Betty’s case provides an example of the applicability of cognitive-behavioral therapy in enhancing personal ability to practice self-care. The client has undergone various episodes of perceived domestic violence, which are attributed to her husband’s dementia. These episodes have resulted in her anxiety about the husband’s worsening situation and the probability of being injured. Currently, the most urgent need for care is based on the client’s increasing anxiety as she cares for her husband amidst his increasing demands. The data for the case was obtained using self-reports, case logs, and daily records of thoughts. The following sections present observations made on the client in addition to effective treatment plans.
Daily Record of Thoughts
Table 1 below summarizes the experiences of the client on the different instances she has faced perceived domestic violence.
Table 1: Betty’s Daily Record of Thoughts
|Date||Situation||Automatic thoughts||Physical response||Emotional response||Cognitive distortion||Changed thought|
|Day 1||Godfrey refused to be involved in various needed activities and had to be compelled.||Godfrey was angry because he could not remember anything.||Godfrey had thrown Betty to one side of the door frame and nearly hurt her.||She felt anxious that Godfrey might throw himself down the stairs.||None||None|
|Day 2||Godfrey had refused to get off the toilet seat and forced Betty to react.||Godfrey was being deliberately awkward and wanting things to go his way.||Betty grabbed Godfrey off the toilet seat and did not think he was hurt.||Hurt and angry||None||None|
Functional Assessment: ABC Framework
Table 2 below gives an overview of the functional assessment for the client based on the antecedents, behaviors, and consequences (ABC) framework. The assessment was conducted based on the queries developed by the National Center on Domestic Violence, Trauma, and Mental Health (2004). Notably, most of the information provided here was given in line with Godfrey’s treatment; hence, it is more focused on Betty’s reactions to Godfrey’s actions.
Table 2: Betty’s Functional Assessment
|Antecedents (What happened before)||Behaviors (What did you do?)||Short-Term Consequences
(What was the result 1 second and 1 hour following behavior?)
(What were the lasting results?)
|Godfrey hit Betty for giving him brisket instead of steak.||She felt afraid and angry and shouted at him after the children went to bed.||He promised never to hit her again.||He never hit her again until his dementia started.|
|The client was held against one side of the door and would have been hurt.||Called the police, moved to spend the night downstairs.||There was a lot of worry about Godfrey’s probable reactions.||Betty realized that Godfrey is only getting worse and more difficult to manage (anxiety).|
|Godfrey refused to get off the toilet seat yet Betty wanted to use the toilet.||She grabbed him off the seat.||He quietly left and went downstairs surprising even Betty; she did not think he was hurt.||He had scars from the grabbing on his arms.|
|Godfrey’s refusal to do things or insistence on his way.||Dragging and harsh talking||Godfrey’s compliance.||Perceived use of force/ elder mistreatment.|
A tentative thought diary was completed for the client as shown in table 3 below.
Table 3: Betty’s Thought Diary
|Day||Situation (What were you doing?)||Thoughts (Anxious, negative, pessimistic)||Feelings (0-low to 10- high)||Alternative thoughts (helpful thoughts)||New feelings (0-low to 10- high)|
|Day 1||Asking Godfrey to leave the toilet||Anxious, angry||4||Surprise, tolerant||3 – pessimistic due to escalating dementia.|
|Day 2||Supporting Godfrey||Anxious, pessimistic||3||Positive||3|
Betty’s case is considered a probable candidate for the application of cognitive-behavioral therapy (CBT) due to the relevance of such an approach for cases similar to that of Betty. According to Eckhardt, Murphy, and Sprunger (2014), domestic violence and elderly abuse have long-term effects on the lives and well-being of victims. Addressing the trauma associated with such violence is thus necessary in order to improve the quality of life of victims. CBT has been traditionally used to enhance the ability of victims of abuse to deal with the outcomes including changes in patterns of thinking, beliefs, values, and attitudes with the objective of improving victims’ quality of life (Cully & Teten, 2008). Additionally, CBT has been found effective as an intervention for individuals suffering from panic and anxiety (Smith, Segal & Segal, 2019). Hamel (2016) points out that CBT is not a distinct therapeutic technique but rather a combination of several approaches aimed at solving daily problems, as well as achieving distinct goals and objectives. Based on these arguments, CBT seems to be a viable therapeutic measure for Betty.
