(Hamilton, 1960) and the Carroll Depression Scales-Revised (Carroll, 1998) to monitor a

decrease in depressed symptoms both before and after an increase in activity resulting from

cognitive restructuring.

Goal 2: Identify interests and develop activity plan

Treatment Rationale: In order to give Joseph some motivation for leaving the home and

develop additional life purpose, Joseph and I can explore some hobbies or enjoyed activities.

Behavioral models postulate that when an individual does not receive enough positive

reinforcement from life, they may experience symptoms of depression and anhedonia (Beck


1983). By identifying Joseph’s interests and exploring options or activities in which Joseph

might derive pleasure from, we can begin to plan out how to performing those activities, similar

to how we explored Joseph’s daily living tasks. In doing so, Joseph will receive positive

reinforcement from the tasks he enjoys and begin to alleviate his symptoms of anhedonia. This

may also give Joseph some additional responsibilities and relationships that he can extract

meaning from and consequently decrease his thoughts and feelings of worthlessness.

Interventions: Joseph and I will use behavioral activation (Skinner, 1953) in order to

develop plans and methods for leaving the home and becoming a part of enjoyable and

interesting activities. Joseph and I will complete assessments to determine what interests he may

enjoy.

Assessment Tools: Joseph and I will complete a Self-Direct Search 5th Edition (SDS) to

uncover Joseph’s interests and tasks he might be good at or enjoy (Holland & Messer, 2013).

Joseph and I may also do a Personal Values Card Sort (Miller, Baca, Matthews, & Wilbourne,

2001) exercise to explore his values and how they relate to tasks and activities he may be

interested in. To monitor his feelings of pleasure Joseph can complete the Pleasant Activities

Schedule (Heiby, 1983) and Frequency of Self-Reinforcement Questionnaire (MacPhillamy &

Lewinsohn, 1982)

Phase 2: Depression Treatment

The second phase will aim to increase Joseph’s self-esteem and self-concept, challenge

his feelings of worthlessness, and increase the quality of his social interactions. We will consider

Joseph’s values as it contributes to his poor self-concept and work toward finding meaning and

purpose in Joseph’s life again without his business or wife. We will do so by addressing Joseph’s


dysfunctional thoughts around himself, his worth, and his interactions and also address Joseph’s

social skills and support.

Goal 1: Decrease dysfunctional thinking

Treatment Rationale: Cognitive therapy (CT) addresses how one’s core belief impacts

their automatic thoughts, resulting feelings, and following behaviors (Beck, 1983). Sometimes

these core beliefs and automatic thoughts are dysfunctional and cause a person to feel and act in

a way that negatively impacts their wellbeing and quality of life, such as Joseph believing no one

should want to spend time with him and that he is worthless (Beck, 1983). Additionally, CT

posits that individuals can experience symptoms of depression resulting from their core beliefs

and automatic thoughts (Beck, 1983)

Intervention: Cognitive restructuring techniques, such as downward arrow techniques or

disputing thought record may help Joseph to recognize that his automatic thoughts and core

belief of feeling worthless are not true and contribute to his feelings of depression. During this

time, Joseph and I can also explore what function his automatic thoughts are serving him so he

may identify triggers and maintaining factors. Consequently, Joseph and I can begin to make

plans to avoid such triggers, learn how to cope with the triggers, and develop maintaining factors

for new thoughts and behaviors. Cognitive restructuring may also help Joseph to alleviate and

challenge his feelings of guilt around being cared for by his daughters. Similarly, cognitive

restructuring might challenge Joseph’s current self-concept and allow him to increase his self-

esteem. By increasing Joseph’s self-esteem he may feel more competent in accomplishing tasks

around his home and his interests. In doing so, he may begin to uncover internal sources of life

worth and purpose and his increased self-esteem will reveal self-worth. As a result, Joseph will

not rely on outside reinforcements, like his job, to evaluate his worth.


Assessment Tools: Joseph’s decrease in dysfunctional thinking and increase in positive

thoughts about himself and others may be monitored through the Automatic Thoughts

Questionnaire Revised (Kendall, Howard, & Hays, 1989) the Cognitive Triad Inventory

(Beckham, Leber, Watkins, Boyer, & Cook, 1986) and the Dysfunctional Attitudes Scale

(Weissman & Beck, 1978). Additionally, completing and reviewing a disputing thought record

may help to demonstrate decreased dysfunctional thinking.

