cbt case study example depression

• Psychotherapy
• Clinical Psychology
• Cognitive Behavioral Therapy

Cognitive Behavior Therapy for Depression: A Case Report

• January 2018

• University of Rajshahi

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• Indian J Psychiatry
• v.62(Suppl 2); 2020 Jan

Cognitive Behavioral Therapy for Depression

Manaswi gautam.

Consultant Psychiatrist Gautam Hospital and Research Center, Jaipur, Rajasthan, India

Adarsh Tripathi

1 Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India

Deepanjali Deshmukh

2 MGM Medical College, Aurangabad, Maharashtra, India

Manisha Gaur

3 Consultant Psychologist, Gaur Mental Health Clinic, Ajmer, Rajasthan, India

INTRODUCTION

Depressive disorders are one of the most common psychiatric disorders that occur in people of all ages across all world regions. Although it may present at any age however adolescence to early adults is the most common age of onset, and females are affected two times more in comparison to the males. Depressive disorders can occur as heterogeneous conditions in clinical scenario ranging from transient minor symptoms to severe and debilitating clinical conditions, causing severe social and occupational impairments. Usually, it presents with constellations of cognitive, emotional, behavioral, physiological, interpersonal, social, and occupational symptoms. The illness can be of various severities, and a significant proportion of the patients can have recurrent illness. Depression is also highly comorbid with several psychiatric and medical illnesses such as anxiety disorders, substance use, obsessive–compulsive disorder, diabetes, hypertension, and cardiovascular illnesses.

Major depressive disorders accounted for around 8.2% global years lived with disability (YLD) in 2010, and it was the second leading cause of the YLDs. In addition, they also contribute to the burden of several other disorders indirectly such as suicide and ischemic heart disease.[ 1 ]

EVIDENCE BASE FOR COGNITIVE BEHAVIORAL THERAPY IN DEPRESSION

Cognitive behavioral therapy (CBT) is one of the most evidence-based psychological interventions for the treatment of several psychiatric disorders such as depression, anxiety disorders, somatoform disorder, and substance use disorder. The uses are recently extended to psychotic disorders, behavioral medicine, marital discord, stressful life situations, and many other clinical conditions.

A sufficient number of researches have been conducted and shown the efficacy of CBT in depressive disorders. A meta-analysis of 115 studies has shown that CBT is an effective treatment strategy for depression and combined treatment with pharmacotherapy is significantly more effective than pharmacotherapy alone.[ 2 ] Evidence also suggests that relapse rate of patient treated with CBT is lower in comparison to the patients treated with pharmacotherapy alone.[ 3 ]

Treatment guidelines for the depression suggest that psychological interventions are effective and acceptable strategy for treatment. The psychological interventions are most commonly used for mild-to-moderate depressive episodes. As per the prevailing situations of India with regards to significant lesser availability of trained therapist in most of the places and patients preferences, the pharmacological interventions are offered as the first-line treatment modalities for treatment of depression.

Indication for Cognitive behavior therapy as enlisted in table 1 .

Indications for cognitive behavioral therapy (situations that can call for preferred use of the psychological interventions) are

CONTRAINDICATIONS FOR COGNITIVE BEHAVIORAL THERAPY

There is no absolute contraindication to CBT; however, it is often reported that clients with comorbid severe personality disorders such as antisocial personality disorders and subnormal intelligence are difficult to manage through CBT. Special training and expertise may be needed for the treatment of these clients.

Patient with severe depression with psychosis and/or suicidality might be difficult to manage with CBT alone and need medications and other treatment before considering CBT. Organicity should be ruled out using clinical evaluation and relevant investigations, as and when required.

There are many advantages of CBT in depression as given in table 2

Advantages of cognitive behavioral therapy in depression

CHOICE OF TREATMENT SETTINGS

CBT can be done on an Out Patient Department (OPD) basis with regular planned sessions. Each session lasts for about 45 min–1 h depending on the suitability for both patients and therapists. In specific situations, the CBT can be delivered in inpatient settings along with treatment as usual such as adjuvant treatment in severe depression, high risk for self-harm or suicidal patients, patients with multiple medical or psychiatric comorbidities and in patients hospitalized due to social reasons.

ASSESSMENT AND EVALUATION FOR THE THERAPY

A detail diagnostic assessment is needed for the assessment of psychopathology, premorbid personality, diagnosis, severity, presence of suicidal ideations, and comorbidities. Baseline assessment of severity using a brief scale will be helpful in mutual understanding of severity before starting therapy and also to track the progress. Clients during depressive illness often fail to recognize early improvement and undermine any positive change. Objective rating scale hence helps in pointing out the progress and can also help in determining agenda during therapy process. Beck Depression Inventory (A. T. Beck, Steer, and Brown, 1996), the Depression Anxiety Stress Scales (Lovibond and Lovibond, 1995), Montgomery-Asberg Depression Rating Scale, Hamilton Rating Scale for Depression are useful rating scales for this purpose. The assessment for CBT in depression is, however, different from diagnostic assessment.

THE USE OF COGNITIVE BEHAVIORAL THERAPY ACCORDING TO SEVERITY OF DEPRESSION

Various trials have shown the benefit of combined treatment for severe depression.

Combined therapy though costlier than monotherapy it provides cost-effectiveness in the form of relapse prevention.

Number of sessions depends on patient responsiveness.

Booster sessions might be required at the intervals of the 1–12 th month as per the clinical need.

A model for reference is given in table 3

The use of cognitive behavioral therapy according to the severity of depression

The general outline of CBT for depression has been discussed in table 4

Overview of cognitive behavioral therapy for depression

CBT – Cognitive behavioral therapy

COGNITIVE MODEL FOR DEPRESSION

Cognitive theory conceptualizes that people are not influenced by the events rather the view they take of the events. It essentially means that individual differences in the maladaptive thinking process and negative appraisal of the life events lead to the development of dysfunctional cognitive reactions. This cognitive dysfunction is in turn is responsible for the rest of the symptoms in affective and behavioral domains.

Aaron beck proposed a cognitive model of depression, and it is detailed in Figure 1 . Cognitive dysfunctions are of the following categories.

Cognitive behavioral therapy model of depression

• Schema - stable internal structure of information usually formed during early life, also include core belief about self
• information processing and intermediate belief are usually interpreted as rules of living and usually expressed in terms of “if and then” sentences
• Automatic thoughts - proximally related to everyday events and in depression, often reflects cognitive triad, i.e., negative view of oneself, world, and future.

Negative cognitive triad of depression as given beck is as following:

• I am helpless (helplessness)
• The future is bleak (hopelessness)
• I am worthless (worthlessness).

CHOICE OF THE PATIENT

Patient-related factors that facilitated response are.

• Psychological mindedness of patients: Patients who are able to understand and label their feelings and emotions generally respond better to CBT. Although some patients in the course of treatment learn those skills during treatment
• Intellectual level of the patient might also affect the overall effectiveness of the treatment
• Willingness and motivation on the part of patients: Although it is not prerequisite, patients who are motivated to analyze their feelings and ready to undergo various homework show a better response to treatment
• Patient preference is single most important factor: After initial assessment of the patient those who prefer psychological treatment can be offered CBT alone or in combination depending on type of depression
• Those with mild to moderate depression CBT can be recommended as a first line of treatment
• Patients with severe depression might need combination of both CBT and medications (and or other treatments)
• Special situations such as children and adolescents, pregnancy, lactation, female in fertile age group planning for pregnancy, medical comorbidities
• Inability to tolerate psychopharmacological treatment
• The presence of significant psychosocial factors, intrapsychic conflicts, and interpersonal difficulties.

Therapist related factors

• Availability of cognitive behavioral therapist/psychiatrist
• The ability of therapist to form therapeutic alliance with the patient.

CLINICAL INTERVIEW FOR COGNITIVE BEHAVIORAL THERAPY

Symptoms and associated cognitions.

Negative automatic thoughts both trigger and enhance depression. It might be helpful to identify unhealthy automatic thoughts associated with symptoms of depression.

Some common symptoms and associated automatic thoughts are given in table 5 .

Symptoms of depression and associated cognitions

Impact on functioning

it is important to know the extent and effect of depression on the overall functioning and interpersonal relationships.

Coping strategies

Sometimes patients with depression might have adapted a coping strategies which make them feel good for short duration (e.g., alcohol consumption) but might be unhealthy in long term.

Onset of current symptoms

Patient's perception about the situation at the onset of symptoms might provide useful information about underlying cognitive distortions.

Background information

Detailed history of patient is necessary, including patients premorbid personality.

The therapist should be able to do the cognitive case conceptualization for the patient as given in Figure 2 .

Case conceptualization for the cognitive model of depression

MANAGING TREATMENT

An outline of the breakup of typical session of CBT is given in table 6 .

Session structure of cognitive behavioral therapy

Starting treatment

First treatment interview has mainly four objectives:

• To establish a warm collaborative therapeutic alliance
• To list specific problem set and associated goals
• To psycho-educate patient regarding the cognitive model and vicious cycle that maintains the depression
• Give the patient idea about further treatment procedures.

CBT can be explained in the following headings

• Behavioral interventions

Working with negative automatic thoughts

• Ending session.

The first treatment interview has four main objectives:

• To establish a warm, collaborative therapeutic alliance
• To list specific problems and associated goals, and select a first problem to tackle
• To educate the patient about the cognitive model, especially the vicious circle that maintains depression
• To give the patient first-hand experience of the focused, workman-like, empirical style of CBT.

These convey two important messages: (1) It is possible to make sense of depression; (2) there is something the patient can do about it. These messages directly address hopelessness and helplessness.

• Identifying problems and goals:-The various problems faced by patients should be included in a list which can include symptoms of depression or social problems (e.g., family conflict). Developing this list at the end of the first session helps in planning treatment goals
• Introducing cognitive model of depression:- In the first session at least a basic idea about how our cognitions affect our emotions and behavior is taught to the patient. The data provided by patient can be used to give insight into behaviors
• Where to start:-Common treatment goal is agreed upon by patient and therapist, therapeutic alliance is of key importance in CBT. Appropriate homework assignment should be given to patient according to predecided goal.

Behavioural interventions

Reducing ruminations.

It has been seen that depressed patients spend a significant amount of time and attention focusing on their shortcomings. Making patient aware of those negative ruminations and consciously diverting attention toward certain positive aspects can be taught to patients.

Monitoring activities

Loss of interest in day to day activities is central to the depression. It has been seen that early behavioral intervention has been increased sense of autonomy in the patients.

Patients are taught to record each and every activity hour by hour on the activity schedule. Each activity is rated 0–10 for Pleasure (P) and Mastery (M). P ratings indicate how enjoyable the activity was, and M ratings how much of an achievement it was. Mostly depressed patients feel low on achievement all the time. Hence, M should be explained as “achievement how you felt at the time of doing.” Patients are instructed to rate activities immediately and not retrospectively.

Example of activity schedule is

Activity Chart Write in each box, activity performed and depression rating from 0-100% (0-minimal, 100-maximum)

Planning activities

Once the patient learns to self-monitor activities each day is planned in advance.

This helps patients by:

• This provides a structure and helps with setting priorities
• This avoids the need to keep making decisions about what to do next
• This changes perception from chaos to manageable tasks
• This increases the chances that activities will be carried out
• This enhances patients’ sense of control.

A plan for activities is made in such a way that both pleasure and mastery are balanced (e.g., ironing cloths followed by listening to music). The tasks which are generally avoided by patient can be divided into graded tasks.

The patient is taught to evaluate each and every day in detail also encouraged to keep the record of unhelpful negative thoughts regarding tasks.

Other important behavioral activities are:-

• Mindfulness meditation: Helps people stay grounded in the present by keeping away from ruminations
• Successive approximation: Breaking larger tasks into smaller tasks which are easy to accomplish
• Visualizing the best part of the day
• Pleasant activity scheduling.

Scheduling an activity in near future which one can look on with mastery and with sense of achievement.

The main tool for this negative automatic thought record.

