A Case Formulation Example

The Dual Disorder CBT Treatment of a Childhood Trauma Survivor

I. Introduction to the Theoretical Model
The approach to this client’s evaluation and therapy is within the Behavioral Therapy domain of
counseling theory. Within the behaviorist strand of counseling theory, Cognitive Behavior
Therapy (CBT)1 has been successfully used to treat Anxiety Disorders.2 In this case study, the
client has Post Traumatic Stress Disorder [PTSD]; which is one of the most multi-problem
mental health categories in the Anxiety Disorder cluster. The clinician uses CBT methodology.
A leading CBT Theorist, Albert Ellis, has developed an enriched CBT model called Rational
Emotional Behavioral Therapy (REBT)3 that fit this client’s treatment needs. The client’s
substance use disorder, separate but entwined with her PTSD, is the second component of her
“dual disorder”. REBT is an effective behavioral therapy model for addressing the
developmental history model of addictions treatment; which is more commonly treated from a
Psychodynamic Therapy domain of counseling theory. In REBT, like a Psychodynamic
[sometimes called Psychoanalytic] method, the client’s historical awareness of her progressive
disease and its distortions in thinking [i.e. “problem denial”] is addressed through what Ellis calls
the ABC’s of irrational thinking.4 The therapist assists the client with an REBT problem self-
assessment; which is called a “First Step” in Minnesota Model chemical dependency treatment.5
In the example transcript of the third session, used for explanatory purpose, the client brings her
daughter to the therapist’s office which creates an enactment of mother—daughter dynamics.
The therapist allows the family dyad to derail naturally between the multiple subjects of
dysfunction that have existed within the family addiction and multi-generational trauma. In the
session, the therapist uses the framing model of REBT to exhibit the inability of the dyad to
resolve here-and-now decisions due to long-standing irrational beliefs about their relationship.

II. Basic Demographic Client Information

Name: Laura Client
Age: 42
Race: Bi-racial1
Sex: Female
Marital Status: Single, Divorced
Employment: Pedicure, Cosmetology without formal education
Referral: Tacoma Indian Center
Treatment: Outpatient Clinic, Individual counseling
1
Native American and European American

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 The key presenting issues are Ms. Client’s efforts to develop a sustained addiction recovery that
includes the level of behavioral health necessary to parent a 14 year old daughter who is on the
Washington State early intervention program for truancy and delinquency [i.e. the BECCA law].

III. Client Background Summary

3.A. Substance Use History

Laura Client was introduced to alcohol use by her family when she was in her pre-school years.
An anecdotal description told in her family is a joke about when the client was a baby and could
“suck down her bottle of beer”—but had a hard time drinking her bottle of milk. She remembers
the ongoing consumption of alcohol from age five when she would drink with her grandmother.
Her substance abuse was established in her elementary years and, by the beginning of junior high
years, she was consuming marijuana, alcohol and hallucinogens [“LSD”]. Prior to reaching
adulthood, dropping out of high school in her senior year, her poly-drug abuse escalated to
adding cocaine [including the highly addictive smoked version called “crack”] and
methamphetamine. As she entered early adulthood years, her memory is clouded by the poly-
drug nature of her drug abuse, but she had further added the highly toxic combined use of heroin
and methamphetamine to her addictive behavior.
3.B. Psychological Functioning and History
Along with childhood neglect through the use of alcohol provided by her family, she was
verbally and physically abused by her parents and grandparents. The middle of three children,
she was the only adopted child. She perceives this difference resulted in her parents treating her
more poorly than her siblings, not feeling accepted by her parents, and even questioning whether
her parents wanted her as a child.
Her mother is an alcoholic. Aside from her very early exposure to alcohol, her mother’s
alcoholic behavior created an environment that she describes as being a “self-medication” reason
for her own teenage and adult alcohol use. At this level, she is able to connect the genetic and
environmental influences on her dependence. She has an inaccurate perception that, outside of
the substance use, she didn’t really have any behavioral health problems. She also fails to
connect her own mother—daughter narrative to her current situation with her daughter.
Once her addictions began to include more expensive and neurochemically addictive drugs
[methamphetamine, heroin and cocaine] she began to engage in prostitution and theft to finance
her lifestyle. She has also experienced psychotic symptoms in her adult life. She does not hear
command voices, but she does hear and see negative auditory and visual hallucinations. An
explanatory anecdote provided by Ms. Client was an incident about 3 years ago when she
believed Satan was talking to her through her cheek. As a result of this psychotic delusion, she
took a scissors and cut out a substantial chunk of her cheek to “remove Satan’s influence.”
Currently, she presents with very low self-esteem, high levels of anxiety, and mood swings
which have been diagnosed as a Bipolar disorder. She is now abstinent from substance use with