The specific therapeutic approach that would be adopted for the case is mind-body therapy. The general process of CBT entails assessment, reconceptualization, acquisition of skills, consolidation, and application of skills, maintenance of skills obtained, and generalization and follow-up on treatment processes (College of Policing, 2015). Sokol (n.d) provides an overview of the distinct assessment processes to determine the most effective approaches specifically for core conceptualization. The mind-body technique has been found effective when applying the basic processes of CBT (Toleffson et al., 2009). The approach focuses on the holistic improvement of quality of life by focusing on spiritual, social, mental, emotional, and behavioral factors, among others (Toleffson et al., 2009). Wei, Si, and Tang (2017) posit that mind-body therapy enhances the individual capacity for self-care and self-knowledge, thereby emphasizing the use of techniques that can be effective towards promoting such outcomes. Some of the techniques of mind-body therapy, as mentioned by Toleffson et al. (2009), include; relaxation, visual imagery, meditation, and group support. These techniques are similar to those listed by the National Institute of Justice (n.d) as effective approaches to CBT. Group support has specifically been mentioned as effective as a form of CBT for individuals suffering from intimate partner violence (Sax, 2012). These approaches have been adopted for effective use in Betty’s case.
Cognitive-Behavioral Case Conceptualization Sheet
Client Name: Betty White Date of Birth: 10.09.1943
Race: Black Gender: Female Age: 73
Personal characteristics: Betty White is a Black Caribbean female aged 73 years old. She has been observed to be potentially at risk of domestic violence or abuse from her husband. She also has self-care deficits and is currently suffering from anxiety due to past events.
Personal interests: Betty desires to keep her home and not send Godfrey to a home for the elderly for the long term.
Interpersonal abilities: She has strong interpersonal abilities and communicates clearly. She is also capable of showing strong emotions and making her opinions known verbally, as well as using non-verbal cues. She also has positive interactions and connection abilities with other people.
Others: She has 3 children; Marcus, Gloria, and Angela. Only Angela lives close to her although she cannot leave her home on short notice as she is a carer for her special needs son.
List of Problems
- The client has been established to be a probable risk of elderly abuse and domestic violence as she takes care of her husband, Godfrey, who is currently suffering from dementia. He has also been violent in the past.
- She feels that Godfrey’s condition is likely to worsen and has developed anxiety because of this.
Relevant Referral Assessment Data
From self-reports and the case assessments conducted by the social worker, the client is of sound cognitive functioning. She however suffers from anxiety due to the projection that her husband’s condition is getting worse and he may hurt her considering the past experiences.
Antecedents (Precipitating factors)
The client has no underlying mental issues, and any indication of violence or harsh talk on her part is triggered by the actions of her husband.
As the Black Caribbean, family values are some of the cultural considerations that must be made during scheduling and executing the treatment processes. The objective is to enable Betty to understand her risk of domestic violence and abuse while upholding the value of family and the importance of taking care of her husband. The ultimate goal is to enable Betty to seek help for herself through accessing care support for Godfrey while believing that such a step would not be equivalent to abandoning her marital responsibilities. The initial reluctance to pursue help could possibly be attributed to the perception that such help would indicate abandonment on her part. She is also a Christian (Baptist), and the religious beliefs could reinforce the reverence for maintaining marital relationships even in the face of abuse.
Protective/ Resiliency Factors
- Betty has shown willingness to be assisted.
- She is also devoid of the developmental and health issues that commonly affect elderly individuals.
- She is still of sound mental capacity to make reasonable decisions.
- Communication capabilities and willingness to contact the caseworker and her daughter in case of any emergencies is an indication of resilience.
- Godfrey has shown the tendency to be abusive/violent prior to dementia.
- The increasingly worsening case of dementia has rendered Godfrey more prone to resistance, as well as an attack on his wife.
- The tendency to be controlling also portrays Godfrey as a potential source of harm to Betty.
Readiness for Change
From the conversations with the social worker, Betty has recognized the pertinent issues requiring change (need for seeking help on her anxiety) and has agreed to pursue additional support where necessary both for herself and for Godfrey.
Impediments to Change
Individual: Cultural values – focus on family.
Family: Betty’s only family member who lives close to her is Angela, who cannot leave her house during an emergency. Betty cannot also get any support from family members in caring for Godfrey.
Betty needs behavioral therapy to address the anxiety issues she faces and also to enhance self-care by allowing Godfrey to spend more time at the center to give her time to attend to self-care needs. A mind-body approach to CBT can be effective towards attaining this objective. The specific techniques that would be adopted include relaxation and group support (she would be connected to groups of people caring for individuals with dementia) as cognitive therapy has been proven effective for such groups.
