case study using cbt

Cognitive Behaviour Therapy Case Studies

Mike Thomas - University of Chester, UK
Mandy Drake - University of Chester, UK
Description

This book uniquely combines CBT with the Department of Health stepped care model to provide the first comprehensive case study-approach textbook. A step-by-step guide to using CBT, the book is structured around case examples of clients who present with the most commonly encountered conditions; from mild depression and GAD to more complex, enduring symptoms and diagnosis like OCD, personality disorder and social phobia.

The distinctive practical format is ideal in showing how to put the principles of CBT and stepped care into effect. As well as echoing postgraduate level training, it provides an insight into the experiences the trainee will encounter in real-world practice. Each chapter addresses a specific client condition and covers initial referral, presentation and assessment, case formulation, treatment interventions, evaluation of CBT strategies and discharge planning.

The book also includes learning exercises and clinical hints, as well as extensive reference to further CBT research, resources and reading. It will be invaluable for trainees on Improving Access to Psychological Therapies (IAPT) programs, and anyone studying graduate CBT courses.

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'This text is more than a cook book representation of CBT - it shows how some real-world creative work can be done'. - Michael Worrell, Consultant Clinical Psychologist & Programme Director CBT Training Programmes, CNWL Foundation Trust and Royal Holloway University of London

The contributors describe therapy experiences with people with problems ranging from depression and specific anxiety problems to personality disorder, and offer reflections on progress, as well as learning exercises and tips for clinical practice.

Great resource for use in skills sessions. Provides more in-depth case studies that we can use across a number of courses.

This book helped my studetns explore real case and debate real solutions.

Excellent case studies for teaching, diverse range of clients and issues.

This is a good book for students to be aware of, when looking at the interventions for working with people with mental health problems.

This is an excellent text book, it gives a step by step guide for lecturers and students alike and is a must for every CBT practitioner.

Great text with well illustrated case examples for a range of different disorders.

As a lecturer I have found it's material useful in case discussions, formulations and role plays for students.

This is a good book. Being a researcher myself in the writings of case studies according to the CBT framework, I find this book essential for my students for they will be able to grasp not only the basics of how to write a CBT case study, but also to comprehend the elements which such research is constituted by

This is an excellent resource. Professor Thomas' in-depth knowledge of CBT enables him to present realistic case-studies. The introductory chapters provide a contemporary view of CBT before we are provided with detailed and varied case histories. I particularly liked the addition of a critique of each case study.

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A Counselling Case Study Using CBT

Jocelyn works as a Human Resources Manager for a large international organisation. She is becoming more and more stressed at work as the company is constantly changing and evolving. It is a requirement of her job that she keeps up with this change by implementing new strategies as well as ensuring focus is kept on her main role of headhunting new employees.

She finds that she is working twelve-hour days, six days a week and doesn’t have time for her friends and family. She has started yelling at staff members when they ask her questions and when making small mistakes in their work. Concerned about her stress levels, Jocelyn decided to attend a counselling session.

Below is an extract from Jocelyn’s first session with her counsellor:

Transcript from counselling session

Counsellor: So Jocelyn, let’s spend a few minutes talking about the connection between your thoughts and your emotions. Can you think of some times this week when you were frustrated with work? Jocelyn : Yes, definitely. It was on Friday and I had just implemented a new policy for staff members. I had imagined that I would get a lot of phone calls about it because I always do but I ended up snapping at people over the phone. Counsellor : And how were you feeling at that time? Jocelyn : I felt quite stressed and also annoyed at other staff members because they didn’t understand the policy. Counsellor : And what was going through your mind? Jocelyn : I guess I was thinking that no-one appreciates what I do. Counsellor : Okay. You just identified what we call an automatic thought. Everyone has them. They are thoughts that immediately pop to mind without any effort on your part. Most of the time the thought occurs so quickly you don’t notice it but it has an impact on your emotions. It’s usually the emotion that you notice, rather than the thought. Often these automatic thoughts are distorted in some way but we usually don’t stop to question the validity of the thought. But today, that’s what we are going to do?

