Clinical Case Formulations

Category	Symptoms and Impairments Other Problems
B—Behavior What the person is doing and not doing; what others can observe; the quality of skills.	Absences from work Cries frequently (puffy eyes) Slow flat tone of voice Sat stiffly Lies in bed alone in free time
A—Affect Internal emotional experience and overt verbal and nonverbal expression of feelings.	Depressed “Misery” Difficulty sharing feelings Confused about her feelings for ex-boyfriend
S—Sensation Awareness of the body; use of senses; what is seen and heard, with minimal filtering through cognition.	Constantly tired Loud noises bother her Lack of energy
I—Imagery Mental imagery about past, present, or future; fantasies and dreams.	Bad dreams May have recurring images of day her father left
C—Cognitive Constructed meaning; self-talk, beliefs and schemas; cognitive skills; mental abilities.	Poor concentration Difficulty making decisions Views sister as “in a different world” Probable schemas include: men can’t be trusted; men change after you marry them; it’s my fault my father left; I’m responsible for my mother’s miserable life; I’m not smart; men find me boring; if I show a man I like him, he’ll lose interest; if I marry, I’ll end up like my mother.
S—Spiritual Religion; nonreligious aspects of spirituality; creativity; moral issues.	No longer attends church No mention of spiritual resources
I—Interpersonal, social, and cultural Relationships with others; family context; membership in social groups; cultural issues; issues of social injustice.	Doesn’t talk to “close friends” or sister about her problems Wasn’t able to communicate with her ex about their relationship Lack of enjoyable social activities Family problems: no positive communication, each person disengaged from other two, Maria accepts responsibility for mother’s happiness, would feel guilty to separate
D—Drug and Biological Physiology; biology; genetics; medical issues; use of legal and illegal drugs, including alcohol.	Difficulty falling asleep Poor appetite (Both related to depression—no medical problems)

Domains of Living	Examples of Skills, Resources, and Assets	Examples of Problems, Weaknesses, and Deficiencies
Health and Safety	Apart from depression she is in good health	Health problems related to depression
Home Management		Unpleasant home situation, but her culture may expect unmarried woman to live at home
Financial Status	Employed	No information about whether she is saving money
Life Planning		Has not set long-term goals
Academic	Successfully completed high school	Believes she’s not smart enough for college
Employment	Employed, seems satisfied with job	Absenteeism attributed to depression
Legal Status	No legal problems
Leisure and Recreation		No mention of any pleasurable activities; spends excessive time at home with unhappy mother
Communication		Does not confide in sister; not able to express feelings
Friendship	Has people at work she calls close friends	Does not use friendships for support; keeps them very impersonal
Family		Unsupportive, depressed mother who has negative views about men and marriage
Emotional Intimacy		Unclear about feelings for man she dated for 2 years; not able to develop close, trusting relationship
Sexuality	Evidently comfortable in sexual identity and gender role	No data about whether she was sexually intimate with boyfriend
Parenting		Not relevant at this time, but may be in future since her parents were poor role models
Religion and Spiritual		No longer attends church of childhood; seems to lack spiritual fulfillment
Cultural	Fully acculturated (3rd generation)	Lacks the close ties to extended family that is characteristic of Latin American cultures

Problem Area	Sample Titles (This is not a final problem list)
Depression	Depression Depression following breakup of relationship
Intimate relationship issue	Difficulty establishing intimate, trusting relationship with a man Difficulty knowing her own feelings and desires in relationship
Emotional	Lack of awareness of feelings Difficulty understanding and expressing her feelings
Family relations	Unsatisfying relationship with mother
Friendship domain	Lack of close friends to confide in Lack of a confidante and social support
Employment/Education	Views herself as lacking ability to succeed in college
Spiritual life	Loss of childhood religious faith Lack of spiritually enhancing experiences in her life

Problem Title	Sample Outcome Goals
Depression following breakup of relationship	Her depressed mood will be alleviated, and she will be attending work regularly and functioning effectively there. She will have the ability to cope better with loss and disappointment in the future.
Difficulty establishing an intimate, trusting relationship with a man	She will be capable of trusting and taking risk to be close. She will be able to communicate on a personal level, understanding the needs and feelings of the other person as well as her own. She will be able to select men who are trustworthy and make her feel emotionally safe.
Difficulty understanding and expressing her feelings	She will be able to describe her feelings, showing attention to bodily cues and using accurate labels. She will be able to express her feelings to another person, if she so desires.
Unsatisfying relationship with mother	She will understand her mother’s strengths and limitations and recognize what can and cannot be changed in mother. She will have put forth her best efforts to improve communication with mother and encourage mother to choose a happier life. She will be able to set goals for her own happiness, even if her mother objects.
Lack of a confidante and social support	She will have one or two people toward whom she can turn for support in times of loss and disappointment. She will decide if she wants to be involved in a community or religious group that provides social support.
Views herself as lacking ability to succeed in college	She will have higher appraisal of her ability to succeed in higher education like her sister. She will make choices about educational and career goals.
Lack of spiritually enhancing experiences in her life	She will make choices about religious and spiritual commitments.

