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Discussed herein is a case review of client Billy Madison, son of the owner and CEO of Madison Hotels through the lens of the theoretical orientation of Cognitive therapy (CT). The client’s presenting symptomology spans multiple domains, including: psychological, behavioral, emotional, academic and relational. Components of CT are discussed herein, including the developer of CT, psychopathologies that CT has shown efficacy in treating, multicultural issues related to client utilizing CT, and CT’s theory of human nature and the therapy process. An additional component that was discussed is CT’s effectiveness in crisis situations, namely suicidality. Provided that CT is well-equipped with various techniques including both psychological and behavioral, only three CT interventions where briefly examined: questioning, thought recording, and behavioral experiments. A psychospiritual analysis was conducted, comparing CT with Christianity. Compatibilities and incompatibilities were outlined for each. A conclusion in treating the client was provided, outlining perceived psychotherapeutic challenges and potential outcomes for the client.

Keywords:  Cognitive Therapy, Psychotherapy, Psychospiritual, Mental Health and Christianity, Psychological, Cognitions, Psychology

Cognitive Therapy Theory: A Case Study Review of Billy Madison

Equipped with both psychological and behavioral techniques, it is not surprising that cognitive therapy (CT) is considered the most researched psychotherapeutic theoretical orientation (Murdock, 2017). CT is relentless when attempting to uncover problematic issues within the individual. Constant cognitive evaluations are foundational in discovering what CT identifies as dysfunctional or distorted cognitions (Murdock, 2017). CT purports that if one’s dysfunctional cognitive set can be restructured, the individual may be able to adapt themselves to achieve a psychologically healthy outcome (Murdock, 2017). Provided that CT’s techniques offer both psychological and behavioral support, both of which the client is struggling with, CT may be effective in treating the client.

Case Conceptualization Using Cognitive Therapy

CT has made considerable contributions to the field of psychotherapy. It is known for being structured in a relatively straightforward manner (Murdock, 2017). As a result of its fundamentally well-structured approach, CT has been one of the most researched therapeutic approaches (Murdock, 2017). Outcome of various studies point to CT being able to treat a variety of psychopathologies (Murdock, 2017). In this regard, CT would appear as an efficacious therapeutic approach for the client.

Developer of Cognitive Therapy

While growing up, Aaron Beck, the developer of CT, contended with his own destructive cognitions relating to his intelligence and academic performance (Murdock, 2017). Beck was stricken at a young age with medical issues that nearly led to his death and caused him to repeat first grade which contributed to the negative cognitions that plagued him (Murdock, 2017). Beck continuously challenged these maladaptive cognitions. There is not much discussion surrounding whether Beck ever removed the negative cognitions, however, evidence suggests that he may have. Murdock (2017) reported that Beck went on to graduate as a top academic student in his high school class. Beck later went onto study psychiatry and was trained as a classical psychoanalyst (Murdock, 2017). In 1960 Beck officially developed the theoretical orientation known today as CT or, in some spheres, Cognitive Behavior Therapy (CBT) (Murdock, 2017).

Human Nature and the Counseling Process

According to CT theory, human nature is founded upon an evolutionary perspective (Murdock, 2017). Beck identified three primary evolutionary goals that relate to human motivation: survival, resource conservation and expansion and procreation (Murdock, 2017). Related to one’s cognitions, Beck identified that the cognitive processes of individuals also went through an evolutionary process that allowed humans to process their ever-changing environments and adapt as necessary (Murdock, 2017).

According to Beck, the Counseling process is structured around three distinct goals: 1.) establishing the therapeutic alliance, 2.) setting goals, and 3.) socializing the client (Murdock, 2017). Related to the therapeutic alliance, Murdock (2017) outlines that CT theory wastes no time in fostering a healthy therapeutic relationship between therapist and client. Within the first session, the therapist should attempt to provide some degree of symptomatic relief to the client (Murdock, 2017).

Apart from the therapeutic alliance, a major facet of CT theory is orienting the client to the counseling process. A part of this process is teaching the client what Beck called the cognitive model while also explaining the structure of future counseling sessions (Murdock, 2017). Teaching the client, the basic constructs of CT theory is a salient facet of CT. As sessions progress, the client is expected to take more control over each session as the therapist moves into a more advisory function (Murdock, 2017). Educating the client has a long-term purpose; Murdock (2017) discusses that once therapy terminates, the hope is for the client to be to become their own pseudo-therapist.