The counsellor proceeds to work through the cognitive behaviour process with Jocelyn as follow:

Step 1 – Identify the automatic thought

Together, the counsellor and Jocelyn identified Jocelyn’s automatic thought as: “No-one appreciates what I do”.

Step 2 – Question the validity of the automatic thought

To question the validity of Jocelyn’s automatic thought, the counsellor engages in the following dialogue:

Counsellor : Tell me Jocelyn, what is the effect of believing that ‘no-one appreciates you?’ Jocelyn : Well, it infuriates me! I feel so undervalued and it puts me in such a foul mood. Counsellor : Okay, now I’d just like you to think for a moment what could be the effect if you changed that way of thinking Jocelyn: You mean, if I didn’t think that ‘no-one appreciates me’? Counsellor : Yes. Jocelyn : I guess I’d be a lot happier in my job. Ha, ha, I’d probably be nicer to be around. I’d be less snappy, more patient.

Step 3 – Challenge core beliefs

To challenge Jocelyn’s core belief, the counsellor engages in the following dialogue:

Counsellor : Jocelyn, I’d like you to read through this list of common false beliefs and tell me if you relate to any of them (hands Jocelyn the list of common false beliefs). Jocelyn : (Reads list)Ah, yes,I can see how I relate to number four, ‘that it’s necessary to be competent and successful in all those things which are attempted’.That’s so true for me. Counsellor : The reason these are called “false beliefs” is because they are extreme ways of perceiving the world. They are black or white and ignore the shades of grey in between.

Applications of CBT

Cognitive approaches have been applied as means of treatment across a variety of presenting concerns and psychological conditions. Cognitive approaches emphasise the role of thought in the development and maintenance of unhelpful or distressing patterns of emotion or behaviour.

Beck originally applied his cognitive approach to the treatment of depression. Cognitive therapy has also been successfully used to treat such conditions as anxiety disorders, obsessive disorders, substance abuse, post-traumatic stress, eating disorders, dissociative identity disorder, chronic pain and many other clinical conditions. In addition, it has been widely utilised to assist clients in enhancing their coping skills and moderating extremes in unhelpful thinking.

March 18, 2010
Case Study , CBT , Counselling , Workplace
Case Studies , Counselling Therapies , Workplace Issues

Comments: 11

I recently had a call (lifeline) from a young person with similar issues as Jocelyn so it was interresting to me to see that I was on the right track helping my client to change her thinking.

I am employed as a counselling psychologist in the dept. of professional studies for graduate students, it’s the way i had been challenging irrational beliefs students hold about themselves, & CBT helps a lot in improving their academic achievement, & helps my counselling to gain ground successfully.

it was a good case study helped a lot I as a student studying about case study on CBT patients !! thanks a lot

Thank you very much. it helped me as I am a student of basic counselling course.

I think the way the process is explained is very helpful.

It’s a very good article.Therapist explicitly challenged the automatic thought and could elicit it very well. CBT is more realistic and genuine. Great case study. Expect more such case details. Thanks.

I concur many students don’t fail exams because they don’t work hard but lack of confidence and negative self talk like I can never pass cbt is powerful in replacing the negative self talk

This type of case study is useful to know about the basic job awareness and what kind of stress the employee has. Mainly useful to know about the lot of information about counseling knowledge.

I am preparing for my internship in counseling and looking for case studies. I found this case study helpful and useful in how to utilize the CBT techniques when working with my potential clients. Thanks

what psychological theory would best help understand the client’s problems and how therapy from that theoretical standpoint will help them?

Cognitive Theory Behaviorism – Operant Conditioning Behaviorism – Classic Conditioning Psychoanalytic Theory Object Relations/Attachment Theory Existential Theory Humanistic Theory

As a psychology student this case study helped me alot in understanding the core values of CBT as well as how important of a role it is in counseling. Thank you!