Thought Record -1

Thought Record – 2

Identifying negative automatic thoughts

Patients learn to record upsetting incidents as soon as possible after they occur (delay makes it difficult to recall thoughts and feelings accurately). They learn:

• To identify unpleasant emotions (e.g., despair, anger, guilt), signs that negative thinking is present. Emotions are rated for intensity on a 0–100 scale. These ratings (though the patient may initially find them difficult) help to make small changes in emotional state obvious when the search for alternatives to negative thoughts begins. This is important since change is rarely all-or-nothing, and small improvements may otherwise be missed
• To identify the problem situation. What was the patient doing or thinking about when the painful emotion occurred (e.g., “waiting at the supermarket checkout,” “worrying about my husband being late home”)?
• To identify negative automatic thoughts associated with the unpleasant emotions. Sessions direct the therapist towards asking: “And what went through your mind at that moment?” Patients become aware of thoughts, images, or implicit meanings that are present when emotional shifts occur, and record. Belief in each thought is also rated on a 0%–100%.

Questioning negative automatic thoughts

Therapist can help patient to discover dysfunctional automatic thoughts through “guided discovery.”

• What is evidence?
• What are alternative views?
• What are advantages and disadvantages of this way of thinking?
• What are my thinking biases?

Common cognitive distortions are

• Black– and– white (also called all– or– nothing, polarized, or dichotomous thinking): Situations viewed in only two categories instead of on a continuum. Example: “If I don’t top the exams. I’m a failure”
• Fortune-telling (also called catastrophizing): Future is predicted negatively without considering other possible, more likely outcomes. Example: “I ll be so upset, i won’t be able to function at all”
• Disqualifying or discounting the positive: The person unreasonably tell oneself that positive experiences, deeds, or qualities do not count. Example: “I cracked the examl, but that doesn’t mean I’m competent; It was a fluke”
• Emotional reasoning: One thinks something must be true because he/she “feels” (actually believe) it so strongly, ignoring or discounting evidence to the contrary. Example: “I know I successfully complete most of my tasks, but I still feel like I’ m incompetent”
• Labeling: One puts a fixed, global label on oneself or others without considering that the evidence might more reasonably lead to a less disastrous conclusion. Example: “I’m a failure. He's not good enough”
• Magnification/minimization: When one evaluates oneself, another person, or a situation, one unreasonably magnifies the negative and/or minimizes the positive. Example: “Getting a C Grade in exams proves how mediocre I am. Getting high marks doesn’t mean I’m smart”
• Selective abstraction (also called mental filter): One pays undue attention to one's negative detail instead of seeing the whole picture. Example: “Because I got just passing marks in one subject in my examinations (which also contained distinctions in other subjects) it means I’m not a good student”
• Mind reading: One believes that he/she knows what others are thinking, failing to consider other, more likely possibilities. Example: “He assumes that his boss thinks that he is a novice for this assignment”
• Overgeneralization: One makes a negative conclusion that goes far beyond the current situation. Example: “(Because I felt uncomfortable at the meeting) I don’t have what it takes to be a group leader”
• Personalization: O ne believes others are behaving negatively because of him/her, without exploring alternative explanations for their behavior. Example: “The watchman didn’t smile at me because I did something wrong”
• Imperatives (also called “Should” and “must” statements): One has a precise, fixed idea of how one or others should behave, and they overestimate how bad it is that these expectations are not met with. Example: “It's terrible that I sneeze as I am a Gym Trainer”
• Tunnel vision: One only views the negative aspects of a situation. Example: “My subordinate can’t do anything right. He's callous, casual and insensitive towards his job.”

Testing negative automatic thoughts: What can I do now?

It is important that cognitive changes that are brought out by questioning are consolidated by behavior experiments.

Ending the treatment

CBT is time-limited goal-directed form of therapy. Hence, the patient is made aware about end of treatment in advance. This can be done through the following stages.

Dysfunctional assumptions identification

Consolidating learning blueprint.

• Preparation for the setback.

Once the patient is able to identify negative automatic thoughts. Before ending treatment patient patients should be made aware about dysfunctional assumptions.

• Where did this rule come from? Identifying the source of a dysfunctional assumption (e.g., parental criticism) often helps to encourage distance by suggesting that its development is understandable, though it may no longer be relevant or useful
• In what ways is the rule unrealistic? Dysfunctional assumptions do not fit the way the world works. They operate by extremes, which are reflected in their language (always/never rather than some of the time; must/should/ought rather than want/prefer/would like)
• In what ways is the rule helpful? Dysfunctional assumptions are not usually wholly negative in their effects. For example, perfectionism may lead to genuine, high-quality performance. If such advantages are not recognized and taken into account when new assumptions are formulated, the patient may be reluctant to move forward
• In what ways is the rule unhelpful? The advantages of dysfunctional assumptions are normally outweighed by their costs. Perfectionism leads to rewards, but it also undermines satisfaction with achievements and stops people learning from constructive criticism
• What alternative rule might be more realistic and helpful? Once the old assumption has been undermined, it is helpful to formulate an explicit alternative (e.g., "It is good to do things well, but I am only human-sometimes I make mistakes"). This provides a new guideline for living, rather than simply undermining the old system
• What needs to be done to consolidate the new rule? As with negative automatic thoughts, re-evaluation is best made real through experience: Behavioral experiments.

The patient should be able to summarize whatever he has learned throughout the sessions.

The following questions might help to set the framework:

• How did my problems develop? (unhelpful beliefs and assumptions, the experiences that led to their formation, events precipitating onset)
• What kept them going? (maintenance factors)
• What did I learn from therapy that helped? Techniques (e.g., activity scheduling) and Ideas (e.g., "I can do something to influence my mood")
• What were my most unhelpful negative thoughts and assumptions? What alternatives did I find to them? (summarized in two columns)
• How can I build on what I have learned? (a solid, practical, clearly specified action plan).

Preparation for the setback

Since depression is recurring illness patient should be made aware about the possibility of relapse.

• What might lead to a setback for me? For example, future losses (e.g., children leaving home) and stresses (e.g., financial difficulties), i.e., events which impinge on patients’ vulnerabilities and are thus liable to be interpreted negatively
• What early warning signs do I need to be alert for?
• Feelings, behaviors, and symptoms that might indicate the beginning of another depression are identified and listed
• If I notice that I am becoming depressed again, what should I do? Clear simple instructions, which will make sense despite low mood, are needed here. Specific ideas and techniques summarized earlier in the blueprint should be referred to.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Mental Health Case Study: Understanding Depression through a Real-life Example

Through the lens of a gripping real-life case study, we delve into the depths of depression, unraveling its complexities and shedding light on the power of understanding mental health through individual experiences. Mental health case studies serve as invaluable tools in our quest to comprehend the intricate workings of the human mind and the various conditions that can affect it. By examining real-life examples, we gain profound insights into the lived experiences of individuals grappling with mental health challenges, allowing us to develop more effective strategies for diagnosis, treatment, and support.

The Importance of Case Studies in Understanding Mental Health

Case studies play a crucial role in the field of mental health research and practice. They provide a unique window into the personal narratives of individuals facing mental health challenges, offering a level of detail and context that is often missing from broader statistical analyses. By focusing on specific cases, researchers and clinicians can gain a deeper understanding of the complex interplay between biological, psychological, and social factors that contribute to mental health conditions.

One of the primary benefits of using real-life examples in mental health case studies is the ability to humanize the experience of mental illness. These narratives help to break down stigma and misconceptions surrounding mental health conditions, fostering empathy and understanding among both professionals and the general public. By sharing the stories of individuals who have faced and overcome mental health challenges, case studies can also provide hope and inspiration to those currently struggling with similar issues.

Depression, in particular, is a common mental health condition that affects millions of people worldwide. Disability Function Report Example Answers for Depression and Bipolar: A Comprehensive Guide offers valuable insights into how depression can impact daily functioning and the importance of accurate reporting in disability assessments. By examining depression through the lens of a case study, we can gain a more nuanced understanding of its manifestations, challenges, and potential treatment approaches.

Understanding Depression

Before delving into our case study, it’s essential to establish a clear understanding of depression and its impact on individuals and society. Depression is a complex mental health disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities. It can affect a person’s thoughts, emotions, behaviors, and overall well-being.

Some common symptoms of depression include:

– Persistent sad, anxious, or “empty” mood – Feelings of hopelessness or pessimism – Irritability – Loss of interest or pleasure in hobbies and activities – Decreased energy or fatigue – Difficulty concentrating, remembering, or making decisions – Sleep disturbances (insomnia or oversleeping) – Appetite and weight changes – Physical aches or pains without clear physical causes – Thoughts of death or suicide

The prevalence of depression worldwide is staggering. According to the World Health Organization, more than 264 million people of all ages suffer from depression globally. It is a leading cause of disability and contributes significantly to the overall global burden of disease. The impact of depression extends far beyond the individual, affecting families, communities, and economies.

Depression can have profound consequences on an individual’s quality of life, relationships, and ability to function in daily activities. It can lead to decreased productivity at work or school, strained personal relationships, and increased risk of other health problems. The economic burden of depression is also substantial, with costs associated with healthcare, lost productivity, and disability.

The Significance of Case Studies in Mental Health Research

Case studies serve as powerful tools in mental health research, offering unique insights that complement broader statistical analyses and controlled experiments. They allow researchers and clinicians to explore the nuances of individual experiences, providing a rich tapestry of information that can inform our understanding of mental health conditions and guide the development of more effective treatment strategies.

One of the key advantages of case studies is their ability to capture the complexity of mental health conditions. Unlike standardized questionnaires or diagnostic criteria, case studies can reveal the intricate interplay between biological, psychological, and social factors that contribute to an individual’s mental health. This holistic approach is particularly valuable in understanding conditions like depression, which often have multifaceted causes and manifestations.

Case studies also play a crucial role in the development of treatment strategies. By examining the detailed accounts of individuals who have undergone various interventions, researchers and clinicians can identify patterns of effectiveness and potential barriers to treatment. This information can then be used to refine existing approaches or develop new, more targeted interventions.

Moreover, case studies contribute to the advancement of mental health research by generating hypotheses and identifying areas for further investigation. They can highlight unique aspects of a condition or treatment that may not be apparent in larger-scale studies, prompting researchers to explore new avenues of inquiry.

Examining a Real-life Case Study of Depression

To illustrate the power of case studies in understanding depression, let’s examine the story of Sarah, a 32-year-old marketing executive who sought help for persistent feelings of sadness and loss of interest in her once-beloved activities. Sarah’s case provides a compelling example of how depression can manifest in high-functioning individuals and the challenges they face in seeking and receiving appropriate treatment.

Background: Sarah had always been an ambitious and driven individual, excelling in her career and maintaining an active social life. However, over the past year, she began to experience a gradual decline in her mood and energy levels. Initially, she attributed these changes to work stress and the demands of her busy lifestyle. As time went on, Sarah found herself increasingly isolated, withdrawing from friends and family, and struggling to find joy in activities she once loved.

Presentation of Symptoms: When Sarah finally sought help from a mental health professional, she presented with the following symptoms:

– Persistent feelings of sadness and emptiness – Loss of interest in hobbies and social activities – Difficulty concentrating at work – Insomnia and daytime fatigue – Unexplained physical aches and pains – Feelings of worthlessness and guilt – Occasional thoughts of death, though no active suicidal ideation

Initial Diagnosis: Based on Sarah’s symptoms and their duration, her therapist diagnosed her with Major Depressive Disorder (MDD). This diagnosis was supported by the presence of multiple core symptoms of depression that had persisted for more than two weeks and significantly impacted her daily functioning.

The Treatment Journey

Sarah’s case study provides an opportunity to explore the various treatment options available for depression and examine their effectiveness in a real-world context. Supporting a Caseworker’s Client Who Struggles with Depression offers valuable insights into the role of support systems in managing depression, which can complement professional treatment approaches.

Overview of Treatment Options: There are several evidence-based treatments available for depression, including:

1. Psychotherapy: Various forms of talk therapy, such as Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT), can help individuals identify and change negative thought patterns and behaviors associated with depression.

2. Medication: Antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs), can help regulate brain chemistry and alleviate symptoms of depression.

3. Combination Therapy: Many individuals benefit from a combination of psychotherapy and medication.

4. Lifestyle Changes: Exercise, improved sleep habits, and stress reduction techniques can complement other treatments.

5. Alternative Therapies: Some individuals find relief through approaches like mindfulness meditation, acupuncture, or light therapy.