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 continuing care in support groups; but has a very hard time dealing with anger and frustration
that she would historically sedate with one or more drugs. In developing services for Laura,
social and health agencies are assisting her develop life skills when she has little or no prior
learning. These deficits are further aggravated by sleeplessness created by dreams similar to the
hallucinations noted above. While abstinent from addictive use of drugs at this time, she reports
the beginning of compulsive overeating late at night [“binge eating”].
3.C. Education
Ms. Client reports to having good grades prior to dropping out in 12th Grade. She reports no
history of Special Education needs. She plans on further education to complete her GED and is
considering post-GED business studies. She reports vocational interests in cosmetology and
pedicure services [“applying make-up and being a nail artist]. She has had no formal education in
either activity.
3.D. Legal History
Ms. Client has been arrested in the past for prostitution and possession of narcotics. In light of
her extensive adult lifestyle of admitted criminal behavior, her time of incarceration appears less
than might be expected.
She was a crime victim with two extensive situations of rape. During the second rape, at age 19,
she was held captive for three days by a man who raped her repeatedly while he put a gun to her
head.
In other areas of contacts with law enforcement, either as a violator or victim, she cannot
remember a lot of her past. She knows that she has had numerous legal interactions, but cannot
recall specifics. She identifies her drug of choice for the last 30 years as being
Methamphetamine, which has extensive connections to the illegal community of drug
manufacture and distribution. It also left her, as she notes, in an ongoing “fog.”
Currently, her major legal issues are in the role of a parent. Her 14 year-old daughter, Jericah, is
involved with the state truancy system [BECCA Bill]. Jericah has stopped attending school and
Laura can’t figure out how to intervene successfully on this behavior. Jericah has a history of
suffering from depression and self-injury [cutting] behavior. Client does believe that a
substantial amount of Jericah’s emotional pain and behavioral health problems are the result of
Laura’s drug abuse and her parallel parental absence during Jericah’s childhood years.
3.E. Social History
In addition to her drug addiction, she also reports her overall lifestyle has been influenced by
problem gambling during periods of active substance use. She reports the assumption that if she
gambled she could get more money for drugs. During the past one year period abstinence from
alcohol and drugs, she has not engaged in gambling behavior.

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 She reports an “on again—off again” boyfriend that goes by the nickname “Yogi.” Yogi is
currently serving a prison sentence. He has a history of being physically and verbally abusive
towards Laura. However, she justifies his behavior by saying that he was only abusive when he
was under the influence of substances. It should be noted that she reports he was “high most of
the time.” He also influences her ability to recover from addiction; reporting that the only times
she has been able to stay clean is when he’s locked up. When he is released from prison, they
usually get back together and then she resumes active substance use. She reports a new
awareness of this dynamic, saying that this time will be different because she “now knows that,
although she may still care about him, they are toxic together.” She is unclear about what this
revelation means in terms of behavior change. She still visits him in jail and reports that he is
sometimes verbally abusive towards her during these visits.
She reports few friends in her social environment; but has a very strong Christian faith that has
provided her access to church-related relationships. She talks about a conversion experience
where “God saved her after he appeared in her dream after a drug possession arrest.” She was
attending bible study which provided her with a sense of relaxation. After that activity ended, her
anxiety increased dramatically. She partakes in activities at the Tahoma Indian Center [Tacoma
WA], which gives her a sense of pride in her heritage and community connection.
She appears to have time management problems with difficulties emerging when she doesn’t
have a structured schedule. For instance, her schedule changed when bible study ended—with
resulting anxiety increasing as her time structure decreased.
She reports being employed as a manicurist. However, the business has been very slow. She is
involved in an unrelated business venture, which she believes will “make her rich”. Basically,
this venture is a spa treatment that she sells during “spa parties.” The process is similar to
Tupperware parties. This business plan hasn’t been working out for her yet; but she is very
hopeful that business will improve.
Ms. Client’s daughter and her religion appear to represent her primary support system.
Unfortunately, her daughter is currently suffering depression of her own. She also has a 21 year-
old son who is in prison. She reports visiting him on a regular basis. She feels most of her family
has “given up on her” or would not be positive influences in her life. Despite this awareness, she
lives with her parents and reports her mother is verbally abusive towards both her and her
daughter. She sleeps on the couch and her daughter Jericah has a small bed in the “storage
room”. This is the same house that she grew up in and she believes it is evil. She uses a dream
she had as a child to describe her feelings where “she was trying to leave the house but the devil
stood at the end of the driveway and wouldn’t let her go.” She believes that the devil is still there
trapping her in that negative environment because “he doesn’t want her to succeed.” She goes on
to portray the house as “full of clutter and negativity”.