Cognitive Behaviour Therapy Case Studies

Mike Thomas - University of Chester, UK
Mandy Drake - University of Chester, UK
Description

This distinctive practical format is ideal in showing how to put the principles of CBT and stepped care into effect. As well as echoing postgraduate level training, it provides an insight into the experiences the trainee will encounter in real-world practice. Each chapter addresses a specific client condition and covers initial referral, presentation and assessment, case formulation, treatment interventions, evaluation of CBT strategies and discharge planning. Specific presenting problems covered include:

- First onset and chronic Depression

- Social Phobia

- Obsessive-Compulsive Disorder

- Generalised Anxiety Disorder (GAD)

- Chronic Bulimia Nervosa and Anorexia nervosa

- Alcohol Addiction

- Personality Disorder

Great resource for use in skills sessions. Provides more in-depth case studies that we can use across a number of courses.

This book helped my studetns explore real case and debate real solutions.

Excellent case studies for teaching, diverse range of clients and issues.

This is a good book for students to be aware of, when looking at the interventions for working with people with mental health problems.

This is an excellent text book, it gives a step by step guide for lecturers and students alike and is a must for every CBT practitioner.

Great text with well illustrated case examples for a range of different disorders.

As a lecturer I have found it's material useful in case discussions, formulations and role plays for students.

Preview this book

Sample materials & chapters, for instructors.

Please select a format:

Select a Purchasing Option

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
Gives researchers the chance to collect information on why one strategy might be chosen over another
Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

It cannot necessarily be generalized to the larger population
Cannot demonstrate cause and effect
It may not be scientifically rigorous
It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
Explanatory case studies : These are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

Archival records : Census records, survey records, and name lists are examples of archival records.
Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research.

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
Read examples of case studies to gain an idea about the style and format.
Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal. The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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v.2(5); 2014 Oct

Cognitive evolutionary therapy for depression: a case study

Cezar giosan.

1 Liberal Arts, Berkeley College, 12 East 41st Street, New York City, New York, 10017

2 Clinical Psychology and Psychotherapy, Babeş-Bolyai University, Republicii 37, Cluj-Napoca, Cluj, Romania

Vlad Muresan

Ramona moldovan, key clinical message.

We present an evolutionary-driven cognitive–behavioral intervention for a moderately depressed patient. Standard cognitive and behavioral therapy techniques focused on the patient's perfectionistic and self-downing beliefs, while novel, evolutionary-informed techniques were used to guide behavioral activation and conceptualize secondary emotional problems related to anger. The treatment reduced depressive symptomatology and increased evolutionary fitness.

Theoretical and Research Basis for Treatment

Depression is one of the most prevalent mental disorders and the third largest contributor to global disease burden, outranking heart disease 1 ; it is the number one contributor to disease burden in developed countries, costing an estimated $81 billion in the U.S. alone 2 and €118 billion in Europe, where it is the most costly mental disorder 3 .

The etiology of depression is far from being completely understood. Factors such as dysfunctional cognitions 4 , 5 demographics 6 , prior major depression 6 , early traumatic experiences 7 , 8 , or negative life experiences (e.g., job loss, loss of a close one) 9 have been shown to be involved.

Current psychological standard of care in depression

Evidence-based treatments for depression are available and extensively used 10 – 14 .

There is evidence that cognitive–behavioral approaches (e.g., see the American Psychological Association's list of empirically validated treatments at http://www.apa.org ) are among the best empirically supported, both in terms of theory and intervention.

Cognitive and behavioral therapy (CBT) is an umbrella term including a variety of therapeutic approaches (i.e., cognitive therapy, rational emotive and behavioral therapy, multimodal therapy, schema-focused therapy, etc.), sharing a common rationale: the mediational role of dysfunctional cognitions in maintaining, predisposing or causing depression 15 – 17 . This has resulted in a proliferation of publications and the development of treatment approaches designed to alter the cognitive contents or processes hypothesized to be depressogenic 18 , 19 .

Beck's theory of depression is arguably the most influential model developed around the causes, course, and treatment of depression 5 . Literature has been consistently showing that people have relatively stable cognitive patterns that develop as a consequence of early learning, and that leads them to make negative and distorted interpretations of specific life events 20 . CBT does not provide an elaborate view of the origin of emotional disturbance, though it acknowledges that it is very likely that different people disturb themselves about highly aversive events differently 21 . More specifically, CBT is based on the premise that psychological problems stem from dysfunctional/irrational cognitions 20 , 22 and, as such, the therapist works with the client to identify and focus on those cognitions in order to modify them and remedy associated emotional and/or behavioral consequences.