Skill Deficits (BL3)

She learned to survive by shutting down physically and emotionally, a coping strategy that helped her endure a very difficult and frightening time in her childhood. She carried these learned skills with her when she began to date and found that they no longer worked for her. These skills, which served her so well in childhood, are now a hindrance to what she wants for her life—an intimate, satisfying relationship. Because of her avoidance of men, she lacks social skills for meeting and establishing even friendships with men.

The following chart gives a list of problems in the left column and a selection of relevant hypotheses in the right.

Sample Problem Titles	Sample Hypotheses
Difficulty coping with chronic illness	Biological Cause (BE1): The disease sets real limits. Medical Interventions (BE2): Adherence to medication regimen is necessary. Loss and Bereavement (CS4): Emotional pain of losing abilities and functions. Conditioned Emotional Responses (BL2): There may be a fear of hospitals or medical procedures. Skill Deficits (BL3): Self-management skills must be learned and implemented. Existential Issues (ES1): May be dealing with issues of meaning. Spiritual Dimension (ES3): Spiritual activities such as prayer may have positive effect. Social Support (SC3): Support contributes to better health outcomes; caregivers may need support. Environment (SC7): Getting hospital bed, moving downstairs can make coping easier.
Excessive and prolonged anxiety over loss of job	Mind-Body Connections (BE3): Client needs stress-management tools such as relaxation training. Skill Deficits (BL3): During times of stress, coping skills and stress-management skills are essential. Metacognitive Perspective (C1): Coostant rumination about a catastrophic future affects his job-search motivation. Cultural Issues (SC2): Having his wife be primary breadwinner is violating a cultural rule and increasing his demoralization. Social Problem Is a Cause (SC5): He was a victim of the recession and unfair practices in his industry, which the government failed to regulate. Environment (SC7): He might benefit from considering relocating to a geographic area with a lower cost of living.
Shyness and lack of confidence in social situations	Skill Deficits (BL3): Relaxation, assertiveness, and social skills can all be taught. Conditioned Emotional Responses (BL2): Exposure techniques have strong research support. Limitations of Cognitive Map (C2): There may be underlying schemas that she is boring, will receive harsh judgment, and does not deserve positive attention. Deficiencies in Cognitive Processing (C3): She may be engaging in mind-reading and misreading neutral cues as rejection.
Difficulty maintaining a long-term relationship	Emotional Focus (BE4): Difficulties accessing more vulnerable emotions. Loss and Bereavement (CS4): Never fully grieved last relationship. Deficits of Self and Relational Capacities (P3): Inability to take view of other; lacks empathy; feels entitled to have other person focus on her needs without having to reciprocate. Spiritual Dimension (ES3): Perhaps client selects people from different religious affiliations; maybe self-esteem is low and she would benefit from spiritual resources to make her feel lovable. Skill Deficits (BL3): May need to learn skills for relating that were not taught in family of origin; may lack skills for initiating contact, dating, and communication. Limitations of Cognitive Map (C2): Beliefs, expectations, and assumptions can cause poor choice of partner, difficulties in trust, and obstacles to working through conflict. Family System (SCI): Looking at family patterns is important in helping a client understand reenactments within family of origin.
Difficulty adjusting to being in college away from home	Developmental Transition (CS3): Adjustment difficulties can be normal at this big transition. Internal Parts (P1): A part of him wants to quit midsemester; another part wants to make it work. Family System (SC1): Parents may be inadvertently sabotaging his separation and transition to adulthood. Dysfunctional Self-Talk (C4): It is important to examine the client’s self-talk to discover barriers to adjustment. Social Support (SC3): He needs help in making new friends and getting engaged in activities. Environment (SC7): Having grown up in a warm climate, he is suffering from the freezing temperatures and misses being near the ocean.
Difficulties associated with poverty and living in high-crime neighborhood	Social Problem Is a Cause (SC5): Economic disparities; lack of funding for neighborhood renewal; the therapist needs to emphasize the strengths and assets that already exist and avoid blaming the victim. Situational Stressors (CS2): Daily activities bring stress because of gang members, drug dealers, and ugliness of urban setting. Cultural Issues (SC2): Therapist from higher SES will have problems understanding and being trusted. Therapist needs to understand the culture of poverty and the cultural groups who have faced discrimination. Freedom and Responsibility (ES2): The client needs to discover alternatives and to see that her choices can have an impact on the future. Social Support (SC3): Therapist needs to function as advocate to get the client resources and help client find mentors who have succeeded in leaving neighborhood.
Difficulty adjusting to birth of first child	Developmental Transition (CS3): Becoming a mother is a very dramatic transition. Social Roles and Systems (CS4): Role change can be associated with loss, even if the change is positive; the client may feel incompetent in her new role. Family System (SC1): Her marriage is going through a change, and it is important that both spouses support each other instead of moving in different directions. Skill Deficits (BL3): She may never have learned any childcare skills. Social Support (SC3): It would be beneficial for her to have group activities with other new moms and infants.
Difficulty integrating back into civilian life after serving military in combat	Trauma (CS5): He was exposed to trauma on a daily basis and needs to be evaluated for PTSD. Mind-Body Connection (BE3): He suffers from stress symptoms and would benefit from learning to manage his arousal level; he may need to learn to feel comfortable at a low level of stimulation. Spiritual Dimension (ES3): He may be suffering from “moral injury”—guilt over how his own behavior in the military transgressed his moral code; he doubts whether forgiveness is possible. Social Roles and Systems (SC4): He has trouble functioning in his employment because the system is so different from the military; he finds the lack of a clear hierarchy frustrating. Family System (SC1): His wife and children seem like a tight coalition and he feels on the outside; his wife is treating him like a patient.

