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CCSXXX10.1177/1534650120924128Clinical Case StudiesFaber and Lee

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Clinical Case Studies

Cognitive-Behavioral Therapy
2020, Vol. 19(4) 239­–257
© The Author(s) 2020
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for a Refugee Mother With [Link]/journals-permissions
DOI: 10.1177/1534650120924128
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Depression and Anxiety [Link]/home/ccs

Jessie Faber1 and Eunjung Lee1

Abstract
This case study illustrates a short-term cognitive behavioral therapy (CBT) for a refugee single
mother of a 4-year-old son to address depression and anxiety symptoms. Although she has
histories of multiple trauma experiences such as sexual abuse and intimate partner violence,
the client preferred to focus on current difficulties rather than trauma histories. As such,
non-trauma-focused CBT utilizing psychoeducation, skill building, activity monitoring and
scheduling, and cognitive restructuring is implemented over 10 individual sessions. The client’s
progress was measured by the Depression Anxiety Stress Scale (DASS-21), the Quality of
Life Enjoyment and Satisfaction Questionnaire–Short Form (Q-LES-Q-SF), and a full-length
Columbia-Suicide Severity Rating Scale (C-SSRS) at the intake, midpoint, and last session. The
client showed improvement in all measures after the treatment, which corresponded with
the client’s verbal reports during the session. This case illustrates the critical clinical decision-
making points made by the therapist, and recommends the evidence-based practice protocol
that considers empirically supported treatments for the comorbidity of depression and anxiety
with multiple trauma experiences, the client preference, and contextual factors in addressing
complex clinical presentations.

Keywords
cognitive-behavioral therapy, gender-based violence, refugee, depression, and anxiety

1 Theoretical and Research Basis for Treatment

Cognitive behavioral therapy (CBT) is used with significant evidence supporting its effective-
ness in treating co-occurring anxiety and depression for people with trauma experiences (Bisson
et al., 2013; Kayrouz et al., 2018). Aaron Beck, one of the founders of CBT, argued that maladap-
tive cognitions are connected to negative emotions and dysfunctional behaviors (A. T. Beck &
Emery, 1985; A. T. Beck et al., 1979). Cognitive theory asserts it is not the situation itself which
elicits an emotional or behavioral response, but rather the individual’s perception of the situation,
which is connected to the person’s underlying core beliefs. Core beliefs or schemas are deep-
rooted and act as a template for assessing experiences. The individual is often unaware of what
their core beliefs are, and how they are impacting their information processing. Although explor-
ing a client’s cognitive information processing at the automatic thought level (i.e., what pops up

1
University of Toronto, Ontario, Canada

Corresponding Author:
Eunjung Lee, University of Toronto, 246 Bloor Street W, Toronto, Ontario M5S 1V4, Canada.
Email: [Link]@[Link]
240 Clinical Case Studies 19(4)

in one’s head), a therapist identifies any irrational beliefs—which are called cognitive errors. The
therapist treats them as hypotheses rather than facts, and assesses their accuracy and rationale by
using techniques such as thought monitoring and change by cognitive restructuring to reduce the
intensity of negative emotions that result from negative thoughts and cognitive errors (Young
et al., 2003). Although modifying and restructuring cognitive errors by new cognitive learning,
new behavioral approaches such as behavioral modification and activation become a perfect mar-
riage with cognitive therapy, thus completing CBT.
Behavioral activation (BA; Dimidjian et al., 2014) has been incorporated into CBT and
has emerged as one of the leading evidence-based treatments for individuals diagnosed with
depression (Vergara-Lopez & Roberts, 2015) and anxiety (Boswell et al., 2017). BA asserts
that people’s behavioral responses to struggles or hardship may reduce one’s ability to fully
experience positive rewards from the environment, highlights the importance of contingen-
cies between behaviors and environments in which occur, and focuses on these contingen-
cies rather than presenting issues per se during the treatment. In the example of depression,
BA operates under the assumption that chronic depressive symptoms are maintained by
receiving low positive reinforcement and often high negative reinforcement from the envi-
ronment, thus narrowing the client’s repertoire of adaptive behaviors and increasing aversive
conditions such as preoccupation with escape and avoidance (Dimidjian et al., 2014; Hopko
et al., 2003; Jacobson et al., 2001; Martell et al., 2001). Anxiety and depression are often
interrelated, and both diagnoses are often associated with avoidance behaviors of environ-
mental stimuli. BA intervention aims to increase activities which provide positive reinforce-
ment, often associated with the experience of pleasure or mastery; decrease engagement in
activities which maintain or increase risk of depression and anxiety; and problem solve when
there are barriers to positive reinforcement (Boswell et al., 2017; Dimidjian et al., 2014).
To assess positive and negative reinforcement behaviors toward new learning and changes, a
close monitoring of contingencies of target behaviors (i.e., presenting issues) is critical. The
focus is not on the immediate changes of the target behaviors but on their various contingencies.
Once various contingencies around positive and negative reinforcements are detailed by func-
tional analysis (FA), bit by bit the contingencies of the target behaviors are modified or activated
which become cumulated into the change of the target behavior. For example, when a client is
depressed and socially anxious, getting rid of these pathologies at once is not the immediate
focus of BA. Rather, a detailed assessment of the contingencies of these symptoms will identify
pervasive target behaviors (e.g., avoidance as negative reinforcement) and consequently not
engaging in enjoyable behaviors (e.g., spending the time with families). Guiding questions to ask
in selecting target behaviors include the following: What is maintaining the presenting issues?
What is getting in the way of engaging in and enjoying life? What behaviors are good candidates
for maximizing change? (Dimidjian et al., 2014).
CBT has been recommended as the first line of psychological treatment for people with a
history of trauma (American Psychological Association [APA], 2017; Bisson et al., 2013).
Among studies on refugees with a trauma history, CBT was found effective (Hinton et al., 2005;
Kayrouz et al., 2018; Mendes et al., 2008; Neuner et al., 2004; Schulz et al., 2006). Buhmann
et al. (2015) illustrate that CBT was promising for refugee populations with several co-morbid
health issues and low level of functioning. In addition, Kananian et al. (2017) found that CBT
may reduce general psychopathological distress and improve quality of life for refugee popula-
tions. However, they note it is important to also provide support in coping with stressors unique
to refugee populations such as uncertainty of refugee status, stressful housing conditions, relo-
cation, and social isolation. For female survivors with intimate partner violence, CBT is also
found effective (Iverson et al., 2011; Lowell & Renk, 2018). Based on these empirical supports
for CBT as the best treatment for clients with trauma experiences presenting with depression
Faber and Lee 241

and anxiety symptoms, this case study illustrates how the therapist customized various CBT
techniques to be clinically responsive to this idiosyncratic client.