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 3.F. Physical History
As reported, Laura Client has been physically abused and assaulted on a repeated basis, has been
raped, has been involved in numerous car accidents (most of which she doesn’t remember) and
has had numerous sexually transmitted diseases [STDs]. As a result of these multiple traumas
and acute health problems, she reports chronic back, hip, and rib pains. She was recently
diagnosed with Hepatitis C. Current test results for other STDs are negative. Her historical
reporting of physical and other health problems is unreliable because her long-term memory has
appears insufficient. She notes memory gaps in much of the last 30 years. This memory deficit
could, hypothetically, be from resistance to talk about known experiences, actual gaps in
memory, or a combination of both.
When she was actively using substances, she was substantially under weight. Although she
realizes this type of actual physical condition, she experiences a body image distortion that she is
“fat and disgusting” because she has gained weight towards a normal level.
She has experienced antibiotic-resistant infections [often called “MRSA”], which caused a puss-
like infection on different parts of her body, including areas on her face.
3.G. Treatment History
Laura Client has been through three different cycles of inpatient—outpatient chemical
dependency treatment. Prior to the current episode of recovery, the longest she was able to stay
clean was for 2 years. When Yogi was released from prison, she relapsed into active substance
use. She has currently been clean for a little over a year. She attends clean and sober support
meetings that are held within her church and at The Tahoma Indian Center.

IV. Multi-Axial Diagnosis

Axis I 298.9 Psychotic Disorder, NOS
309.81 Post Traumatic Stress Disorder
304.83 Polydrug Dependence, in sustained remission
296.33 Depression
Axis II 799.9 Diagnosis Deferred
Axis III Hepatitis C
Sleep Disorder
Minor Body Aches and Pains
Axis IV Temporary Vocational Disability
Lack of Primary Support
Involvement with Legal System through Daughter
Axis V Global Assessment of Functioning=40

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 Laura Client has been diagnosed as Bipolar in other settings due to her obvious Depression and
mood swings. In her current clinical setting, she exhibits Depression with a mood that swings
into the agitation state in a way more consistent with Post Traumatic Stress Disorder than a
manic phase. She reports the following three criterion areas for diagnosing PTSD
1. Historical numbing through substance use and faulty memory mechanisms.
2. Hypervigalence and Central Nervous System arousal with fear of control loss, prolonged
agitation and nightmare sleep interruption.
3. Re-experiencing trauma response with anger, paranoia, problems with intimate
relationships and social connections and thoughts of suicidality.
Laura Client has been the victim of assault and sexual violence from childhood forward; along
with life-threatening automobile accidents. All of these traumas, separately, are consistent with
generating Acute Stress Disorders. She does not acknowledge any social or health interventions
to address those behavioral health crises; confirming a basis to associate the above-noted PTSD
criterion to the multiple traumas. The major treatment response differences between Bipolar and
PTSD diagnoses would be medication and cognitive attribution.
The major difference in psychiatric medication management between PTSD—Depression and
Bipolar would typically be strength of prescriptive emotional regulation [e.g. Depakote addition
to an SSRI mood medication]. It is important that the primary care provider or Psychiatrist
monitor medication response to further refine diagnosis between Bipolar and PTSD disorders.
The major difference in cognitive attribution between the two disorders would be:
1. Bipolar. Biological cause of mood swings; with a minor focus on changing
interpersonal stressors to support a primary medication management strategy.
2. PTSD. Interpersonal trauma cause of mood swings; with a minor focus on changing
medication to support a strategy of primary resolution of interpersonal stressors.
The current client treatment plan developed for dual disorder services begins with the second
paradigm; with parallel medication monitoring to identify Manic or Hypomanic episodes that
might indicate the presence of Bipolar Disorder instead of, or concurrent to, PTSD.
Ms. Client has extensive vegetative symptoms of Depression: scattered concentration, eating
pattern changes, sleep disruption and lack of mental energy. She has substantial behavioral
problem patterns of serious depressed mood; including: suicidality, hopelessness and lowered
self esteem.
The etiology of Laura’s Psychotic episodes is not clearly defined; though the law of parsimony
would suggest they are connected as symptoms of the Depression or PTSD. Medication
management and treatment that reduces Axis IV stressors should reduce, and ultimately
eliminate, the non-command hallucinosis.