Chart I.D in Appendix I provides an outline of the format for the report, using the SOHP acronym for each problem. After completing a draft of the report, evaluate whether you have met the 28 standards (see Chart I.A, Appendix I). Expect to revise the report once or twice to meet the standards.

Data from the case of Maria (pp. 425–428) are used for the following sample report, with a little imaginary data added to fill in the objective data sections. Three problems are defined.

Data	Hypotheses	Ideas for Plan
Jennifer identified the desired behavior as “sitting at my desk, concentrating on the task of writing, for 3-hour blocks of time” and listed undesired behaviors as going to the refrigerator, cleaning files, making telephone calls, and watching TV. She decided that antecedents of productive work were a tidy desk, lumbar support for her back, and encouraging inner talk like “Stick with it, you’re making progress.” Antecedents of dysfunctional behavior were excessive clutter, physical pain, and negative inner talk like “It’ll never be done, I don’t deserve a doctorate.”	Antecedents and consequences (BL1) A behavioral analysis will yield a plan using positive reinforcement and response cost.	She will set up a contingency contract: For every 3 hours of work, she would reward herself with a snack and reading one chapter in a novel. For failing to complete the 3-hour time block, she would write a $10 check and send it to a political party that she detested.
She had a completed draft to show the chair of her committee. The professor liked the content, but pointed out a skill deficit in her writing skills: Her paragraphs were poorly organized and her ideas did not flow in a logical order.	Skill Deficits (BL3) Her difficulties stem not just from anxiety but also from weaknesses in academic skills.	Jennifer needs to improve her skills. Possible strategies include getting a book on writing, taking a course, or finding a tutor.
As she was nearing the end, she started to experience intense anxiety, sweaty palms, loss of concentration, shaking hands, and a feeling of dizziness.	Conditioned Emotional Responses (BL2) The idea of finishing may be a trigger for intense anxiety.	I can teach her relaxation techniques and suggest that she implement them when she notices the earliest sign of rising anxiety.