2 Case Introduction
Patient Characteristics
At the time of the treatment, the client was a 29-year-old single woman. She is the primary care-
giver of her 4-year-old son who she lives with. She was self-employed working part-time as a
hair stylist at home; however, her main source of income was social assistance. Her highest level
of education was completing high school. The client was a refugee originally from Saint Vincent
and the Grenadines, a southern Caribbean nation. The client came to Canada in 2006, fleeing a
physically abusive partner. She has no familial support in Canada and limited social supports.

Sociocultural Context
In St. Vincent, women are often extremely vulnerable to gender-based violence as many are eco-
nomically dependent on their partners due to the high rate of unemployment among women
(IWRAW, 2009). Moreover, reports of gender-based violence are often not taken seriously, leav-
ing women susceptible to repeated incidents of violence (UQAM’s International Clinic for the
Defense of Human Rights, 2014). When seeking protection or justice for gender-based violence,
women are faced with various barriers including a lack of institutions which provide specific
services to this population including legal care, psychological support, and health services
(UQAM’s International Clinic for the Defense of Human Rights, 2014).
Gender-based violence is reported around the world including Canada (Ansara & Hindin,
2010; Barrett et al., 2019) and St. Vincent (Yang, 2014). It is pervasive in St. Vincent as the patri-
archal structure of society does not adequately address the issue of gender-based violence. Over
the past 10 years, over 4,490 Vincentians (4% of the current population) have sought asylum in
Canada, the majority being women (Yang, 2014). According to statistics composed by the UN
Office of Drugs and Crime, there were 426 cases of sexual violence (rape and sexual assault) in
St. Vincent in 2011 (Immigration and Refugee Board of Canada [IRBC], 2013). The rate of
sexual violence in St. Vincent in 2011 was 289 cases per 100,000 people. In comparison, the rate
of sexual violence in Canada was 77 cases per 100,000 in 2011 (IRBC, 2013). In March 2019,
the Human Rights Committee confirmed this ongoing and serious concern in St. Vincent about
high levels of violence especially against girls and women, as the state law does not recognize
marital rape, and domestic violence seems to go unpunished and unreported (Centre for Civil and
Political Rights, 2019). Scholars note that women who have experienced violence are often vul-
nerable and subject to mental health struggles such as depression, anxiety, and post-traumatic
stress disorder (PTSD; De La Rue & Ortega, 2019).

3 Presenting Complaints
The client was referred to an outpatient mental health community agency in an urban metro
city by her family doctor to treat symptoms of anxiety and depression. With respect to depres-
sion and anxiety symptoms, the client described having a low mood most of the time and
constant worries over finances, parenting, and social situations which have been persistent
since moving to Canada. Her low mood and decreased energy negatively impacted her daily
functions, including her interactions with her son, as she struggled to support his social activi-
ties. This made her feel more depressed about her parenting skills and self-image as a mother.
In addition, the client also experienced stress around her finances, as she was self-employed,
242 Clinical Case Studies 19(4)

running a home business as a hairstylist. Her family doctor ruled out any physical health
related concerns and made the referral.

4 Client History
The client reported a 13-year history of symptoms of anxiety and depression. She reported that
her mental health issues began when she moved to Canada. She stated that she did not experience
symptoms of anxiety and depression when she was living in St. Vincent. She denied receiving
counseling in the past and denied the current and past use of psychiatric medications. She reported
she has been hospitalized once for psychiatric purposes in 2008 after an attempted suicide using
pills and alcohol. She reported that this attempt was done impulsively and was triggered by trau-
matic experiences from an abusive relationship with an ex-partner, who she was with at the time
in Canada. She reported attempting suicide as a way to escape the relationship.
The client also experienced trauma growing up, as she reported she was sexually abused by
her neighbor when she was 10 years old. She stated that she had never disclosed the abuse to
anyone apart from the therapist upon her initial visit at the clinic and had not fully processed the
trauma. The client also reported having been in multiple physically and emotionally abusive
relationships, one when she was 16 in her home country, which forced her to flee to Canada,
another in 2008 in Canada as noted earlier, and one in her 20s.
The client stated that she had no family support in Canada, as her family remained in St.
Vincent. She stated that she speaks with her parents on the phone but does not share her personal
struggles with them. She reported a close relationship with her aunt, who was like a mother to
her. Although conversing with her aunt over the phone approximately once a week, she reported
difficulties of sharing her mental health struggles with the family as they did not discuss mental
health issues in their culture. With respect to social network in Canada, the client described hav-
ing two friends, with whom she spoke approximately once a month but did not share her mental
health issues.

5 Assessment
At the initial visit, the client appeared her stated age, and was well groomed and dressed appro-
priately for the weather. She maintained good eye contact, and was pleasant and cooperative. She
spoke in a clear and coherent manner. Her speech was of normal rate and tone. Her affect was
depressed, which was congruent with her mood, and was of normal range and reactivity. She
became visibly emotional at times throughout the session, particularly when discussing trauma.
No issues with thought process was observed. There was no observable gait or psychomotor
issues. She exhibited good insight and judgment. She denied experiencing any symptoms of hal-
lucinations, delusions, or mania.
As reported, her chronic low mood and constant worries began in 2006 after moving to Canada
when she was 16 years old. In terms of her depressive symptoms, she reported having low moti-
vation and energy, issues with sleep, as well as difficulty concentrating, socializing, and with-
drawing from contact with family and friends. She reported that she experienced fatigue and will
sometimes stay in bed for long periods of time. She also reported she experiences a sense of
worthlessness and guilt.
In terms of her anxiety symptoms, she reported chronic and constant worries in the follow-
ing areas: feeling nervous talking to people, being highly self-critical, worried how she was
perceived by others, and anxious in group settings. She also reported having racing thoughts,
finding it difficult to relax, and experiencing sleep difficulties, which left her restless with
chronic fatigue. She experienced anxiety related to the application process for permanent resi-
dency status, as she wanted to apply but feared rejection and the implications this would have
Faber and Lee 243

Table 1. DASS-21 Scores and Their Ranges in Interpretation.

