# Clinical Cases: Psychotherapy Modalities

## Case 1: Cognitive Behavioral Therapy for Depression

### Patient Demographics
- **Age:** 38 years old
- **Sex:** Male
- **Occupation:** Software engineer

### Chief Complaint
"I've been feeling worthless and stuck. I don't think medication alone is helping."

### History of Present Illness
The patient is a 38-year-old man with major depressive disorder who was started on sertraline 100 mg daily 8 weeks ago with partial response. His PHQ-9 has improved from 19 to 13. He reports improved sleep and appetite but continues to experience low mood, anhedonia, and pervasive negative thoughts. He is interested in adding psychotherapy to his treatment.

He describes persistent thoughts that he is a "failure" despite objective success (senior position, good salary). He avoids social invitations because he believes people will find him boring. He has stopped exercising and hobbies he previously enjoyed, stating "what's the point?" He ruminates for hours about past mistakes and future failures.

### Mental Status Examination

**Appearance:** Well-groomed, casual business attire

**Behavior:** Cooperative, psychomotor slowing noted

**Mood:** "Low, stuck"

**Affect:** Constricted, dysphoric

**Thought Process:** Linear but ruminative, negative bias evident

**Thought Content:** Pervasive negative self-evaluation; no suicidal ideation

**Insight:** Good - recognizes patterns of negative thinking

**Judgment:** Good

### Diagnosis
- Major Depressive Disorder, Single Episode, Moderate, Partial Response to Pharmacotherapy

### CBT Formulation

**Activating Event:** Receives constructive feedback at work

**Automatic Thought:** "My boss thinks I'm incompetent. I'm going to get fired."

**Cognitive Distortions Identified:**
- Mind reading ("My boss thinks I'm incompetent")
- Fortune telling ("I'm going to get fired")
- Catastrophizing (jumping to worst outcome)
- All-or-nothing thinking ("I'm either perfect or I'm a failure")
- Emotional reasoning ("I feel incompetent, so I must be incompetent")

**Emotional Response:** Anxiety, sadness, shame

**Behavioral Response:** Avoids boss, works late to overcompensate, withdraws from colleagues

**Physiological Response:** Muscle tension, fatigue, poor sleep

### CBT Treatment Plan

**Phase 1: Behavioral Activation (Sessions 1-4)**

*Rationale:* Breaking the cycle of inactivity that maintains depression
- Monitor current activity levels with mood ratings
- Schedule pleasurable activities (exercise, hobbies, social contact)
- Graded task assignments (start small, build up)
- Track mood changes with increased activity

*Homework:*
- Activity log with mood ratings
- Schedule 3 pleasurable activities per week
- Resume exercise 2x weekly

**Phase 2: Cognitive Restructuring (Sessions 5-12)**

*Identify Automatic Thoughts:*
- Use thought records to capture triggering situations
- Identify specific automatic thoughts
- Rate belief strength (0-100%)

*Examine Evidence:*
- What evidence supports this thought?
- What evidence contradicts it?
- What would I tell a friend in this situation?
- What's the worst that could happen? Best? Most likely?

*Example Thought Record:*

| Situation | Automatic Thought | Emotion | Evidence For | Evidence Against | Balanced Thought | New Emotion |
|-----------|------------------|---------|--------------|------------------|------------------|-------------|
| Boss gives feedback on report | "I'm incompetent, I'll be fired" | Anxious 85%, Sad 70% | Report needed revisions | I've had good reviews, got promoted last year, everyone gets feedback | "This is normal feedback. One report revision doesn't define my competence." | Anxious 30%, Sad 20% |

*Identify Deeper Beliefs:*
- Core belief: "I'm not good enough"
- Developed from: Critical father, competitive childhood environment
- Work on modifying core beliefs with behavioral experiments

**Phase 3: Maintaining Gains (Sessions 13-16)**

- Review skills learned
- Develop relapse prevention plan
- Identify early warning signs
- Plan for future challenges

### Session Example (Session 6)

**Therapist:** "Last week, you mentioned feeling worthless after the team meeting. Let's look at that using a thought record. What was the situation?"

