Topic 9: Behavioral Exposure and Case Formulation & Treatment Plan {by 3/25}

[Behavioral Exposure] – Practice an Anxious Patterns Record on yourself. Answer the following: (1) Were you able to get a clearer picture of the relationship between the triggering event, negative automatic thought, and physiological response? (2) What were your anxiety related behaviors (only share what you are comfortable with)? (3) How were these behaviors and the outcome reinforcing your thoughts and physiological response?

[Behavioral Exposure] – Watch PDA-11: Behavioral Techniques – In Vivo Exposure [PDA-10 is helpful, too].  (1) When the client was in the produce section, what was the most helpful technique to reduce her anxiety? (2) When having a panic attack in the aisle, how was it therapeutically beneficial for the client to try and “wait it out” for a few minutes rather than immediately leaving the grocery store? (3) What were some indicators after the in vivo exposure technique that it was effective for the client?

[Case Formulation & Treatment Plan] – For this discussion, share at least two main thoughts: (1) Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)? (2) Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?

Your original post should be posted by 3/25.  Have your two replies posted no later than 3/27.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

67 Comments (+add yours?)

  1. Cassandra Miller
    Mar 19, 2021 @ 07:50:24

    1.
    When I completed the Anxious Patterns Record on myself, I really did feel as though I was able to get a much clearer picture of the relationship between these three variables. The event that triggered me had to do with an interview for a practicum placement that was not able to fulfill the requirements I needed. This may not seem like a very triggering event but I have looked at a lot of places in CT, but due to my need to do a different internship (since I will be moving) it has been very difficult to find one. In addition, this struggle is exacerbated by my full-time job working for children with behavioral disorders which demands a lot of my time and attention. I have been trying to find something that could mold into my work schedule since the school year ends on June 22 and this failed meeting seemed to be the catalyst for all of my pent-up worry and anxiety. The associated negative automatic thoughts that I had surrounding this event were: I will never work this out, I have no extra time, I’m taking on too much, my boss is going to be frustrated with me, and I’m falling apart. All of these thoughts led to me having the following physiological responses: feeling like I had a lump in my throat, a tightened chest, tears welling up in my eyes, feelings of frustration/heightened arousal, and muscle tightening.
    I exhibited a few safety behaviors which were calling my mom and speaking with my close co-worker about the issue. I immediately did this to try and control the feelings of anxiety, but really feel like I just looked to them for immediate support and validation for my busy schedule. Also, I had planned on working on my schoolwork when I got home, but instead procrastinated and got into multiple conversations with my family members. These behaviors initially led to the outcome of me feeling very upset and ranting to my family members in a catastrophizing manner. I also magnified all of the small stressors and combined them all, which not only escalated my feeling of a lack of control, but also heightened my physiological symptoms. However, after doing this rant I was provided short term relief, as I had gotten everything off of my chest and felt as though I could think more logically. Once I began to feel a bit better, I prepared a text message for my boss about the possibility of not being able to continue this full-time position if I cannot secure a practicum that fits into my schedule. This plan to chat the next day after sending the text, also provided short term relief, but it did cause me to avoid more pressing concerns; such as shifting around other areas of my schedule that could provide me with more stress relief. The amount that I have fit into my life, may be too much, so I may need to shift some parts around in the long run. All in all, it did feel better to get things off of my chest, but I also wonder if I am just putting a band aid on a bigger wound?
    2.
    When the client was in the produce section it seemed that the most helpful technique to reduce her anxiety was shutting her eyes and mentally trying to slow down her thoughts and breathing pattern. It also helped that Dr. V reminded her that this feeling will pass since it usually does after 15 minutes or so and reminded her of how far she had come. This seemed to provide some perspective for Lindsay. When she began to have a panic attack in the aisle it was beneficial for her to wait it out because she was at the peak of her symptoms and they had been happening for long enough that she only had about a few more minutes before they would pass. By sticking it out she was able to see that these symptoms were not permanent and that her stress and anxiety actually could decline while participating in the triggering event. This could be observed when her anxiety two minutes prior had been a 9 rating and two minutes after went down to a 7 rating. Some indicators that this in vivo exposure was effective for her was that she made comments such as, “I can’t believe I did that,” and “I feel like I can finally get my life back.” She also rated her current anxiety as a 3, which is very telling, as she had previously suspected that she would have a heart attack or panic attack in the grocery store. This in vivo exposure seemed to motivate her to continue therapy and made her very optimistic about future success.
    3.
    A CBT case formulation is very important for effective therapy as it is vital for purposeful, efficient, and effective treatment planning. It includes a broad list of client factors such as: precipitating and maintain factors, cross sectional views, longitudinal views, a working hypothesis, and a DSM diagnosis. The working hypothesis essentially combines all of these factors and directly influences a client’s treatment goals and interventions. When the therapist has an expanded view of the client, they are better able to identify the most vital and relevant treatment areas that they should focus on. It also allows them to best individualize the client’s treatment so that they have a higher likelihood of being motivated to follow through and exhibit observable change. As the client progresses through therapy the therapist should make changes to this working hypothesis and continuously assess the client to make sure they are still best serving their needs and goals.
    It is necessary to have specific, concrete, and measurable goals whenever possible so that the client is better approaching and recognizing behavioral change. The more specific and clear a goal is the easier it is to follow through on and stick to. In addition, the client can strive for something that is objective instead of trying to follow a generally unclear goal such as to be happier. A more specific, concrete, and measurable version of this goal would be something like: client will participate in 2 social events per week and take at least 20min a day for themselves. This would obviously not apply to every client who shared this goal, because every treatment plan needs to be individualized, but it is a good example of something clear-cut that the client could actually work on. In addition, the goals should build upon each other; the therapist will want to start the client with smaller steps so that they can experience small successes (building stamina) and then slowly move them towards their larger goals. Finally, by assigning goals in this manner, the client is able to notice their own change and feel accomplished through their own observable/measurable improvements, which one cannot do as easily when working towards a subjective goal. The therapist is also able to clearly show the client their own improvements by using these measurements comparatively as therapy goes on.