Efficacy Provided Through Research

Among the many therapeutic theoretical orientations, CT is well-supported empirically in being an effective psychotherapy for treating various psychopathologies (Murdock, 2017). As a result of being one of the most well-researched therapeutic approaches, CT has been tested utilizing several diagnostic categories and has shown to be effective in each (Murdock, 2017). CT theory showed better outcomes compared to other treatments and better outcomes than no-treatment groups as well (Murdock, 2017).

It is worth noting that CT and CBT are at times interchangeable and that some research findings on the efficacy of CT are characterized under the therapeutic approach of CBT (Murdock, 2017; Hofman et al., 2012). Outfitted with the foundation of CT, Moghadam et al. (2020) conducted a study that proved CBT efficacious in treating clients with post-traumatic stress disorder (PTSD). Although CT has been empirically proven to be efficacious across multiple psychopathologies, other studies have demonstrated it to be not as efficacious as other psychotherapeutic approaches (Murdock, 2017).

Most Effective Diagnoses with Cognitive Therapy

With roots in exploring depression as outlined by Freud, it is no surprise that CT has been shown to be effective in treating clients with depression (Murdock, 2017). Although it may be true that CT was developed from the pursuit of researching depression, CT does not stop there. The literature reveals that CT is suited to treat several other psychopathologies and issues such as, but not limited to, anxiety, personality disorders, insomnia, schizophrenia, psychotic disorders, somatoform disorders, chronic pain, female hormonal conditions and eating disorders (Murdock, 2017; Hofman et al., 2012). Provided CT’s / CBT’s ability as an efficacious psychotherapy treatment across several psychopathologies, Hofman et al. (2012) discussed how it is surprising that CT / CBT is not first choice of therapeutic treatment for mental disorders in some countries.

Appropriate for the Client

CT is equipped with several psycho-assessment instruments and therapeutic techniques that seem well suited for the client in question. Given that CT is more scientifically oriented, it is encouraged that clients go through a thorough diagnostic evaluation (Murdock, 2017). Components of the diagnostic evaluation include a holistic psychological picture of the individual, identification of any biologically originating syndromes and determination of whether a psychopharmacological approach is warranted or if the individual needs to be hospitalized.

This client’s poor academic achievement, continuous adolescent-like behavior and experience of losing his mother at a young age, point towards the need for the client to be diagnostically evaluated. Additionally, the client is having relationship issues with his father and girlfriend. Provided that CT is equipped with role-playing techniques, these techniques may prove to be useful in assisting the client with working through his chaotic relationship issues.

Ethical Issues that May Arise

Considering the clients reason for entering therapy, ethical issues may occur. The client and his father made an agreement that the client would seek therapy in hopes of one day taking over his father’s company, Madison Hotels. Ethical issues could arise if the father is not invited into the therapeutic alliance but seeks client progress from the therapist. The therapeutic alliance, being a strong component in therapeutic outcomes (Murdock, 2017), should be protected at all costs. Additionally, the idea of the father “suggesting” that the client receive therapy could be worthy of ethical concerns. The client himself initially was not interested in psychotherapy, however, it was only after the father “suggested” getting help did the client seek psychotherapy.

Multicultural Issues

Fundamentally, CT is developed with an individualistic approach which, for this client, is well suited. Provided that the client is a 27-year old Caucasian male, multicultural issues should not be an issue. CT is considered culturally diverse and has proven through research that it is applicable for various cultural backgrounds (Murdock, 2017). Although CT is culturally diverse, CT theory is known to somewhat neglect sociocultural and environmental factors (Murdock, 2017) which, for this client, would be detrimental. The client is surrounded by adults whose behavior is similar to his own, and the fact that the client has been exceedingly financially supported his whole life should be taken into consideration. Exploring sociocultural and environmental factors for this client would be beneficial.

Cognitive Therapy for Crisis Situation

The literature shows support for the utilization of CT in crisis situations, namely, suicide crisis interventions. Studies by Ghahramanlou-Hollow (2018) and Rozek and Bryan (2020) focused on suicide treatment measures for participants with PTSD, recent suicide attempts or history of significant suicidal ideation. In both studies, results indicated that participants achieved positive outcomes such as reduction in suicidal ideation and PTSD symptoms (Ghahramanlou-Hollow, 2018; Rozey, & Bryan, 2020). It is noteworthy that classical CT was not the sole therapeutic orientation utilized in both studies. Provided that CT theory is foundational for various therapeutic approaches (Murdock, 2017; Hofman et al., 2012), CT type interventions paired with other procedures were utilized within each study (Ghahramanlou-Hollow, 2018; Rozey, & Bryan, 2020).


