Case of cognitive behavioral therapy write up begins from the moment the client walks into the clinic. Case formulation entails all the information asked by the therapist and especially responses from the client. According to Beck (2011), it is very important that the therapist take notes from the onset of meeting the client, this will make case formulation easier to write up, serve as a reference back tool and minimize redundancy in questioning. The therapist will collect detailed case history such as; identifying information, chief complaint, History of present illness, psychiatric history, personal and social history, medical history, mental status check, and DSM-IV-TR Diagnosis (Beck, …show more content…
The therapist will write about precipitants of the client’s mental condition (Beck, 2011). It is very important to identify causes of the client’s mental state, what aggravates it and what makes it better. Then proceed to cross-sectional view of current cognitions behavior. This part will entail assessment of automatic thoughts and how these automatic thoughts affects the client. The focus is on the client’s current cognition and behavior and not based on the clients past history. The next step to formulate a case is the longitudinal view of cognitions and behavior (Beck, 2011). The client tends to make assumptions, which could serve as a coping strategy for them. These assumptions should be placed in this category of a case formulation. Next is to assess the strengths and assets of the client by identifying certain characteristics of the client that is positive despite all the negativity (Beck, 2011). For example, having the courage to see a therapist is a good exhibit of a client’s strength. The final step of case formulation is to create a working hypothesis, referred to as the summary of conceptualization (Beck, 2011). This part entails the summary of the client’s mental condition. The therapist will use this part to summarize his/her understanding of client’s condition based on the interview. The focus should be on the onset of condition, effect on daily activities, coping skills, and how one negative thought led to many negative thoughts for the