Depression from an evolutionary perspective

Because of the universality and prevalence of mental illness, attempts have been made in Evolutionary Psychology to explain the possible functions of utility of some symptoms 23 – 25 . From this perspective, some mental disorders are seen as having present or past fitness advantages 26 and therefore might have been naturally selected (e.g., mild and moderate depression) 27 or are viewed as exaggerated responses to certain stimuli that constituted dangers in our evolutionary history (e.g., phobias) 28 , 29 .

Depression has been tackled in the evolutionary psychology research because of its high prevalence (5–10% in the US) 30 , universality 31 , and upward course 32 , as well as because it sometimes leads to devastating fitness consequences, such as suicide 33 . Unlike the prevalent medical view, which views depression as a brain disorder 34 – 36 , current evolutionary insights explain this condition by hypothesizing the functions it may serve 37 – 39 . From this perspective, depression is seen as a mechanism signaling fitness (i.e., reproductive) problems or risks (e.g., low mood is associated with lesser likelihood of engaging in risk-taking behaviors) 40 .

Cognitive evolutionary therapy for depression

CBT focuses on changing dysfunctional cognitions, thus leading to improvements in the depressive symptoms 4 , 20 . From this perspective, dysfunctional beliefs are seen as proximate, or immediate causes of depression. But some have argued, for example, that Beck's cognitive distortions are a consequence of depression, not a cause of it 41 . In other words, the underlying evolutionary, or ultimate causes that might contribute to depression and to dysfunctional thinking are not addressed directly in the current therapeutic approaches and a unifying evolutionary-driven paradigm providing explanations about the ultimate causes of depression is lacking.

A Cognitive Evolutionary Therapy for depression (CET) would focus, besides proximal causes, on distal (ultimate, or evolutionary) mechanisms as well, such as inclusive fitness or reproductive success, which are thought to lead to depression when prevented from functioning optimally 42 . Such an approach enhances the CBT paradigm by including information about the hypothesized adaptive functions of depressive symptoms, along with direct interventions on fitness-enhancing factors. In addition, attention is paid to unhealthy behaviors that generally lower fitness, targeting them specifically in the therapeutic process 42 , 43 .

Human behavior generally revolves around a finite set of biological and social adaptive problems (e.g., shelter/security, nutrition, sexuality, mating, parenting, and in-group and between-group interaction 44 . Research has shown that when people are successful at meeting these goals, they generally experience well-being and happiness 43 . Not meeting these goals has been associated with dissatisfaction, depression, tension, or frustration 43 .

CET enhances the classical CBT approach by focusing on guiding the patients in solving fitness-related problems and by using an evolutionary-aware conceptualization in some of the problems they may encounter 42 . Like in the classical CBT, at the beginning of the therapy the psychotherapist and the patient select and define the list of problems that will be addressed during treatment. However, unlike the classical CBT, where the patients typically volunteer these problems, in CET they are identified at intake by an evaluation of the patients' fitness 42 . During the therapy, discussions about human nature from an evolutionary standpoint can encourage the patients to experience acceptance, a key ingredient in CBT 45 , 46 , by acknowledging basic human limitations. These evolutionary arguments can become powerful tools in the disputing process, commonly used in the standard CBT. Thus, evolutionary psychology concepts (e.g., cognitive modularity 47 , 48 , parental investment theory 49 , 50 , conspicuous consumption 51 , 52 and costly signaling theory 53 , 54 ) can offer useful explanations for depressive symptomatology and the mechanisms underpinning it.

While some authors have hypothesized the potential therapeutic benefits of evolutionary approaches in clinical practice 55 , there is virtually no empirical research testing the clinical implications (and applications) of these theories. To our knowledge no study has so far addressed the practical implications of this recent progress. The present case study is a first attempt aimed at examining the efficacy of CET for depression.

Case Formulation

For the present case study we selected the treatment of one of the patients enrolled in a randomized clinical trial, which tests the efficacy of CET for Depression 42 . This study was approved by the Ethics Commission of Babe–Bolyai University.

