Running head: CASE STUDY ANALYSIS

Assignment #2: Case Study Analysis

Molly Hayes
University of Lethbridge
Instructor: Dr. Robert Cey
Due Date: March 22, 2015

CASE STUDY ANALYSIS

Abstract
This paper offers analyses for case studies on two fictitious clients, Candice and Shirley. Each
case analysis provides a brief review of the clients experiences through the lenses of various
learning theories, a more in-depth conceptualization through one chosen appropriate theoretical
lens, and a treatment plan including objective, short and long-term intervention plans, and
limitations. Learning theories examined in the case analyses include behaviourism, cognitivism,
social cognitivism, and complex learning. The main theoretical approach for Candice is
cognitivism and features cognitive-behavioural (CBT) intervention techniques. The main
theoretical approach for Shirley is metacognitivism and features metacognitive therapy (MCT)
and CBT intervention techniques. This document includes two appendices that outline case
conceptualization approaches from the CBT and MCT models.

CASE STUDY ANALYSIS

Case Study A: Candice

Candice and Learning Theories
Candice is a 30-year-old teacher who struggles with poor mental and physical health
since her divorce (Cey, 2015). Although Candice finds her job fulfilling, she experiences mood
swings, physical self-consciousness, inability to follow through with her goals, feelings of
inadequacy, and low self-esteem (Cey, 2015). From behaviourism perspective, failures are
associated with negative feelings and therefore people can learn to avoid situations where failure
may occur (Ormrod, 2012). Through this lens, Candices lack of success with weight loss is
associated with previous failed attempts and thus is an example of classical conditioning. The
social cognitive theory explains that learning can occur by observing the behaviour of another
person (Ormrod, 2012). Candices negative self-image reflects what Ormrod (2012) described as
the perception reciprocal causation. Others have modeled a response-consequence between
happiness and weight and therefore from this perspective, Candice likely believes that her
depression is due to her appearance.
The theories of complex learning highlight the utilization of metacognition in self-regulation
(Ormrod, 2012). Self-regulation involves goal setting, planning, self-motivation, attention
control, self-monitoring, and self-reflection (Proust, 2010; Ormrod, 2012). Candices lack of
success with improving her health can therefore be viewed as a deficit in self-regulation
(Ormrod, 2012). The theory of cognitivism explains that learning is internal, utilizes memory for
organization and encourages behaviours that are affected by expectations and emotions (Ormrod,
2012). The cognitivism perspective describes Candices experiences with her divorce as
cognitively linked to feelings of inadequacy.

CASE STUDY ANALYSIS

Conceptualizing the Presenting Issue Using Cognitivism

Although the theories discussed above provide insight into the elements impacted
Candices experiences, cognitivism best caters to Candices strengths and appropriately
addresses her struggles with self-efficacy and self-esteem and overall symptoms. Based on
Schwitzers (1997) approach, the below subheadings outline Candices presenting concerns and
includes additional cognitive-behavioural case points (Wright, Basco, & Thase, 2006).
Problem identification. Candice experiences mood swings, low mood, weight gain, poor
self-efficacy and self-esteem, and negative self-image. Associated concerns include a divorce
resulting from her husbands infidelity, failed attempts at weight loss, lack of social support, and
limited personal role definition.
Thematic groupings. The main themes include depressive affect, lack of personal
successes, and maladaptive beliefs about attractiveness, happiness, and sense of self, and feelings
of worthlessness, and unattractiveness.
Theoretical inference. Based on the linkages between Candices behaviours, feelings,
and cognitions, the appropriate theoretical approach is cognitive-behaviour therapy (CBT).
Additional CBT points suggested by Wright et al. (2006). Candices career choice
displays strengths associated with academic success, leadership skills, and organization. Possible
automatic thoughts for Candice are I am not attractive and I am a failure; an underlying
schema is I am worthless. Please see Appendix A for a more detailed model of this component.
Treatment Objectives
Candices short-term treatment objectives include improving awareness of depressive
symptoms and body-image concerns, setting short-term personal goals, and uncovering