Severity Depression Anxiety Stress

Normal 0–4 0–3 0–7
Mild 5–6 4–5 8–9
Moderate 7–10 6–7 10–12
Severe 11–13 8–9 13–16
Extremely severe 14+ 10+ 17+

Source. Adapted from Parkitny and McAuley (2010).

Note. DASS-21 = Depression Anxiety Stress Scale.

for her and her son. The client avoided certain situations to alleviate symptoms of depression
and anxiety in the short term. Her avoidance behaviors included avoiding social situations,
staying in bed for long periods of time, canceling appointments, and neglecting to engage in
activities which she previously found enjoyable. Related physical symptoms of anxiety include
nausea, shortness of breath, and an increased heart rate. However, she denied any worries
about her physical symptoms and fears of having a future attack, and did not see it as an acute
attack, thus ruling out panic disorder.
The client was exposed to various traumatic events throughout her life. She reported she expe-
riences emotional distress when speaking or thinking about her trauma, and often avoids intru-
sive trauma-related thoughts, reminders, and feelings. Some of her symptoms of depression may
also be related to post-trauma stress responses, including her negative affect, exaggerated self-
blame and guilt, decreased interest in activities, isolation and overly negative thoughts, and
assumptions about herself and the world. As the client did not want to talk about any trauma
experiences and related symptoms, a detailed assessment is limited to understand her post-trau-
matic stress responses.
From the client’s self-reports, it was evident to see that these symptoms caused significant
distress and impairment in her everyday life. Based on the presenting symptoms, the therapist
hypothesized a comorbid diagnosis of persistent depressive disorder (PDD) and generalized anx-
iety disorder (GAD). Although, many of her symptoms aligned with social anxiety, the therapist
was mindful that her anxiety symptoms were reported beyond social situations including her
constant worries about being financially challenged, being a bad mother, and being rejected for
her residence. Also, her avoidance behaviors and fears around social interaction are more likely
to be correlated with her experiences of trauma. Adjustment disorder was ruled out as the onset
of her depression and anxiety was in 2006, 13 years ago. When she entered therapy, there was no
specific stressor that occurred in a recent period (i.e., 3 months).
The client was asked to complete three assessment questionnaires in the initial assessment
interview: the Depression Anxiety Stress Scale (DASS-21; Lovibond & Lovibond, 1995), the
Quality of Life Enjoyment and Satisfaction Questionnaire–Short Form (Q-LES-Q-SF; Endicott
et al., 1993; Rucci et al., 2007), and a full-length Columbia-Suicide Severity Rating Scale
(C-SSRS; Posner et al., 2010, 2011). The DASS-21 is a 21-item self-report 4-Likert-type scale
which measures the emotional states of depression, anxiety, and stress. As the sub-categories,
DASS-Depression focuses on self-reports of low mood, motivation, self-esteem, and self-
worth; DASS-Anxiety focuses on physiological arousal, perceived panic, and fear; and DASS-
Stress on tension, irritability, and ability to relax. The DASS-21 scale shows high internal
consistency and validity (Parkitny & McAuley, 2010). Table 1 illustrates how the DASS-21
scores are interpreted.
The Q-LES-Q-SF questionnaire is a 14-item 5-Likert-type scale self-report measure used to
assess the degree of enjoyment and satisfaction experienced by the client in various areas of daily
244 Clinical Case Studies 19(4)

functioning, including satisfaction with physical health, leisure activities, and social relation-
ships (Endicott et al., 1993; Rucci et al., 2007). The scores in Q-LES-Q-SF indicate that the
higher scores on the questionnaire, the greater level of enjoyment and satisfaction. The lowest
possible score is 0%, indicating zero life satisfaction, and the highest score is 100% indicating
high life satisfaction. The Q-LES-Q-SF questionnaire shows high internal consistency and valid-
ity and is among one of the most frequently used outcome measures in psychiatry research
(Stevanovic, 2013). The C-SSRS is a self-report tool used to quantify the severity of one’s sui-
cidal ideation and behavior (Posner et al., 2011). The C-SSRS targets four specific areas of sui-
cide risk: severity of suicidal ideation, intensity, frequency and controllability of suicidal ideation,
suicidal behavior, and the degree of lethality of suicidal behavior.
Upon the client’s initial assessment, her DASS-21 scores were Depression 14, Anxiety 17, and
Stress 18, putting her in the “extremely severe” range for each category. Her Q-LES-Q-SF score
was 32%, indicating low life satisfaction. The C-SSRS score indicates her suicide risk is medium
for lifetime history (her score: 17) and low (her score: 0) for recent ideation, plan, and intent. A
screener version of the C-SSRS was used during subsequent sessions with the client, to which the
client denied any current suicidal ideation and stated that her son was a strong protective factor
for her.