Data	Hypotheses	Ideas for Plan
“My women friends who work look down at me for being a full-time mom.” “Shouldn’t I want to make something of my life?” “I would love to be a therapist, but I’m scared of the responsibility.”	Freedom and Responsibility (ES2) She needs to make a choice based on her own true desires, rather than what other people think.	Help her sort out her wishes and “shoulds.” Promote cost-benefit analysis of different alternatives. Have discussions about need to find source of motivation within, rather than in the opinions of friends.
“My kids don’t need me anymore.” “I want to start putting my own needs first.”	Developmental Transition (CS3) She is ready to move to a new stage where she explores new opportunities. She has a chance to complete a developmental task that she missed by marrying very young.	Psychoeducation about developmental stages. Recommend group for “midlife career change” to get support and explore options.
“My husband doesn’t want me to work; he says he will be embarrassed if his business associates think we need the money.”	Social Problem Is a Cause (SC5) Society imposes gender roles that keep women in a subordinate role.	Offer a feminist perspective: that she has internalized gender roles. Explore past decision points in her life, and help her feel empowered to make whatever choice she wants.

Maria: A Sample Case Formulation Report

Identifying Data

Maria is a 22-year-old, single, Latina woman who lives at home with her 41-year-old mother and her younger sister, Teresa, a 20-year-old college student, two doors away from her maternal grandparents. Maria has been employed as a secretary for the same company since graduating from high school 4 years ago.

Presenting Problems/Reason for Referral

Two months ago Maria broke up with her boyfriend of 2 years, Tony. For the past two months she has been severely depressed, with frequent crying spells. She said that her depression began after she and Tony broke up. She found it hard to concentrate on her job, had difficulty falling asleep at night, and had a poor appetite. She stated that she had always had occasional periods of “feeling down,” but her present feelings of misery were worse than anything she has ever experienced. She was referred to this counseling center by the Employee Assistance Program of her company because of absences and poor concentration at work.

Clinical Observations

Maria, an attractive, slim, dark-haired woman, was dressed neatly for her first interview. Her eyes were puffy and ringed with dark circles. She answered questions and related information about her life history in a slow, flat tone of voice, which had an impersonal quality to it. She sat stiffly in her chair with her hands in her lap, moving very little during the interview.

Background

Maria is the older of two girls. Her Latino Catholic parents were born in the United States and married right after high school. Both sets of grandparents emigrated from Guatemala and settled in a predominantly Latino neighborhood. The paternal grandparents died when Maria was young, but her maternal grandparents have always been an active part of her family.

Maria describes her childhood as “unhappy” because her father, a truck driver, was frequently absent, and when he was home, her parents were “constantly fighting.” Sometimes her father would “throw things and shout,” while her mother would become “sullen and withdrawn” and refuse to speak to either her husband or daughters. Maria recalls that her mother often told her daughters that she “had ruined her life” by marrying their father, who had demanded that she drop out of college after completing 3 years.

The happiest times in her childhood were between the ages of 6 and 9, when her father would take the two girls to a park or movie while her mother, who expressed no interest in joining them, went to her parents’ home after church. By the time she turned 10, Maria recalled that her father “could not be relied on” because he failed to return home, as promised, to take his daughters on outings. A very significant event in Maria’s childhood was her 12th birthday, when her father missed her birthday party despite having promised to be there. Her father permanently left the family that night, after accusations of infidelity by his wife. Maria and her sister overheard the argument and his departure, but said nothing to each other, nor did they leave their room to talk to their parents. Her father never sent money to support the family, nor has he been heard from since his departure. Her mother prohibited mention of his name. Maria recalls that whenever she thought of her father, it was always with a feeling that she had been responsible in some way for his leaving the family: “If it hadn’t been for my birthday, my parents would not have gotten into an argument and my father would not have gone away.”

After the departure of her father, her mother got a job in a supermarket and has worked there ever since. Maria described her mother as a “constant complainer” who would come home tired from work each day, complain about how hard she had worked, and refuse to talk to her daughters. She often expressed the belief that she had sacrificed her life to make her children happy and “all she ever got in return were grief and unhappiness.”

Problem List
Problem 1: Depression following breakup of relationship
Problem 2: Difficulty establishing intimate, trusting relationship with a man
Problem 3: Lack of close friendships

Problem 1: Depression following breakup of relationship

Maria has symptoms of acute depression that are contributing to absenteeism and poor work performance.

Outcome Goals: Her depressed mood will be alleviated and she will be attending work regularly and functioning effectively at work. She will have the ability to cope better with loss and disappointment in the future.