Goal 2: Improve Social and Interpersonal Skills

Treatment Rationale: Social support plays a major role in the development and treatment

of depressed symptoms (Coyne, 1976). Social support reinforces positive social interactions and

if a client is not receiving positive reinforcement from social interactions, or limited social

interactions, than it is possible the client may begin experiencing symptoms of depression as the

result of limited reinforcements (Gotlib & Whiffen , 1989). Joseph’s self-isolating behaviors are

decreasing the social reinforcements he receives and contribute to his feelings of worthlessness

and symptoms of depression.

Intervention: In treatment, Joseph can begin to do assertiveness training and social skills

training to improve his social interactions and gain social reinforcements. Such reinforcements

from others will increase Joseph’s self-esteem and self-concept, will empower Joseph to become

more active and more confident, and will ultimately contribute to Joseph feeling less worthless

and depressed.

Assessment Tools: Enhancements in Joseph’s social skills can be assessed through an

Interpersonal Events Schedule (Youngren, Zeiss, & Lewinsohn, 1975) and a Social Adjustments

Scale (Paykel, Weissman, Prusoff, & Tonks, 1971) to measure and record Joseph’s cognitions

around social interactions and his ability and growth in effective social functioning.


Phase 3: Develop Coping Skills and Relapse Prevention

The third phase will address Joseph’s current coping styles, create and develop new

helpful coping styles, and work toward planning and relapse prevention. Clients who have

experienced depression in the past are at a higher risk of developing depression (APA, 2013).

Relapse prevention is an essential part of Joseph’s ongoing treatment and we will do so by

creating safety plans and relapse prevention plans. It is also important that Joseph begin to

develop coping mechanisms other than using distraction. We will do so by enhancing adaptive

coping skills and improving Joseph’s problem solving abilities.

Goal 1: Develop Coping Skills/Improve Problem Solving Ability

Treatment Rationale: Although distraction is often a helpful coping mechanism for

depressive symptoms, (Broderick, 2005) having only one coping mechanism to rely on can be

harmful (Galatzer-Levy, Burton, & Bonanno, 2012). In Joseph’s case is maintaining his feelings

of worthlessness and inability to cope with the loss of his wife and business. Adaptive coping

may not only enhance Joseph’s mood but can also prevent Joseph from relapsing into future

depression (Nezu, Nezu, & Perri, 1989)

Intervention: Problem solving therapy techniques will help Joseph to identify triggers

and antecedents of his current episode, decrease the impact that his symptoms has on his overall

functioning, teach him skills to cope with current problems in the future (Nezu, Nezu, & Perri

1989). Joseph can learn problem solving and coping techniques that will help him to confront his

losses resolve his feeling surrounding the loss. Improved problem solving abilities will enable

Joseph to come to terms with his losses and move forward from his feelings of grief and

depression.


Assessment Tools: To assess Joseph’s problem solving abilities and increase in coping

skills, Joseph can complete the Social Problem Solving Inventory Revised (D’Zurilla, Nezu, &

Maydeu-Olivares, 2002) and the Problem Solving Inventory (Heppner, 1988).

Goal 2: Relapse Prevention

Treatment Rationale: Creating a plan against relapse can have an impact on the

development of future depressive symptoms and relapse (Nezu, Nezu, & Perri, 1989). Safety

plans and self-care plans may increase a client’s ability to cope with stressful life situations and

inhibit depressive symptoms from reoccurring.

Interventions: In treatment, Joseph can create a safety/relapse plan by assessing his

strengths and values throughout cognitive therapy interventions and cognitive restructuring.

Joseph can identify some of his strengths and values as the result of his disputing thought

records, acceptance paradox, and the values activity. Joseph can also use his problem solving

abilities to apply his strengths to adaptive coping strategies and prevent further depressive

symptoms. During this time, Joseph and I will identify antecedents to depressive symptoms,

possible future triggers and antecedents, and barriers to following through with his recently

developed coping and problem solving skills. Through planning, Joseph can feel prepared,

confident, and empowered to cope with his current and future distress and increase his self-

esteem and self-concept.

