Psychiatric History

This discussion is based on a case study of an adolescent client named Brittany. You will read through her history of treatment and formulate continuing care with a CBT approach. Please read through the Case Study (Word) and follow the instructions. You may find the Psychology Tools: Hindsight Bias website helpful as you consider CBT techniques for the discussion that follows.

For your initial post, answer the following questions in APA format.

What cognitive behavioral techniques might be appropriate to use with Brittany as she explores her angry feelings toward her parents who want her to be her “old self,” an identity that Brittany clearly rejects?
Adolescence is a time of social experimentation and identity development. How would a cognitive behavioral therapist determine what portion of Brittany’s feelings of “not fitting in” are consistent with her developmental stage and what portion are indicative of social skills difficulties?
How would you use cognitive behavioral therapy techniques in a culturally sensitive manner to address Brittany’s feelings about being the only biracial student in her class?
How might the principles from REBT be applied to the case study?

CBT Case Discussion

Brittany Case Study (Corey, 2017)

Brittany is a 16-year-old girl of mixed Caucasian and African American descent. Her family has recently moved from a large, diverse, metropolitan area to a small mid-western town. According to her mother and father, Brittany did not respond well to the move.

Prior to the move, Brittany’s parents reported that she was a very well-behaved child who did well in school and participated in extracurricular sports. She was an active member of the student council and worked after school at a coffee shop in the local mall to save money for college. Brittany dreamed of becoming a veterinarian. However, all of this changed when she arrived at her new school. She has only been in school 3 months and is already failing chemistry and shows no interest in after school activities. She was kicked off the track team after only two practices for arguing with the coach. She has been suspended once for fighting with another student and sent to detention 14 times for speaking disrespectfully to her teachers and disrupting class. Of great concern to Brittany’s mother is that Brittany has recently dyed her hair pink and pierced her lip. Brittany’s father is concerned because she is generally disagreeable at home, refuses to do her chores, and has not completed a homework assignment in 3 weeks. Brittany’s parents brought her to counseling because they are at a loss for how to control her behavior. They hope that therapy can help Brittany change back to her “old self.”

Psychiatric History

Dr. Bailey Works with Brittany from a Cognitive Behavioral Perspective:

When I greeted Brittany in the waiting room, she was sitting on the couch with her back turned toward her parents. Her parents were eager to speak with me alone. Although I value their input and would make time to speak with them at a later time, I was clear that this particular session belonged to Brittany. In hearing this, Brittany smirked at her parents and quickly walked into my office. When I asked Brittany how she felt about coming to counseling, she replied, “Well, at least it is better than having to talk to them!” as she rolled her eyes in the direction of the waiting room.

In talking with Brittany, several themes of her life became clear. One of these themes involved her contention that her parents had already changed her life quite drastically by moving her across the country to a new school. In this setting, none of the other students resembled her in terms of ethnicity, interests, or sophistication. She had no intention of “changing back” to her “old self” just to please them. The next issue Brittany mentioned was that she found her new school “too easy,” and her teachers to be “closed-minded,” and therefore not worth listening to or respecting. Third, Brittany mentioned that she deeply missed her friends from home and felt that her new peers were unable to accept her because she was so different from them in her upbringing, culture, and beliefs. She finally noted that she was the only biracial student in her grade and that she felt alone and isolated. When I asked her about her behavioral outbursts at school, Brittany articulately explained that she feels she is responding appropriately to an impossible situation. She was clear that she did not care if her peers, teachers, and parents felt she was acting out because none of them would ever accept her. However, she agreed to participate in therapy because she “didn’t like feeling sad and bitter all the time” and wanted to work on getting in less trouble at school. Although Brittany was tired of detention, she was adamant that she had no desire to work on her behavior at home because she felt her parents deserved what they got for moving her in the first place.

Ideally, I believed it would be helpful for Brittany to work on creating a more positive relationship with her parents from a developmental psychopathology perspective. At the same time, I realized that Brittany was a teenage girl working on the important task of individuation and was appropriately focused on asserting her own identity within her family context. Hence, some familial discord at this point in time was to be expected. As such, Brittany and I agreed that we would focus on her school-related goals during our time together. Brittany was very clear that we would discuss her parents only if it pertained to school and as she felt it was necessary to vent about how they “complicated her life” and “misunderstood her.” I agreed to her boundary, but also let her know that I was open to talking about her relationship with her parents if that was something she would like to explore, but that this was not an expectation of therapy. It was her choice.

Some of Brittany’s ideas, feelings, and actions are considered age-appropriate tasks of adolescent identity development, such as experimentation with social roles and personal appearance. It was also clear that Brittany’s attitude and behavior in her new environment were clearly disrupting her functioning in key developmental areas, namely, her school performance and social interactions. As a CBT therapist, I was acutely aware of Brittany’s use of “absolute” terms in her language as she described her circumstances. Her account of her life was filled with many overt and covert “musts” and “shoulds” as well as a good deal of “all or nothing” thinking. Brittany held several fixed, maladaptive beliefs, or cognitive distortions, about her new environment. These distortions caused angry and sad feelings that, in turn, directly affected her behavior. As her cognitive behavioral therapist, I was very interested in working with Brittany in changing her maladaptive thoughts, feelings, and behaviors into more constructive beliefs, sentiments, and actions.

The first cognitive behavioral technique Brittany and I used together was learning to identify and label her cognitive distortions. For example, after two counseling sessions Brittany was able to tell me that her belief that “none of her peers would ever accept her” contained two types of cognitive distortions: all-or-nothing thinking and jumping to conclusions. In her next session, Brittany learned that she could dispute her self-defeating thoughts through examining the evidence that supports them. For example, although Brittany feared social rejection, she was able to realize that she really did not have any factual evidence to support her unrealistic fear that every student in the school would reject her both currently and in the future. Brittany playfully admitted that she didn’t have a crystal ball and could not foresee the future and that perhaps, some day, some other student might actually want to be her friend.

Once Brittany learned to identify and accurately label her cognitive distortions, we began to reframe her inaccurate beliefs and responses into more helpful, adaptive thoughts and actions. For example, Brittany was able to take her existing, maladaptive belief that all of the teachers at her school were “closed-minded” and “not worth listening to” and modify these convictions in ways that were more in line with her goal of not getting in trouble. Brittany now listens to her teachers and evaluates whether or not they are closed-minded before she decides whether or not to speak disrespectfully to them. Over time spent in therapy, Brittany found that she actually felt better about herself when her thoughts, actions, and feelings were geared toward helping her be successful rather than geared toward maladaptive behaviors that led to undesirable outcomes like detention and being grounded. Over the last 2 months, Brittany has only served three detentions.

Follow-Up: You Continue as Brittany’s Therapist:
Brittany has made progress in identifying and reframing her cognitive distortions. However, she still remains angry with her parents for moving her family across the country and is still behaving poorly at home. Likewise, she continues to have trouble making friends with her peers. She continues to feel that she is very different from other students in terms of her beliefs, culture, and interests.


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