CASE STUDY ANALYSIS

automatic thoughts. Candices long-term treatment objectives include decreasing the severity of
her symptoms, following through with goals, and improving her self-esteem and self-efficacy.
Short-term treatment plan. To improve Candices understanding of depressive
symptoms mini-lessons will be provided on the CBT model of relationships between affect,
behaviour, and cognitions (Wright et al., 2006). To acknowledge her body-image concerns,
recommended readings (Wright et al., 2006) on feminism and societal pressures will be offered.
To validate Candices experience with depression and provide insight for the therapeutic process,
symptom check homework will be assigned (Wright et al., 2006).
In order to structure the therapy sessions, and provide opportunities for Candice to
experience success with self-regulation, short-term goals related to overall well-being will be set
(Wright et al., 2006). Interventions to assist in goal setting will include behavioural activation,
the offering of suggested tasks to improve experiences, and activity scheduling, the planning of
such tasks and other related activities (Wright et al., 2006). Completing activity logs will be used
to assess Candices level of enjoyment with each activity she engages. Activity logs will provide
the counsellor with indications of stress, areas of strength, triggers for depressive symptoms, and
highlights potential goal opportunities (Wright et al., 2006). Additionally, Candices automatic
thoughts and associated schemas will be uncovered by assigning out-of-session thought
recording and checklists (Wright et al., 2006). Thought records and checklists can be used insession to help Candice uncover the links between her automatic thoughts and her emotions and
behaviours and can assist in the development of strategies for addressing schemas and modifying
automatic thoughts (Wright et al., 2006).
Long-term treatment plan. CBT aims to modify automatic thoughts by using Socratic
questioning to highlight opportunities for change, the use of thought change records to unveil

CASE STUDY ANALYSIS

rational alternatives to automatic thoughts, and by using homework to identify and modify
cognitive errors (Wright et al., 2006). To provide Candice with opportunities to experience
personal success, the CBT tools of activity scheduling, activity monitoring, and graded task
assignment will be used (Wright et al., 2006). By using planned activities and associated rating
scales, Candice and her counsellor can monitor her experiences and plan events that are
attainable and thus promote feelings of adequacy and also events that promote self-esteem.
Graded task assignments will be utilized to chunk Candices goal into more manageable pieces.
In order to improve Candices self-esteem and self-efficacy, her automatic thoughts will be
modifying using Socratic questioning, thought change records, the identification and
modification of cognitive errors using homework and cognitive rehearsal (Wright et al., 2006).
Mindfulness and relaxation techniques will be taught to promote self-affirmation and self-care
(Forsyth & Eifort, 2007). The identification of Candices existing schemas, by conducting a life
history review, will assist in the development of more productive schemas (Wright et al., 2006).
Limitations of treatment plans. Although a life history will be conducted to provide
context for Candices schemas, most CBT techniques do not effectively validate or address a
clients past experiences (Corey, 2009). Additionally, the CBT approach generally comes across
to clients as being simplistic and superficial (Corey, 2009) and therefore may reinforce Candices
feelings of worthlessness.
Case Study B: Shirley
Shirley and Learning Theories
Shirley is an intelligent 45-year-old unemployed accountant who has experienced
increasing anxiety after becoming a victim of a sexual assault (Cey, 2015). Shirleys anxiety
prevents her from going outside, meeting basic needs, and maintaining employment (Cey, 2015).

CASE STUDY ANALYSIS

Shirley has increased the dosage of anti-anxiety medications of the years as her symptoms have
become more intense; she is interested in returning to work and would like to be off medication
(Cey, 2015). The social cognitive learning theory explains that a persons expectations of the
outcome of behaviour impact the elicitation of the behaviour; if it is expected that a behaviour
will minimize an unpleasant outcome, then the behaviour will be engaged (Ormrod, 2012). In
terms of Shirleys avoidance, it can be suggested then that she has learned to avoid situations that
elicit her anxious thoughts and thus she engages in behaviours that minimize that discomfort.
Although it is not likely that Shirley learned to exhibit these behaviours from exposure to
others exhibiting the same behaviours, as suggested by the social cognitive approach (Ormrod,
2012), it is possible that environmental factors promoted her learning of avoidance behaviours.
The behaviourism theory explains the impact of Shirleys sexual assault on her anxiety
presentation by suggesting that her anxiety has been higher order conditioned (Ormrod, 2012).
From the behaviourism perspective, Shirley has linked being outside of her home and working to
the trauma of her sexual assault, which has conditioned a fear response. Similarly, it is evident
that Shirley has generalized her fears of being assaulted to other situations and has led to
avoidance learning (Ormrod, 2012).
From the cognitive perspective, Shirleys slow development of anxious symptoms can be
described as an example of latent learning (Ormrod, 2012). The cognitive theory explains that
learning involves the development of a mental representation of events that are not always
displayed in overtly (Ormrod, 2012). Therefore, Shirleys delayed anxiety behaviours could be a
reflection of the developing mental representation of her trauma. Memory theories account for
Shirleys increase of anxiety over time by explaining that memories become more solidified with