6 Case Conceptualization
From the history taking, it was apparent that the client had experienced various negative adverse
life experiences including experiences of grief, violence, and trauma. The client experienced
sexual abuse as a child, miscarried a baby at age 16, and experienced physical and emotional
abuse from a partner which led her to flee from her own country. At such a young age, she was
uprooted from her family, community, and cultural support and became a refugee in Canada. In
addition, since moving to Canada she experienced two abusive relationships with intimate part-
ner violence, one in her late teens and one in her 20s. She acknowledged these traumas; however,
when gently invited to talk about them, the client declined. Specific diagnostic questions about
PTSD (e.g., how often do you have intrusive thoughts and memories about the trauma experi-
ences?) were diverted by the client. Therefore, the impacts of the client’s trauma history on her
current symptoms and life were not extensively explored. Given her visible emotional distress
while reporting trauma experiences (e.g., crying at times and reporting as a matter-of-fact at other
times), as well as her negative affect and her avoidance of trauma-related thoughts, feelings, and
reminders, it can be hypothesized that she was suffering from some symptoms of post-traumatic
stress. It is not uncommon among trauma survivors to alternate between avoiding and being
flooded with trauma memories and experiences (Herman, 1992). Although she reported that her
symptoms of anxiety and depression only started when she moved to Canada in 2006, it is likely
that the history of trauma and growing up in an unsafe environment might have been related to
her presenting symptoms and avoidant behaviors. Her ongoing struggles of interpersonal rela-
tionships and changes in personality characteristics such as low self-esteem, self-blame, negative
assumptions about herself and the world, decreased interest in activities, and self-isolation also
signaled symptoms of PTSD (Cloitre et al., 2012).
Given her preference of not focusing on past trauma experiences, it appeared to be crucial to
respect her preference and provide present-focused and client-centered approaches. Honoring the
client’s goals and listening to the client’s wishes and stories are critical especially for someone
like this client who has experienced multiple traumas and violence where she lost power and
control over the various situations in her life (Herman, 1992). Alliance, goal consensus, and
empathy were found to be pan-theoretical and trans-pathological factors that enhance treatment
efficacy in psychotherapy (Norcross & Lambert, 2019). For this client with the comorbidities of
depression and anxiety as well as plausible PTSD, it would be important to pay attention to these
Faber and Lee 245

trans-pathological aspects in selecting and delivering treatments. Building alliance, conveying

empathy, and exploring and monitoring the client’s goals were illustrated in detail later in the
treatment process.
Initially, the treatment goals identified by the client consisted of decreasing symptoms of anxi-
ety and depression including low self-esteem and learning how to cope with presenting stress
such as managing her finances and her small business, feeling insecure of her current status in
Canada, and better attending to her son’s needs. While exploring her goals for therapy, several
avoidance behaviors were identified such as isolating herself from friends and family, avoiding
“play dates” for her son, spending long periods of time in bed, procrastinating her goals of devel-
oping her business, and applying for permanent residency status. Also, her negative view of
herself (i.e., I am not a good mother) was apparent. This exploration in the initial sessions helped
both the client and therapist to clearly see how the cognitive filtering and avoidance behaviors
contributed to symptoms of depression and anxiety and interfered with goal achievement.
In addition to empirically supported evidence supporting CBT for people with the comorbid-
ity of PTSD, depression, and anxiety as well as the client preference (i.e., non-trauma focused)
and stated goals, the therapist also considered contextual contingencies in selecting treatments.
The agency where the therapist was working while having served this client used CBT as the
primary treatment approach with a structured CBT training program using a manualized CBT
(Nathan, Rees, Lim, & Smith, 2019; Nathan, Rees, Lim, Smith, & O’Donnell, 2019), and ongo-
ing supervision, optimally supporting the therapist to support the client in need. The services
offered at this agency were short-term, offering 12 sessions as the maximum amount the client
could access at each referral. Also, the client was referred to the therapist within the time limit
where the therapist would complete the training internship in 3 months. These contextual contin-
gencies in the service provision system were added to the rationale of choosing the 12-week
individual CBT.

7 Course of Treatment and Assessment of Progress

Sessions 1 and 2: Engagement, Goal Setting, and Contract
The therapist paid attention to building alliance by closely following the client’s story, conveying
her understanding to the client, validating the client’s experiences, and respecting her goals of
therapy. The client’s goals were explored and set in the initial session and revisited in the second
session. The goal setting led the therapist to provide psychoeducation about CBT as the best-fit
treatment for the client at the moment. During this contract period, the therapist took the time to
invite the client to ask questions and share any concerns about the therapy in general and the
selected CBT approaches in particular. She was open to CBT, noting “this approach could help”
as she struggled with negative thoughts, motivation, and engagement in enjoyable activities.
Psychoeducation on the CBT model was introduced mostly in the first two sessions but incor-
porated across the therapy process to strengthen the client’s new learning and skill building. The
client and therapist discussed how thoughts, emotions, physical responses, and behaviors are all
interconnected. The therapist then applied this concept to situations the client was experiencing,
to enhance her understanding. BA principles were introduced and discussed, including principles
of positive and negative reinforcement, and how avoidant behaviors may have sustained the cli-
ent’s symptoms of depression and anxiety. The importance of activity monitoring and scheduling
enjoyable activities into her everyday life was discussed as the immediate positive reinforcement
and empowerment can result in an improvement in her overall mood (Dimidjian et al., 2014).
Psychoeducation on depression and anxiety including the typical signs and symptoms was
discussed in the first two sessions. The client reported that she found this information to be vali-
dating as she recognized that she was not “crazy” but was impacted by past traumas and currently
246 Clinical Case Studies 19(4)

experiencing symptoms of psychological illnesses such as depression and anxiety. Providing

psychoeducation assisted the client by validating and accepting her struggles and experiences,
which seemed to foster alliance building (Young et al., 2014).
After this initial alliance building, the therapist checked with the client to see if she would be
open to receiving information on how to address stressful moments using relaxation techniques.
With her agreement on this therapy task, the client was introduced to two relaxation techniques
including diaphragm breathing and progressive muscle relaxation and was encouraged to incor-
porate these exercises into her daily routine. In the second session, she reported that she found
deep breathing helpful when she was experiencing physical symptoms of anxiety including
shortness of breath, nausea, and an increased heart rate.
Finally, therapy structure and expectations were discussed and collaboratively agreed upon.
The client agreed to complete homework assignments and understood the importance of practic-
ing the skills in-between sessions to maximize the therapy effects. She was agreeable to meeting
once per week for the first six sessions, and after a mid-term evaluation at the sixth session, the
frequency could be adjusted to potentially meeting biweekly until therapy was completed. The
client was given an “activity schedule” as a homework assignment, where she was asked to track
the activities that she would do throughout her week and rate them from 1 to 10, with 10 being
very enjoyable, and 1 being not enjoyable at all. This assignment provided the therapist with a
better understanding of the client’s day-to-day activities and was used as a baseline measure. This
assignment was successfully completed by the client every week throughout therapy, which sig-
naled her commitment to therapy and change. Over the treatment duration, each week she was
encouraged to incorporate one or two enjoyable activities into her schedule in attempt to increase
positive reinforcement in her environment. Some of the enjoyable activities she incorporated
included watching a movie with her son, exercising, getting her nails done, going for a walk, and
styling her hair.