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 V. Treatment Planning

5.A. Summary of Clinical Presentation

Laura Client presented to Catholic Community Services [CCS] for therapy in May of 2007. She
entered the CCS five-session community pro bono service program.
First Session. Her overall mood at our initial session was overly optimistic and forgiving of the
contribution of others to her difficulties [e.g. abuse perpetrators]. She credits this attitude as
coming from the principles of her Christian faith, saying she has “forgiven all the people that
hurt her because God taught her the importance of forgiveness. She openly talked about her
extensive history of traumatic experiences. Her descriptions were devoid of significant negative
emotion, consistent with PTSD numbing, and delivered in a nonchalant and “matter of fact”
manner.
Second Session. During her second session we discussed her own expectations and goals for
therapy. Talking about her concerns led to a realization of her very low self-esteem. An agreed-
to framing of her needs led to the goal of improving her current functioning and increasing her
positive self-evaluation. This should result in her self-esteem experiencing an associated
increase. In selecting therapy strategies to meet that goal, we agreed that, although her historical
addictions and relapse prevention will be important in the treatment plan, we would focus more
on her interpersonal difficulties with historical assessment more focused on the cognitive—
affective distortions from the PTSD. The short-term objectives, as a group, are to increase her
self-esteem, deal with anxiety more effectively, and improve her relationship with her daughter
Jericah.
Third Session. We had planned on finalizing a treatment plan during our third session, which
could be the blueprint for additional sessions at CCS and/or social service support at the Tahoma
Indian Center. However, at that session, her daughter came in with her in an unannounced
manner which, as noted in the introduction, resulted in a session of facilitated mirroring and
framing their interpersonal expectations for the client to see that, if her daughter simply
“forgave” her; this would not lead to a gain in self-esteem, reduction in anxiety or initiate a
satisfying mother-daughter relationship. During the session, the clinician framed parent-child
boundaries according to the mother’s perceptions of the ideal interpersonal communication style.
The therapist attempted to support this dynamic by framing the mother’s verbal requests for
forgiveness and follow-up “parental” guidance on how Jericah “should” view the world. In
addition, the therapist facilitated the mother’s active discussion of her vocational role in her spa
sales business so the daughter would “understand” her status as the future family breadwinner.
Even with therapist framing and advocacy for Laura’s Parent-Child2 dialogue, the interpersonal

2
Eric Berne, in Transactional Analysis Theory, describes this as an adult authority figure using nurturing and/or
critical guidance to another person in a manner to evoke subservient [“childlike”] responses.

