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Introduction
Cognitive behavioral therapy (CBT) is a collaboration between the client and therapist to help clients change negative thinking caused by mental disorders and psychological distress (Hofmann, Asnaani, Vonk, Sawyer, Fang, 2012). According to Taylor (2006), “the goal of cognitive behavioral therapy is to teach a client to replace distorted thinking and unrealistic cognitive appraisals with more realistic and adaptive appraisals” (p.18).

Theory
The Cognitive behavioral theory is based in understanding how negative thoughts can affect occupational performance.The focus is the client and the current problems they are facing and assist them in recognizing those thoughts that are affecting their social relationships or work related matters. Cognitive behavioral theory implies that an individual’s behavior is mainly influenced by internal and external stimuli, and client is capable of manipulating those stimuli to be able to reach their life goals (Rokke & Rehm, 2001). This theory was selected because our client has suffered trauma from domestic violence leading to negative thoughts which are interfering with her occupational performance.

Evidence
Domestic violence is a form of trauma that can lead to post-traumatic stress disorder (PTSD). There is strong evidence that cognitive behavioral therapy is effective in decreasing symptoms in PTSD and depression (Iverson, Gradus, Resick, Suvak,Smith & Monson, 2011). Women who participated in a particular study had suffered multiple forms of interpersonal violence. They incorporated Cognitive Process Therapy (CPT) which is a form of CBT to help clients learn skills and recognize when they have cognitive distortion thoughts and be able to incorporate an alternative thought that would allow them to have a more balanced life (Iverson, Gradus,Resick, Suvak,Smith & Monson, 2011). Occupational therapists can use CBT for clients who need assistance in changing their disturbed thinking into positive ones in order for them to participate in their daily occupations.

Case Study
After removing herself from an abusive relationship, Leslie has tried to focus all of her attention on her work responsibilities, but her social interactions with coworkers is being affected. Multiple times she has been invited to work events and she has rejected each offer. Leslie’s thoughts revolve around placing blame on herself, feeling she deserves to be alone and that she is worthless. This is also causing her difficulties with relationships outside of work because she distances her from anyone that attempts to get near. The occupational therapist decides to administer the COPM to find out what occupations are being affected.

Intervention Plan

Problem Statement
Unable to form social relationships due to negative thoughts of self-worthlessness.

Outcomes: Leslie will change her negative thoughts into positive thoughts in order to change maladaptive behaviors that are preventing her from forming social relationships with others.

long term goals
1. For two weeks, Leslie will independently maintain a thought record by identifying negative thoughts, and changing them to neutral or positive, in order to improve social participation by discharge.
2. Leslie will participate in a work social event and report 3 instances where she utilized thought stopping as a strategy to replace negative thoughts with positive imagery to improve social participation by 2 months.

short term goals
1. Leslie will keep a daily thought log where she identifies at least 2 negative thoughts a day in order to improve self-awareness in 1 week.
2. Using a thought record, Leslie will utilize benefit finding strategies to change at least 5 negative thoughts to neutral or positive in order to improve thoughts of self-worth in 3 weeks.
3. Leslie will respond to compliments during 30 minute one on one role-play session by maintaining eye contact, demonstrating good body language, and giving at least 2 reciprocal compliments in 1 month.

Intervention format: Individual

Description of the setting

Supplies (if any) paper, pen/pencil

Agenda & description

Initial interview and assessment (30 min.)

• Therapist began relationship building with client and continued to develop rapport throughout the session.
• COPM was administered.
• Most significant problems defined by the client were lack of social interactions, inability to budget, and distractibility at work.

Set goals (10 min.)

• Determine client appropriateness and readiness

Teach and educate the client on CBT (10 min.)

• Client was educated on the process of CBT and why it’s effective
• Introduce the thought record as a strategy
• Client identified 3 persistent negative thoughts with 2 verbal cues

Assign homework (5 min.)

• Instruct the client to complete thought record throughout the week, and report back with her log during scheduled therapy sessions.

Summarize and elicit feedback (5 min.)

Documentation
SOAP Note

S: Leslie stated “I feel bad about myself and I do not think anyone likes me. This is why I do not attend social events with other people.”

O: COPM was administered and client identified three areas of concern. This included lack of social interactions, where her perceived satisfaction rate was 1 out of 10 and perceived performance was 3 out of 10. Based off this result, the therapist and client collaborated to create 3 short term and 2 long term goals for therapy. Client was hesitant in creating the goals. She did not feel the goals were attainable because she was not capable, but she decided to keep them as is. Client was educated on the process of CBT, and introduced the thought diary technique. As part of this technique, client identified 3 negative thoughts requiring 2 verbal cues. Therapist and client discussed why these thoughts were considered negative and their possible consequences. For homework, client was assigned to complete the thought diary outside of the therapy sessions to identify daily negative thoughts. Leslie was open to the homework assignment and agreed to complete the thought log for next session.

A: During today’s session, the client presented as attentive and collaborative. The COPM results indicated that improving social relationships was her top priority. She had difficulty with conceptualization of goals due to lack of self-efficacy. Although, she had difficulties creating the goals she decided to keep the goals and complete the homework assignment which indicates her willingness to change. Leslie required verbal cues to identify negative thoughts indicating lack of insight. Leslie understood why the thoughts were considered negative indicating that although she lacks insight she has potential to gain insight.

P: Client will benefit from continued use of the thought record to increase insight into negative thoughts and assist her in changing these into neutral or positive thoughts. Further therapy sessions are needed to explore techniques such as positive imagery and thought stopping to further improve negative thought processes and increase social participation.

References

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive therapy and research, 36(5), 427-440.

Iverson, K. M., Gradus, J. L., Resick, P. A., Suvak, M. K., Smith, K. F., & Monson, C. M. (2011). Cognitive–behavioral therapy for PTSD and depression symptoms reduces risk for future intimate partner violence among interpersonal trauma survivors. Journal of consulting and clinical psychology, 79(2), 193.

Rokke, P. D., & Rehm, L. P. (2001). Self-management therapies. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (2nd ed., pp. 173–210). New York: Guilford Press

Taylor, R. (2006). Cognitive Behavioral Therapy For Chronic Illness And Disability. New York, NY: Springer Science+Business Media, Inc.