S: During the months preceding the breakup, Tony had been insisting that she decide whether she wanted to marry him or not, and she felt incapable of making a decision. He broke up with her unexpectedly during a dinner date, stating that she did not seem to have very strong feelings for him. She did not try to explain her feelings to him but just “felt numb” and asked to be taken home, and neither of them initiated contact since that event two months ago. She has had difficulty falling asleep at night, bad dreams, and poor appetite; she feels constantly tired, loud noises bother her, she cries frequently, and avoids being around people. She has missed work several times during the past month and has just “sat around the house crying.” She went to her family doctor because she was concerned over her lack of energy, but no medical problems were found. She asked the doctor to prescribe something to help her sleep so she would not be so tired and could concentrate better.
She stated that she “was not sure why she was so depressed.” She had always had occasional periods of “feeling down,” but those moods usually lasted “only about a day,” and passed when she became involved in some other activity. Her depressed moods in childhood were associated with her mother criticizing her for not doing as well in school as her sister Teresa did. She began to think that she “was not smart enough to get good grades.” She always became despondent when she got into an argument with her mother, When Maria was feeling intense feelings of disappointment, as when her father did not show up for her birthday party, she kept them to herself.
O: Even when she shared the painful details of her father’s departure, she spoke in a monotone. Her mental status is consistent with depression.
H: The onset of Maria’s depression corresponds to the loss of a significant 2-year relationship (Loss and Bereavement [CS4]). She seems stuck at a stage of numbness, not having expressed emotions that are usually associated with grieving. She lacks understanding of the relationship between the loss and her response (she stated she “was not sure why she was so depressed”).
Maria’s deficits in accessing, understanding, and expressing her feelings prevent her from moving forward in dealing with the loss of her boyfriend (Emotional Focus [BE4]). Her mother never helped her deal with sadness and anger from her father’s disappearance, and was, in fact, a role model for depressive behaviors and emotional withdrawal instead of healthy coping with loss and disappointment.

Many underlying schemas (Limitations of Cognitive Map [C2]) contribute to and maintain Maria’s current depression. She has a faulty cognitive map for coping with disappointment: In her family, she learned “Don’t talk about it” and “pretend nothing happened.” There are cognitive barriers to being happy that stem from her mother’s influence: “If my mother disapproves of a man, I can’t be happy with him,” “I need my mother’s permission to be happy,” or “Because I ruined my mother’s life, I need to atone by being as miserable as she is.” Based on her father’s desertion, she believes, “If someone leaves me, it’s my fault.” Her mother’s constant criticism and negative comparisons to her sister led to the core belief “I am no good and don’t deserve to be loved.” Thus, the loss of a boyfriend taps into deep feelings of worthlessness, shame, and guilt.
P: The major strategy for helping her cope with her depression is to explore her feelings and let her express emotions surrounding the loss (Loss and Bereavement [CS4] and Emotional Focus [BE4]). I will explain that her symptoms are a normal response to a loss, and provide a rationale for how talking about her feelings can help reduce the somatic symptoms. I will want to create a safe relationship, use empathic responses, and model emotional expression in my voice and words. I will definitely use specific feeling words to help her develop an emotional vocabulary. I will assign homework to read about grief (e.g., Colgrove, Bloomfield, & McWilliams, 1976) and give her journal assignments to write about her thoughts and feelings before and after the breakup. I hope that the benefits she gets from putting feelings into words and expressing her pain to an empathic, caring person will correct her faulty belief (Limitations of Cognitive Map [C2]) that it is better not to talk about problems. I will monitor her report of sleep, appetite, energy level, concentration, and work attendance to assure that the humanistic strategy is effective and that a medication referral is not necessary.
Cognitive interventions will be integrated with an empathic humanistic approach. For instance, when she says, “It’s my fault that Tony broke up,” I’ll ask her to examine the evidence and to consider alternate explanations. We will examine her relationship with her mother, and I will help her identify and challenge the core schemas of worthlessness that she has developed from her mother’s words and actions. I will help her develop a more positive cognitive map, which will include the beliefs, “I deserve to be happy,” and “I am not responsible for my mother’s happiness.”

Once she begins to let herself experience those painful feelings related to Tony, she will tap into the pain of her father’s desertion. That issue is addressed under Problem 2. I will need to persuade her that she needs to deal with the trauma of her father’s desertion to reduce her risk for future depression, and that for the sake of these long-term benefits, she needs to have the courage to face emotional pain.

Problem 2: Difficulty establishing an intimate, trusting relationship with a man

Maria’s only long-term relationship ended two months ago. She was indecisive about her feelings toward Tony, never developed trust for him, and was unable to openly share her thoughts and feelings.

Outcome Goals: Maria will be able to communicate on a personal level, understanding the needs and feelings of the other person as well as her own. She will be able to select men for dating who are trustworthy and make her feel emotionally safe.