Treatment Plan for Sarah: After careful consideration of Sarah’s symptoms, preferences, and lifestyle, her treatment team developed a comprehensive plan that included:

1. Weekly Cognitive Behavioral Therapy sessions to address negative thought patterns and develop coping strategies.

2. Prescription of an SSRI antidepressant to help alleviate her symptoms.

3. Recommendations for lifestyle changes, including regular exercise and improved sleep hygiene.

4. Gradual reintroduction of social activities and hobbies to combat isolation.

Effectiveness of the Treatment Approach: Sarah’s response to treatment was monitored closely over the following months. Initially, she experienced some side effects from the medication, including mild nausea and headaches, which subsided after a few weeks. As she continued with therapy and medication, Sarah began to notice gradual improvements in her mood and energy levels.

The CBT sessions proved particularly helpful in challenging Sarah’s negative self-perceptions and developing more balanced thinking patterns. She learned to recognize and reframe her automatic negative thoughts, which had been contributing to her feelings of worthlessness and guilt.

The combination of medication and therapy allowed Sarah to regain the motivation to engage in physical exercise and social activities. As she reintegrated these positive habits into her life, she experienced further improvements in her mood and overall well-being.

The Outcome and Lessons Learned

Sarah’s journey through depression and treatment offers valuable insights into the complexities of mental health and the effectiveness of various interventions. Understanding the Link Between Sapolsky and Depression provides additional context on the biological underpinnings of depression, which can complement the insights gained from individual case studies.

Progress and Challenges: Over the course of six months, Sarah made significant progress in managing her depression. Her mood stabilized, and she regained interest in her work and social life. She reported feeling more energetic and optimistic about the future. However, her journey was not without challenges. Sarah experienced setbacks during particularly stressful periods at work and struggled with the stigma associated with taking medication for mental health.

One of the most significant challenges Sarah faced was learning to prioritize her mental health in a high-pressure work environment. She had to develop new boundaries and communication strategies to manage her workload effectively without compromising her well-being.

Key Lessons Learned: Sarah’s case study highlights several important lessons about depression and its treatment:

1. Early intervention is crucial: Sarah’s initial reluctance to seek help led to a prolongation of her symptoms. Recognizing and addressing mental health concerns early can prevent the condition from worsening.

2. Treatment is often multifaceted: The combination of medication, therapy, and lifestyle changes proved most effective for Sarah, underscoring the importance of a comprehensive treatment approach.

3. Recovery is a process: Sarah’s improvement was gradual and non-linear, with setbacks along the way. This emphasizes the need for patience and persistence in mental health treatment.

4. Social support is vital: Reintegrating social activities and maintaining connections with friends and family played a crucial role in Sarah’s recovery.

5. Workplace mental health awareness is essential: Sarah’s experience highlights the need for greater understanding and support for mental health issues in professional settings.

6. Stigma remains a significant barrier: Despite her progress, Sarah struggled with feelings of shame and fear of judgment related to her depression diagnosis and treatment.

Sarah’s case study provides a vivid illustration of the complexities of depression and the power of comprehensive, individualized treatment approaches. By examining her journey, we gain valuable insights into the lived experience of depression, the challenges of seeking and maintaining treatment, and the potential for recovery.

The significance of case studies in understanding and treating mental health conditions cannot be overstated. They offer a level of detail and nuance that complements broader research methodologies, providing clinicians and researchers with invaluable insights into the diverse manifestations of mental health disorders and the effectiveness of various interventions.

As we continue to explore mental health through case studies, it’s important to recognize the diversity of experiences within conditions like depression. Personal Bipolar Psychosis Stories: Understanding Bipolar Disorder Through Real Experiences offers insights into another complex mental health condition, illustrating the range of experiences individuals may face.

Furthermore, it’s crucial to consider how mental health issues are portrayed in popular culture, as these representations can shape public perceptions. Understanding Mental Disorders in Winnie the Pooh: Exploring the Depiction of Depression provides an interesting perspective on how mental health themes can be embedded in seemingly lighthearted stories.

The field of mental health research and treatment continues to evolve, driven by the insights gained from individual experiences and comprehensive studies. By combining the rich, detailed narratives provided by case studies with broader research methodologies, we can develop more effective, personalized approaches to mental health care. As we move forward, it is essential to continue exploring and sharing these stories, fostering greater understanding, empathy, and support for those facing mental health challenges.

References:

1. World Health Organization. (2021). Depression. Retrieved from https://www.who.int/news-room/fact-sheets/detail/depression

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

3. Beck, A. T., & Alford, B. A. (2009). Depression: Causes and treatment. University of Pennsylvania Press.

4. Cuijpers, P., Quero, S., Dowrick, C., & Arroll, B. (2019). Psychological treatment of depression in primary care: Recent developments. Current Psychiatry Reports, 21(12), 129.

5. Malhi, G. S., & Mann, J. J. (2018). Depression. The Lancet, 392(10161), 2299-2312.

6. Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., … & Schatzberg, A. F. (2016). Major depressive disorder. Nature Reviews Disease Primers, 2(1), 1-20.

7. Sapolsky, R. M. (2004). Why zebras don’t get ulcers: The acclaimed guide to stress, stress-related diseases, and coping. Holt paperbacks.

8. Yin, R. K. (2017). Case study research and applications: Design and methods. Sage publications.

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Case Formulation in Cognitive-Behavioral Therapy: A Principle-Driven Approach

By Gillian A. Wilson, MA, and Martin M. Antony, PhD––Department of Psychology, Ryerson University

Cognitive-behavioral treatments are often described in step-by-step manuals. They provide strategies for treating a specific psychological disorder or diagnosis as opposed to addressing the specific problems and symptoms of a particular person.

Manualized treatments may fall short as they tend to adopt a general approach to treatment versus creating a specific approach tailored to each client.

While manualized treatments may be useful under certain circumstances—for example when individuals with a specific diagnosis have highly overlapping symptoms and problems—there are circumstances that call for a more flexible, individualized approach.

Here, we will focus on this specialized method known as a case formulation .

What is case formulation and when is it useful?

A case formulation is a hypothesis about the psychological mechanisms that cause and maintain an individual’s symptoms and problems (Kuyken et al., 2009; Persons, 2008).

It’s a principle-driven approach that targets mechanisms grounded in basic psychological theories—such as cognitive theory, classical and operant conditioning.

As outlined by Persons (2008), a case formulation can be useful when:

• A client has several disorders or problems.
• No treatment manual exists for a particular disorder or problem.
• A client has numerous treatment providers.
• Problems arise that are not addressed in a manual—nonadherence or therapeutic relationship ruptures.

Steps in Case Formulation

The case formulation should be developed in collaboration with the client to ensure engagement and increase commitment to treatment.

To develop a strong case formulation, the following steps are recommended (Persons, 2008):

• Conduct a thorough assessment to determine the presence of specific diagnoses, symptoms, and problems. It’s important to create a list of all of the client’s presenting symptoms and problems in various areas and life domains (i.e., panic attacks, excessive worry, low mood, poor academic performance, relationship difficulties).
• Factors that predisposed the client to develop the symptoms and problems
• Factors that precipitated the most recent episode
• Maintaining factors
• Protective factors
• Set up experiments to test out the initial case formulation. The results of these tests will confirm or disprove hypotheses about factors that cause or maintain the client’s symptoms and problems. For example, a therapist may use a thought record to test out whether a client’s procrastination stems from perfectionistic beliefs, which may reveal that procrastination or difficulty initiating tasks is instead due to thoughts of hopelessness. The case formulation should be revised based on the results.
• The case formulation should continue to be tested and revised throughout treatment with the goal of targeting mechanisms involved in the onset and maintenance of the client’s symptoms and problems. With ongoing consent of the client, it should be used as a guide for treatment planning and clinical decision making.

Components of Case Formulation 

A case formulation should provide a coherent summary and explanation of a client’s symptoms and problems. It should include the following components (Persons, 2008):

• Problems: Psychological symptoms and features of a disorder, and related problems in various areas of life—social, interpersonal, academic, occupational.
• Mechanisms: Psychological factors—cognitive, behavioral—that cause or maintain the client’s problems. Mechanisms are the primary treatment targets.
• Origins: Distal factors or processes that lead to the mechanisms and thereby predispose the client to developing certain psychological symptoms and problems.
• Precipitants: Proximal factors that trigger or worsen the client’s symptoms and problems. Precipitants can be internal—physiological symptoms that trigger a panic attack—or external—a stressful life event that triggers a depressive episode.

The following is an example of a case formulation, based on recommendations by Persons (2008). It illustrates how a case formulation approach provides a parsimonious description of the cognitive and behavioral mechanisms underlying a client’s myriad of symptoms and problems.

When Rachel was in elementary school, her classmates laughed at her during her class presentations and teased her because of her stutter (ORIGINS). This led Rachel to develop the core schemas “I am socially awkward,” and “People are overly critical.” (COGNITIVE MECHANISMS). As an adult, she was preparing for a presentation at work (PRECIPITANT), and thought to herself, “I am going to humiliate myself in front of my colleagues.” (COGNITIVE MECHANISM). This lead to feelings of anxiety (PROBLEM). As a result, she called in sick the day of her presentation (BEHAVIORAL MECHANISM) and thought “I am a failure” (COGNITIVE MECHANISM) which lead to feelings of sadness and shame (PROBLEMS). She stayed in bed all day (PROBLEM) to avoid these feelings (BEHAVIORAL MECHANISM).

See also: Exposure Therapy for Anxiety-Related Disorders

A case formulation is an invaluable tool for highlighting how a client’s problems and symptoms are related. It aids the therapist in accurately identifying and targeting underlying psychological mechanisms with increased efficiency, leading to improved therapeutic outcomes

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Recommended Readings

Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. New York, NY: Guilford Press.

Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. New York, NY: Guilford Press.

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Journal of Depression and Therapy

Current Issue Volume No: 1 Issue No: 2

Cognitive Behavior Therapy in The School Setting: A Case Study of A Nine Year Old Anxious Boy with Extreme Blushing

Francine c. jellesma  1  .

1 Research Institute Child Development and Education

Within the field of school psychology there is a gap between research and practice, caused by difficulties in translating the programs from research to the realities of the school setting. Illustrations of real-life cases may help school psychologists gain insight into the application of interventions. The purpose of this study was to describe an example of small group cognitive behavior therapy in the school setting. It concerned test anxiety with extreme blushing. A single subject case study of a nine year old Dutch boy was described. Interviews, observations and questionnaires were used for evaluation, as well as a standard national achievement test. The results indicate that the test anxiety and blushing decreased and on the achievement test three years later, performance was good.  As it concerns a case study, the results are discussed tentatively. It was concluded that the intervention was successful without alterations to the program. This study provides an illustration of research put into practice.

Author Contributions

Academic Editor: Addo Boafo, Royal Institute of mental health research

Checked for plagiarism: Yes

Review by: Single-blind

Copyright ©  2017 Francine C.Jellesma,et al.

The authors have declared that no competing interests exist.

Download as RIS , BibTeX , Text (Include abstract )

Introduction

This article describes a successful intervention for a nine year old boy presenting emerging test anxiety and extreme blushing. The treatment consisted of a group-based cognitive therapy (CBT) in the school setting. This case-study illustrates how CBT can be applied within primary school addressing test anxiety when the concern is not only on the level of an emerging mental health problem, but also on a specific symptom. Mental health problems are a major concern in primary education because they negatively affect socio-emotional as well as academic school functioning. Within the ecological context perspective of Bronfenbrenner schools represent a key component of the child’s microsystem: they are one of the most proximal influences on a child, and understandably, represent the primary setting where children show impairment due to mental health problems 1 . Research demonstrates that school-based cognitive-behavioral interventions that focus on small groups or individual students yield improvements in emotional, behavioral, social, and academic functioning 2 . Nevertheless, within the field of school psychology there is a gap between research and practice that seems to be caused by difficulties in translating the programs from research to the realities of the school setting 3 . Illustrations of real-life cases may help school psychologists gain insight into the application of interventions.