**Patient:** "I was in a meeting and didn't speak up about an idea I had."

**Therapist:** "And what went through your mind at that moment?"

**Patient:** "That I'm too shy to succeed. That everyone thinks I'm useless."

**Therapist:** "Those are powerful thoughts. Let's examine them. What evidence supports the thought that everyone thinks you're useless?"

**Patient:** "Well... people didn't seem interested in what I was saying earlier."

**Therapist:** "Okay, any other evidence?"

**Patient:** "Not really. I guess I'm assuming."

**Therapist:** "And what evidence contradicts that thought?"

**Patient:** "My colleague asked my opinion on something after the meeting. And I did get positive feedback on my last project."

**Therapist:** "So based on all the evidence, what's a more balanced way to think about that meeting?"

**Patient:** "Maybe not speaking up doesn't mean everyone thinks I'm useless. It could just be I was hesitant that day."

### Expected Outcomes
- CBT for depression: ~50-60% response rate
- Combined with medication: Best outcomes
- Skills are durable - lower relapse rates than medication alone when discontinued

---

## Case 2: Dialectical Behavior Therapy for Borderline Personality Disorder

### Patient Demographics
- **Age:** 26 years old
- **Sex:** Female
- **Occupation:** Barista (part-time)

### Chief Complaint
"I can't control my emotions. I keep ruining every relationship I have."

### History of Present Illness
The patient is a 26-year-old woman with a history of borderline personality disorder, presenting for treatment after her fourth psychiatric hospitalization this year for suicidal ideation following a breakup. She has a pattern of intense, unstable relationships, marked emotional reactivity, chronic feelings of emptiness, impulsive behaviors (binge eating, spending), and non-suicidal self-injury (cutting forearms) used to regulate emotions.

She describes her emotions as "going from 0 to 100 in seconds" and struggles to bring herself back down. She frequently splits people into "all good" or "all bad" and has difficulty tolerating being alone. She experiences identity disturbance ("I don't know who I am") and dissociative episodes when stressed.

She has tried multiple medications with limited benefit and several brief courses of therapy that ended when she felt the therapist didn't understand her.

### Mental Status Examination

**Appearance:** Multiple visible scars on forearms, dressed in black

**Behavior:** Initially guarded, becomes tearful then irritable within session

**Mood:** "Empty... terrible... I don't know"

**Affect:** Labile, rapidly shifting, intense

**Thought Process:** Linear but dramatic

**Thought Content:** Chronic suicidal ideation without current intent; no homicidal ideation

**Insight:** Partial - recognizes patterns but feels unable to change

**Judgment:** Impaired during emotional crises

### Diagnosis
- Borderline Personality Disorder
- Major Depressive Disorder, Recurrent

### DBT Formulation

**Biosocial Theory:**
- Biological vulnerability: Emotional sensitivity from early age
- Invalidating environment: Childhood emotional neglect, told her feelings were "too much"
- Result: Never learned emotion regulation skills, learned that extreme behavior gets emotional needs met

**Target Hierarchy:**
1. Life-threatening behaviors (self-harm, suicidal behaviors)
2. Therapy-interfering behaviors (missing sessions, not completing homework)
3. Quality of life interfering behaviors (relationship chaos, impulsivity)
4. Skills acquisition

### DBT Treatment Plan

**Standard DBT Components (12-month commitment):**

**1. Individual Therapy (weekly):**
- Behavioral chain analysis of target behaviors
- Solution analysis and skills application
- Exposure-based treatment for emotional cues
- Dialectical strategies (acceptance + change)

**2. Skills Training Group (weekly, 2.5 hours):**

*Module 1: Core Mindfulness (2 weeks)*
- "What" skills: Observe, Describe, Participate
- "How" skills: Non-judgmentally, One-mindfully, Effectively
- Wise Mind concept (emotion mind + reasonable mind)

