CASE WRITE-UP EXAMPLE

PART ONE: INTAKE INFORMATION

IDENTIFYING INFORMATION AT INTAKE:

Age: 56

Gender Identity and Sexual Orientation: Male, heterosexual

Cultural Heritage: American with European heritage

Religious/Spiritual Orientation: Belongs to the Unitarian Church; was not attending church at intake

Living Environment: Small apartment in large city, lives alone

Employment Status: Unemployed

Socioeconomic Status: Middle class

CHIEF COMPLAINT, MAJOR SYMPTOMS, MENTAL STATUS, AND DIAGNOSIS:

Chief Complaint: Abe sought treatment for severe depressive symptoms and moderate anxiety.

Major Symptoms

Emotional: Feelings of depression, anxiety, pessimism and some guilt; lack of pleasure and

interest

Cognitive: Trouble making decisions, trouble concentrating

Behavioral: Avoidance (not cleaning up at home, looking for a job or doing errands), social

isolation (stopped going to church, spent less time with family, stopped seeing friends)

Physiological: Heaviness in body, signiﬁcant fatigue, low libido, diculty relaxing, decreased

appetite

Mental Status: Abe appeared to be quite depressed. His clothes were somewhat wrinkled; he didn’t

stand or sit up straight and made little eye contact and didn’t smile throughout the evaluation.

His movements were a little slow. His speech was normal. He showed little aect other than

depression. His thought process was intact. His sensorium, cognition, insight and judgment

were within normal limits. He was able to fully participate in treatment.

Diagnosis (from the Diagnostic and Statistical Manual or International Classiﬁcation of Disease):

Major Depressive Disorder, single episode, severe, with anxious distress. No personality disorder

but mild OCPD features.

CURRENT PSYCHIATRIC MEDICATIONS, ADHERENCE AND SIDE EFFECTS; CONCURRENT

TREATMENT: Abe was not taking psychiatric medication and was not receiving any treatment for his

depression.

CURRENT SIGNIFICANT RELATIONSHIPS: Although Abe had withdrawn somewhat from his family, his

relationship with his two grown children and four school-age grandchildren were good. He

The Case Write-Up is a conceptualization tool designed to help you formulate cases. It is not

designed for client use.

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sometimes visited them or attended his grandchildren’s sporting events. He had a great deal of

conﬂict with his ex-wife and he had completely withdrawn from his two male friends. He was

relatively close to one cousin and less so to one brother. He saw and spoke to his other brother and

his mother infrequently and didn’t feel close to them.

PART TWO: HISTORICAL INFORMATION

BEST LIFETIME FUNCTIONING (INCLUDING STRENGTHS, ASSETS AND RESOURCES): Abe was at his

best when he ﬁnished high school, got a job, and moved into an apartment with a friend. This period

lasted for about six years. He did well on the job, got along well with his supervisor and co-workers,

socialized often with good friends, exercised and kept himself in good shape, and started saving

money for the future. He was a good problem-solver, resourceful and resilient. He was respectful to

others and pleasant to be around, often helping family and friends without being asked. He was hard-

working, both at work and around the house. He saw himself as competent, in control, reliable and

responsible. He viewed others and his world as basically benign. His future seemed bright to him. He

also functioned highly after this time, though he had more stress in his life after he married and had

children.

HISTORY OF PRESENT ILLNESS: Abe developed depressive and anxious symptoms 2 ½ years ago. His

symptoms gradually worsened and turned into a major depressive episode about 2 years ago. Since

that time, symptoms of depression and anxiety have remained consistently elevated without any

periods of remission.

HISTORY OF PSYCHIATRIC, PSYCHOLOGICAL OR SUBSTANCE USE PROBLEMS AND IMPACT ON

FUNCTIONING: Abe became quite anxious about 2 ½ years ago when his supervisor changed

his job responsibilities and provided him with inadequate training. He began to perceive himself

as failing on the job and became depressed. His depression increased signiﬁcantly when he lost

his job six months later. He withdrew into himself and stopped many activities: helping around the

house, doing yardwork and errands, seeing his friends. His wife then became highly critical and his

depression became severe. He had not had any problems with alcohol or other substances.