Test anxiety refers to feeling tense, fearful, and worried in evaluative situations 4 . It has formally been defined by Dusek as an “unpleasant feeling or emotional state that has physiological and behavioral concomitants and that is experienced in formal testing or other evaluative situations” (p.88) 5 . It has been estimated that between 10% to 40% of all students suffer from various levels of test anxiety 6 . In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; 7 ), test anxiety is included indirectly as: “Individuals with Social Phobia often underachieve in school due to test anxiety(…)”. Bögels et al. argue that pervasive test anxiety is a form of social phobia (or social anxiety disorder), if fear of negative evaluation by others is the core issue, as was true for the current case 8 . Test anxiety poses students at risk for underperformance on achievement tests, poor grades, repeating a grade and school drop-out 9 , 10 , 11 , 12 . As such, it is important for schools to reduce test anxiety in their students effectively 13 .

Blushing can be one of the symptoms of test anxiety 7 . According to the communicative account of blushing, blushing has a remedial function. It communicates to observers that one is sensitive to their judgment 14 . Experimental research shows that blushing causes others to make more favorable appraisals. A blushing person is considered to be more trustworthy, less responsible for violating a norm and more friendly compared to a person that does not blush, but for example only shows shame 15 . Despite these positive effects, blushing is involuntary and uncontrollable and signals to others the presence of emotions that a person perhaps would like to suppress. The social blushing theory states that blushing occurs when a person receives undesired social attention 16 . Particularly in young people, blushing is a bodily symptom that can occur in situations of increased self-consciousness 17 , and these situations are common for children with test anxiety. Further, it is important to note that blushing is not only an especially salient physiological reaction (feeling warm cheeks), it is also clearly observable to others. As blushing often occurs in situations where one would rather not increase the attention of others, blushing can be highly aversive and for anxious individuals it can become a source of shame and anxiety in its own right 18 .

In the case presented in this article, a nine year old boy was referred to the school psychologist because the teacher noticed that his learning was impaired by a fear of failure. Whereas the teacher felt it was important for him to be able to concentrate on learning; the boy and his family concentrated on the experienced worries, fears, nervousness and extreme blushing. In other words, the important outcomes were: reduction of test anxiety, blushing and the more indirect outcome of school achievement. An important question of the case study was whether the blushing would be reduced by a CBT that was focused on test anxiety. This was the expectation because, not only is CBT one of the interventions that is recommended for treating test anxiety 13 , 19 ; Drummond and Su argue that anxiety management strategies in clinical settings reduce fear of blushing and blushing itself 20 . They demonstrated that social anxiety rather than expected or perceived blushing can increase facial blood flow during embarrassment. Therefore, reduction of anxiety should also lead to subsiding of the blushing.

Importance of this Study

In general, case studies are important because they help make something being discussed more realistic for teachers, school boards, and others. Case studies help people to see that what they have learned or read about a subject is not purely theoretical but instead can serve to create practical solutions to real dilemmas. With respect to interventions in schools, there is discussion about the use of existing programs because people sometimes reason that those problems are unlikely to be successful for a specific case or child 3 . The thought is that the child is an individual that in some aspects departs from the population of children for which the program was developed. Protocols and programs are seen as cookie-cutter approaches that in practice are unfit. With the current study, an example of a program put into practice for a specific child that departs from peers with test anxiety because of the extreme blushing, provides a clear example that CBT can be followed effectively and can meet specific individual needs.

Case Representation

Tim was a nine year old boy from a two-parent family of average social economic status. He lived with his parents and younger brother near his school in a small town in the Netherlands. Tim had entered school at age 4, which is common in the Netherlands where kindergarten and primary school are integrated.

Referral Information

The fourth grade teacher referred Tim to the care coordinator (CC) of the school because she noticed that he displayed clear signs of distress (frequent, visible blushing and expressions of worry) and that his learning progress was unexpectedly low. The CC discussed the referral with Tim’s parents who confirmed that Tim seemed to be bothered a lot by fear of failure and associated distress. The parents agreed for Tim to be seen by the school psychologist (i.e., author of the paper). In order to remain objectively, all assessments and observations were discussed with a second person, a social worker, who also co-observed the second last session of the therapy.

Tim and his parents were interviewed separately from each other using a semi-structured interview. Tim explained that he was very nervous at school before and during tests, and when speaking in front of the class or several classmates. His major concern was that he blushed frequently. According to Tim: “It happens all the time and I get really embarrassed”. Tim said that he would like to show more initiative in certain situations, such as playing a game, but that his shyness and nervousness withheld him from doing so. With concern to his school work, Tim often felt unable to concentrate and had many worries (“I think I will fail”, “I feel uncertain about the task”, “I think I might not be smart enough”).

Tim’s parents showed great involvement and his mother recognized some of the anxiety symptoms from her own youth. The parents confirmed that Tim was bothered frequently by his anxiety and felt helpless in not being able to reassure him. Tim’s parents knew that he blushed a lot at school whereas at home he was much more relaxed. The parents were discussing repetition of the fourth grade with the CC because of the little progress that Tim made during the school year. They thought that their son was “a sweet, open and bright boy”, but that his fears interfered with his ability to learn. They thought that Tim not only had low test scores, but also had actually learned less than he would have done when he had not been anxious. The symptoms seemed to have developed over a period of one year. The onset of test anxiety at this age falls within the normal range.

Tim completed two self-confidence subscales of the School Attitudes Questionnaire (SAQ; 21): expressive skills and self-confidence in examinations. The SAQ is a psychometrically sound and well-accepted diagnostic tool in the Dutch educational system. Each of the SAQ items consisted of a proposition, and the participant is asked to judge if the proposition is applicable to himself or herself on a short Likert-type response scale that has three options: that is the case , I don’t know , and that is not the case . Construct validity and reliability of these scales are good 21 . In comparison to the norm scores, Tim showed confidence well below the average (stanine 3) on the self-confidence in examinations scale (an example of an item is: During a school test I am usually calm and able to work with concentration ) and extremely low (stanine 1) on the expression scale (an example of an item is: I get shy when everyone in the classroom suddenly looks at me ).

Treatment Plan

In this study, a Dutch program was used entitled “Je kunt meer dan je denkt” (literally translated to “You can do more than you think”, a Dutch expression meaning that you shouldn’t underestimate your abilities). It is a program for small groups of children aged 6-12. It consists of eight sessions and one booster session. The sessions took place in the two months prior to summer vacation and the booster session was given in the second week of the new school year. The intervention was given on Mondays directly after school, in the remedial teaching classroom of the school. Besides Tim, five other children participated: four girls (one of which was from the same classroom) and one boy, which was Tim’s nephew, who was in the third grade.

The core components of CBT are: teaching children to identify and label irrational thoughts and to replace them with positive self-statements or modify them by challenging their veracity (cognitive component); exposure and relaxation training (behavioral components) 22 . These components were integrated in each session, that consisted of: a summary of the last session, discussion of the homework, introduction of a new topic, relaxation exercises, exposure, a game, complimenting oneself (the children wrote down something that they were proud of), and reviewing the session. The exposure consisted of the children taking turns to stand in a puppet theater and talk about a predefined topic. The children were allowed to choose for how long they would talk and could choose to hide in the puppet theater. The games intended to allow children practice group presentations in a fun way. After each session, the children received a letter with a summery and a homework assignment.

Course of Treatment

In the first session, the psychologist introduced herself with a collage, then talked with the children about why they were in the intervention group and what they would like to learn. Tim said that he would like to become less anxious and that he wanted to ‘stop blushing so frequently’. He said: “I hate it when it happens. I feel it and I just know that my face is all red”. A story was told about a child with test anxiety and afterwards the children discussed what they recognized. Tim recognized the emotional, cognitive and physical symptoms that were included in the story. The rules were made together with the children. They were formulated positively (e.g., we are quiet when another person is talking, we are kind to each other). The children then did a game pretending animals in duo’s and the others had to guess. Tim complimented himself on making a rule. In reviewing the session, it was clear that Tim had experienced some nervousness, but nevertheless also felt sufficiently safe. While talking, Tim blushed several times.

The children had to introduce themselves with a collage that they had made as a homework assignment. Tim was clearly nervous when doing so, but the positive responses of the other children seemed to reassure him. The breathing exercise went really well. The exposure exercise was more difficult. Tim choose to present himself, and used two sentences. He was blushing. Afterwards a game with different types of moving (e.g., running, jumping) was played. Tim anxiously observed the behavior of the others, but during the game did become a bit more brave in his behavioral expression. He complimented himself on doing all the exercises.

Tim had successfully worked with the homework assignment (repeating the relaxation exercised). The topic explained and discussed was emotions. The children then played a game pretending they entered a bus, and each time all the passengers would show the same emotional expression as the child who entered. Tim really enjoyed the game. He asked if it could be repeated, which was done after the session was officially finished. The relaxation went well and during the exposure exercise Tim showed slightly more fun, although was still blushing. He answered a question of one of the girls. An exercise was done in which the children had to walk to the belonging emotion labels that were spread around the room while the psychologist mentioned short situations. Tim was able to explain his answers and showed emotional insight. Tim complimented himself on being kind. During the session Tim asked the other children whether he was blushing. He had to smile when one of the others told him that he did, but that it was cute.

Tim had spent a lot of work on his homework assignment collecting pictures from newspapers and magazines with emotions on them. The cognitive model of emotional response was explained and practiced using the smart board with several examples. After the relaxation and exposure exercise, the children also role-played several situations, thoughts and feelings according to the model. Tim again asked the other children whether he was blushing and opened up about his feelings of embarrassment when classmates laughed about him at moments of blushing. The more positive responses from his peers in the group seemed to help. He further was stimulated to try the relaxation techniques (which was homework again) at times when he felt he would blush. Tim complimented himself on cooperating so well.

This session, the children learned to discriminate between positive, helping thoughts and negative thoughts. Tim was quite able to make this distinction, but found it very hard to think of positive thoughts that he could use for his real-life examples. He accepted help from the other children. As a game, the children had to act crazy. Tim tried a few odd dancing steps, but mainly laughed which seemed to be his way to escape out of a situation he found uncomfortable. Nevertheless, during this session Tim did not blush. Tim complimented himself on getting hot chocolate for everyone at the start of the session.

In this session, the children further worked on replacing their negative thoughts. In the relaxation exercise, not only breathing and bodily techniques were used, but also dreaming about positive events. The game of the second session was repeated, but this time the children were asked to move in a way that corresponded with certain thoughts (e.g., I can do this!). Tim had worked on altering his thoughts and showed improvement in finding positive thoughts. Tim volunteered to be second in the exposure exercise. He complimented himself on being more present in the group. Tim had blushed only during the game.

The children learned that it is OK to make mistakes. Tim had also heard this message before by his parents and teacher and was very willing to share experiences with the other children. In the game children had to move objects in a circle without using their hands. The exposure went really well. Tim took several minutes. During the relaxation exercise, Tim was laughing with one of the girls. Tim had not blushed during this session. He complimented himself for helping others.

The topic was finding solutions for problems. Tim participated well. In the game the children worked together in two teams getting across the room in different ways and Tim showed some initiative, that he later complimented himself on. The exposure exercise went as well as the previous session. Tim felt sorry that it was the last session. Tim had not blushed.

End of program

After the eight sessions, the parents were given information about Tim’s progress. They also received advice on how to help Tim with relaxation and changing negative thoughts into helpful thoughts. In the booster session, the children received a reminder of all the techniques that they had learned. Tim enjoyed this session and made a relaxed impression.

Observations

Observations during the sessions revealed decreases in Tim’s anxiety and blushing. The parents were interviewed after the eight sessions and they felt that there was a significant decrease in Tim’s fear of failure. They still agreed that it would be best for Tim to repeat the fourth grade and had more faith that he would make progression now.

Interview with Tim

On the booster session, Tim was interviewed during the booster session. He was happy to share some positive experiences.. He said that he felt that although it was exciting to be in a class full of new children, he felt more secure than in the past and had already made some new friends. This was an expected improvement, as in the last session, Tim had explained that even thought his confidence in expression was low, he felt that he would be able to become more experienced and he seemed highly motivated to show more social initiative. Further, Tim now thought he blushed much less frequently and he explained that: “I now also know that a lot of children do not think it is stupid when I blush”. With schoolwork he found it easier to concentrate and he thought that he would become one of the brightest students of his classroom now he felt more confident.

Questionnaire

On the SAQ, Tim had shown an increase in confidence directly after the eight sessions: his self-confidence in examinations had become average (stanine 6) and his confidence on the expression scale had grown, but was still low (stanine 2). At the second post-intervention assessment (booster session), his confidence on both scales was above average (stanine 8 and 9 respectively). For a picture of the whole group improvement, the graphs of the raw scores of all children are presented in Figure 1

As can be seen, all children showed improvement on at least one of the two scales.