S: As a teenager, Maria preferred going out with a group rather than being alone with one boy, because in a group she did not feel compelled to carry on a conversation. When she dated boys, she worried that they would find her boring. Her mother made disparaging remarks about the boys she and her sister dated and about men in general.

Maria met Tony at a party 2 years ago, when she was 20 and he was 23. She liked him from the first time they met, but she was very careful not to show her feelings, for fear that he would not be interested in her if he knew that she liked him. She described Tony as a talkative and friendly person, of similar background. She said that he, too, had difficulty expressing his feelings, and that he resorted to kidding around or changing the topic instead of talking about personal matters. They dated off and on for a number of months and then started to see each other exclusively until the time of their breakup. Maria enjoyed being with Tony but she was troubled by her mother’s attitude toward him. Her mother did not seem to like Tony and was very cold and aloof whenever he came to the house. Four months prior to the breakup, Tony got a job promotion and said that he wanted to marry Maria. When she tried to discuss the topic of marriage, her mother said, “All men are nice before they get married, but later their true nature comes out.”
Maria was confused about her feelings toward Tony and about his feelings toward her. She was “not sure whether she loved him,” but she knew she would be unhappy if they stopped seeing each other. Maria had never told Tony about the events that occurred at the time her father left the family, nor about her fear that she would end up in a situation similar to her mother’s. When she asked him how he felt about her, Tony became annoyed and said it was “obvious what his feelings were because he wanted to marry her.” After several confrontations over whether she would marry him or not, he broke up with her on a dinner date. Maria stated that she was both relieved and upset that Tony had forced the issue and essentially made the decision for her.

O: She answered questions but did not take any initiative. Her content focused on facts and behaviors rather than on feelings. When asked to guess what Tony was thinking and feeling before they broke up, she stared blankly and was unable to generate any hunches.

H: Maria’s difficulty with intimacy is not limited to romantic relationships; she has never had a trusting, intimate relationship with anyone. She lacks competence in a broad array of skills that are necessary for developing a healthy relationship (Skill Deficits [BL3]; Emotional Focus [BE4]); she has defended herself against vulnerability because of the circumstances of her father’s desertion (Unconscious Dynamics [P4]); she has faulty schemas about men and marriage and a low opinion of her own worth (Limitations of Cognitive Map [C2]); and she shows an inability to separate herself from her mother (Family System [SC1]).

The focus on emotional awareness and expression described under Problem 1 will serve to build skills needed for successful intimate relationships. Because of her lack of basic communication skills, her appraisal of herself as a boring conversationalist may be accurate. She also lacks decision-making competence, which involves knowing what she wants, being able to evaluate alternative choices, and experiencing herself as an active creator of her life instead of a passive object of other people’s decisions.
The father’s desertion not only left her vulnerable to depression but also impaired her ability to trust men and view herself as lovable. Unless she deals with that trauma emotionally, she will be likely to reenact it in her adult life: repeatedly finding a man who will leave her, and ending up depressed but unable to talk about it. In staying with Tony, she was either staying in a minimally satisfying relationship because of low expectations of a loving relationship, or she was protecting herself from being hurt by numbing her loving feelings. She is comfortable with a superficial, undemonstrative relationship because it allows her to maintain her defenses against feeling emotional needs and to feel protected from rejection and abandonment. (Unconscious Dynamics [P4]). If a relationship got closer, it would stir up the painful feelings from her childhood. She needs to be able to access those feelings in a safe setting and develop the courage to be vulnerable with a trustworthy person.
Maria has developed many schemas that prevent a satisfying intimate relationship (Limitations of Cognitive Map [C2]). Even before her father left, she was developing the belief that “men can’t be trusted,” based on his unreliable behavior. Her mother’s opinions also contributed to her negative beliefs about men and marriage: The belief that men are nice before they marry but then turn bad is a powerful barrier to commitment. She believes that she will end up like her mother if she gets married: abandoned by the man she trusted. That belief will function as a self-fulfilling prophecy if it is not modified.
Family System (SC1) concepts are useful for understanding Maria’s inability to separate emotionally from her mother. Her younger sister received positive appraisals from their mother, whereas Maria was shamed and devalued. Maria also seems to be designated to be responsible for her mother’s happiness (because her mother blames her for her unhappiness), and so she needs her mother’s seal of approval to enter marriage. Unless Maria can remove herself from this family role, she will be unable to make a commitment to any man, as her mother will sabotage her daughter’s movement toward independence.