Session 3: Behavioral Monitoring and Modification

The third session deepened the understanding of common patterns of behaviors that the client
exhibited when experiencing symptoms of anxiety and depression, and how these behaviors
might be contributing to her presenting symptoms. From a behavioral perspective, it was plau-
sible that the client’s history of unsafe and invalidating environments might be related to her
current avoidant behaviors, as she was negatively reinforced for avoiding social interactions as
she avoided feeling devalued and unsafe. This might result in a lack of positive reinforcement in
her environment, as she spent time alone and did not engage in enjoyable activities. To assist the
client in recognizing the connection between her avoidant behaviors and depressive moods, the
therapist assisted the client to identify a target behavior and collaboratively conducted its func-
tional analysis. With the therapist’s prompting questions to explore the target behavior (i.e., What
is maintaining the presenting issues? What is getting in the way of enjoying life? What behaviors
are good candidates for maximizing change?), the client identified isolating herself in a secluded
area as the behavior she wanted to focus on. When asked about a recent time she engaged in this
behavior, the client shared that she canceled an appointment with a customer to avoid social
interaction. The therapist asked what happened after she canceled. The client stated that after
canceling she felt guilty as she knew she was struggling financially, and she feared her clients
would stop booking appointments with her. When she felt guilty, she often went back to bed and
avoided interacting with others and leaving the house. When asked how these actions impacted
her emotions, she was able to identify that she often felt sad, lonely, and isolated.
Next, the client was introduced to graded tasks to address the target behaviors. The client and
therapist brainstormed small steps which might assist her in achieving the goal of reducing her
self-isolating behaviors, particularly canceling work appointments. She reported that she tried to
Faber and Lee 247

schedule three appointments per week but then usually canceled one or two of them. A small step
discussed was to reduce the number of hair appointments made each week to decrease her
chances of burnout and cancelation, thus making both the work commitment and her emotional
reactions more manageable. For example, she set a goal to book one appointment per week,
gradually increasing the amount of appointments when she felt ready. This small step and subse-
quent success could work as antidepressants to the depressive symptoms which might bring more
desirable behavioral changes in the future (Dimidjian et al., 2014).
The client provided another example of an avoidant behavior she hoped to address. As a recent
example, she noted avoiding an invitation for a playdate for her son. Although she was on the
phone with another mother who wanted to set up the playdate, she reported her heart was racing,
and she got anxious about anticipating social interactions with other parents and excused herself
from the play date. After this conversation, she felt more depressed with feelings of being a bad
mother. She felt like she failed her son by not encouraging him to play with friends and engage
in other social activities. Then she stayed in bed for several hours until her son came back from
preschool and could not engage with his friends for the rest of that day. Conducting FA of the
target behaviors then helps the therapist to intervene various contingencies. The therapist and
client brainstormed some graded tasks the client could do to address the avoidant behavior, and
subsequently reduce her low mood and feelings of guilt. Some examples of graded tasks included
the following: Instead of answering the phone and putting herself on the spot when her mood is
low, letting the voicemail pick up the message and check it when she feels less depressed, and
during the phone conversation, checking if it is possible to drop her son off for the play date yet
to address her own anxiety for this time but still allowing her son to have opportunities to play
with other kids. BA scholars note choosing the smallest possible action to achieve the fastest suc-
cess, as even the smallest of steps are progress and act as a starting point to address the patholo-
gies that the client suffers from (Dimidjian et al., 2014; Lee & Toth, 2016).

Sessions 4 and 5: Cognitive Errors and Restructuring

The client continued completing the activity calendar which included one or two enjoyable
activities, monitoring of her avoidance behaviors and implementing the graded tasks. While
working on modifying her target behaviors, the client shared her experience of daily negative
thoughts and struggles to cope with these thoughts. She reported that when she experienced
negative thoughts, she often resorted to isolating with avoidant behavior. With conveying
empathic understanding of her situation (e.g., being a single mother with the young child,
struggling to make ends meet with a limited income, and low social support), the therapist vali-
dated her being stuck in the negative cognitive space. With permission, the therapist intro-
duced the concept of cognitive errors; how repetitive negative experiences in life created
negative thoughts in the client’s mind which were then consolidated into rigid cognitive errors.
The therapist also introduced cognitive restructuring as a way to assist her in challenging these
thoughts and subsequently reduce the associated avoidant behaviors (Young et al., 2014).
Cognitive restructuring included teaching the client how to remind herself where the negative
thought was coming from and assessing the validity of the thought with evidence for or against,
and how to resist and rescript them.
Some common thoughts the client shared in sessions included that she viewed herself as a bad
mother. She often had this thought after engaging in avoidance behaviors, for example, when she
avoided making “play dates” for her son as she did not want to interact with other parents. In
addition, she had this thought when she could not adequately complete tasks that she believed
exemplified a “good mother,” for example, getting her child to school on time every day. She
then felt guilty and resorted to isolating herself to cope, which led to a vicious cycle of depression
as illustrated in Figure 1.
248 Clinical Case Studies 19(4)

Figure 1. Simplified old versus new cycle in CBT.

Source. Figure 1 is adapted from behavioral activation diagram present in [Link]
activation-therapy-treating-depression/.
Note. CBT = cognitive behavioral therapy.