CASE STUDY ANALYSIS

elaborate rehearsal (Ormord, 2012); therefore the more that Shirley recalled her traumatic
experience over time, the stronger impact it had on her behaviours.
The theories of complex learning describe the development of metacognitive strategies to
address problems, and self-regulate (Wells & Purdon, 1999). Metacognition is the active
monitoring, interpreting, evaluating, and regulating of cognitions as they relate to external
sources and other internal processes (Wells & Purdon, 1999). From this perspective, Shirleys
experiences with anxiety have been triggered by the trauma of her sexual assault and maintained
by the metacognitive processes she engages in. It is evident by Shirleys behavioural presentation
that she is engaging in self-regulatory behaviours such as planning for basic tasks, avoidance,
and increase in medication, in an attempt to control her anxiety. Wells (1999) explained that such
behaviours are reflective of metacognitive structures that monitor behaviours and feelings and
appraise them as beneficial, therefore leading to the continuation of the behaviours.
Conceptualizing the Presenting Issue Using Metacognition
Although each learning approach presented above provide insight into Shirleys internal
experiences, the approach the best caters to Shirleys strengths of intelligence and internal
motivation, and her struggles with persistent maladaptive cognitive patterns is metacognitive
therapy (MCT). Using the Schwitzer (1997) case conceptualization model and Wells (1999)
MCT case conceptualization map, the below subheadings outline Shirleys presenting concerns.
Problem identification. Shirley was a victim of a sexual assault and experiences chronic
and generalized anxiety characterized by an inability to maintain employment, fears of engaging
in activities outside of her home, discomfort in confined spaces other than her home, and
excessive planning activities that meet her basic needs. Additional concerns include a lack of
income, and a lack of significant relationships and family nearby.

CASE STUDY ANALYSIS

Thematic groupings. The main thematic groupings for Shirleys case include
generalized anxiety, post-traumatic stress, anxious affect, avoidance behaviours, and irrational
beliefs about working and the benefits of her maladaptive cognitive structures.
Theoretical inference. Based on Shirleys avoidant behaviours, generalized anxiety, and
maladaptive cognitive patterns, the appropriate theoretical approach is MCT.
Additional MCT points. Based on Wells (1999) metacognitive model, Shirleys likely
obtrusive cognition that triggers her anxiety is what if I am sexually assaulted? Possible
metacognitive beliefs include If I dont go outside, I wont get assaulted, and Anxiety
prevents me from working. Possible worries include planning for basic tasks will make me
safe, and I will lose control if I stop worrying.
Treatment Objectives
The short-term objective is to promote control over worrying and modify metacognitive
beliefs about worrying. The long-term objectives include the development of adaptive coping
strategies, establishing employment, and improve activities outside of the home.
Short-term treatment plan. To address Shirleys beliefs about the uncontrollable nature
of her worries and the belief that worrying requires medication the following interventions will
be utilized. Self-report measures will be assigned to uncover Shirleys anxious thoughts and
verbal questioning will be used to discover the perceived consequences of not worrying (Wells,
1999). A case conceptualization will be developed and shared with Shirley as a representation of
how her worries impact her emotions, thoughts, and behaviours (see Appendix B). In order to
modify Shirleys metacognitive beliefs and worries, she will engage in worry postponement
experiments to provide her with evidence that worrying can be controlled (Wells, 1999).
Psychoeducation will be offered on the effects of medication on the brain and body to help