Judy (not the real name) is a 22-year-old student who was referred for therapy by friends after a difficult break-up that affected her school performance and personal life. She is the only child of a typical middle-class family, living by herself during the school year and going back home (to a different city) during the holidays.

The patient enrolled in treatment after signing an informed consent. The initial psychiatric evaluation revealed that she had no prior history of depression or other psychiatric conditions.

The patient underwent CET following the protocol described by Giosan et al. 42 . The initial problem list presented by the patient included depressed mood, feelings of guilt, and anger because of the dissolution of a 6-month-old dysfunctional relationship. Judy felt personally responsible for the break-up, and believed that she would never be able to experience a similar level of emotional involvement again. Judy's goals for therapy were to get over the relationship and better cope with her situation. (At the time, in an attempt to distract herself, the patient was involved in binge drinking and reckless partying).

We selected this specific case because it illustrates the specific techniques used in CET and the rationale behind using it as an add-on to the classical CBT intervention. As further detailed below, the clinical conceptualization and the actual treatment both benefited from the evolutionary theory 2 by explaining the difficulties in overcoming depression using evolutionary insights and 3 by guiding and explaining the relevance of secondary goals (diet, exercise) in treating the patient's primary goals (depressive symptoms).

Self-report measures and the Structured Clinical Interview for DSM-IV 56 were administered to the patient throughout the treatment. Table Table1 1 presents them, along with the scores (Table (Table1 1 ).

Scores for the self-report measures administered at the beginning, during, at the end of treatment, and at follow-up

BDI-II, beck depression inventory-II 58 ; ABS, attitudes and beliefs scale 2 60 ; ATQ, automatic thoughts questionnaire 62 ; PANAS-P, positive and negative affect schedule – positive score; PANAS-N, positive and negative affect schedule – negative score 65 ; FES, fitness evaluation scale; ETO, expectation of therapeutic outcome; WAI, working alliance inventory 67 ; CSQ, client satisfaction questionnaire 68 .

The Structured Clinical Interview for DSM-IV (SCID) 56 is the most widely used diagnostic exam used to determine DSM-IV Axis one disorders, designed to be administered by a mental health professional. It consists in the Overview, Mood Episodes, and Anxiety Disorders modules. The Overview module collects information about socio-demographic variables (i.e., date of birth, marital status, number of children, level of education, and employment status), drugs use, drinking, medication, physical and psychological treatment history (including any treatments, past or current, for depression), and current social functioning. The Mood Episodes and Anxiety Disorders Modules follow the diagnostic criteria of the DSM-IV-TR 57 for mood episodes and anxiety disorders.

The Beck Depression Inventory-II (BDI-II) 58 is one of the most widely used self-report measures of depression symptoms, and it includes 21 items referring to various psychological and physical symptoms (e.g., feeling sad, guilty, hopeless, being agitated). It has high test–retest reliability (1 week) (Pearson r = 0.93) and high internal consistency (Chronbach's α = 0.91) 58 , 59 .

The Attitude and Belief Scale II ( ABS-II ) 60 is a self-report scale, with good psychometric properties, designed to measure irrational beliefs. The ABS-II has been shown to be a reliable and valid measure of rational and irrational beliefs 60 , 61 .

The Automatic Thoughts Questionnaire (ATQ) 62 is a 30-item self-report measure used to asses depression-related cognitions, with good convergent validity, internal consistency, and test–retest reliability 63 . The ATQ has also been shown to be sensitive to changes in the depression levels 64 .

The Positive and Negative Affect Scale (PANAS) 65 is a 20-item self-report questionnaire, designed to assess positive and negative affect. The PANAS can be used to assess mood on various time scales by altering the instructions. Possible time scales include moment, today, past few days, week, past few weeks, year, and general. The validity and internal consistency of the PANAS is good, with test–retest reliability being the highest for the “general” temporal instruction 65 .

The Expectancies of the Therapeutic Outcome are measured using four items on a 9-point Likert Scale. The items measure the patient's perceived usefulness of the treatment (e.g., “How logical does this treatment seem to you?”; “How efficient do you think this treatment will in reducing the symptoms that you experience?”). The scores range from 0 to 32.