*Module 2: Distress Tolerance (6 weeks)*
- Crisis survival skills (TIPP, ACCEPTS, IMPROVE)
  - TIPP: Temperature, Intense exercise, Paced breathing, Progressive relaxation
  - ACCEPTS: Activities, Contributing, Comparisons, Emotions, Push away, Thoughts, Sensations
- Radical acceptance
- Willingness vs. willfulness

*Module 3: Emotion Regulation (6 weeks)*
- Identifying and labeling emotions
- Reducing vulnerability (PLEASE: treat PhysicaL illness, balance Eating, avoid mood-Altering substances, balance Sleep, get Exercise)
- Opposite action
- Building positive experiences

*Module 4: Interpersonal Effectiveness (6 weeks)*
- DEAR MAN (asking for what you need)
- GIVE (maintaining relationships)
- FAST (maintaining self-respect)
- Balancing priorities vs. demands

**3. Phone Coaching (as needed):**
- Brief calls between sessions for skills application
- Not for processing therapy content
- Available for crisis skills coaching

**4. Consultation Team (for therapists):**
- Weekly team meeting
- Prevents therapist burnout
- Ensures adherence to DBT model

### Session Example: Behavioral Chain Analysis

**Target Behavior:** Cut forearms after argument with boyfriend

**Chain Analysis:**

*Vulnerability Factors:*
- Hadn't slept well
- Skipped lunch
- Already anxious about work review

*Prompting Event:*
- Boyfriend said he needed space for the evening

*Links (Thoughts, Feelings, Behaviors):*
1. Thought: "He doesn't love me anymore"
2. Feeling: Panic (9/10)
3. Behavior: Called him 6 times
4. His response: Didn't answer
5. Thought: "He's going to leave me"
6. Feeling: Rage (10/10), then emptiness
7. Behavior: Threw phone
8. Feeling: Shame (9/10)
9. Thought: "I'm too much, I deserve to hurt"
10. Behavior: Cut forearms
11. Feeling: Relief (temporary), then shame

*Consequences:*
- Short-term: Emotional relief, decreased intensity
- Long-term: Boyfriend more distant, scars, shame

**Solution Analysis:**
- Could have used TIPP skills at panic stage (cold water on face)
- Could have called different friend instead of repeated calls
- Could have used opposite action at "I deserve to hurt"
- Skills to practice: Distress tolerance before emotion becomes overwhelming

### Dialectical Dilemmas in Session

**Therapist balances:**
- Validating her emotional pain (acceptance) WHILE
- Teaching that self-harm is not effective (change)

**Example:**
"It makes complete sense that you felt abandoned when he didn't answer. Those feelings are painful and real. AND cutting isn't working as a long-term solution - you felt better for 10 minutes, then felt shame for days. What could we try differently next time?"

---

## Case 3: Psychodynamic Psychotherapy

### Patient Demographics
- **Age:** 42 years old
- **Sex:** Female
- **Occupation:** Attorney

### Chief Complaint
"I keep choosing the wrong partners. I want to understand why I keep repeating the same mistakes."

### History of Present Illness
The patient is a 42-year-old woman presenting for therapy after her third failed long-term relationship. She describes a pattern of choosing partners who are emotionally unavailable or critical. Despite being highly successful professionally, she describes chronic low self-esteem in relationships and fears of abandonment that lead her to tolerate mistreatment.

She describes her childhood as "fine on the surface" but on exploration reveals a distant father who prioritized work and was emotionally unavailable, and a mother who was critical and demanding of perfection. She learned to earn love through achievement and has difficulty believing she is worthy of unconditional affection.

