Case Study – A CBT Success Story (Lesson 15/30)

Free Sample Lesson of The Flourishing Function: Anti-Depression Program

This a free sample lesson, of the full 30-lesson Flourishing Function Program. The program is primarily audio-based, so feel free to grab some headphones, hit play, and go on a walk.

Lesson Transcript

As we come to the close of the CBT-intensive module two, I want to provide a case study loosely based on real patient data. Though all of the exercises I’ve shared so far are powerful in their own right, nothing is more powerful than seeing how it all comes together, and how the process can work for you.

Felicia is a college student who has recently been struggling with her self-worth, to the point of moderate depression. Though her self-esteem had never been particularly high, she always felt that if she was at least able to succeed in school and get good grades, she had worth and was not a failure.

Her first semester of college had been a wake-up call. Not only was it much harder to succeed academically, she also had to support herself with a job at the campus fitness center. She was struggling to balance it all and falling behind in school, and her self-regard was crumbling.

She missed her family and friends back home, and she hadn’t made any close friends in school due to her busy schedule. Making matters worse, her boyfriend was also still in her hometown, and he had urged her to stay instead of going off to school. Sometimes he would try to pressure her to drop out and move back home, and their fights would often become heated and hurtful.

She made an appointment with her school’s mental health counselor, who was fortunately trained in CBT, and provided her with some resources to help resolve her depression and improve her mental health.

The initial concerns she expressed were academic – she wanted to get back on track in her assignments more than anything. And at first, she was annoyed by some of the exercises her counselor gave her. She was worried that she was going to drop the ball in school and work, and now even more assignments were being piled onto her plate.

But she was gradually coaxed into making time for the assignments as her counselor assured her that these were powerful exercises for improving her mental health, motivation, and productivity. She learned that negative moods and decreased energy can often be the result of automatic thoughts and negative beliefs about herself.

At the end of her first session, she was asked to keep a log of her moods and automatic thoughts. At first, it just seemed she was sad and depressed almost all the time, and it was hard to come up with specific thoughts. But she managed to come up with a few in the first week, and she brought them to her next session. Here is her first log entry:

Mood: Sad, embarrassed (50%):

Situation: Getting exam grades back

Automatic Thought: I can’t believe I got another C on this exam. I really tried hard on this one – I’m just not smart enough.

In the session, her counselor applauded her for coming up with a few of those thoughts. Then they went through each one together, coming up with evidence for and against each of the thoughts.

For the thought listed above, she came up with a few pieces of evidence. Her evidence for the thought was the C she got on this exam, a C on an exam in another class, and a D on a recent assignment. Her evidence against was that she has a B average in most classes, and she got an A on the previous exam.

Her counselor asked her a few more questions to generate more evidence. Had she ever gone to her professor for help? Had she asked classmates to study with her? She said no to both.

She was asked if she thought it was possible that her low grades could be the result of her approach to studying, or the fact that she had other responsibilities taking up time, rather than reflecting her overall intelligence or competence. She agreed that these were valid possibilities.

After going through these pieces of evidence, Felicia’s counselor taught her about cognitive distortions. She said the assumption that getting a C must mean she isn’t intelligent enough fits the pattern of Jumping to Conclusions, a common distortion that causes negative moods. And the automatic focus on her C while excluding her good grades was a classic example of the Mental Filter distortion.

After learning about some of her flawed interpretations, Felicia said she felt a bit better, though she wasn’t fully convinced. Her counselor asked her to keep logging her thoughts over the next week, to try her hand at compiling the evidence for and against her thoughts, and to see if she can identify some distortions underlying them.

She did her best to balance this assignment with her other responsibilities, and returned for her next session. She even noted that her mood had lifted through the process of identifying evidence for her beliefs. She shared one of the log entries she had made on her own:

Mood: Depressed, insecure, ashamed (80%)

Situation: Looking at the pile of work that I’m behind on

Automatic Thought: I don’t have what it takes to get through college. I’m going to have to drop out and move back home.

Evidence For: Three late assignments, had to call out of work to study, behind on paper due this week

Evidence Against: Passed previous semester, on track to pass this one, praised for job at work last week

Distortion: Catastrophizing, Jumping to Conclusions (Fortune Telling)

Her counselor acknowledged the great work she had done in logging and questioning her thoughts. There was one more step in the restructuring process: Forming a balanced, alternative belief. She asked Felicia if she could reformulate her original thought in a balanced and reasonable way.

Felicia came up with the alternative belief, “Getting through college will be the hardest thing I’ve ever done, and it’s possible that I will fail, but I will most likely get through it.” The counselor asked her to rate how depressed, insecure, and ashamed she felt now when thinking about how behind she was. Felicia said the intensity of her mood had gone down to 40%, half of its original intensity.

She was making excellent progress in just a few weeks, but it was clear that improving her depression and self-esteem was going to take more time. They needed to go deeper. They went through the cognitive restructuring process with a few other thoughts, including one that going to her professor for help wouldn’t improve her test results, and her professor would just think she was stupid.

They decided to test this assumption through a simple experiment. Felicia would go to one of her professors for help and see how they reacted. She was reluctant at first, and she tried to put it off, but her counselor assured her that this would help her correct her beliefs and performance. They laid out the experiment together before ending the session.

Felicia came back the following week and shared the results of her experiment. She went to her professor’s office hours with a list of questions and expressed her concerns about her grades. And her predictions turned out to be completely wrong. Her professor was delighted to see her and eager to help out.

As it turns out, her professor had been noticing some common patterns on her tests and papers. She ended up with some very helpful tips in the future, and she now felt that her professor was on her side.