J. S. Beck (1995) indicates that one’s cognitive core beliefs shape one’s understanding of
how they view themselves, the world, and others—that he called the cognitive triad. Using the
downward arrow questioning, the therapist explored her negative thought of herself by asking
“if you are not a good mother, what does that say about you?” The client responded by saying,
“I am not good enough in general.” This view of self was related to the client’s views of the
future, as she believed her experiences would result in total failure. Her view of others/the
world appeared to be not trustworthy, judgemental, and unsafe due to her interpersonal vio-
lence and traumatic experiences.
The therapist introduced a thought record and assisted the client to complete it together in
the fourth session to assess the thought that she was a bad mother. With prompting, she was
able to come up with evidence that did not support this thought. The therapist asked, “Can you
think of times when you felt like you were a good mother?,” “Is this thought true 100% of the
time?,” and “If you had a close friend who was at times struggling to get her child to school on
time, would you call her a bad mother?” The client was able to recognize that this thought was
not always true and that there are many instances where she felt like a good mother, for exam-
ple, when her son cried for her and was comforted, and when she made him food that he
enjoyed as he was a picky eater. She was able to establish alternative thoughts which assisted
in reducing the intensity of her negative self-appraisal and emotions. The client was agreeable
to completing a thought record on her own and brought it to the following sessions along with
the weekly activity logs (i.e., tracking her enjoyable activities and addressing the occurrence
of avoidance behaviors). After the cognitive restructuring exercises, despite her overall nega-
tive views of self, others, and future, her cognitive triad, especially view of self and future at
times remained hopeful, as she reported being motivated to “get better” for her son and was
aware of herself as being important to him.

Session 6: Expanding Cognitive Restructuring From Automatic Thoughts to Core

Beliefs
The sixth session continued to build on the CBT concepts taught in Sessions 4 and 5. The client
was guided to review her completed thought records and try to identify common themes in her
automatic thoughts. A common reoccurring thought the client brought up throughout therapy was
Faber and Lee 249

that she was “not good enough” as the mother, hairstylist, daughter, and friend. This belief was
assessed and reevaluated for cognitive errors collaboratively in the session. The client was asked
to reflect and list as many experiences as she could, which showed that her belief was not com-
pletely true all the time. Her list included, “My son tells me he loves me, and he is comforted by
me. My clients continue to see me for their hair and nails even after I cancelled their previous
appointments.” During the cognitive restructuring exercises, the client was asked to think of an
alternative balanced belief to replace her current one. She stated,

Sometimes I don’t feel good enough, but I know that I am doing my best as a mother, my son needs
me, and I know I provide good hair and nail services because my clients keep coming back and some
only want to see me.

The client was able to recognize evidence that did not support her deeply rooted negative
thoughts and used the evidence against to support and implement a new, balanced belief. The
client reported that she was concerned about how difficult it will be to eliminate this core belief
in her life. The therapist validated this concern and reassured her that replacing negative core
beliefs with more balanced beliefs would take time and practice to become fully integrated into
one’s belief system. The therapist explained that her current core beliefs had been developing
for years and would take more than brief sessions to combat; however, learning the tools and
techniques to challenge these beliefs would provide a good foundation for change. The client
reported feeling hopeful and validated by this information, and she recognized the hope by
verbalizing that it would be possible to change her beliefs and acknowledging that it would be
an ongoing process.

Session 7: Evaluating Progress

After six sessions, a mid-point check-in evaluating therapy progress occurred. The therapist
asked the client her thoughts about her individual progress since beginning therapy. The client
reported that she was enjoying the therapy process and believed that her self-awareness and moti-
vation had improved. She reported that she found the “activity calendars” particularly helpful as
she felt accountable to set activity goals including both enjoyable and mastery activities.
Moreover, she reported that she found the use of graded tasks helpful in following through with
her activity goals each week. She reported that she felt more confident in her work life and shared
that she had new goals related to her home business which included launching a website and sell-
ing merchandise. The client completed the DASS-21 and Q-LES-Q-SF questionnaires to assess
mid-therapy progress. Her scores were as follows: Depression 11, Anxiety 15, and Stress 14 in
DASS-21 and Q-LES-Q-SF: 34%.
Although her scores did not improve significantly after the initial six sessions, there were
signs of improvement in all categories except for the Q-LES-Q-SF score which remained the
same. Up to this point, the client was introduced to new concepts each session. This may explain
the less significant mid-score changes, as the focus thus far was psychoeducation as opposed to
application. Moving forward, the focus was on consolidation of this new learning and applying
the new skills in her everyday life.

Sessions 8 and 9: Consolidating the New Learning Toward Strengthening

Relationships
Although consolidating the new learning in her daily life, the therapist was mindful of the ther-
apy coming to an end. Sessions 8 and 9 were thus focused on how to maintain the learning in her
life as well as revisiting whether the therapy accomplished the client’s therapy goals set in the
250 Clinical Case Studies 19(4)

beginning. The client identified early on in therapy that she isolated herself from her friends and
family, and often neglected her self-employment responsibilities. The client reported that she
wanted to work on following through with plans made with friends, staying in touch with her
relatives, and reducing the amount of work appointments made each week to reduce cancel-
ations. The therapist brainstormed and conducted graded tasks with the client in attempt to break
down the target behaviors into more manageable and realistic activities. Some small steps
included calling her aunt once per week and texting her friends back within 1 day. She also set a
goal to do an enjoyable activity with a friend once per week and decided she would start by meet-
ing for a short period of time (e.g., 15 min), and progressively increase the amount of time.
During these activities, it became apparent that strengthening her personal and work relation-
ships would assist her in achieving her goals.
In addition, it was found that the client needed assertive communication as a way to assist
her in communicating her wants and needs with others. During the graded activity scheduling,
she was concerned about others being upset if she were to set boundaries on the relationships
(e.g., only communicating once a week). The client and therapist discussed what it meant in
her social and cultural groups to communicate frankly and examined some common myths
about assertive communication. The therapist highlighted that it was important to recognize
when she was feeling overwhelmed or required time to herself, and how being able to com-
municate her needs to friends and family in culturally appropriate ways would enhance the
relationship rather than damage it. How to communicate her needs to each friend and family
member was brainstormed and practiced in session. The therapist played the role of a friend
who wanted to get together. Rather than making plans then later canceling and having feelings
of guilt, the client was encouraged to assertively communicate that she could not meet right
now, but perhaps asking for another time when she was feeling better for the get-together.
Through several role-plays in Sessions 8 to 9, the client stated that practicing these commu-
nication skills was helpful, particularly for her business, as she said that she often booked
appointments with clients and then canceled when feeling overwhelmed. She stated that these
skills would assist her in recognizing when she was overwhelmed with appointments and
communicating with her clients that she would have to book them for a later date when she
could manage better.