The reliable change index is a statistic that we can use to work out whether a change in an individual’s score is statistically significant, based on how reliable the measure is. It is defined as the change in a client’s score divided by the standard error of the difference for the test(s) being used. If the RCI is 1.96 or greater, then the difference is statistically significant (1.96 equates to the 95% confidence interval). For the scores of Tim, the improvement in self-confidence in examinations was significant on both occasions: RCI 1 = 5.22 and RCI 2 = 7.14, when compared to the pre-intervention measurement. The improvement between the first and second post-intervention assessment was significant as well (RCI = 2.24). Similarly, for Tim’s confidence on the expression scale, although the short time improvement was clinically small (from a stanine 1 to a stanine 2), it was significant (RCI 1 = 3.08) and the improvement on the second post-intervention assessment was also significant RCI 2 = 10.77. The improvement between the first and second post-intervention assessment of expression confidence was significant as well (RCI = 7.69).

Interview with the Teacher

For the long term evaluation of Tim’s success, Tim’s sixth grade teacher was interviewed three years later. This is the last grade of primary school in the Netherlands. Tim’s teacher said that she knew Tim as a very gentle and kind boy. He did not seem anxious and there were no signs of test anxiety or social inhibition. According to the teacher: “Tim can sometimes feel a bit shy in new, social situations, but then he is able to discuss this.” The teacher did not notice any blushing in Tim anymore.

School Advice

For the final outcome, Tim’s academic success, we looked at his performance on the official national test that children take in the sixth and that is used to inform the parents and the school about the child’s appropriate high school level (in combination with the impression that the school has formed). On this test, Tim received advice to go to senior general secondary education (HAVO) , which qualifies students to enter higher professional education (HBO).

In this study, it was investigated what the effects of a small group CBT were for a case of test anxiety with extreme blushing. The current paper described the improvements of Tim during a program that was given in weekly sessions. Multiple informants and methods provided information that supported that the program was sufficient for both the anxiety as well as the blushing. The positive effect on the school achievement was also supported. The findings therefore confirmed our hypotheses.

With respect to the blushing, it was found that no adjustments to the program needed to be made. The blushing was, however, given attention to in response to initiatives of Tim to share his feelings on this topic. Within the small group CBT there it was possible for all children to share their thoughts and feelings and specific concerns. This may be a factor that is essential to meet the specific needs of all children in a group based program. For this purpose, it seems essential to create a therapeutic environment that feels safe and secure 23 . The relationship with the psychologist 24 , but also feelings of safety and friendship between the children should be fostered as these aspects are an important precondition for emotional disclosure in school-aged children 25 . Making positive rules together with the children (e.g., ‘We listen to each other’) and verbally reinforcing prosocial behavior are concrete examples of how this can be established.

The improvement in Tim’s confidence in expressing himself in the presence of others showed a ‘sleeper effect’ (i.e., a delayed effect of treatment) 26 . This effect might have occurred because Tim needed more practice and positive experiences before an increase in confidence could be achieved. During the treatment, Tim already showed great improvement in the exposure exercise, but there are many different situations in which expression oneself for an audience is needed (e.g., getting a turn in class or being invited for a social event). What is interesting is that Tim already expressed self-assurance in using the learned techniques in order to become more confident directly after the program. When the results of an intervention seem to be disappointing, it therefore might be informative to ask children about their faith in further improvement and to monitor this.

In conclusion, this case study is an illustrative example of how small group CBT can be applied in the school setting. The gap between research and practice needs to be narrowed because the school setting can have a great impact on a child and is also an important setting where children present mental health problems. The current problem of test anxiety is a clear example of this. The success of the intervention supports the possibilities of schools in fostering a healthy socio-emotional development in children.

Acknowledgements

With thanks to the child, parents and school to give their permissions. There were no conflicts of interest for the author of this paper. She was working on a voluntary basis.

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A Counselling Case Study Using CBT

Jocelyn works as a Human Resources Manager for a large international organisation. She is becoming more and more stressed at work as the company is constantly changing and evolving. It is a requirement of her job that she keeps up with this change by implementing new strategies as well as ensuring focus is kept on her main role of headhunting new employees.

She finds that she is working twelve-hour days, six days a week and doesn’t have time for her friends and family. She has started yelling at staff members when they ask her questions and when making small mistakes in their work. Concerned about her stress levels, Jocelyn decided to attend a counselling session.

Below is an extract from Jocelyn’s first session with her counsellor:

Transcript from counselling session

Counsellor: So Jocelyn, let’s spend a few minutes talking about the connection between your thoughts and your emotions. Can you think of some times this week when you were frustrated with work? Jocelyn : Yes, definitely. It was on Friday and I had just implemented a new policy for staff members. I had imagined that I would get a lot of phone calls about it because I always do but I ended up snapping at people over the phone. Counsellor : And how were you feeling at that time? Jocelyn : I felt quite stressed and also annoyed at other staff members because they didn’t understand the policy. Counsellor : And what was going through your mind? Jocelyn : I guess I was thinking that no-one appreciates what I do. Counsellor : Okay. You just identified what we call an automatic thought. Everyone has them. They are thoughts that immediately pop to mind without any effort on your part. Most of the time the thought occurs so quickly you don’t notice it but it has an impact on your emotions. It’s usually the emotion that you notice, rather than the thought. Often these automatic thoughts are distorted in some way but we usually don’t stop to question the validity of the thought. But today, that’s what we are going to do?

The counsellor proceeds to work through the cognitive behaviour process with Jocelyn as follow:

Step 1 – Identify the automatic thought

Together, the counsellor and Jocelyn identified Jocelyn’s automatic thought as: “No-one appreciates what I do”.

Step 2 – Question the validity of the automatic thought

To question the validity of Jocelyn’s automatic thought, the counsellor engages in the following dialogue:

Counsellor : Tell me Jocelyn, what is the effect of believing that ‘no-one appreciates you?’ Jocelyn : Well, it infuriates me! I feel so undervalued and it puts me in such a foul mood. Counsellor : Okay, now I’d just like you to think for a moment what could be the effect if you changed that way of thinking Jocelyn: You mean, if I didn’t think that ‘no-one appreciates me’? Counsellor : Yes. Jocelyn : I guess I’d be a lot happier in my job. Ha, ha, I’d probably be nicer to be around. I’d be less snappy, more patient.

Step 3 – Challenge core beliefs

To challenge Jocelyn’s core belief, the counsellor engages in the following dialogue:

Counsellor : Jocelyn, I’d like you to read through this list of common false beliefs and tell me if you relate to any of them (hands Jocelyn the list of common false beliefs). Jocelyn : (Reads list)Ah, yes,I can see how I relate to number four, ‘that it’s necessary to be competent and successful in all those things which are attempted’.That’s so true for me. Counsellor : The reason these are called “false beliefs” is because they are extreme ways of perceiving the world. They are black or white and ignore the shades of grey in between.

Applications of CBT

Cognitive approaches have been applied as means of treatment across a variety of presenting concerns and psychological conditions. Cognitive approaches emphasise the role of thought in the development and maintenance of unhelpful or distressing patterns of emotion or behaviour.

Beck originally applied his cognitive approach to the treatment of depression. Cognitive therapy has also been successfully used to treat such conditions as anxiety disorders, obsessive disorders, substance abuse, post-traumatic stress, eating disorders, dissociative identity disorder, chronic pain and many other clinical conditions. In addition, it has been widely utilised to assist clients in enhancing their coping skills and moderating extremes in unhelpful thinking.

• March 18, 2010
• Case Study , CBT , Counselling , Workplace
• Case Studies , Counselling Therapies , Workplace Issues

Comments: 11

I recently had a call (lifeline) from a young person with similar issues as Jocelyn so it was interresting to me to see that I was on the right track helping my client to change her thinking.

I am employed as a counselling psychologist in the dept. of professional studies for graduate students, it’s the way i had been challenging irrational beliefs students hold about themselves, & CBT helps a lot in improving their academic achievement, & helps my counselling to gain ground successfully.

it was a good case study helped a lot I as a student studying about case study on CBT patients !! thanks a lot

Thank you very much. it helped me as I am a student of basic counselling course.

I think the way the process is explained is very helpful.

It’s a very good article.Therapist explicitly challenged the automatic thought and could elicit it very well. CBT is more realistic and genuine. Great case study. Expect more such case details. Thanks.

I concur many students don’t fail exams because they don’t work hard but lack of confidence and negative self talk like I can never pass cbt is powerful in replacing the negative self talk

This type of case study is useful to know about the basic job awareness and what kind of stress the employee has. Mainly useful to know about the lot of information about counseling knowledge.

I am preparing for my internship in counseling and looking for case studies. I found this case study helpful and useful in how to utilize the CBT techniques when working with my potential clients. Thanks

what psychological theory would best help understand the client’s problems and how therapy from that theoretical standpoint will help them?

Cognitive Theory Behaviorism – Operant Conditioning Behaviorism – Classic Conditioning Psychoanalytic Theory Object Relations/Attachment Theory Existential Theory Humanistic Theory

As a psychology student this case study helped me alot in understanding the core values of CBT as well as how important of a role it is in counseling. Thank you!

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Article contents

Integrating cbt and cft within a case formulation approach to reduce depression and anxiety in an older adult with a complex mental and physical health history: a single case study.

Published online by Cambridge University Press:  12 October 2020

Depression and anxiety are major contributors to growing healthcare costs in the UK, particularly with an increasingly ageing population. However, identification of mental health needs in older adults has been overshadowed by a tendency to focus on physical health issues, despite the established co-morbidity of depression, anxiety and physical health conditions. When older adults seek psychological support, treatment options may vary and may be time limited, either because of protocol guidance or due to the resource constraints of psychology services. Time-limited treatment, common in many adult services, may not best meet the needs of older adults, whose physical, cognitive and emotional needs alter with age. It is, therefore, important to identify treatments that best meet the needs of older adults who seek psychological support, but who may arrive with complex mental and physical health histories. This paper aims to explore how a case formulation-driven approach that draws on the theoretical underpinnings of cognitive behavioural therapy (CBT) and compassion-focused therapy (CFT) can be used to reduce anxiety and depression in an older adult with a complex multi-morbid mental and physical health history. This study employs a single-case (A–B) experimental design [assessment (A), CBT and CFT intervention (B)] over 28 sessions. Results suggest the greatest reductions in depression and anxiety (as measured using PHQ-9 and GAD-7) occurred during the CFT phase of the intervention, although scores failed to drop below subclinical levels in any phase of the intervention. This case highlights the value of incorporating CFT with CBT in case formulation-driven interventions.

(1) To consider the value of using case formulation approaches in older adult populations.

(2) To demonstrate flexibility in balancing evidence-based interventions with service user needs by incorporating CBT and CFT to treat anxiety and depression in an older adult.

(3) To present a clinical case to identify how assessment, formulation and treatment of anxiety and depression are adapted to best meet the needs of older adults with complex co-morbid mental and physical health conditions.

(4) To appreciate the impact of contextual factors, such as austerity measures, on therapeutic work with individuals with long-standing mental and physical health difficulties.

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• Nicola Birdsey (a1)
• DOI: https://doi.org/10.1017/S1754470X20000410

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Case Example: Jill, a 32-year-old Afghanistan War Veteran

This case example explains how Jill's therapist used a cognitive intervention with a written worksheet as a starting point for engaging in Socratic dialogue. 

About this Example

Jill's Story

Jill, a 32-year-old Afghanistan war veteran, had been experiencing PTSD symptoms for more than five years. She consistently avoided thoughts and images related to witnessing her fellow service members being hit by an improvised explosive device (IED) while driving a combat supply truck. Over the years, Jill became increasingly depressed and began using alcohol on a daily basis to help assuage her PTSD symptoms. She had difficulties in her employment, missing many days of work, and she reported feeling disconnected and numb around her husband and children. In addition to a range of other PTSD symptoms, Jill had a recurring nightmare of the event in which she was the leader of a convoy and her lead truck broke down. She waved the second truck forward, the truck that hit the IED, while she and her fellow service members on the first truck worked feverishly to repair it. Consistent with the traumatic event, her nightmare included images of her and the service members on the first truck smiling and waving at those on the second truck, and the service members on the second truck making fun of the broken truck and their efforts to fix it — “Look at that piece of junk truck — good luck getting that clunker fixed.”

After a thorough assessment of her PTSD and comorbid symptoms, psychoeducation about PTSD symptoms, and a rationale for using trauma focused cognitive interventions, Jill received 10 sessions of cognitive therapy for PTSD. She was first assigned cognitive worksheets to begin self-monitoring events, her thoughts about these events, and consequent feelings. These worksheets were used to sensitize Jill to the types of cognitions that she was having about current day events and to appraisals that she had about the explosion. For example, one of the thoughts she recorded related to the explosion was, “I should have had them wait and not had them go on.” She recorded her related feeling to be guilt. Jill’s therapist used this worksheet as a starting point for engaging in Socratic dialogue, as shown in the following example:

Therapist: Jill, do you mind if I ask you a few questions about this thought that you noticed, “I should have had them wait and not had them go on?”

Client: Sure.

Therapist: Can you tell me what the protocol tells you to do in a situation in which a truck breaks down during a convoy?

Client: You want to get the truck repaired as soon as possible, because the point of a convoy is to keep the trucks moving so that you aren’t sitting ducks.

Therapist: The truck that broke down was the lead truck that you were on. What is the protocol in that case?

Client: The protocol says to wave the other trucks through and keep them moving so that you don’t have multiple trucks just sitting there together more vulnerable.

Therapist: Okay. That’s helpful for me to understand. In light of the protocol you just described and the reasons for it, why do you think you should have had the second truck wait and not had them go on?

Client: If I hadn’t have waved them through and told them to carry on, this wouldn’t have happened. It is my fault that they died. (Begins to cry)

Therapist: (Pause) It is certainly sad that they died. (Pause) However, I want us to think through the idea that you should have had them wait and not had them go on, and consequently that it was your fault. (Pause) If you think back about what you knew at the time — not what you know now 5 years after the outcome — did you see anything that looked like a possible explosive device when you were scanning the road as the original lead truck?

Client: No. Prior to the truck breaking down, there was nothing that we noticed. It was an area of Iraq that could be dangerous, but there hadn’t been much insurgent activity in the days and weeks prior to it happening.

Therapist: Okay. So, prior to the explosion, you hadn’t seen anything suspicious.

Client: No.

Therapist: When the second truck took over as the lead truck, what was their responsibility and what was your responsibility at that point?

Client: The next truck that Mike and my other friends were on essentially became the lead truck, and I was responsible for trying to get my truck moving again so that we weren’t in danger.

Therapist: Okay. In that scenario then, would it be Mike and the others’ jobs to be scanning the environment ahead for potential dangers?

Client: Yes, but I should have been able to see and warn them.

Therapist: Before we determine that, how far ahead of you were Mike and the others when the explosion occurred?

Client: Oh (pause), probably 200 yards?

Therapist: 200 yards—that’s two football fields’ worth of distance, right?

Client: Right.

Therapist: You’ll have to educate me. Are there explosive devices that you wouldn’t be able to detect 200 yards ahead?

Client: Absolutely.

Therapist: How about explosive devices that you might not see 10 yards ahead?

Client: Sure. If they are really good, you wouldn’t see them at all.

Therapist: So, in light of the facts that you didn’t see anything at the time when you waved them through at 200 yards behind and that they obviously didn’t see anything 10 yards ahead before they hit the explosion, and that protocol would call for you preventing another danger of being sitting ducks, help me understand why you wouldn’t have waved them through at that time? Again, based on what you knew at the time?

Client: (Quietly) I hadn’t thought about the fact that Mike and the others obviously didn’t see the device at 10 yards, as you say, or they would have probably done something else. (Pause) Also, when you say that we were trying to prevent another danger at the time of being “sitting ducks,” it makes me feel better about waving them through.

Therapist: Can you describe the type of emotion you have when you say, “It makes me feel better?”

Client: I guess I feel less guilty.

Therapist: That makes sense to me. As we go back and more accurately see the reality of what was really going on at the time of this explosion, it is important to notice that it makes you feel better emotionally. (Pause) In fact, I was wondering if you had ever considered that, in this situation, you actually did exactly what you were supposed to do and that something worse could have happened had you chosen to make them wait?

Client: No. I haven’t thought about that.

Therapist: Obviously this was an area that insurgents were active in if they were planting explosives. Is it possible that it could have gone down worse had you chosen not to follow protocol and send them through?

Client: Hmmm. I hadn’t thought about that either.

Therapist: That’s okay. Many people don’t think through what could have happened if they had chosen an alternative course of action at the time or they assume that there would have only been positive outcomes if they had done something different. I call it “happily ever after” thinking — assuming that a different action would have resulted in a positive outcome. (Pause) When you think, “I did a good job following protocol in a stressful situation that may have prevented more harm from happening,” how does that make you feel?

Client: It definitely makes me feel less guilty.

Therapist: I’m wondering if there is any pride that you might feel?

Client: Hmmm...I don’t know if I can go that far.

Therapist: What do you mean?

Client: It seems wrong to feel pride when my friends died.

Therapist: Is it possible to feel both pride and sadness in this situation? (Pause) Do you think Mike would hold it against you for feeling pride, as well as sadness for his and others’ losses?

Client: Mike wouldn’t hold it against me. In fact, he’d probably reassure me that I did a good job.

Therapist: (Pause) That seems really important for you to remember. It may be helpful to remind yourself of what you have discovered today, because you have some habits in thinking about this event in a particular way. We are also going to be doing some practice assignments that will help to walk you through your thoughts about what happened during this event, help you to remember what you knew at the time, and remind you how different thoughts can result in different feelings about what happened.

Client: I actually feel a bit better after this conversation. 

Another thought that Jill described in relation to the traumatic event was, “I should have seen the explosion was going to happen to prevent my friends from dying.” Her related feelings were guilt and self-directed anger. The therapist used this thought to introduce the cognitive intervention of "challenging thoughts" and provided a worksheet for practice. The therapist first provided education about the different types of thinking errors, including habitual thinking, all-or-none thinking, taking things out of context, overestimating probabilities, and emotional reasoning, as well as discussing other important factors, such as gathering evidence for and against the thought, evaluating the source of the information, and focusing on irrelevant factors. 

More specifically, Jill noted that she experienced 100 percent intensity of guilt and 75 percent intensity of anger at herself in relation to the thought "I should have seen the explosive device to prevent my friends from dying." She posed several challenging questions, including the notion that improvised explosive devices are meant to be concealed, that she is the source of the information (because others don't blame her), and that her feelings are not based on facts (i.e., she feels guilt and therefore must be guilty). She came up with the alternative thought, "The best explosive devices aren't seen and Mike (driver of the second truck) was a good soldier. If he saw something he would stopped or tried to evade it," which she rated as 90 percent confidence in believing. She consequently believed her original thought 10 percent, and re-rated her emotions as only 10 percent guilt and 5 percent anger at self.

Treating PTSD with cognitive-behavioral therapies: Interventions that work

This case example is reprinted with permission from: Monson, C. M. & Shnaider, P. (2014). Treating PTSD with cognitive-behavioral therapies: Interventions that work . Washington, DC: American Psychological Association. 

Other Case Examples

• Cognitive Therapy Philip, a 60-year-old who was in a traffic accident (PDF, 294KB)
• Eye Movement Desensitization and Reprocessing Mike, a 32-year-old Iraq War Veteran
• Narrative Exposure Therapy Eric, a 24-year-old Rwandan refugee living in Uganda (PDF, 28KB)
• Prolonged Exposure Terry, a 42-year-old earthquake survivor

• Open access
• Published: 10 September 2024

Interdisciplinary CBT treatment for patients with odontophobia and dental anxiety related to psychological trauma experiences: a case series

• Yngvill Ane Stokke Westad 1 ,
• Gina Løge Flemmen 1 ,
• Stian Solem 1 ,
• Trine Monsen 1 ,
• Henriette Hollingen 1 ,
• Astrid Feuerherm 3 ,
• Audun Havnen 2 , 4 &
• Kristen Hagen 5 , 6 , 7  

BMC Psychiatry volume  24 , Article number:  606 ( 2024 ) Cite this article

Metrics details

While cognitive-behavioural therapy (CBT) is a well-established treatment for odontophobia, research is sparse regarding its effect on patients with dental anxiety related to psychological trauma experiences. This study aimed to evaluate changes in symptoms and acceptability of interdisciplinary Torture, Abuse, and Dental Anxiety (TADA) team treatment for patients with odontophobia or dental anxiety. We also wanted to describe the sample’s oral health status. The TADA teams offer targeted anxiety treatment and adapted dental treatment using a CBT approach.

The study used a naturalistic, case series design and included 20 consecutively referred outpatients at a public TADA dental clinic. Pre- and post-treatment assessments included questionnaires related to the degree of dental anxiety, post-traumatic stress, generalized anxiety, and depression. Patients underwent a panoramic X-ray before treatment. Before dental restoration, patients underwent an oral health examination to determine the mucosal and plaque score (MPS) and the total number of decayed, missing, and filled teeth (DMFT). Patients were referred to dentist teams for further dental treatment and rehabilitation (phase 2) after completing CBT in the TADA team (Phase 1). Results from the dental treatment in phase 2 is not included in this study.

All patients completed the CBT treatment. There were significant improvements in symptoms of dental anxiety, post-traumatic stress, and depression and moderate changes in symptoms of generalized anxiety. Dental statuses were heterogeneous in terms of the severity and accumulated dental treatment needs. The TADA population represented the lower socioeconomic range; 15% of patients had higher education levels, and half received social security benefits. All patients were referred to and started adapted dental treatment (phase 2).

Conclusions

TADA treatment approach appears acceptable and potentially beneficial for patients with odontophobia and dental anxiety related to psychological trauma experiences. The findings suggest that further research, including larger controlled studies, is warranted to validate these preliminary outcomes.

Trial registration

The study was approved by the regional ethical committee in Norway (REK-Midt: 488462) and by the Data Protection Board at Møre and Romsdal County Authority.

Peer Review reports

Patients with mental disorders have a greater risk of oral and dental diseases than the general population. Psychiatric diagnoses are associated with poor dental status, such as carious, missing or filled teeth or surfaces [ 1 ], and patients with severe mental illness are almost three times more likely to lose all of their teeth compared to the general population [ 2 ]. This may be caused by several individual or cumulative factors, such as the inability to perform self-care, diet and lifestyle factors, difficulties in accessing health care services, poor economic status, a negative attitude towards health care providers, shame and anxiety, difficulties cooperating with treatment, and drug use and drug treatment side effects [ 1 , 3 , 4 , 5 , 6 ].

Patients referred for dental anxiety treatment have moderately high levels of comorbid psychological conditions [ 7 ], and this patient group differs with respect to the age of onset, origins, and manifestations [ 8 ]. Individuals with high dental anxiety report more mental health symptoms, poorer oral health, more avoidance behaviour, and more irregular dental visits than those with no or low anxiety [ 9 , 10 , 11 , 12 ]. Furthermore, large variations in oral health and dental treatment needs have been found in patients with dental anxiety and phobia [ 13 , 14 ].

Patients with anxiety disorders, especially post-traumatic stress disorder (PTSD), could be especially prone to developing fears of dental treatment [ 15 ]. The study found that 42.0% of patients with PTSD reported high dental anxiety, compared to 17.6–31.3% in other psychiatric groups, and 4.2% in healthy controls [ 15 ]. Approximately 20% of female patients seeking dental care may have encountered childhood sexual abuse [ 16 ]. Patients who have experienced traumatic events may exhibit distinct psychological and emotional responses that can complicate the treatment process [ 16 , 17 , 18 ]. Furthermore, elements of abuse can resemble the dental treatment environment and make it difficult to tolerate dental treatment [ 17 , 19 , 20 ]. This suggests that it is important for treatment and professionals to be considerate of the patient’s trauma history [ 21 , 22 ].

In 2010, the Norwegian Department of Health concluded that patients who were exposed to torture, sexual abuse, and/or violence in close relationships and/or had odontophobia had inadequate treatment options in the Norwegian public oral health care service [ 23 ]. Based on an overriding goal of ensuring equal access to oral health services regardless of ethnic background, sex, personal finances, and life situations, it was decided to establish interdisciplinary “Torture, Abuse and Dental Anxiety (TADA) teams” nationally. These teams consist of both clinical psychologists and oral health professionals. TADA teams offer anxiety treatment and/or adapted dental treatment based on cognitive-behavioural therapy (CBT) principles.