The Working Alliance Inventory (WAI) is a 12-item self-report global measure of the working, or therapeutic alliance, presenting good psychometric properties 66 , 67 .

The Client Satisfaction Questionnaire 68 – 70 is an 8-item instrument used to evaluate the patients' satisfaction with the treatment.

The Fitness Evaluation Scale (FES) is a 45-item (58 if the patient has children) scale, adapted and expanded by the authors from the High-K Strategy Scale (HKSS) 71 , tapping into various dimensions and biosocial goals theorized to make up the indicators of fitness, as detailed in the Background section. The HKSS has been shown to be negatively associated with depressive symptomatology 72 and psychopathology in general 73 . The FES was preliminarily validated on a sample of 146 subjects and presents good internal consistency (Cronbach's Alpha = 0.93). The FES is the therapist's starting point in prescribing the evolutionary-driven interventions, as further detailed below.

Judy was assessed for eligibility for treatment with the SCID 56 . Following the initial assessment the patient was assigned to treatment and evaluated psychologically regularly as detailed in Table Table1 1 .

Case conceptualization

Judy is a 22-year-old female student, belonging to a middle-class family, who was referred to psychotherapy after a difficult break-up that affected school performance and general quality of life. At intake, the level of depressive symptomatology measured with the BDI-II was 23, signifying moderate depressive symptomatology 58 , confirming the initial SCID clinical diagnosis. The level of expectancy for therapeutic outcome was 32 out of 32, showing that the patient was highly motivated and believed in the efficacy of the intervention offered. She reported intense depressed mood and bereavement, guilt, anger, trouble concentrating, and diminished interest in pleasurable activities. The completion of the FES revealed fitness deficiencies on the following dimensions: (1) low perceived attractiveness (the patient believed that she was not attractive, despite evidence to the contrary such as her friends' opinions and the therapist's own judgment); (2) poor eating habits (the patient predominantly consumed junk food), and (3) lack of physical exercise. Thus, the therapy goals list set at the beginning of the treatment included working on the dysfunctional coping behaviors (e.g., weekend drinking) and improving on the fitness deficiencies identified by the FES. The patient was offered a clinical conceptualization that centered on the evolutionary causes of depressive symptomatology (i.e., fitness problems) and proximal causes consisting of dysfunctional cognitions. Specifically, Judy's depression was explained as being caused by a set of fitness-related issues, namely, unbalanced diet, lack of exercise, and poor self-image expressed through dysfunctional cognitions. The latter led to rigid irrational thoughts such as “I must be appreciated by my ex-boyfriend or else I am worthless”, “I will never find someone that will make me feel the same, and that is horrible”, or and “I am a stupid, weak person for not getting over it already.”

The main focus of treatment was to engage the patient in behaviors targeted at increasing fitness, while challenging the dysfunctional thoughts and increasing confidence in more rational and functional alternatives.

Course of Treatment

Following the protocol described elsewhere 42 , the first treatment session focused on educating the patient about depression and psychotherapy in general, emphasizing the importance of homework, taking responsibility for change and adjusting her expectations about what can be gained through therapy. Judy had a clear understanding about what psychological treatment entailed and what her responsibilities as a patient were.

Also, in the first session we focused on specific CET insights that helped her to gain a clearer understanding of the problems she was confronting, thus leading to a more accepting attitude about her symptoms. Thus, the patient was explained that cognitive structures that were adaptive in a Pleistocene environment are now “mismatched” with the current environment, sometimes leading to dysfunctional emotions and behaviors 74 , 75 . The patient was also explained that some scholars see Depression as an adaptation that might have conferred fitness benefits in the Environment of Evolutionary Adaptedness (EEA) 31 , by encouraging cooperation and eliciting support from group members, things that are much harder to achieve in the modern society. Finally, the patient was informed about the research linking depression and fitness-enhancing behaviors, namely the relationship between diet and depression 76 , 77 and exercising and depression 78 . While the patient had a general idea about the positive associations between diet, exercise and health, the realization that these associations hold true in the case of depression, too, helped in motivating her to begin exercising more and thinking about adjusting her diet in the sense of incorporating foods that our ancestors typically consumed 76 , 77 . This was the point in Session 1 where we established a realistic behavioral activation plan that would tap into the above-mentioned fitness-related dimensions (diet and exercise). The homework focused on detailing the behavioral activation plan with specific behaviors that the patient was instructed to work on in the following weeks.