Session 10: Termination

Initially the therapy was structured as 12 sessions. Because the client canceled twice due to child
care and transportation issues, Session 10 was the last session before the therapist ended her
internship. In this session, the client completed the DASS-21 and Q-LES-Q-SF questionnaires to
assess progress. Her scores were Depression 5, Anxiety 12, and Stress 8 in DASS-21 and Q-LES-
Q-SF: 46%.
As shown in Figure 2, compared with pre-therapy, the client’s scores improved significantly
in every category. Prior to therapy, the client’s DASS-21 scores for depression, anxiety, and stress
all fell into the “extremely severe” category. Her scores after completing therapy place her in the
“mild” category for depression and stress. Although she still remains in the “extremely severe”
category for anxiety, her self-reported anxiety symptoms did decrease from 17 to 12. In addition,
her Q-LES-Q-SF score went up 14%, indicating notable improvement in her perception of her
overall quality of life. The client reported that she felt validated by this observation and was
proud of her progress. She reported that learning about new skills to address depression and anxi-
ety symptoms assisted her in coming to terms with her presenting issues. She was able to clearly
articulate the connection between her depression and anxiety symptoms and her behavior/daily
routine. She reported that using BA skills including activity calendars, goal setting, and graded
tasks equipped her to engage in enjoyable activities and reach her goals which in turn had posi-
Faber and Lee 251

Figure 2. DASS-21 and Q-LES-Q-SF scores: pre, mid, and post therapy comparison.
Note. DASS-21 = Depression Anxiety Stress Scale; Q-LES-Q-SF = Quality of Life Enjoyment and Satisfaction–Short
Form.

tive impacts on her overall mood. The therapist highlighted her achievement and her steady com-
mitment to make this change happen.
Going forward, the therapist invited any concerns and questions about “after” therapy. The
therapist provided psychoeducation on preventing and managing so-to-speak lapses and relapses.
This included understanding and recognizing triggers and signs of relapse. The client and thera-
pist reflected on potential triggers and explored how the client felt and acted when she was expe-
riencing mild/moderate versus severe depression and anxiety. Then the client and therapist
collaboratively planned an early intervention to address triggers and signs of relapses, which
included engaging in self-care and enjoyable activities such as going to get her nails done, using
thought records to address negative thoughts, and using available community resources when
needed such as walk-in counseling.
Finally, the client was invited to engage in goal setting post-therapy. Some goals included the
following: continuing to use the skills and strategies taught in therapy including cognitive restruc-
turing, activity scheduling, relaxation techniques, and graded tasks. The client also set goals
related to her business, such as increasing her appointments to twice a week without canceling
and when comfortable moving to three times a week. She also hoped to set up a company website
and social media page to advance her business. Finally, the client planned to access a local
Women’s Resource Center referred to her by the therapist. The client hoped to use their services
specifically catered to refugee women, to assist her in completing paperwork related to her per-
manent resident application.

8 Complicating Factors
There were various complicating factors present throughout this case. The client was not working
full-time and was financially supported by social assistance and part-time self-employment
which was very precarious. She reported experiencing financial barriers which impacted her
252 Clinical Case Studies 19(4)

ability to engage in activities she enjoyed including shopping, going out with her close friends,
and self-care activities like getting her hair and nails done. Culturally, it was important to the cli-
ent to present herself as “put together” as she did not want others to view her as someone who is
struggling both financially and mentally. When she was unable to engage in activities, she
enjoyed due to financial barriers, this exacerbated her shame and guilt.
She experienced guilt and shame for accessing welfare which may have contributed to her
deeply seeded beliefs that she is not good enough. In addition, the client emphasized throughout
treatment that her family and friends are not aware of the extent of her mental health struggles.
She was adamant that she addresses these struggles herself, as she did not want to be viewed as
a failure or burden to family members. The client believed that her presenting symptoms were a
result of failure and, therefore, she waited many years before attempting therapy. This is common
among the Afro-Caribbean community, as people often access “traditional” health care interven-
tions after unsuccessful attempts at naturalistic approaches or “self-help” methods (Archibald,
2011). Psychoeducation on her presenting symptoms assisted the client in recognizing her mental
health issues were not the result of “failure.” In addition, the therapist tailored the treatment to
respect the client’s cultural principles by ensuring that the client was not suggested to confide in
family or friends, but rather begin by learning strategies to self-manage her symptoms. This
empowered the client as she had a sense of control and choice. It assisted her in remaining posi-
tive throughout therapy and enhanced her commitment to improving her symptoms for herself
and her son. In addition, the therapist worked with the client to find low-cost enjoyable activities
such as going for a walk, going for coffee with a friend, exercising, and going to the library.

9 Access and Barriers to Care

Throughout the therapy process the client’s involvement was inconsistent at times due to barriers
including child-care and transportation. The client experienced accessibility issues as she did not
own a car and needed to take multiple buses to access the service. The client stated that she pre-
ferred to take a taxi to the agency as public transportation was inconsistent, took a long time, and
made her feel anxious and at times unsafe due to large amounts of people confined to a small
area. The client’s financial situation also posed a barrier as taking a taxi to the agency was costly
and she felt like she could not justify spending the money, feeding back to her negative thought
around “I am not good enough to spend the money to take care of myself.”
The client was the primary caregiver of her son and was sometimes unable to find adequate
child care during therapy appointments. The agency did not provide child-care options making it
more difficult for the client to access care. To navigate this barrier, the therapist did follow-up
over the phone with the client when appointments were rescheduled and twice missed. Although
the length of therapy was prolonged due to canceled appointments and rescheduling, the client
was still able to complete 10 sessions and reported a positive overall experience. Since follow-up
was not institutionally embedded in the agency due to a long waitlist, the onus was often on the
client to follow-up. This made it difficult to understand the short- and long-term effects of ther-
apy, and whether the therapy was successful in maintaining gains made in therapy for the client.

10 Treatment Implications of the Case

This case study illustrates some of the potential strengths and limitations of using CBT for refu-
gee women with a history of gender-based violence. The psychoeducation aspect of CBT may be
particularly beneficial as it helps to normalize and validate the client’s experiences. This was
confirmed with the client; she noted that the psychoeducation aspect was helpful in understand-
ing what mental health is, and what treatment can do to help. It helped her understand that she
was not “crazy,” but was experiencing symptoms of psychological struggles such as depression
Faber and Lee 253

and anxiety. This may be helpful when working with a broader population of refugee women, as
mental health may not be discussed or understood culturally, thereby taking the time to educate
and harness understanding is integral in making therapy successful.
CBT may be particularly beneficial for women who have experienced gender-based violence
but do not feel ready to directly address trauma. Within the umbrella of CBT, some are trauma-
focused (Bohus et al., 2013; Courtois & Ford, 2016; Lenz et al., 2017) and others are non-trauma
focused (Krupnick et al., 2008). There is some debate about the effectiveness of trauma-focused
versus non-trauma focused, as some highlight the efficacy of trauma-focused CBT (Bisson et al.,
2013; Lenz et al., 2017), whereas others note it is also beneficial to offer non-trauma-focused
CBT (Erfold et al., 2016; Gillies et al., 2016; Imel et al., 2013). When working with clients who
have experienced trauma, there are often debates around the level of attention a therapist should
give to trauma memory processing and exposure. However, there is typically agreeance on the
significance of establishing safety first by stabilizing and strengthening the clients’ capacities for
current functions and managing daily life (Cloitre et al., 2012; Herman, 1992). In this case study,
the client reported that she did not want to discuss her past trauma but instead wanted to keep
therapy present-focused. With the exception of schema-focused CBT, traditional CBT focuses on
the issues and difficulties that are happening presently in the client’s life as opposed to delving
into root causes of distress or symptoms (Fenn & Byrne, 2013; Young et al., 2014). For clients
who are not prepared or interested in discussing and directly addressing past trauma and its
symptoms, non-trauma-focused CBT may assist in teaching the skills and strategies to cope with
presenting symptoms, while still respecting the client’s wish to abstain from exposing trauma
memories (Erfold et al., 2016; Imel et al., 2013; Lenz et al., 2017).
There may be some potential benefits and challenges that could arise when using CBT with
culturally diverse populations (Zigarelli et al., 2016). Although the client from this case study
was fluent in English, it is likely that other refugee clients may not be. It is important to consider
the use of an interpreter for clients who are not English-speaking, and how this may affect ther-
apy outcomes. Tutani and colleagues (2017) highlight some common concerns among therapists
when working with interpreters which include difficulty in expressing empathy and a lack of
shared understanding. Despite these concerns, there is a growing body of research which sug-
gests that facilitating therapy through interpreters can be as effective as an intervention that does
not require interpretation (Lambert & Alhassoon, 2015; Woodward et al., 2020).
Although the client showed promising progress with respect to her post-therapy DASS-21 and
Q-LES-Q-SF scores, it is important to acknowledge that there are still various complex chronic
issues which were left unresolved. We acknowledge not providing a follow-up as a significant
limitation of the treatment, and it is thus difficult to understand if the therapy was successful post-
therapy in maintaining gains the client made in therapy and how the complexities of trauma may
affect them. This case thus highlights the importance of making therapy accessible to clients in
need after providing short-term therapy interventions.

11 Recommendations to Clinicians and Students

It is not uncommon in the current clinical practice to see clients with chronic, complex, and mul-
tiple psychological stressors which are further complicated with contextual factors (e.g., cross-
border migration and refugee status and a limited service delivery without follow-up). This
complexity makes therapists overwhelmed and at times struggle to make clinical decisions in
selecting therapy tasks. This case is an example that illustrates both the complex case presenta-
tions and several critical clinical decision-making points. Following the evidence-based practice
(EBP) protocols (Regehr et al., 2007), the therapist made three critical clinical decisions. First,
what are the empirically supported evidences for the client with the comorbidity depression and
anxiety and plausible PTSD? Recent systematic reviews and meta-analyses on psychological
254 Clinical Case Studies 19(4)

services across psychopathologies indicate that all treatments across different therapy approaches
are better than waitlist (Bisson et al., 2013; Imel et al., 2013; Lenz et al., 2017). These reviews
shared the effectiveness of CBT for this population. Next, is this approach acceptable and prefer-
able to the client? The client preferred not to focus on past trauma but to address her current
presenting issues. The therapist and client agreed to conduct non-trauma-focused CBT as this
aligned with the client’s preference and also adhered to empirical evidence which indicates that
non-trauma-focused CBT is still beneficial to address depression and anxiety symptoms for cli-
ents who have a history of trauma experiences and plausible PTSD symptoms (APA, 2017).
Finally, is the chosen treatment feasible considering contextual factors? Therapists, their institu-
tions, and working systems (e.g., policies and governing bodies) are all important factors to
consider in therapy. The therapist agency uses CBT as the primary therapy approach and provides
structured training and supervision, thus having prepared the therapist optimally to provide CBT
to the client. The therapist also considered sociocultural contexts of the client (e.g., low socioeco-
nomic status that compromised her service access and access to enjoyable activities, and refugee
status that compromised her social network) into the therapy process and tasks. For example,
when the client could not make it to therapy due to child care and/or transportation issues, the
therapist accommodated by providing a brief check-in with her homework tasks and engaged in
therapy relationship building over the phone. Therefore, we recommend therapists in practice
and in training to consider these clinical decision-making points while utilizing the three compo-
nents of the EBP.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD
Eunjung Lee [Link]

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Author Biographies
Jessie Faber, MSW, RSW, is a graduate of the Factor-Inwentash Faculty of Social Work, Health and
Mental Health specialization, University of Toronto, Canada. Prior to this she completed her BA in political
science and earned her BSW at McMaster University. Her research interests include mental health service
delivery and outcomes, and trauma and mental health issues related to refugee and newcomers, particularly
women.
Eunjung Lee, PhD, MSW, RSW, is an associate professor and endowed chair in Mental Health and Health
at the Factor-Inwentash Faculty of Social Work, University of Toronto in Canada. She is a psychotherapy
process researcher focusing on cross-cultural clinical practice in community mental health. Using critical
theories in language, discourse and power, her research focuses on everyday interactions in clinical practice
and simulation-based learning in social work education, as well as immigration, transnationalism, and poli-
tics of multiculturalism and welfare state.