Previous studies have showed promising results regarding the effectiveness of CBT for odontophobia [ 24 , 25 , 26 ]. However, there is a lack of studies specifically evaluating CBT for patients with odontophobia and dental anxiety who have been exposed to sexual abuse, violence in close relationships, or torture. To our knowledge, there is not any published studies on the effect of dental anxiety treatment in patients with post-traumatic stress symptoms related to abuse or torture in their literature review. However, we found one study that reported an effect of CBT treatment on dental anxiety in patients with post-traumatic stress symptoms triggered by previous dental treatment [ 27 ]. It is uncertain whether findings from that study could be generalized to patients with more extensive and severe trauma experiences originating from torture, abuse, or violence in close relationships.

The aim of this study was therefore to evaluate the change in symptoms from pre-treatment to post-treatment after integrated psychological and dental treatment for a vulnerable patient group who have been exposed to torture, sexual abuse, and/or violence in close relationships and/or who have odontophobia, in a naturalistic case series design, This is important given that the implementation of TADA teams is unique, and the service has not been evaluated [ 28 ].

Participants and procedure

A naturalistic case series design was used. The inclusion criteria for the TADA treatment were: (a) confirming a history of being subjected to torture, abuse, and/or violence in close relationships and/or confirming clinical symptoms of odontophobia (including blood/injection/injury- phobias), (b) being aged 21 years or more at the point of orientation, (c) being willing and having the ability to commit to a treatment plan prepared in collaboration with an interdisciplinary treatment team, and (d) understanding the rationale and treatment principles for the relevant course of treatment. The exclusion criteria were patients who: (a) had an organic disorder such as dementia, delirium, or severe memory problems, or suffered from a severe depressive disorder, mania, or ongoing psychosis at the time of evaluation, and (b) had known cognitive/language delays corresponding to an intellectual disability and were not considered to be able to benefit from the treatment approach because of this.

Patients were invited to the TADA clinic for an orientation with a clinical psychologist (1–2 appointments) after referral. During the orientation, the motivation to commit to therapy was addressed (e.g., willingness to meet at regular intervals for CBT treatment appointments and to gradually expose themselves to feared events). At the time of orientation, patients who confirmed having dental treatment difficulties (e.g., did not seek dental treatment, failed to carry out dental treatment, and/or endured dental treatment with great difficulty), and/or being exposed to sexual abuse/violence/torture, and were willing to commit to CBT treatment, underwent a diagnostic evaluation and were accepted into the TADA treatment program.

After interdisciplinary CBT treatment (phase 1), patients were referred by the first TADA team to the second TADA team (phase 2). Patients referred to the second TADA team were required to attend their first appointment unaccompanied. The first meeting involved reviewing discharge summaries from the first TADA team and developing a treatment plan for dental restoration. The second TADA dentist team (Phase 2) did not function as CBT therapists in this study. If patients did not need full-scale interdisciplinary CBT treatment at the point of orientation, they were referred directly to a TADA dentist team for adapted dental treatment. If needed, the TADA team referred patients to emergency dental treatment before or after the CBT intervention. Both interdisciplinary CBT treatment and dental treatment were delivered free of charge. The TADA dentist and dental nurse involved in phase 1 have their CBT training from continuous guidance and working in collaboration with the CBT trained psychologist. The TADA team involved in phase 2 consist of another dentist and dental nurse with basic training in CBT provided by the TADA psychologist. Both TADA teams participate in annual courses to maintain basic skills in CBT.

Prior to treatment initiation, dental anxiety was assessed with the specific phobia disorder module of the Mini International Neuropsychiatric Interview (MINI) version 7.0.2. [ 29 ] and dental fear and anxiety symptom questionnaires. Patients exposed to torture, sexual abuse, or violence in close relationships were included in the study regardless of whether the diagnostic criteria for odontophobia were met. These patients were further assessed with questionnaires assessing exposure to potentially stressful life events [ 30 ] and related posttraumatic stress symptom severity [ 31 ]. The patients answered their highest level of education completed (primary school, upper secondary school, college/university up to 5 years, or college/university over 5 years). Patients with college/university experience were defined as “higher education”. Furthermore, patients answered their current marital status (single, cohabiting/married, or in a relationship, but not cohabiting). The degree to which personal economy status had affected dental treatment execution was answered as either “not at all”, “to some extent” or “to a large extent”.

The Modified Dental Anxiety Scale (MDAS) [ 32 ] is a brief, self-administered questionnaire consisting of five questions regarding different dentist treatment situations. Each item is scored on a Likert scale ranging from “1” (not anxious) to “5” (extremely anxious). The item scores are summed to produce a total score ranging from 5 to 25. A cut-off score of 19 indicates high dental anxiety [ 33 , 34 ].

The Dental Fear Survey (DFS) [ 35 , 36 ] is a brief measure of dental anxiety and fear that consists of 20 items. Each item is scored on a Likert scale from “1” (never or not at all) to “5” (always or very much). Total DFS scores range from 20 to 100, with increasing scores indicating higher levels of fear. A total score of 20 indicates “no fear,” a score of 21–40 indicates low fear, a score of 41–79 indicates moderate fear, and a score of 80–100 indicates high fear [ 35 , 36 ].

The Stressful Life Events Screening Questionnaire (SLESQ) [ 30 , 37 ] is a 13-item questionnaire assessing lifetime exposure to various traumatic experiences. Each item represents different traumatic experiences and is scored as either “yes” or “no” depending on whether the individual has been exposed to the incident. This questionnaire was used exclusively at pretreatment to screen for exposure to potential traumatic experiences.

The PTSD Checklist for the DSM-5 (PCL-5) [ 31 ] is a 20-item questionnaire assessing 20 PTSD criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5). Each item is scored on a Likert scale ranging from “0” (not at all) to “4” (extremely) based on the occurrence of symptoms during the last month. A total cut-off score of 33 has been found to efficiently detect PTSD [ 38 ]. Only patients who were confirmed to have been exposed to potentially traumatic life events completed the PCL-5.

The Patient Health Questionnaire-9 (PHQ-9) [ 39 ] consists of nine items measuring depressive symptoms. Each of the nine DSM-IV criteria is scored on a Likert scale ranging from “0” (not at all) to “3” (nearly every day) with total scores ranging from 0 to 27, with higher scores reflecting greater depression severity. PHQ-9 scores of 5, 10, 15, and 20 represent mild, moderate, moderately severe, and severe depression, respectively.

The Generalized Anxiety Disorder-7 (GAD-7) [ 40 ] is a brief measure for assessing symptoms of generalized anxiety disorder. The measure consists of seven items measuring worry and anxiety symptoms. Each item is scored on a Likert scale, ranging from “0” (not at all) to “3” (nearly every day). A total score above 10 is considered to be within the clinical range. The GAD-7 is also a measure of anxiety symptoms in general [ 41 ].

The mucosal plaque score (MPS) [ 42 ] is designed to evaluate oral health and oral hygiene. The index consists of two measures: a four-point mucosal score (MS) and a four-point plaque score (PS). The scores are combined, and the total score ranges from 2 to 8, with higher scores indicating poorer oral health and oral hygiene.

The decayed, missing, and filled teeth index (DMFT) quantifies a person’s total number of untreated decayed, missing, and filled teeth and is commonly used in oral epidemiology to quantify the extent of caries [ 43 ]. “Decayed” corresponds to primary or secondary caries in dentin, while “Missing” and “Filled” correspond to missing teeth due to caries, root residues/carious teeth beyond repair and filled/restored teeth with no sign of caries in dentin, respectively. 3rd molars were excluded from the DMFT evaluation, except in situations where these functioned as second molars. The index is frequently used to evaluate and monitor oral health and in oral health interventions [ 44 , 45 ].

Oral health and dental status examinations

Before interdisciplinary CBT treatment, the TADA patients underwent a panoramic X-ray (orthopantomography; OPG). OPG provides a panoramic single radiograph image of the teeth, maxilla, mandible, and adjacent tissue. OPG is a frequently employed radiological examination [ 46 ]. The TADA dentist conducted a dental status evaluation when the patients could tolerate the procedure. To evaluate a patient’s oral health status and dental treatment needs, the dentist determined their mucosal and plaque score (MPS) and the total number of decayed, missing, and filled teeth (DMFT).

CBT intervention (phase 1)

The TADA treatment consisted of two phases. In the first phase, patients were offered interdisciplinary CBT treatment before being referred to an other TADA dentist team for further dental treatment and rehabilitation (second phase).

The interdisciplinary CBT treatment team consisted of a dentist, a dental nurse, and a clinical psychologist delivering CBT together. During orientation to TADA treatment, a psychologist prepared the patient for CBT treatment by providing psychoeducation and rationale for exposure therapy, mapped catastrophic thoughts and safety and avoidance behaviours, examined the patient’s motivation for treatment, and clarified the treatment framework (e.g., treatment duration and structure, dental treatment clarification). The CBT treatment team then offered cognitive-behavioural treatment to challenge patients’ catastrophic thoughts and beliefs about dental treatment and find ways to adapt dental treatment to make it feasible. Patients with odontophobia or dental anxiety related to exposure to torture, sexual abuse, or violence in close relationships also received trauma-relevant psychoeducation and were taught skills on how to cope with trauma symptoms to facilitate new remedial learning experiences. The CBT intervention did not include trauma therapy directly focusing on the primary traumatic event. In addition to cognitive restructuring, in-vivo exposure therapies were conducted, tailored to maximize the disconfirmation of each patient’s unique catastrophic beliefs. While these exposure therapies varied somewhat among patients, the majority of CBT sessions included exposure to activities such as using dental mirrors, probes, polishing, administering anaesthesia, tartar cleaning, drilling, filling procedures, and, when necessary, the process of obtaining impressions and extracting root residues or teeth. Throughout the CBT phase, both dental healthcare professionals and a psychologist were typically present.

Anxiolytic drugs were not offered as part of the treatment intervention. The standard CBT treatment consisted of weekly therapy sessions (1–1.5 h) for up to 12 sessions. All exposure sessions were carried out in vivo in the dental office. The extent of the psychologist’s involvement during exposure sessions was evaluated on an individual basis. Additional sessions could be granted if the TADA team expected the patient to benefit from further follow-up.

Dental treatment intervention (phase 2)

Only limited dental treatment was carried out in the interdisciplinary CBT phase of the TADA treatment. In this phase, dental treatment was carried out only for the purpose of exposure and for facilitating new learning experiences. In case of acute infections and an immediate need for dental treatment before or during CBT treatment, patients were referred for dental treatment under general anaesthesia before further CBT treatment was provided. Two patients (10%) in this sample underwent dental treatment under general anaesthesia during the CBT intervention phase.

After interdisciplinary CBT treatment, patients were referred to a different TADA dentist team consisting of a dentist and a dental nurse for dental treatment and rehabilitation. This second phase of the treatment was not time limited. These TADA dentist teams were trained in CBT interventions but did not work collaboratively with a psychologist.

Statistical analyses

A repeated-measures ANOVA was conducted to examine changes in symptoms from pre- to posttreatment. The proportion of missing data was 10.5%. To address missing data, the expectation maximization (EM) method in SPSS, version 29, was utilized to replace missing values. The use of the EM algorithm is appropriate when less than 25% of data are missing and the missing data are deemed to be missing at random, which was confirmed to be the case for the present dataset (Little`s MCAR test X² (18.798), df  = 17, p  = .340).

Demographic and clinical characteristics

Twenty-seven patients were referred for TADA treatment during the designated trial period. Of these patients, we were unable to reach four patients on the waiting list to offer them an initial appointment. Furthermore, two patients declined treatment. Of these two patients, one had already managed dental treatment at the time of orientation, and the other did not want TADA treatment. One patient did not meet the inclusion criteria after treatment orientation and evaluation. Consequently, 20 consecutive patients referred to the regional TADA outpatient clinic for adults in the county of Møre and Romsdal, Norway, were included (please see Fig.  1 for the flow chart). Of these 20 patients, 12 were referred by oral health personnel (dentists, dental hygienists, oral surgeons), four were referred by general practitioners, two were referred by psychiatric services, and two referred themselves.