HISTORY OF PSYCHIATRIC, PSYCHOLOGICAL OR SUBSTANCE ABUSE TREATMENT, TYPE, LEVEL

OF CARE AND RESPONSE: Abe and his wife had three joint outpatient marital counseling sessions

with a social worker about 2 years ago; Abe reported it did not help. He reported no other previous

treatment.

PERSONAL, SOCIAL, EDUCATIONAL AND VOCATIONAL HISTORY: Abe was the oldest of three sons.

His father abandoned the family when Abe was eleven years old, and he never saw his father again.

His mother then developed unrealistically high expectations for him, criticizing him severely for not

consistently getting his younger brothers to do homework and for not cleaning up their apartment

while she was at work. He had some conﬂict with his younger brothers who didn’t like him “bossing”

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them around. Abe always had a few good friends at school or in the neighborhood. After his father

left, he developed a closer relationship with his maternal uncle and later with several of his coaches.

Abe was an average student and a very good athlete. His highest level of education was a high

school diploma. Abe started working in the construction industry in high school and had just a few

jobs in the industry between graduation and when he became depressed. He worked his way up in

customer service until he became a supervisor. He got along well with his bosses, supervisors and

co-workers and had always received excellent evaluations until his most recent supervisor.

MEDICAL HISTORY AND LIMITATIONS: Abe had a few sports-related injuries in high school but

nothing major. His health was relatively good, except for moderately high blood pressure, which he

developed in his late forties. He didn’t have any physical limitations.

CURRENT NON-PSYCHIATRIC MEDICATIONS, TREATMENT, ADHERENCE AND SIDE EFFECTS: Abe

was taking Vasotec, 10 mg, 2x per day with full adherence to treat high blood pressure. He had no

signiﬁcant side eects. He was not receiving any other treatment.

PART THREE: THE COGNITIVE CONCEPTUALIZATION DIAGRAM

Attached.

PART FOUR: THE CASE CONCEPTUALIZATION SUMMARY

HISTORY OF CURRENT ILLNESS, PRECIPITANTS AND LIFE STRESSORS: The ﬁrst occurrence of Abe’s

psychiatric symptoms began 2 ½ years ago when Abe began to display mild depressive and anxious

symptoms. The precipitant was diculty at work; his new supervisor had signiﬁcantly changed his job

responsibilities, and Abe experienced great diculty in performing his job competently. He began to

withdraw from other people, including his wife, and started spending much of the time when he was

home sitting on the couch. His symptoms steadily worsened and increased very signiﬁcantly when

he lost his job and his wife divorced him, about two years ago. His functioning steadily declined

after that. At intake, he was spending most of his time sitting on the couch, watching television, and

surﬁng the web.

MAINTAINING FACTORS: Highly negative interpretations of his experience, attentional bias (noticing

everything he wasn’t doing or wasn’t doing well), lack of structure in his day, continuing

unemployment, avoidance and inactivity, social withdrawal, tendency to stay in his apartment and

not go out, increased self-criticism, deterioration of problem-solving skills, negative memories,

rumination over perceived current and past failures, and worry about the future.

VALUES AND ASPIRATIONS: Family, autonomy and productivity were very important to Abe. He aspired

to rebuild his life, to recapture his sense of competence and ability to get things done, to get back to

work, to become ﬁnancially stable, to re-engage in activities he had abandoned and to give back to

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others.

NARRATIVE SUMMARY, INCORPORATING HISTORICAL INFORMATION, PRECIPITANTS, MAINTAINING

FACTORS AND COGNITIVE CONCEPTUALIZATION DIAGRAM INFORMATION: For most of his

life, Abe demonstrated many strengths, positive qualities and internal resources. For many years

he had had a successful work history, marriage and family. He had always aspired to be a good

person, someone who was competent and reliable and helpful to others. He valued hard work

and commitment. His strongly held values led to adaptive behavioral patterns of holding high, but

realistic, expectations for himself, working hard, solving his problems independently and being

responsible. His corresponding intermediate beliefs were, “If I have high expectations and work hard,

I’ll be okay. I should solve problems myself. I should be responsible.” His core beliefs about the self

were that he was reasonably eective and competent, likeable and worthwhile. He saw other people

and his world as basically neutral or benign. His automatic thoughts, for the most part, were realistic

and adaptive.