Her counselor asked her how much confidence she placed in her original belief that asking professors for help wouldn’t make a difference, or would make them think she was stupid. She now only believed this about 10%, dramatically improving her view on asking professors for help.

Unfortunately, Felicia experienced a setback in her overall progress this week. She told her counselor that the cognitive restructuring had really been helping – at least that’s how it seemed. And after meeting with her professor, she felt empowered and excited. She even logged the thought, “this CBT stuff might actually work!”

But the next day, she got in a big fight with her boyfriend. She had called him feeling optimistic, but he seemed to only shoot down her progress and discourage her. They both ended up saying hurtful things to one another, and she walked out of it feeling worthless, like she would never be good enough, even if she could get things together at school.

Her counselor had picked up on several cues over the last few weeks that indicated there were some problematic core beliefs underlying Felicia’s automatic thoughts. She saw that Felicia equated her worth almost entirely to her academic performance. She viewed the possibility of dropping out of school as completely catastrophic. And she seemed to have an unhealthy, possibly abusive relationship with her boyfriend.

She asked if Felicia would go through another exercise with her called the Downward Arrow technique. She picked out one of the previous automatic thoughts, “I don’t have what it takes to get through college. I’m going to have to drop out and move back home.” And she asked Felicia repeatedly to answer the question “If this is true, what does this mean about me?”

Here are Felicia’s responses:

I’m not intelligent or competent. (If this is true, what does this mean about me?)


I’m a total failure. (If this is true, what does this mean about me?)


I have no worth. No one will love me.

As suspected, Felicia had some deeper schemas, relating to her personal virtues and identity, driving her depression. Through some deeper exploration, she learned that Felicia had been raised in a cold and abusive environment. She never felt worthy, and it wasn’t until she started succeeding in school that she first felt like an admirable person.

She walked away from these experiences with a deeply embedded belief that if she wanted to have worth, she needed to earn it through her work in school. She had to be outstanding in order to keep from being inferior, and failing in school or work meant failing as a person.

It also resulted in dysfunctional intimate relationships throughout her life. She became so used to her emotional needs not being met, that she fell into a pattern of dating people who disrespected her and discouraged her from reaching her potential. She felt largely alone her whole life, and anytime someone seemed to pay attention to her emotions, she would inexplicably push them away.

Because she could not rely on her intimate relationships or friendships to support her positive identity, her well-being was completely reliant on the work domain, and this was the one that was struggling now. Although CBT usually didn’t require digging into these deep beliefs or childhood experiences, it seemed absolutely necessary to her counselor in this case.

Felicia and her counselor worked together to come up with, and build up some alternative core beliefs for some of her current ones. Here are the positive schemas they came up with.

I am valuable as a person, not just in my work

I am worthy of supportive, loving relationships

My virtues do not depend on my perfection

She wrote these beliefs down and started writing down daily experiences that supported them. She noted that her professors and classmates showed signs of respecting and supporting her, even though she was not doing exceptionally well in all of her classes. She even got asked out by one of her classmates who was studying with her, and who seemed to be genuinely interested in her.

After a few more weeks of meeting with her counselor and completing the exercises, she showed up for one session, beaming with excitement. She said that she was happier than she had been in years, and she couldn’t believe how far she had come so quickly. She had made a point of opening up to the possibility that her new, positive beliefs were true, and she started finding evidence for them everywhere she looked.

After growing increasingly tired of her boyfriend’s disrespect, and finally starting to believe she deserved better, she broke things off with him. She wasn’t ready to pursue anything with her classmate and felt like she had enough on her plate this semester. But actually allowing others to help her had gradually built her a group of friends who cared about her and her success.

She even had a few examples of positive emotions she had logged, and some great mental habits she was working on building. When asked how confident she was in her new, positive core beliefs, she reported a 50% increase on average. Of course it would take longer to completely obliterate the beliefs she had held since childhood, but she had improved immensely and finally began to believe that she had worth as a person.

After reassessing her initial diagnosis of depression and evaluating progress toward her goals, she agreed with her counselor that she no longer needed the therapy sessions. But she promised to keep logging her thoughts, questioning her assumptions, and restructuring her dysfunctional beliefs.



You’ve heard Felicia’s story, and I’d like to ask you to share yours. But unlike Felicia, you’ve only had a week to practice the methods we’ve covered. It’s likely that restructuring your negative thoughts and beliefs will take at least a few more weeks to start showing major results.

But I do want to emphasize that if you do complete these exercises, consistently, you should start seeing major results before long. In fact, you may be seeing signs of this progress already. If so, share anything you’ve learned, any negative moods you’ve been able to weaken, or any core beliefs you have identified and started shifting over the last seven lessons.

And I’ll see you tomorrow, as we jump into module three and continue our ascent toward the peaks of well-being!

Key Takeaways

– The thoughts that pop into our minds and the beliefs underlying them are the immediate source of our moods, and by changing those thoughts, we can dramatically alter our moods.

– This process begins with logging our moods, and their associated situations and automatic thoughts.

– We must then question these thoughts by compiling objective evidence for and against those beliefs. We can then identify distortions and formulate an alternative, balanced belief.

– For persistent assumptions, we can put our beliefs to the test through behavioral experiments. When possible, we should design experiments that prove or disprove our assumptions.

– In some cases, thoughts will be reflections of deeper core beliefs, or schemas, and there are a number of methods we can use to identify and replace these beliefs with more positive core beliefs.

The Flourishing Function: Anti-Depression Program

This has been a free sample lesson, of the full 30-lesson Flourishing Function Anti-Depression Program. To learn more about the full program, hit the button below: