FINAL CASE COUNSELING REPORT
SEMESTER: 1st, ACADEMIC YEAR: 2024-2025
COURSE NAME: Cognitive Behavioural Therapy
COURSE CODE: PSY313DE01
Student’s name:
ID:
1. Client Information
Name, age, gender, relationship status
Primary diagnosis and date of initial assessment
For example:
Age: 56 Gender Identity and Sexual Orientation: Male, heterosexual
Cultural Heritage: American with European heritage
Religious/Spiritual Orientation: Belongs to the Unitarian Church. Was
not attending church at intake.
Living Environment: Small apartment in large city, lives alone.
Employment Status: Unemployed Socioeconomic Status: Middle class
2. PRESENTING PROBLEMS AND DISANOSIS
Include chief complaint, major symptoms, mental status, and diagnosis:
Chief Complaint: For example, Mr. Sơn sought treatment for severe depressive symptoms and
moderate anxiety.
Major Symptoms:
- Emotional: For example, Mr. Abe had feelings of depression, anxiety, pessimism, and some
guilt; lack of pleasure and interest
- Cognitive: For example, Mr. Abe was trouble making decisions, trouble concentrating
- Behavioral: For example, Mr. Abe had Avoidance (not cleaning up at home, looking for a
job, or doing errands), social isolation (stopped going to church, spent less time with family,
stopped seeing friends)
Physiological: For example, Mr. Abe felt heavy in body, significant fatigue, low libido,
difficulty relaxing, decreased appetite
Mental Status: Mr. Abe appeared to be quite depressed. His clothes were somewhat
wrinkled; he didn’t stand or sit up straight and made little eye contact and didn’t smile
throughout the evaluation. His movements were a little slow. His speech was normal. He showed
little affect other than depression. His thought process was intact. His sensorium, cognition,
insight, and judgment were within normal limits. He was able to fully participate in treatment.
Diagnosis:From DSM5, the Major Depressive Disorder, single episode, severe, with anxious
distress was found in Mr. Abe.
3. THE CASE CONCEPTUALIZATION
HISTORY OF CURRENT ILLNESS, PRECIPITANTS AND LIFE STRESSORS:
the first occurrence of abe’s psychiatric symptoms began 2 ½ years ago when abe began to
display mild depressive and anxious symptoms. t
The precipitant factors: he was was difficulty at work; his new boss had significantly changed
his job responsibilities and abe experienced great difficulty in performing his job competently. he
began to withdraw from other people, including his wife, and started spending much of the time
when he was home sitting on the couch. his symptoms steadily worsened and increased very
significantly when he lost his job and his wife divorced him, about two years ago. his functioning
steadily declined after that. at intake, he was spending most of his time sitting on the couch,
watching television, and surfing the web.
The maintaining factors: Highly negative interpretations of his experience, attentional bias
(noticing everything he wasn’t doing or wasn’t doing well), lack of structure in his day,
continuing unemployment, avoidance and inactivity, social withdrawal, tendency to stay in his
apartment and not go out, increased self-criticism, deterioration of problemsolving skills,
negative memories, rumination over perceived current and past failures, and worry about the
future.
The protective factors: pleasure , pleasure and values
Mr. Abe has pleasure aspects such as: ……..
Mr. Abe has mastery aspects such as:……………
Mr. Abe considered family very important, for example: He aspired to rebuild his life, to
recapture his sense of competence and ability to get things done, to get back to work, to become
financially stable, to re-engage in activities he had abandoned, and to give back to others.
4. CBT Treatment plan
Overall treatment plan: The plan was to reduce Abe’s depression and anxiety, improve his
functioning as getting a job and social interactions, and increase positive affect.
Specific treatment plan
Problems Activities for cognitive Treatment Expected Follow up
bihavior change schedule outcome of schedule
treatment
Date/ Date/
month/ year month/ year
1 Social Reconnect with others:
isolation Scheduled times to get
together with friends and
family; assessed which
friend would be easiest to
contact, evaluated
automatic thoughts (“He
won’t want to hear from
me”; “He’ll be critical of
me for not having a job”),
discussed what to say to
friend about having been
out of touch; did behavioral
experiments to test
interfering thoughts.
2. Examined advantages and
Unemployment disadvantages of looking
/ for similar job as before
versus initially getting a
different job (one that
would be easier to obtain
and perform); evaluated
and responded to hopeless
automatic thoughts, “I’ll
never get a job and even if I
do, I’ll probably get fired
again,” problem-solved
how to update resume and
look for a job; roleplayed
job interview.
3. Avoidance Re-engage in avoided
activities: Scheduled
specific tasks around the
house to do at specific
times; did behavioral
experiments to test his
automatic thoughts (“I
won’t have enough energy
to do this,” “I won’t do a
good enough job on this.”)
Evaluated and responded to
automatic thoughts (such
as, “Doing this will just be
a drop in the bucket.”)
Scheduled social activities
and other activities that
could bring a sense of ©
2018. Adapted from J. Beck
(in press) Cognitive
Behavior Therapy: Basics
and Beyond, 3rd edition.
pleasure. Taught Abe to
give himself credit for
anything he did that was
even a little difficult and
keep a credit list.
3 Depression Provided psychoeducation
about symptoms and
impact of depression;
evaluated beliefs about
deserved criticism;
evaluated positive and
negative beliefs about
rumination and worry; did a
behavioral experiment to
see impact of mindfulness
of the breath; prescribed
mindfulness exercise each
morning and during the day
as needed.
5. Summary of treamnet outcomes ( mention every result of the treament)
For example:
At the end of weekly treatment, Abe got better:
Regardings depression, he was almost degreed, from 10 to 3;
Regarding job, ee subsequently got a full-time job that he liked and did well in,
Regarding avoidance and isolation, he became more engaged with friends and family, and he
felt much better.
Reference:
Adapted from J. Beck (in press) Cognitive Behavior Therapy: Basics and Beyond, 3rd editi
Beck. A. T. (1987). Cognitive Therapy of Depression. NY: The Guilford Press
Beck, A. T., Freeman, A., David, D. D. & Associates (2004). Cognitive therapy of personality
disorders. NY: The Guilford Press
Corey, G. (2005). Theory and Practice of Counselling and Psychotherapy (7th Ed). California:
Brooks/Cole – Thomson Learning.