But the meaning Abe put to certain adverse childhood experiences made him vulnerable

to having his negative beliefs activated later in life. His father left the family permanently when Abe

was 11 years old, which led him to believe that his world was at least somewhat unpredictable. His

mother criticized him for failing to reach her unreasonably high expectations. Not realizing her

standards were unreasonable, Abe began to see himself as not fully competent. But these two beliefs

weren’t rock solid. Abe believed that much of his world was still relatively predictable and that he was

competent in other ways, especially in sports.

As an adult, when Abe began to struggle on the job, he became anxious, fearing that

he wouldn’t be able to live up to his deeply held values of being responsible, competent, and

productive. The anxiety led to worry, which caused diculties in concentration and problem-solving,

and his work suered. He started to view himself and his experiences in a highly negative way and

developed symptoms of depression. His core belief of incompetence/failure became activated and

he began to see himself as somewhat helpless and out of control. His negative assumptions

surfaced: “If I try to do hard things, I’ll fail.” “If I ask for help, people will see how incompetent I

am.” So, he began to engage in dysfunctional coping strategies, primarily avoidance. These coping

strategies helped maintain his depression.

Failing to be as productive as he thought he should be and avoiding asking for help

and support from others, along with harsh criticism from his wife for not helping around the

house, contributed to the onset of his depression. He interpreted his symptoms of depression

(e.g., avoidance, diculty concentrating and making decisions, and fatigue) as additional signs of

incompetence. Once he became depressed, he interpreted many of his experiences through the

lens of his core belief of incompetence or failure. Three of these situations are noted at the bottom

of the Case Conceptualization Diagram.

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Once Abe became depressed, he started to view other people dierently. He feared

that they would be critical of him, and he withdrew socially. Historically, he had seen his world as

potentially unpredictable. After losing his job and being blindsided by his wife, he began to view his

world as less safe (especially ﬁnancially), less stable and less predictable.

PART FIVE: TREATMENT PLAN

OVERALL TREATMENT PLAN: The plan was to reduce Abe’s depression and anxiety, improve his

functioning and social interactions, and increase positive aect.

PROBLEM LIST/CLIENT’S GOALS AND EVIDENCE-BASED INTERVENTIONS

Unemployment/Get a job: Examined advantages and disadvantages of looking for a job similar to

what he did before versus initially getting a dierent job (one that would be easier to obtain and

perform); evaluated and responded to hopeless automatic thoughts, “I’ll never get a job and

even if I do, I’ll probably get ﬁred again,” problem-solved how to update resume and look for a

job; roleplayed job interview.

Avoidance/Re-engage in avoided activities: Scheduled speciﬁc tasks around the house to do

at speciﬁc times; did behavioral experiments to test his automatic thoughts (“I won’t have

enough energy to do this,” “I won’t do a good enough job on this.”) Evaluated and responded to

automatic thoughts (e.g. “Doing this will just be a drop in the bucket.”) Scheduled social activities

and other activities that could bring a sense of pleasure. Taught Abe to give himself credit for

anything he did that was even a little dicult and keep a credit list.

Social isolation/Reconnect with others: Scheduled times to get together with friends and family;

assessed which friend would be easiest to contact, evaluated automatic thoughts (“He won’t

want to hear from me;” “He’ll be critical of me for not having a job”), discussed what to say to

friends about having been out of touch; did behavioral experiments to test interfering thoughts.

Ongoing conﬂict with ex-wife/Investigate whether improved communication skills can help/

Decrease sense of responsibility for divorce: Taught communication skills such as assertion

and did behavioral experiments to test thoughts (“It won’t make any dierence. She’ll never stop

punishing me/being mad at me.”). Did a pie chart of responsibility.

Depressive rumination and self-criticism/Reduce depressive rumination: Provided

psychoeducation about symptoms and impact of depression; evaluated beliefs about deserved

criticism; evaluated positive and negative beliefs about rumination and worry; did a behavioral

experiment to see impact of mindfulness of the breath; prescribed mindfulness exercise each

morning and during the day as needed.

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PART SIX: COURSE OF TREATMENT AND OUTCOME

THERAPEUTIC RELATIONSHIP: At the beginning of treatment, Abe was concerned that I might be critical

of him and he thought he should be able to overcome his problems on his own. I provided him

with my view—that he had a real illness for which most people require treatment, that his diculties

stemmed from his depression and didn’t indicate anything negative about him as a person, and that it

was a sign of strength that he was willing to see if treatment could help. He seemed to be reassured.

