Sample Case Conceptualization and Treatment Summary

Pseudonym: XX XX
DOB: 1998
AGE: 16
LANGUAGE: English

DATES OF TREATMENT: 11/2014 5/2015

THERAPIST: Joshua Gonsher, MS Ed, MA
SUPERVISOR: Layla Kassem, PhD, PsyD
DATE OF REPORT: June 18, 2015

CASE CONCEPTUALIZATION:
Biological considerations are the first predisposing factors that led to XX's depression.
His mother has suffered from depression and anxiety, and his father and brother battle addiction,
so he was at an increased risk of developing a mental illness. Further, XX was born anatomically
female though considers himself male and empathizes with marginalized sexually minorities;
though he has not been victimized for his status, as heretofore he had not self-identified as
transgendered, he may be internalizing their getting bullied. Environmental vulnerabilities and
psychosocial stressors also exist with his growing up in an unstable home and being witness to
his parents' unhappy, loveless marriage, provingto himthat relationships are unstable and of
convenience only. The perceived verbal abuse from his father and the insults of his brother
combine with his personality traits of low self-esteem and foster his core belief of worthlessness.
Additionally, though XX states he has several friends, according to his definition of what friends
are, they seem not to function as true friends, which adds to his negative core belief that he is
unlovable. Finally, XX has stated that his goals in therapy do not merely arise from his gender
dysphoria, but since he has seen global gender discrimination and sexual marginalization, his
belief in an unloving and unfair existence is furthered because of it.
The precipitating factors that led to the onset of XX's depression may include recent
conflicts within his peer group and trouble with his friends, examples of the cognitive distortion
of personalization, in addition to the psychological gender dysphoric change in his life that began
two years ago. As the unhappiness XX has with his biological gender has been growing, so has
his progressive sensitivity to the self-centeredness and narrow-mindedness of his intolerant

father. Additionally, a life-threatening accident involving XX's mother and brother scared XX
and may have added to his burgeoning belief that the world is unfair, the future is hopeless, and
life is not worth living.
The factors that perpetuate XX's current experience include his avoidance of prospects
that could decrease his depression (e.g., behavioral activation: meeting people who are in a
similar predicament to his) and his cognitive distortions (e.g., his catastrophizing with his
anxious features, his black-or-white/dichotomous thinking in his consideration that he is
worthless and unlovable, his selective attention to events that prove his core beliefs but not to
those that lack evidence). Further, although XX's relationship with his mother is often positive,
communication between them is frequently muddled. XX, jumping to conclusions, assumes his
mother will not understand him, will not support him, and therefore does not approach her with
his concerns, but all she wants is to know how she can help him get better (MOTHER, personal
communication, April 11, 2015). XX's father, on the other hand, does not support him and
instead embarrasses and insults him with his "ignorance" (XX, personal communication, April
23, 2015). Moreover, his parents' child-rearing styles, rather than being authoritative and helping
XX increase autonomy and responsibility, are authoritarian (his father) or permissive (his
mother), too constricting or too loose, respectively. The adults in XX's life, about whom he cares
deeply, are not collaborating nor in harmony, and the parental relationship that XX expected to
move smoothly has nearly deteriorated, additional testimony to the hopelessness of his life.
Finally, instead of meeting XX's siblings' needs, his parents have disregarded them in pursuit of
their own, which may have led to his depression, his sister's moving out, and his brother's
substance abuse.
XX has several protective and positive factors that have begun to moderate the impact of
his depression and gender dysphoria and that will be helpful in further treatment. Although he is

often down, he is still able to work at an effective level, succeeding in school and earning almost
all As, which demonstrates resilience. He is thoughtful, seems highly motivated to change his
current situation, and concerns himself with others' needs. He understands that success in therapy
is possible and depression is treatable. Moreover, XX does not want to end up like his father or
brother, whom he feels are immature and do not grow. Finally, XX loves animals, funny movies,
and spending time with his mother, events and activities that will increase his joy and provide
proof that add worth to life and reasons for living.
This therapist understands XX's problems as caused by his distorted cognitions that he is
worthless. He has a severe lack of self-esteem that has stemmed from his father's verbal abuse
and brother's insults, which ignores his successes and attends only to his failures. XX works hard
in school despite this low self-worth in an attempt to compensate but demonstrates an
unwillingness to make his needs known, resulting in depression. XX believes that he is unlovable
and cannot understand that his friends really want to spend time with him. His sister attends
school out of state, which XX distorts as being abandoned from someone for whom he cares
deeply. XX feels the world is unloving and full of people who shirk their responsibilities (e.g.,
his father and brother are unemployed and have problems with addiction). XX's negative
automatic thoughts come out of his intermediate belief of 'If I try to do something new, I screw
up.' Then, when he stumbles over his words or earns a bad grade on a test, the events provide
evidence that he is a failure. This idea comes from an 'I am worthless' core belief, which was
formed when his father and brother treated him as no good. This assumption prevents XX from
attempting unfamiliar activities or causes him to try too hard and overcompensate; the results of
both can be failure, therefore reinforcing his belief that he is worthless and cannot succeed.