The client is presenting behavior resembling that of an adolescent. The client is a 27-year old male, but is underdeveloped academically, psychologically, and emotionally. The client expresses some desire for help, however, given the client’s previous attempts at therapy, it appears that this reach for help could be fabricated. There was an agreement between the client and the client’s father about seeking treatment. This agreement between the two could be an underlying motivation for the client seeking therapy. The relationship between the client and his father is not a good one. The client expresses a high level of anxiety over attempting to get his life situated to please his father and one day become the CEO of Madison Hotels.


CT therapists waste no time in attempting to help the client. Strategic questions are relied on to identify dysfunctional and distorted cognitions (Murdock, 2017). Based on observations, the client may be psychologically underdeveloped due to dysfunctional and distorted cognitions related to his intelligence and academic performance. Time should be spent attempting to identify dysfunctional and/or distorted cognitions related to the client’s adolescent-like behavior, beliefs about his level of competence in running Madison Hotels, as well as his cognitions related to his mother passing. Identifying distorted / dysfunctional cognitions will allow the client to start the process of restructuring his cognitive set.

Thought Recording

Provided that CT focuses on one’s cognitions, recording those cognitions for later evaluation is critical. Under the direction of the therapist, individuals are to record their cognitions between sessions so an evaluation can be conducted for future sessions (Murdock, 2017). Related to the client in question, given that there are multiple problematic domains, recording all thoughts for all domains may be difficult. However, the client should record his thoughts for later evaluation by the client and the CT therapist. For example, related to this case, the client could record his thoughts related to becoming the CEO of Madison Hotels. These recordings will allow the client and therapist to examine which cognitions would be considered psychologically unhealthy and which cognitions would be psychologically healthy.

Behavioral Experiments

Behavioral experiments focus on one’s manifested actions, however, this technique is only a means to examine and challenge one’s cognitions (Murdock, 2017). First, the client and therapist discuss a belief about a given situation or task. The client is then asked to perform that task and report on what occurred during the situation or task. The therapist and client then evaluate what is reported and discuss any identified dysfunctional beliefs that may have been identified. Related to this case, the client in question can challenge his belief of being a poor academic performer by returning to school and reporting on what occurs.

Spiritual Application

Literature supports that spirituality, religion and psychospiritual components are important domains of human history and are also important for one’s own biopsychosocial development (Sira & Foster, 2020; Hays & Erford, 2018). For this client, however, introducing psychospiritual material could prove problematic. Based on observation research, the client often descends into a psychologically adolescent state when discussions become too serious. If the client was remotely interested in learning about psychospiritual matters, perhaps approaching the situation from an adolescent perspective may be more effective. Additionally, employing the questioning technique to gauge the client’s current psychospiritual position may be efficacious. In this way, the client is sharing what they currently believe as opposed to having the gospel of Jesus preached to them.

Even though the integration of Christianity and psychology has been the center of contentious discussion for decades, the literature supports the idea that psychology and Christianity can complement one another (Andrews et al., 2017; Jones & Butman, 2011). As no two philosophies will ever be identical, conducting a psychospiritual comparison between Christianity and CT will result in finding both compatibilities and incompatibilities. CT is a cognitively focused therapeutic theoretical orientation and therefore may best align with Christianity when compared with other psychotherapeutic orientations. Although the discussion herein will not be able to contain a comprehensive psychospiritual compatibility assessment, what follows are three components of CT that compare to Christianity well: 1.) Continuous cognitive assessments, 2.) the central construct of automatic cognitions, and 3.) dysfunction related to the cognitive set of one’s reality (Murdock, 2017).

Continuous cognitive assessments are foundational to the therapeutic approach of CT. Therapist are continuously assessing the client’s cognitions which is also suggested by the Word of God. Proverbs 4:23 (AMP) states that one should guard their mind and become a steward, diligently analyzing what enters. Secondly, related to automatic cognitions, 1 Peter 5:7 (AMP) warns believers of randomly generated cognitions that may lead to anxiety and worry. The Apostle Peter, in these instances, suggest casting anxious and worrisome cognitions upon Jesus and allowing Him to take care of these troubling cognitions (1 Peter 5:7, AMP).