P: A major component of therapy will be building a strong therapist-client relationship. This will be the first time that Maria will experience a trusting, emotionally open relationship with another human being. In the process of talking about her relationships, her mother and family system, and the loss of her father, she will be building skills (Skill Deficits [BL3]) of communication and “feeling awareness” (Emotional Focus [BE4]). I will use self-disclosure to help her experience how people communicate in intimate relationships and will occasionally ask her to take the role of the other people in her stories—her mother, sister, or boyfriend—to help her develop perspective-taking skills.

As she experiences her emotional pain from her father’s (and Tony’s) desertion, she will learn to tolerate those feelings and not need to numb herself. It may be beneficial for her to do the Gestalt exercise of imagining her father in an empty chair and expressing her feelings directly to him. I anticipate that there will be tears and anger, and I hope to help her empathize with the sad, lonely child that she was, who was in no way to blame for her parents’ conflict and her father’s poor character. When she is able to access and understand her feelings about her father, she will have insight into how those buried feelings were activated by Tony’s sudden breakup. With time, her defensive strategies (Unconscious Dynamics [P4]) will no longer be needed to avoid vulnerable feelings.
At appropriate times, I can challenge her faulty beliefs (Limitations of Cognitive Map [C2]) regarding her responsibility for her father’s desertion and her mother’s happiness. As she becomes clearer about her own needs and her right to be happy, I will have her revisit her relationship with Tony. She may discover that this was not a very intimate relationship, and that she did not have strong feelings; in that case, she will be clearer about what she wants as she starts dating. Alternatively, she may realize that she did have deeper feelings but was not yet able to trust or express her needs and feelings. Then, we could explore the possibility of her contacting him and talking about her new realizations.
Assuming that she does not renew a relationship with Tony, Maria will begin to date new men, and therapy sessions will focus on her experiences with men and the reactions from her mother. I will use opportunities to build dating and relationship skills (Skill Deficits [BL3]), perhaps role-playing how to communicate her feelings or maintain an interesting conversation. I will encourage Maria to talk about sexual feelings and choices as those issues become salient. If she begins to get close to a man, I predict her mother will try to sabotage her happiness and separation; in that case, I will teach Maria about Family System (SC1) concepts and give her options for responding to her mother that are compatible with her values. We could explore whether her grandparents could provide support to counter her mother’s disapproval.

Problem 3: Lack of close friendships

Maria does not have close friends and maintains a distant relationship with her sister, who lives in the same house. She does not confide in the people she calls “friends” and had no social support while she was deciding about a marriage proposal and coping with a breakup. She no longer attends church.

Outcome Goals: Maria will have one or two friends in whom she confides and can turn to for support in times of loss and disappointment. She will decide if she wants to be involved in a community or religious group that provides social support.

S: Maria considers two women at work her “close friends,” yet she never talked to them about her relationship with Tony or about her feelings of depression after the breakup. She was not able to talk these issues over with her sister, who she felt was “living in a completely different world” now that she was attending college. Maria indicated that she had always had a number of children to play with and had several friends when she was a teenager. She recalled, however, that it was always very difficult to share her feelings with her friends and tell them about events that were troubling her. Maria and her sister “got along fairly well” growing up, but they had never confided in each other. She said that she had always had trouble expressing her emotions, and she felt that Teresa had the same problem. As described in the Background section, the two sisters never talked with each other about their father’s departure. Maria never expressed to anyone her feelings of guilt over her father’s leaving. When the sisters were younger, their only social activities together were going to church and visiting relatives. Maria stopped attending church when she started dating Tony and admits that she has lost the religious feelings she had as a child.

O: Maria answered all questions and seemed motivated to share personal information. However, she gave short answers and did not elaborate unless she was prompted.

H: Maria needs friends, but there are only casual acquaintances in her life. Having friends would (a) serve as a buffer against depression (Problem 1), (b) give her experiences in trust and vulnerability in a safer context than a romantic relationship, and (c) provide fun and pleasure in her free time, which is currently dominated by contact with a depressed, complaining mother. Her lack of skills in emotional expression and conversation (Skill Deficits [BL3]), a deficiency mentioned under both prior problems, prevents her from turning casual acquaintances at work into real friends. Her beliefs about being “less than” others (Limitations of Cognitive Map [C2]) would lead her to doubt that others would be interested in her problems or would want to spend time with her outside of work. Her younger sister is a potential source of support, but cognitive factors serve as barriers: There were rules growing up about not communicating about their shared loss, and Maria believes that “if my sister is in college, she can’t be interested in me.”