Finally, though his general attitude toward the future is that nothing will improve, he has shown
progress weakening this schema and his negative core beliefs.
TREATMENT PLAN:
XX's long-term therapy goals are to relieve his depressive symptoms, especially suicidal
ideation, and return to his previous level of effective functioning; discuss and modify
maladaptive cognitions of low self-esteem or guilt and fear of rejection and abandonment that
lead to depression; and reestablish hope in himself, the world, and the future (Jongsma, Peterson,
& Bruce, 2014). As this therapist had planned on seeing XX for no more than 28 weeks, not
every goal was completely met; however, the intent was to set mechanisms in place and to teach
XX how to accomplish them even after termination.
The short-term objectives and accompanying therapeutic interventions that helped XX
reach these goals were to have him describe his mood state, energy level, amount of control he
had over cognitions, and sleeping patterns. This therapist provided him empathy and built rapport
to create a safe space wherein XX could share his feelings and evaluate his depressive symptoms
when describing them. XX also expressed his present and past suicidal ideation by determining
the current level and history of suicidality and evaluating risk. XX shortly reported having no
further wishes to harm himself, yet this therapist continued assessing and monitoring his suicide
risk and would offer hospitalization plans if XX's state were deemed too dangerous. Finally, XX
detected and offered alternatives to maladaptive thoughts that perpetuated depression by
completing weekly thought logs as homework to find his triggers and the connections between
cognitions, feelings, and behaviors; engaging in Socratic questioning to evaluate the evidence for
and against these beliefs; and reinforcing his shift in thoughts, emotions, and actions away from
negative self-referral to positive, more realistic perceptions (Jongsma, Peterson, & Bruce, 2014).
TREATMENT IMPLEMENTATION:

Each session began with a check-in to see how XX's mood was over the previous week
and then to see how it had been that day. This therapist then compared XX's mood with his thenpresent affect to determine the amount of incongruence, which, then, if it were present and XX
did not list it in the ensuing agenda, became the item around which the session was based. XX
was asked if anything were left over from the previous meeting, if he had completed the
homework and how he felt while doing it, and what should be discussed that day. This therapist
then administered various interventions from the treatment plan during the following session.
Since XX's mood upon beginning therapy was so low, this therapist hoped to see an
improvement in his depression observable in only one session. Mere questioning of a client's
maladaptive assumptions was all that was thought necessary to reduce symptomatology, in that
XX would realize the errors in his cognition and change immediately. While this lack of success
was partially due to the therapist's unrealistic expectations, XX's instant cure could not be
reached since he had never previously challenged his thought processes. That one has cognitive
distortions may be met with disbelief or an unwillingness to accept it. Nevertheless, as the
sessions progressed, Socratic questioning became the most effective tool in the identifying,
challenging, and replacing of the errors in XX's thinking, at which he has become quite
proficient. This therapist observed that though he may still make mistakes, he can do it on his
own with some help.
Also at the outset of treatment, this therapist wished to diagnose XX with GAD and
sought to assess its presence further, but after only one session, it became clear that therapy
would subsequently focus on depression with anxious features, as full criteria for GAD were
clearly not present. Further, as this therapist had been treating mostly female students with
anxiety or depression, he thought XX's situation was going to be no different. However, after the

second session, XX revealed that what was truly bothering him was his dysphoria at being as a
transgendered individual, as well as his depression.
This information was processed in supervision and then incorporated into the treatment
plan. Since he had had no encounter with any transgendered person whatsoever, this therapist
modified his prior beliefs about working with individuals of this nature and examined best
practices. Research from Janssen and Erickson-Schroth (2013) provided guidelines for how to be
present for such clients. Though this therapist normally takes a more directive standpoint, their
study suggested a more removed and safer, available stance. Finally, Sue and Sue (2012) instruct
the culturally competent therapist not to invalidate the reality of the client. If XX says the
therapist has committed a microaggression against him, this therapist would not get defensive; he
would be open to explore issues such as gender and/or race. When XX revealed his gender
identity, this therapist and he discussed how his coming out to a straight, Jewish, White, married
male was and overcame that potential obstacle.
TREATMENT OUTCOME:
As stated above, this therapist assessed how XX was faring at the start of each session
with a Cognitive Therapy check-in and documented it in XX's chart. XX's subjective responses
to the therapist's inquiries of how he felt therapy was progressing were noted and discussed.
When XX felt he had spoken his piece and the daily goals had been met, he decided that therapy
would conclude then though it may have been earlier than the allotted 50-minute hour. This was
in line with the therapist's belief that the client is the expert at himself and the clinician is present
merely to serve his best interests.
This therapist assessed XX every three months to see if he were improving. If XX and
this practitioner agreed that treatment goals needed to change, then the remainder of that session
and subsequent homework assignments were dedicated to creating short-term and long-term
therapeutic goals. The first assessment, in January, showed that XX wished to engage more in

art, sleep better at night, and reduce further his feeling down. This therapist wrote these goals in
his chart and continued discussing them in session. It was the most recent assessment (i.e.,
April), though, when XX decided he wanted to come out to his mother and be admitted to an
inpatient clinic, as his suicidal thoughts were becoming increasingly more difficult to manage.
This clinician originally treated XX with the belief that his depression would be resolved by the
time this therapist left the practice; after this past assessment, this clinician no longer felt
comfortable terminating and leaving XX on his own. While XX has made great strides in therapy
as has been shown and has finally felt safe enough to share the biggest secret "I've ever had to
keep" (personal communication, December 2, 2014)this therapist may not be CBT-competent
enough to treat him, or this depression may be treatment resistant.