The flow of TADA treatment after referral

The mean time since the last dental treatment was 10.7 years (range = 0–30 years). The study participants had an average age of 41.8 years (range = 21–64 years), 75% were female, and 65% were married or cohabiting. A minority of patients had completed higher education, and half received social security benefits. A significant proportion of individuals (70%) stated that their personal finances, in part or significantly, had affected their ability to pursue dental treatment. Furthermore, the patients had been on a waiting list for a duration of 42 months prior to the start of phase 1 of the TADA treatment.

All patients in this sample met the diagnostic criteria for odontophobia, and all underwent interdisciplinary CBT treatment. No patients were referred directly to the TADA dentist team after treatment orientation. Furthermore, no patients were referred for trauma therapy before or during CBT treatment by the TADA teams. Two patients were granted additional exposure sessions (one and seven sessions).

Ten patients reported that domestic violence and/or abuse experiences were the cause of their dental anxiety. Of the other ten patients, three patients did not report traumatic incidents, while seven did not relate their abuse/violence experiences as the cause, or sustaining cause, of their odontophobia. None of the patients stated that they were survivors of torture experiences. 70% reported a history of sexual abuse, as measured by the stressful life event questionnaire. Furthermore, 65% reported exposure to violence in close relationships. 55% reported being survivors of both sexual abuse and violence in close relationships. Patients exposed to potential stressful life events reported a mean of 6.3 (range = 3–11) potential traumatic experiences.

70% of patients reported having comorbid psychiatric disorders, and six (30%) patients simultaneously received general mental health treatment. Patients did not have to end their ongoing treatments to be included in the study. The most prevalent comorbid diagnoses were mood disorders (35%), attention-deficit/hyperactive disorder (30%), and posttraumatic stress disorder (30%). Table  1 summarizes the sample’s characteristics.

There were no dropouts during the interdisciplinary CBT phase of the TADA treatment program. On average, patients received 10.8 interdisciplinary CBT sessions (SD = 2.6, range = 6–19 sessions). All patients were referred to the TADA dentist team following the completion of the CBT intervention. Additionally, all patients attended further dental appointments and initiated dental treatment and rehabilitation.

Changes in symptoms

There was a significant reduction in the symptoms of dental anxiety from pre- to post-treatment as measured with the MDAS (λ = 0.07, F (1,19) = 262.10, p  < .001, d  = 3.07). There was also a significant reduction in symptoms of dental fear as measured with the DFS (λ = 0.25, F (1,19) = 57.36, p  < .001, d =  2.18).

For the 17 patients who reported having traumatic experiences, there were large reductions in symptoms of post-traumatic stress as measured with the PCL-5 (λ = 0.56, F (1,16) = 12.43, p  = .003, d  = 3.04). For the whole sample, there was an improvement in symptoms of depression as measured with the PHQ-9 (λ = 0.50, F (1,19) = 19.36, p  < .001, d  = 1.00), and there were moderate improvements in symptoms of generalized anxiety as measured with the GAD-7 (λ = 0.74, F (1,19) = 6.60, p  < .001, d  = 0.57). A summary of the analyses is displayed in Table  2 .

Subgroup analyses were conducted to inspect possible effects of ongoing psychological treatment, and to compare possible differences between patients with and without a history of abuse. The results are summarized in supplemental Table S1 . There were no associations between ongoing psychological treatment and changes in MDAS and DFS. However, patients with ongoing psychological treatment showed less improvement in symptoms of depression and anxiety. Patients with a history of abuse reported similar changes in symptoms as patients without such history.

Oral health and dental treatment needs

The average DMFT score for the total sample was 18.8 (range 10–36). The patients in the sample had on average 6.6 decayed teeth, 5.6 missing teeth and 6.7 filled teeth. See Table  3 for the total average DMFT score and MPS. On average, patients had an MPS of 2.8 (range 2–6).

The present study aimed to evaluate the implementation of integrated psychological and dental treatment within the TADA team for a sample of patients exposed to traumatic events and/or diagnosed with odontophobia. Overall, the sample reported positive treatment outcomes. Notably, no patients declined further dental treatment after the CBT intervention, indicating that the treatment was both accepted and tolerated by the participants.It is promising that all patients in this sample completed the interdisciplinary CBT treatment intervention despite their previous psychological trauma experiences, high degree of psychiatric comorbidities, prolonged dental avoidance behaviour, and the absence of anxiolytic drug administration. Additionally, all patients were referred to and started dental treatment and rehabilitation. These results suggest that the treatment approach was acceptable for vulnerable patients with a history of traumatic experiences and patients with odontophobia. This finding is significant given that the implementation of TADA teams is unique, the service has not been evaluated, and characteristics of the specific patient group have not been described in detail [ 28 ].

There were large and significant improvements in all measures of dental fear and phobia after CBT treatment. However, some studies indicated that a relatively large proportion of patients do not show improved dental attendance despite reporting reductions in their dental anxiety level following different treatments [ 47 ]. Our findings are align more closely with a previous meta-analysis on behavioural interventions for dental fear in adults, showing medium to large effect sizes for self-reported dental anxiety after behavioural interventions and post-treatment attendance at dental visits with rates between 33% and 100% within 6 months after treatment [ 25 ]. All patients initiated dental treatment, but the study lacks information concerning long-term dental care attendance. Additionally, consistent with other research indicating wider positive life changes after CBT for dental anxiety treatment, our study found decreased symptoms of depression and generalized anxiety following treatment [ 48 , 49 ].

Most patients in our sample had a history of being exposed to potentially traumatic life experiences and had a high prevalence of comorbid psychiatric diagnoses. The significant reduction in posttraumatic stress symptoms suggest that the treatment was well tolerated and could alleviate PTSD symptoms. Although the treatment did not have a direct focus on altering the primary traumatic experience and related psychopathology, the treatment intervention did focus on managing trauma symptoms as presented in the dental care setting. The purpose of this was to make it possible for the patients to have new and corrective learning experiences with dental treatment and to alter dental-related catastrophic thoughts and behaviours. These results are thus in line with research that indicates that the exposure of patients to corrective information that violates their expectations is central to fear reduction in psychological therapy [ 50 ]. Furthermore, these results support previous findings from qualitative studies of trauma-informed treatment interventions and indicate that interdisciplinary CBT could be potentially beneficial and feasible for patients exposed to psychological trauma caused and/or maintained by reasons other than previous dental treatment experiences [ 20 , 21 , 51 ].

The patients included in this study had a formal diagnosis of dental phobia at treatment entry and had avoided dental treatment for over a decade. The longevity of dental avoidance in our sample was concordant with other findings [ 25 , 52 ]. In summary, we found significant variations in oral health and dental treatment needs as measured by the total MPS and DMFT score. Dental treatment needs were heterogeneous, varying between no/little to many dental treatment needs. We found that the dental status of the sample was in line with a previous study on treatment-seeking patients with odontophobia in Norway [ 13 ] and Sweden [ 14 ]. The Norwegian study found a DMFT mean score of 16.4 in their sample while the Swedish study found an average DMFT score of 18.6, compared to 18.8 in the current study. We also found significant variations in oral health as measured by the total MPS. This is also in line with the previous studies on dental status in treatment-seeking odontophobia patients in Norway [ 13 ] and Sweden [ 14 ]. The variations in the MPS reflect that some patients had a reduced ability for dental-related self-care behaviour, while others had an intact ability to take care of their own oral health despite severe dental anxiety.

Most patients reported having a low socioeconomic background, which could be associated with a heightened risk of dental fear [ 53 ]. Many patients in the sample (70%) stated that their personal economic status, in part or significantly, had affected their ability to receive dental treatment. These findings suggest that a considerable number of patients in the TADA intervention would have faced financial constraints, making it unlikely for them to independently pursue dental treatment due to limited financial resources. The fact that the TADA treatment (both CBT and dental treatment and rehabilitation) was delivered free of charge, therefore, appears to have been important for patients to be able to overcome their dental treatment difficulties. The availability of affordable treatment could play an important role in facilitating access to necessary dental treatment interventions for these patients.

Interdisciplinary CBT treatment was given. Due to limited resources, oral health care personnel are often required to provide anxiety treatment without access, or with limited access, to psychological expertise. The findings in this study suggest that mental health professionals could be a valuable allies for oral health care personnel.

The current case series study must be considered in light of several limitations. The small number of participants and the lack of a control condition makes it impossible to determine whether the findings are unique to TADA treatment and to evaluate the relative efficacy of the treatment received. The study also lacked a long-term follow-up assessment. Furthermore, some patients with dental fear have been subjected to torture [ 54 ]; however, such experiences were not reported by the current sample, making it difficult to generalize the findings to patients with a history of torture. The study also lacked information about substance abuse and previous negative experiences with dental care.

This study indicates that interdisciplinary CBT in the context of TADA teams could be both beneficial and acceptable for odontophobia and dental anxiety related to sexual abuse and violence. The results suggest that mental health professionals could be important allies for oral health professionals when caring for patients with severe dental anxiety and odontophobia. System-oriented interventions could benefit from interdisciplinary collaboration, striving to offer seamless and effective treatment options to vulnerable patient populations. A larger controlled study examining the long-term effects of TADA treatment is warranted.

Data availability

The anonymized datasets used during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Cognitive-Behavioural Therapy

Torture, Abuse, and Dental Anxiety

Posttraumatic stress disorder

Mucosal and Plaque Score

Decayed, Missing, and Filled Teeth

The Modified Dental Anxiety Scale

Dental Fear Survey

Generalized Anxiety Disorder-7

Patient Health Questionnaire-9

PTSD Checklist for DSM-5

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Acknowledgements

The authors thank all the patients who participated in the study, the TADA dental nurses and all TADA dentist teams who participated in the data collection. They also thank Møre and Romsdal County Authority for the encouragement and support for conducting the study protocol.

Open access funding provided by NTNU Norwegian University of Science and Technology (incl St. Olavs Hospital - Trondheim University Hospital). The study and study protocol were founded by Møre and Romsdal County Authority.

Open access funding provided by NTNU Norwegian University of Science and Technology (incl St. Olavs Hospital - Trondheim University Hospital)

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Authors and affiliations.

Molde Competence Clinic for Public Dental Health Service, Møre and Romsdal County Authority, Molde, Norway

Yngvill Ane Stokke Westad, Gina Løge Flemmen, Stian Solem, Trine Monsen & Henriette Hollingen

Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway

Audun Havnen

Center for Oral Health Services and Research, Mid-Norway (TkMidt), Trondheim, Norway

Astrid Feuerherm

Nidaros Division of Psychiatry, Community Mental Health Centre, St. Olav’s University Hospital, Trondheim, Norway

Molde Hospital, Møre og Romsdal Hospital Trust, Molde, Norway

Kristen Hagen

Bergen Center for Brain Plasticity, Haukeland University Hospital, Bergen, Norway

Department of Mental Health, Norwegian University of Science and Technology, Trondheim, Norway

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YASW was responsible for data collection and drafting and revising the work.KH, SS and AH were responsible for the data analysis and interpretation. TM, GF, HH and AF, KH, SS and AH participated in the data collection, interpretation and/or revision process of the manuscript. All authors gave their final approval of the version to be published.

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Correspondence to Kristen Hagen .

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The study was approved by the regional ethical committee in Middle Norway (REK-Midt: 2022/488462) and by the Data Protection Board at Møre and Romsdal County Authority. Informed written consent were obtained from all participants. The participants were informed that participation in the study was voluntary and that they had the right to withdraw from the study at any time without any consequences for their treatment. All procedures were performed in accordance with the relevant guidelines and regulations.

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The authors declare no competing interests.

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Westad, Y.A.S., Flemmen, G.L., Solem, S. et al. Interdisciplinary CBT treatment for patients with odontophobia and dental anxiety related to psychological trauma experiences: a case series. BMC Psychiatry 24 , 606 (2024). https://doi.org/10.1186/s12888-024-06055-w

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Received : 13 July 2023

Accepted : 30 August 2024

Published : 10 September 2024

DOI : https://doi.org/10.1186/s12888-024-06055-w

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• Odontophobia
• Dental anxiety
• Psychological trauma
• Oral health
• Interdisciplinary treatment

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