Assessment Tools: Joseph and I will create a safety/relapse contract, which will provide

Joseph with concrete steps and methods he can use to combat depressive symptoms. The plan

will be developed through Joseph’s own self report of which skills and interests he enjoys and

feels most confident in using in the future.

Cultural Considerations


Some cultural differences to consider when carrying out treatment with Joseph include

religious differences, a generational age gap, and gender differences. In terms of Joseph’s

religion, Joseph has expressed that he was raised Jewish, while I have been raised Christian.

Both myself and Joseph have been raised under a specific religion yet no longer follow or

practice that religion. I will have to account for the past oppression and differing values that

Joseph has learned or experienced as the result of his Jewish heritage and be sure to keep those

values and lessons in mind when creating treatment plans and identifying strengths (Leighton,

2014). Additionally, our age difference may have an impact on Joseph’s perception of me as a

counselor and on my understanding of his upbringing and current problems (Minamisawa,

Suzuki, Watanabe, Imasaka, Kimura, Takeuchi, & Uchida, 2011). It important that I display

accurate empathy for Joseph to develop our alliance and instill a sense of trust and compassion

so Joseph perceives me as competent at understanding his current problems and worthy of

hearing his struggles. Similarly, Joseph being male and my being female may impact my

understanding of Joseph’s values and importance of certain gender roles and gender stereotypes

(Anderson, & Levitt, 2015). It may also cause me to overemphasize gender roles in Joseph’s

conceptualization. To avoid such misunderstanding, I will conduct the values activity with

Joseph and further explore his upbringing to gain a better understanding of what gender role he

feels are important, the extent to which he values them, and how they are currently impacting his

self-concept.

Ethical and Legal Considerations

In working with Joseph to provide counseling service, it is important to consider a variety

of American Counseling Association (ACA) ethical codes and morals before implementing

treatment. In CBT, client collaboration and autonomy is frequently emphasized and clients are


often involved in deciding how to proceed with treatment, which techniques can be

implemented, and what goals the client is comfortable working on. To comply with ACA ethics

codes and morals I will consider the autonomy and benefice morals as well as codes A.1.c, A.2.a

and A.2.b, and A.4.b concerning informed consent, confidentiality, counseling plans, and

awareness of counselor values (ACA, 2014). If Joseph feels his role in the relationship is being

devalued or ignored, then treatment plans or practices will be modified to fit Joseph’s particular

needs and requests. Additionally, in terms of providing tests and using assessment tools to

diagnose and monitor progress with Joseph, I must also consider codes C.7.a and C.7.b as well as

all the codes under section E (ACA, 2014). By considering the codes and being aware of the

consequences and risks of using such assessments, Joseph and I can be sure to use tools that are

helpful to treatment. If the time comes where the tools are updated, revised, or no longer relevant

to Joseph’s treatment, Joseph and I will agree to discontinue use. Furthermore, I will have to

consider myself and Joseph’s cultural differences as well and my own values in creating

treatment plans, goals, and implementing techniques with Joseph and consider additional codes

such as B.1.a to avoid any cultural insensitivity (ACA, 2014). If Joseph begins to feel as though

his cultural values or beliefs are being challenged by treatment than we will agree to discontinue

that particular goal, treatment method, assessment, or technique. In addition, I will want to

consider Joseph’s retirement and being cared for by his daughters. It is possible that his

daughters may pay for sessions, or need to be involved in treatment planning. I will consider

codes B.1.b, B.1.c, B.3.d, B.4.b, and B.5.c concerning respect for privacy, confidentiality, third

party payments, couples and family counseling, and release of confidential information (ACA,

2014). If Joseph’s daughters need to be informed of treatment plans, Joseph will be informed of

the risks of involving his family and reminded of his rights to privacy, limits of confidentiality as


well as provided released information. Lastly, termination procedures and completion of

treatment will have to be carried out properly and I will consider code A.11.c in deciding when

to terminate and appropriate termination procedures (ACA, 2014). If Joseph feels as though

termination is abrupt, premature, or harmful, then Joseph and I can adjust treatment plans or

extend treatment in order to terminate at a time and way that is most beneficial.


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Stepps Case Conceptualization (10_12_15)

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