Lastly, CT theorists consider “dysfunction” as a set of distorted or dysfunctional cognitions that an individual possesses as reality (Murdock, 2017). Murdock (2017) discusses the remedy stating that if one were to reconstruct their dysfunctional cognitive set, the new psychological modification would produce neurophysiological modifications, positively impacting the individual. This idea of modifying one’s dysfunctional cognitive set is discussed by the Apostle Paul in Romans 12:2 (AMP). The Apostle Paul highly recommends that believers should not accept the world’s dysfunctional cognitions, rather they should constantly renew their cognitive set with the Word of the Living God (Romans 12:2, AMP).

Related to incompatibilities, one does not have to look very far to discover where CT and Christianity differ. No two philosophies will be completely congruent, and this holds true while conducting a psychospiritual analysis between CT and Christianity. First, Jones and Butman (2011) discuss that most cognitively based therapeutic theoretical orientations consider human knowledge and wisdom as the source of truth instead of God and His Word. However, in John 14:6 (AMP), Jesus states that He alone is the source of Truth and the only true way of Life. Jones and Butman (2011) provide their own thoughts stating that as God is the creator of life, it would behoove individuals to seek out God’s wisdom and direction for life and meaning rather than seeking meaning and life purpose from failed human knowledge.

Second, CT theorists generally accept that irrationalities are the source of humanity’s fundamental problems (Jones & Butman, 2011). While irrationalities are identified within both Christianity and CT, Christianity holds a different perspective of the fundamental problem of humans. The Apostle Paul, in his letter to the church of Rome, discusses that all of humanity fundamentally shares the same underlying struggles of life: sin (Romans 3:23, AMP).

Lastly, while CT’s perspective of a healthy individual is one of being psychologically well, seeking survival, reproduction, sociability, and acquisition of various resources, the Word of God specifies that there is more to life than what CT proports as healthy. In Mark 8:36 (AMP), Jesus discusses how life is much more than acquiring what the world considers as valuable by asking what it would matter if one were to gain all the world has to offer but in the end forfeits his own soul. Although CT’s incongruencies with Christianity are obvious, one should consider integrating the compatibilities outlined above which may prove to be efficacious to living a Christian lifestyle.


CT is well outfitted with several techniques that deal with the individual from psychological and behavioral perspectives (Murdock, 2017). This client’s symptomology fits within the scope of CT’s psychotherapeutic toolkit. As the client appears to be stuck within the Peter Pan condition (Peterson, 2017), CT may be efficacious in exploring the cognitions that result in his adolescent behavior. Challenges may arise when the client is faced with any serious discussions as he typically devolves into adolescent behavior when confronted with adult-type conversations. If the client can put forth the effort suggested by CT, he could see dramatic psychological, academic, and emotional improvements.


Andrews, B., Watson, P. J., Chen, Z. J., & Morris, R. J. (2017). Postmodernism, positive psychology and post-traumatic growth within a Christian ideological surround. Journal of Positive Psychology12(5), 489–500.

Ghahramanlou-Holloway, M., LaCroix J. M., Perera K. U., Neely, L., Grammer, G., Weaver, J., Novak, L. A., Colborn, V., & Lee-Tauler, S. Y. (2018). Inpatient psychiatric care following a suicide-related hospitalization: A pilot trial of post-admission cognitive therapy in a military medical center. General Hospital Psychiatry, 63, 46-53.

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Jones, S. L., & Butman, R. E. (2011). Modern psychotherapies: A comprehensive Christian appraisal (2nd ed.). Downers Grove, IL

Moghadam, S. A., Kazemi, R., Taklavi, S., & Naeim, M. (2020). Comparing the effectiveness of eye movement desensitization reprocessing and cognitive behavioral therapy in reducing post-traumatic stress disorder. Health Psychology Report, 8(1), 31–37.

Murdock, N. L. (2017). Theories of counseling and psychotherapy: A case approach (custom package) (4th ed.). Upper Saddle Creek, NJ: Pearson.

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Rozek, D. C., & Bryan C. J. (2020). Integrating crisis response planning for suicide prevention into trauma‐focused treatments: A military case example. Clinical Psychology, 76(5), 852-864.

Sira, N., Lamson, A., & Foster, C. L. (2020). Relational and spiritual coping among emerging and young adult cancer survivors. Journal of Holistic Nursing38(1), 52–67.

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