CASE STUDY ANALYSIS

10

Shirley exert more control over her physiological symptoms of anxiety (Wright et al., 2006).
These lessons will be used to aide Shirley in postponing her medication administration and
planning as additional worry postponement experiments. These interventions will allow Shirley
to gain an understanding that worries can be controlled and that they lead to physiological
symptoms that maintain the worry itself. Shirleys metacognitive beliefs will become weakened
and will allow for the integration of alternative strategies (Wells, 1999).
Long-term treatment plan. To build the foundation for new strategies, Shirley will
complete a worry narrative that describes in written words her cognitions about her feared
scenarios (Wells, 1999). Shirley will then engage in a feared scenario, compare her experience
with the narrative and allow her to examine how worrying distorts reality (Wells, 1999). A costbenefit analysis for avoiding situations will be completed to show Shirley the costs of her
avoidances on her quality of life (Forsyth & Eifort, 2007) and allow her to replace the cognitions
that guide avoidance with ones that promote action (Wright et al., 2006). To encourage Shirley to
engage in more activities outside of her home, a graded task assignment (GTA) intervention will
be used to help her gain confidence in taking action (Wright et al., 2006). Shirleys GTA may
involve starting with small errands that will get progressively longer and more challenging. The
GTA approach will also be used to help Shirley obtain employment.
Limitations of treatment plan. The limitations of the treatment plan include its failure
to address the potential of Shirley to be experiencing significant post-traumatic stress, and
medication dependency. Because MCT is a specialized form of CBT (Wells, 1999), it is also
possible that this approach will not effectively address Shirleys emotional experiences or
potential self-efficacy deficits.

CASE STUDY ANALYSIS

11

References
Cey, R. (2015). CAAP 6631-Case studies [Class Handout]. Lethbridge: University of
Lethbridge. Retrieved from https://moodle.uleth.ca
Corey, G. (2009). Theory and practice of counselling and psychotherapy (8th ed.). Belmont, CA:
Thomson Brooks/Cole.
Forsyth. J. P., & Eifert, G. H. (2007). The mindfulness and acceptance workbook for anxiety. A
guide to breaking free from anxiety, phobias, and worry using acceptance and
commitment therapy. Oakland, CA: New Harbinger Publications Inc.
Ormrod, J. E. (2012). Human learning (6th ed.). Upper Saddle River, NJ: Pearson Educational
Inc.
Proust, J. (2010). Metacognition. Philosophy Compass, 5(11), 989-998. doi: 10.1111/j.17479991.2010.00340.x
Schwitzer, A. M. (1997). The inverted pyramid framework applying self psychology constructs
to conceptualizing college student psychotherapy. Journal of College Student
Psychotherapy, 11(3), 29-47. doi: 10.1300/J035v11n03_05
Wells, A. (1999). A metacognitive model and therapy for generalized anxiety disorder. Clinical
Psychology & Psychotherapy, 6(2), 86-95. doi: 10.1002/(SICI)10990879(199905)6:2<86::AID-CPP189>3.0.CO;2-S
Wells, A., & Purdon, C. (1999). Metacognition and cognitive-behaviour therapy: a special issue.
Clinical Psychology & Psychotherapy, 6(2), 71-72. doi: 10.1002/(SICI)10990879(199905)6:2<71::AID-CPP186>3.0.CO;2-G
Wright, J. H., Basco, M. R., & Thase, M. E. (2006). Learning cognitive-behavior therapy: An
illustrative guide. Arlington, VA: American Psychiatric Publishing, Inc.

CASE STUDY ANALYSIS

12

Appendix A
CBT Case Conceptualization (Wright et al., 2006, p. 51)

Symptoms: mood swings, depressed

mood, weight gain, poor self-efficacy and
self-esteem

Formative influences: divorce due to

infidelity
Interpersonal issues: several failed
weight loss attempts, lack of social
support

Working hypothesis: depression is

caused by a belief of worthlessness
learned by experiences with divorce
and reinforced by negative self-talk

Biological, genetic, medical factors:

none known
Strengths/assets: successful career,
organized, confident, leadership skills
Typical automatic thoughts, emotions,
behaviours:
- I am not attractive, I am a
failure
- Depression, sadness
- Avoidance and quitting

Underlying schemas: I am worthless

Treatment plan: CBT techniques

CASE STUDY ANALYSIS

13

Appendix B
MCT Case Conceptualization (Wells, 1999)

Trigger: What if I am
assaulted?

Positive metacognition: If I
dont go outside, I wont get
assaulted.

Type 1 worry: If I dont plan, I

wont be safe.

Negative metacognition:
Anxiety prevents me from
working.

Type 2 worry: I will lose

control if I stop worrying

Behaviour:
- Avoid work
- Avoid going
outside
- Take
medication

Thought control:
You need medication
to stop worrying
I will be fine if I just
dont go outside, then
I wont have to worry
about it

Emotion:
Im sweating and
having a hard time
working, I must be
losing control