Origins of Working Hypothesis
The client believes she is not undergoing any abuse or domestic violence. Moreover, her score on the symptoms of abuse scale are quite low (minimum score in every category), thus indicating that she is currently not undergoing domestic abuse even though she may be at risk. However, she feels drained because of taking care of her husband and his increasing demands, and the emphasis on getting his way complicates things further. She already feels relieved because her husband is off to the center two days a week, which gives her more time to care for herself. The therapy, therefore, would not be aimed at addressing the issues of anxiety and self-care in the client.
Relevant Core Beliefs
The most important belief for this client is her belief in marriage and in caring for her husband.
Diagnostic Impression/ Educational Classification
The clients’ primary condition is classified under anxiety disorders and will be handled as such.
- The primary problem faced by Betty is anxiety and self-care deficiency, and these issues will be the core targets for the intervention.
- The intervention for Betty is not because she has exhibited signs of elderly abuse but because she is at risk of abuse emanating from her husband’s condition.
Goals for Consideration
- To help Betty deal with the anxiety she currently feels about her husband’s worsening condition and to improve in self-care.
- To change Betty’s belief towards understanding that asking for support for Godfrey from the center does not amount to a violation of her role as his carer.
- To foster habits that will enable Betty to live her life optimally in spite of her husband’s condition through the use of mind-body therapy.
- To identify practices that can help Betty better manage her husband’s demands through the help of others.
Signature: _____________________ Date: ___________________
Betty White’s case is a complicated one because the initially intended recipient of therapy, Godfrey, has turned out not to be the person in need of therapy. Considering that Godfrey’s behaviors are understood to be aggravated by dementia, it is possible to help in managing his condition through support from others. Betty, on the other hand, denies that she may be suffering from abuse, which is acceptable given that the issues of violence only increased after Godfrey started suffering from dementia. The planned CBT would thus be aimed at helping Betty address her anxiety about her husband’s condition and to promote self-care. The best way to achieve this is to create opportunities for self-care through seeking support for Godfrey. Relaxation techniques and support groups for individuals caring for dementia patients have considered the most appropriate treatment approaches for Betty’s condition.
College of Policing. (2015). Cognitive Behavioural Therapy (CBT) for Domestic Violence. Retrieved from https://whatworks.college.police.uk/toolkit/Pages/Intervention.aspx?InterventionID=28
Cully, J. A., & Teten, A. L. (2008). A therapist’s guide to brief cognitive-behavioral therapy. Department of Veterans Affairs South Central MIRECC, Houston.
Eckhardt, C. I., Murphy, C., & Sprunger, J. G. (2014, August 28). Interventions for perpetrators of intimate partner violence. Psychiatric Times. Retrieved from https://www.psychiatrictimes.com/view/interventions-perpetrators-intimate-partner-violence
Hamel, J. (2016). Evidence-based domestic violence perpetrator treatment. Retrieved from https://domesticviolencetrainings.org/evidence-based-domestic-violence-perpetrator-treatment/
National Center on Domestic Violence, Trauma, and Mental Health. (2004). Responding to domestic violence: Tools for mental health providers. National Center on Domestic Violence, Trauma, and Mental Health.
National Institute of Justice (n.d). Practice profile- Interventions for domestic violence offenders: Cognitive behavioral therapy. Retrieved from https://www.crimesolutions.gov/PracticeDetails.aspx?ID=16
Sax, K. (2012). Intimate partner violence: A group cognitive-behavioral therapy model. The Group Psychologist. Retrieved from https://www.apadivisions.org/division-49/publications/newsletter/group-psychologist/2012/11/partner-violence
Smith, M., Segal, R., & Segal, J. (2019). Therapy for anxiety disorders. Help Guide Organization International. Retrieved from https://www.helpguide.org/articles/anxiety/therapy-for-anxiety-disorders.htm
Sokol. L. (n.d). Advanced CBT for therapists: Case conceptualization.
Toleffson, D. R., Webb, K., Shumway, D., Block, S. H., & Nakamura, Y. (2009). A mind-body approach to domestic violence perpetrator treatment: Program overview and preliminary outcomes. Journal of Aggression, Maltreatment & Trauma, 18, 17-45.
Wei, G-X., Si, G., & Tang, Y-Y. (2017). Editorial: Brain-mind-body practice and health. Frontiers in Psychology. Retrieved from https://www.frontiersin.org/articles/10.3389/fpsyg.2017.01886/full