Because religion can be a powerful source of support (Spiritual Dimension [ES3]), I need to find out more about her feelings about her religion. It is possible that she might want to explore other churches, besides the one her mother and grandparents attend, to find a community of young singles of similar backgrounds and values.

P: I believe that a good client-therapist relationship will give her a model of the processes and skills that are part of friendships. I will explain to her the benefits of friendship and social support and suggest that she select two people from work with whom she would like to become closer. We could rehearse how she would propose getting together (Skill Deficits [BL3]) and practice conversational skills to bring more intimate subjects into the relationship. I would encourage her to talk to her sister and test her beliefs that she and her sister have nothing in common (Limitations of Cognitive Map [C2]). A discussion of religion (Spiritual Dimension [ES3]) might lead her to build a support system through a church. Because Maria is comfortable in group activities, it might be helpful to encourage her to find a group in the community that gives her a chance to practice communication skills and initiate friendship, as well as to develop new interests.

Case Management Discussion

A warm and empathic therapeutic relationship is fundamental for helping Maria to express feelings, develop trust in another person, and build relationship skills. Because Maria is currently in a crisis, I would recommend twice-a-week sessions for the first few weeks. The first goal is resolving the depression (Problem 1) and getting her back to her prior level of functioning through encouraging her to share feelings, conducting cognitive interventions, and teaching her about grief reactions. Through our conversations, I will be encouraging her to express herself fully. I will be accepting of her level of skills and avoidance, and monitor my countertransference if I begin to feel impatient. I don’t want her to feel that she is getting a “bad grade” in therapy or that I am critical of her, like her mother is. Preliminary discussion of the need for friendships to serve as social support (Problem 3) might lead her to take steps to create more closeness in her friendships or with her sister.

After the crisis of her depression is resolved, sessions will be changed from twice weekly to weekly. We will deal with the deeper issues of her childhood, especially the loss of her father and the lack of support from her mother. I will be monitoring several aspects of her functioning: her awareness of her feelings, reduction in fear of feeling deeply, ability to freely disclose at a personal level, modification of her core schema of worthlessness and her negative beliefs about men, correction of her faulty sense of responsibility for her father’s disappearance and mother’s unhappiness, and conversational skills. We will focus on outside relationships as well as using our own relationship to help her understand how other people think and feel.

As therapy progresses, I anticipate that she will report positive progress in developing friendships and experiencing moments of intimacy and trust with other people. When she describes difficult interpersonal experiences, we can use therapy to practice communication skills. For instance, if her mother disparages a man she is dating, we can address how Maria can talk to her mother. As she becomes more mature and independent, her mother may attempt to sabotage her growth. As Maria’s self-worth improves and her social contact with her sister increases, she may express interest in college courses and a more interesting career. I will support her autonomy as she makes decisions. As we near termination, we can decrease the frequency of sessions, instead of ending abruptly. At the end of therapy, Maria will have a strong sense that she is entitled to be happy, can cope effectively with loss and disappointment, and can attract good friends and potential partners.

Note on cultural and relationship factors: Maria is a third-generation Latina woman who is living with her mother, a cultural norm for unmarried women. I am from a culture (English-Scottish ancestry) that supports more independence in young women, and I need to be careful about imposing my values. The fact that I am a single woman, also in my twenties, will contribute to a positive relationship. A possible transference reaction is that Maria might see me as someone who would judge her negatively like her mother, and I need to be alert for those moments in therapy.

Sample 1

Sample 2

Sample Answers

Sample 1: Difficulty managing feelings of guilt, frustration, and anger while caring for elderly mother

Situational Stressors (CS2)

Cultural Issues (SC2)

Limitations of Cognitive Map (C2)

Social Support (SC3)

Sample 2: Frustration over not being in a romantic relationship

Developmental Transition (CS3)

Deficits in Self and Relational Capacities (P3)

Skill Deficits (BL3)

Sample 3: Excessive anxiety associated with school performance

Dysfunctional Self-Talk (C4)

Deficiencies in Cognitive Processing (C3)

Skill Deficits (BL3)

Cultural Issues (SC2)

Sample 4: Fear and distrust of men

Trauma (CS5)

Deficiencies in Cognitive Processing (C3)

Cultural Issues (SC2)

Skill Deficits (BL3)

Here Are Samples for Two Problems

Sample Plan

Maria: A Sample Case Formulation Report