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 communication remained tangential, largely unproductive and provided a wealth of verbal data
to further work with the client’s perceptions using REBT in future sessions.
Session Four. The basic tenets of a treatment plan were prepared, with supervisory consultation,
and discussion was initiated with Ms. Client in the fourth session. At this session, she no longer
exhibited confidence that she had the interpersonal intimacy skills to fully and effectively parent
Jericah. There was also an absence of the assertion that forgiveness, by itself, represented a
solution for long-term family dysfunction.
Session Five. At what would have been the terminal session, Laura Client did not attend her
scheduled appointment. Since this behavior has the high probability of representing her
trepidation to discontinuing therapy, a treatment plan was developed for CCS to conduct a
utilization review in order to authorize additional sessions. After approval of the treatment plan,
the therapist and CCS case coordination staff will conduct follow-up contact to re-engage her in
the treatment plan.
5.B Treatment Plan
The treatment interventions are outlined by priority. The measurement by objectives will be
established with the client at her first session.
Psychotic Disorder, NOS; 298.9. The first session will begin with coaching in use of the King
County WA Crisis Line [211] and local Emergency Rooms with a contract for safety. The client
will be referred to the CCS consulting Psychiatrist for a medication evaluation and monitoring
plan; which will include intervention on hallucinosis, vegetative symptoms of Depression and
ongoing review of Bipolar versus PTSD criteria.
Post Traumatic Stress Disorder, 309.81. The client-therapist will use the “Courage to Heal”
Workbook to reframe her developmental cognitions, reality-test rational-emotive perspectives
and practice resulting behavioral change in real-life social situations.
Polydrug Dependence, in sustained remission, 304.83. The client will practice behavioral
change in 1-to-1 settings, with mentor [“sponsor”] and peers in the community of recovery; as
well as group settings in AA and NA meetings. This will include participating in all-women’s
meetings to process her personal discoveries in the PTSD workbook activities.
Depression, 296.34. Along with medication management, the therapist will assist the client
develop functional boundaries and effective parental relationships with her daughter in conjoint
sessions that continue the Structural Family Therapy intervention begun in Session Three.
VI. Case Discussion
In a client emerging from the distorted perceptions of an addicted lifestyle that is further
compromised by PTSD; it is important to reality test their developmental history with particular
attention to techniques of Rational Emotive Behavioral Therapy. When REBT is augmented with
a workbook like “Courage to Heal”, the client is challenged to move towards a more rational

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 interpersonal world view and visualize new behaviors. This reframing and guided visualization
represent classic examples of Cognitive Behavioral Therapy using Bandura’s Social Learning
Model6 to prepare for transfer of training to real-life environments. CBT homework activities can
be naturally designed for the addiction recovery culture of mentors, meetings and social
activities.
In Session Three, the clinician used Structural Family Therapy7 techniques that fit well in
supporting CBT approaches. PTSD and addiction are both disorders that destroy clear
interpersonal boundaries and further result in problems with intimate relationships. Structural
Family Therapy seeks to create clear boundaries through the therapist joining the family system;
which in this case is the mother-daughter subsystem. The therapist entered Laura-Jericah’s
subsystem and used REBT reframing statements to support the client’s faulty perceptions of how
her relationship with her daughter “should be.” Laura was able to view this enactment as a
fantasy model when, even supported by the therapist’s advocacy, the interpersonal
communication continuously derailed and was largely ineffective. Structural Family Therapy,
sometimes called Structural Strategic Family Therapy, is a CBT model of choice for adolescents
experiencing depression in dysfunctional family systems8--which is the current situation for
Jericah and her mother Laura.
While CBT strategies, such as REBT and Structural Family Therapy, create a strong theoretical
and evidence-based rationale for treating the dual disorder client in this case study--it is also
taxing to the clinician’s personal resources. This is particularly true in the Structural Family
Therapy intervention which came about in an unplanned, but fortuitous, manner. When
facilitating a partially delusional mother-daughter interaction, it is almost impossible to avoid the
intrusion of a therapist’s own counter-transference issues. By staying on a well-defined CBT
approach, instead of a less linear and more symbol-laden psychodynamic approach, the therapist
maintains their own best protective shield of rational assessment during the exchange.
Nevertheless, the potential to be pulled off course requires use of supervision and, where
possible, audiotape transcription to self-assess the interaction at a later emotional distance.

Citations
1
"A Guide to Understanding Cognitive and Behavioural Psychotherapies" British Association of Behavioral and
Cognitive Psychotherapies. Retrieved on 2007-1-1
2
Beck, A., (1993). Cognitive Therapy and the Emotional Disorders, NY: Penguin, 1993.
3
Ellis, Albert (1975). A New Guide to Rational Living. Prentice Hall.
4
Ellis, Albert (2001). Overcoming Destructive Beliefs, Feelings, and Behaviors: New Directions for Rational
Emotive Behavior Therapy. Prometheus Books.
5
Spicer, Jerry (1993). The Minnesota Model: The Evolution of the Multidisciplinary Approach to Addiction
Recovery. Center City MN: Hazelden.
6
Bandura, A. (1986). Social Foundations of Thought and Action. Englewood Cliffs, NJ: Prentice-Hall.
7
http://www.minuchincenter.org. The Salvadore Minuchin Center for the Family.
8
Journal of Family Therapy. Special Issue—Family and Couple Interventions in Depression. 25(4):406-416,
November 2003.

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Dr. David Moore ÞΩ Argosy University-Seattle