### Mental Status Examination

**Appearance:** Professional, polished

**Behavior:** Intellectualizing, controlled

**Mood:** "Fine... actually, not fine. Sad, I suppose."

**Affect:** Constricted initially, softens when discussing childhood

**Thought Process:** Articulate, intellectualized, avoids emotion initially

**Insight:** Developing

### Psychodynamic Formulation

**Core Conflicts:**
- Desire for love and connection vs. expectation of rejection
- Need for autonomy vs. fear of abandonment
- Wish to be valued for self vs. learned pattern of earning love through achievement

**Object Relations:**
- Internalized critical mother object → harsh internal critic
- Internalized absent father → expectation that love figures will be unavailable
- Seeks relationships that confirm these internal expectations (repetition compulsion)

**Defense Mechanisms:**
- Intellectualization: Uses logic to avoid painful emotions
- Rationalization: Justifies staying in poor relationships
- Reaction formation: Presents as strong and independent to hide vulnerability

**Attachment Style:** Anxious-preoccupied

### Psychodynamic Treatment Plan

**Goals:**
1. Develop insight into unconscious patterns
2. Understand how past relationships influence present choices
3. Work through feelings about early relationships
4. Develop healthier internal object relations
5. Make different choices in relationships

**Treatment Frame:**
- Weekly sessions, 45-50 minutes
- Open-ended duration (typically 1-3 years for personality-focused work)
- Consistent time, place
- Use of couch optional (this patient prefers face-to-face)

### Key Psychodynamic Concepts Illustrated

**1. Transference:**
The patient begins to experience the therapist in ways that mirror early relationships.

*Example:* After therapist takes a vacation, patient is distant in the following session.

**Therapist:** "You seem a bit withdrawn today. I wonder if my absence last week stirred up some feelings."

**Patient:** "I'm fine. You're entitled to a vacation."

**Therapist:** "Of course. But I notice you looked away when you said that. Sometimes when important people aren't available, even for good reasons, it can bring up old feelings."

**Patient:** (tearful) "I just... I felt like you forgot about me. Like I don't matter when you're not in the room."

*This opens exploration of how father's emotional absence created feelings of being forgettable.*

**2. Interpretation:**
Linking present patterns to past experiences.

**Patient:** "I don't understand why I stayed with Mark for so long. He was clearly never going to commit."

**Therapist:** "I wonder if something felt familiar about waiting for someone who couldn't fully show up for you."

**Patient:** (pause) "Like my father. I was always waiting for him to notice me."

**3. Working Through:**
Repeated exploration of themes from multiple angles.

Over many months, the patient comes to understand:
- She chose unavailable partners because it was familiar
- She stayed because she believed she could "earn" their love through being perfect
- Her self-worth was contingent on external validation
- She deserved love not based on achievement

**4. Defense Analysis:**

**Patient:** "I don't know why you keep asking about my feelings. This is a waste of time. I need practical advice."

**Therapist:** "I notice when we get close to feelings about your father, you often shift to wanting practical solutions. That makes sense - feelings about him might be quite painful."

### Session Example (Late in Treatment)

**Patient:** "I met someone new. He's actually emotionally available. It's strange - it makes me uncomfortable."

**Therapist:** "Tell me more about the discomfort."

**Patient:** "It feels too easy. Like I'm waiting for the other shoe to drop. I keep looking for signs he's going to disappoint me."

**Therapist:** "Does that remind you of anything?"

**Patient:** "That's what I always did with my father. Scanning for signs he'd let me down. At least then it didn't hurt as much when he did."

**Therapist:** "And now you're bringing that same scanning into a new relationship."

**Patient:** "I don't want to. This man is different. I'm different now. I don't have to protect myself in the same way."

*This represents therapeutic progress - the patient now has insight and can make different choices.*

### Outcome Measures
- Structured psychodynamic outcome measures less common
- Quality of relationships
- Self-esteem
- Reduced anxiety in relationships
- Ability to form secure attachment

---

## Image Attribution

![Psychotherapy Modalities Comparison](case_01_image.jpg)

*Image: Diagram comparing cognitive-behavioral, psychodynamic, and interpersonal therapy approaches including theoretical foundations, techniques, and typical treatment durations. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.*