The next few sessions 3 – 7 focused on standard CBT tasks and techniques, aimed at enhancing the therapeutic relationship and negotiating behaviors that addressed fitness problems revealed at intake by FES. A specific problem that benefited in an important way from the evolutionary conceptualization was the difficulty Judy had to accept her reaction to the break-up. After realizing that being rejected affected her more than what she expected, she began to experience anger with herself. This kind of secondary emotions (i.e., emotions about emotions) are often an obstacle to the therapeutic change 45 , 79 , 80 . In Judy's case, her anger about her depression was caused by rigid beliefs such as: “I shouldn't be so upset about him; I'm a weak person because I'm depressed over the end of the relationship”. In clinical practice, the therapist cannot address the problem of depression until the secondary emotion (anger in this case) is resolved 45 , 81 . Indeed, one of the main reasons why Judy didn't get over the break-up by herself was her inability to accept her fallibility (i.e., the fact that as a fallible human being, she is allowed to make mistakes, and feel depressed). Furthermore, every attempt from her friends or from the therapist to help with the depression resulted in the activation of her perfectionistic belief (“I shouldn't be depressed about him, and I am a weak, worthless person because I am”) and the resulting anger, which prevented her from gaining insight on why she was depressed in the first place.

The evolutionary conceptualization of Judy's depression greatly helped in teaching the patient to accept herself, an effect visible in a 7-point drop on the BDI-II after the fourth session (see Table Table1). 1 ). Judy was explained that in the tribal living of the EEA, being rejected by a desirable mate in the group had severe fitness, status and reputation costs. In this context, a strong motivation for not being rejected and for hanging on to what we now call a dysfunctional relationship, would have been adaptive. However, she was further explained, the environment we are adapted to was very different from the present one: Firstly, there were few potential partners to choose from, as we lived in groups of 150–200 tribe members 82 . Secondly, being rejected often had higher reputational costs than today, and finding another high-quality mate was less likely. This evolutionary mismatch proved to be an important argument toward explaining to Judy why she was so fixated on her ex-boyfriend, further helping her to accept herself as a fallible human being. This important milestone in the treatment was followed by cognitive restructuring homework focused on changing the irrational belief “I should get over it faster, and if I can't I'm a weak, worthless person” to its more rational and useful counterpart “I'd like to get over it faster, but I can accept if it takes some more time, and if it does, it doesn't mean I'm a weak person, but a normal, fallible human being”. After challenging this perfectionistic demand, cognitive work focused on the global evaluation that underlined her depressive mood (e.g., “If he rejects me that means I'm unattractive and worthless” and “If I'm not going to feel the same thing again nothing is worth living for”). We will not go into great detail about the CBT techniques as we followed existing CBT guidelines for depression 4 , 83 , 84 . Instead we will focus on specific evolutionary-informed techniques used in this patient's treatment.

Sessions 7–11 focused on maintaining the behavioral habits of healthier dieting and exercise, by finding alternative behaviors, so as not to reach saturation. Indeed, our ancestors would have likely travelled in different places every day, and we tried to build such variation in Judy's exercising routine, to avoid reaching boredom. Dieting was also addressed with behavioral techniques, by guiding the patient to replace fast-foods with healthier alternatives such as vegetables and foods low in saturated fats and high in Omega-3's 76 , while continuously reinforcing the connection between a healthy diet and positive health and psychological outcomes. By session 8 Judy's depressive symptomatology was down substantially (from 22 at intake to 7 on the BDI-II at the eight session, a decrease of 68%), and at this point we began to address expectations about relationships, namely that a relationship based on a rollercoaster of physical and verbal aggression followed by intense physical attraction isn't sustainable or desirable on the long run. Assertive communication was also practiced with her, and we explored the patient's expectations and preferences about future romantic partners. By the end of therapy Judy was beginning a new relationship, based on the mutual respect and communication, which was satisfying and enjoyable for both partners. The patient successfully rejected her ex's advances when he tried to get her back, something that she previously never thought she would be able to do.