He demonstrated a level of trust in me from the beginning—he was open about his diculties and

collaborated easily. Initially, when he reported what he had accomplished on his Action Plans, he was

skeptical when I suggested that these experiences showed his positive attributes. But he was able to

recognize that he, too, would see these activities in a positive light if someone else in his situation

had engaged in them. Abe mostly provided positive feedback at the end of sessions. He was able to

appropriately let me know when I misunderstood something he said. In summary, he was able to

establish and maintain a good therapeutic relationship with me.

NUMBER AND FREQUENCY OF TREATMENT SESSIONS, LENGTH OF TREATMENT: Abe and I met

weekly for 12 weeks, then every other week for four weeks, then once a month for four months, for

a total of 18 sessions over eight months. We had standard 50-minute CBT sessions.

COURSE OF TREATMENT SUMMARY: I suggested, and Abe agreed, that we work ﬁrst on (1) getting

Abe to get out of his apartment almost every day (2) spending more time with his family and (3)

cleaning up his apartment. Doing these things increased his sense of connectedness and his sense

of control and competence (and decreased his belief that he was incompetent and somewhat out

of control). (Later we worked on spending more time with friends and volunteering). Increasing his

social activities improved his social support and fulﬁlled his important values of close relationships

and being helpful and responsible to other people. We also worked on decreasing his depressive

rumination. Once he was functioning somewhat better, we worked on ﬁnding employment. He

started o by doing construction for his friend’s business. Our ﬁnal goal was to see if he could

improve his relationship with his ex-wife—but he could not.

MEASURES OF PROGRESS: Abe scored 18 on the PHQ-9 and 8 on the GAD- 7 at intake and his sense of

well-being on a 0-10 scale was 1. I continued to monitor progress by using these three assessments

at every session. At the end of treatment, his PHQ-9 score was 3, his GAD-7 score was 2 and his

sense of well-being score was 7. Although he still had some days that were dicult, on more days

than not, he felt much better.

OUTCOME OF TREATMENT: Abe’s depression was almost in remission at the end of weekly treatment.

He subsequently got a full-time job that he liked and did well in, was more engaged with friends

and family, and he felt much better. When he returned for his last monthly booster session, his

depression was in full remission and his sense of well-being had increased to an 8.

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(TRADITIONAL) COGNITIVE CONCEPTUALIZATION

DIAGRAM EXAMPLE

Name: Date: Diagnosis:

RELEVANT LIFE HISTORY and PRECIPITANTS

Father leaves family when Abe is 11 years old. He never sees him again. Mom is

overburdened, criticizes when he can’t meet her unrealistic expectations. Precipitants to

current disorder: Abe struggles and then loses his job and undergoes divorce.

CORE BELIEF(S) (during current episode)

I’m incompetent/a failure.

COPING STRATEGIES (during current episode)

Avoids asking for help and avoids challenges.

INTERMEDIATE BELIEFS: CONDITIONAL ASSUMPTIONS/ATTITUDES/RULES (during

current episode)

It’s important to be responsible, competent, reliable and helpful.

It’s important to work hard and be productive.

During Depression:

(1) If I avoid challenges, I’ll be okay, but if I try to do hard things I’ll fail.

(2) If I avoid asking for help, my incompetence won’t show but if I do ask for help, people will

see how incompetent I am.

SITUATION #2

Thinking of asking son for

help in revising resume

SITUATION #1

Thinking about bills

SITUATION #3

Memory of being criticized

by boss

AUTOMATIC THOUGHT(S)

I should be able to do this on

my own.

AUTOMATIC THOUGHT(S)

What if I run out of money?

AUTOMATIC THOUGHT(S)

I should have tried harder.

EMOTION

Sad

EMOTION

Anxious

EMOTION

Sad

MEANING OF A.T.

I’m a failure.

MEANING OF A.T.

I’m a failure.

MEANING OF A.T.

I’m a failure.

BEHAVIOR

Avoids asking son for help

BEHAVIOR

Continues to sit on couch;

ruminates about his failures

BEHAVIOR

Ruminates about what a

failure he was

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