As a consequence of working on self-acceptance 45 , 79 , 80 and developing her rational thinking skills, her low opinion about her own attractiveness – one of the problems identified at intake by the FES – improved substantially by the end of therapy.

In the last session we used standard CBT techniques to work with Judy toward developing the skills to become her own future therapist and to prevent relapse 20 , 45 . The low BDI-II score that Judy achieved by the eight session was maintained until the end of the therapy (BDI-II = 7), which falls into the minimal or no depression range (0–13) 59 . Measures for both cognitions (ATQ & ABS-II) and negative emotions (PANAS-N) showed significant improvement, while there was also a substantial increase in evolutionary fitness (FES total score = 103 at intake FES total score at the end of therapy = 146).

A 3-month follow-up revealed that these therapeutic gains were maintained, with the BDI-II score continuing to show minimal to no depression. The other clinical outcomes measured also showed lasting positive effects (see Table Table1 1 ).

Concluding Remarks on Therapy Process and Outcome

This case study suggests that evolutionary techniques embedded in cognitive–behavioral therapies are beneficial in increasing an individual's perceived fitness, which, in turn, can lead to positive clinical outcomes. Identifying and addressing fitness problems in therapy, alongside patient-identified problem areas, can constitute, at least in some cases, an important adjuvant to the cognitive–behavioral therapy for depression. As seen in the case of this patient, the evolutionary-driven conceptualization can provide the patient with an extra level of prediction and control, thus increasing compliance and enhancing positive expectations about the treatment outcome.

The enhanced approach presented in this article should be relevant to most patients, and thus should be considered as a tool for enhancing the clinical conceptualization and intervention techniques of standard CBT. However, with patients that are very high on religiosity, or who explicitly reject Darwin's theory of evolution, a more traditional approach should be used in the conceptualization phase. Behavioral activation and fitness-enhancing techniques, however, can be used regardless of the patient's religious beliefs.

These findings add support to recent studies that document links between depression and reproductive success 72 . Further studies should examine the effects of targeting fitness factors on depression in a controlled manner.

Conflict of Interest

None declared.

Towards a new theory of student self-assessment: Tracing learners’ cognitive and affective processes

Published: 28 September 2023
Volume 18 , pages 945–981, ( 2023 )

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Nathan Rickey ORCID: orcid.org/0000-0002-0044-0204 1 ,
Christopher DeLuca 1 &
Pamela Beach 1

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Despite their essential role in learning, the cognitive and affective underpinnings of student self-assessment are not yet well understood. This research responded to calls to examine how students in K-12 contexts think and feel while engaged in evidence-informed self-assessment activities (i.e., self-assessment processes). We drew on a framework of classroom assessment as the co-regulation of learning to theorize the cognitive and affective self-regulatory operations learners may activate during self-assessment. Leveraging a collective case study, we collected digital trace data as participants, a class of Year 12 students ( n = 16) in England, completed a self-assessment-based English literature lesson. In the lesson, participants completed a writing task, self-generated feedback using resources, and revised their writing using a study website. Matomo Analytics, a web analytics platform, ambiently collected session recording, heatmap, and keystroke log data. Participants also completed an exit survey to provide qualitative data on their cognitive and affective processes. We analyzed logs of trace data using transition graphs and graph theoretic statistics to identify patterns across participants’ self-assessment processes. Analyzing trace data concurrently with qualitative and heatmap data, we mapped each participant’s cognitive and affective processes as they self-assessed and revised their writing. Findings highlighted key cognitive and affective operations across participants, pointing to mechanisms whereby participants’ self-assessment processes shaped their learning, and illuminated the recursive nature of self-assessment processes. Informing an initial theory of self-assessment processes, this research advances a core component of classroom assessment theory and practice.

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Using multiple, contextualized data sources to measure learners’ perceptions of their self-regulated learning

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