    Reply

    • Pawel Zawistowski
      Mar 23, 2021 @ 04:34:18

      Cassie,

      Thank you for sharing. I think it is wonderful that you have a support network you can reach out to help you feel better during stressful life situations. It seems like the anxious pattern record really made you think about many contributing factors to your anxiety provoking situations. You also provided a very good and detailed description of some of the physiological responses you experienced. I am curious to know if you found this exercise helpful in understanding your anxiety and if it will help you in future dealings with circumstances that cause intense emotional distress.

      Reply

    • Laura Wheeler
      Apr 15, 2021 @ 22:53:17

      Hi Cassie! I thought your response about the timing of the clients panic symptoms in the grocery store was really interesting, and something I hadn’t thought about while watching the interaction myself. You’re absolutely right, if we focus on the times at which she scored her symptoms, they escalated and reached their peak and were starting to decrease- so we can assume it would have passed soon anyway- though I really hadn’t even considered that. I also appreciate that you identified more specific and thoughtful factors in calmly her during her time in the produce section. I had focused mostly on the fact that she focused on her breathing and tried to calm herself, but I definitely learned to be more careful of the small details in considering all the things you were able to point out. Again, you’re right that even Dr. V offering words of encouragement and her closing her eyes seemed to help!

      Reply

  2. Althea Hermitt- Mcpherson
    Mar 21, 2021 @ 23:09:53

    (1) Were you able to get a clearer picture of the relationship between the triggering event, negative automatic thought, and physiological response?
    The anxious pattern record helps me to break down each part of the situation and helps me to assess the component part instead of just thinking about the situation and the catastrophic end result. Thinking specifically about the triggering events, the automatic thoughts, and the physiological response helped me to not be so focused on the outcome of my initial negative automatic thought. This, therefore, gave me a clearer picture of the relationship between each component and help me to see what I was feeling the way I did.

    (2) What were your anxiety related behaviors (only share what you are comfortable with)?
    My anxiety-related behaviors included heavy breathing, rapid heart palpitation, nervousness (muscle tension, trembling, feeling shaky), positive self-talk, and deep breathing. I also thought about the consequences of avoiding the behavior altogether or taking medication to reduce my distress.

    (3) How were these behaviors and the outcome reinforcing your thoughts and physiological response?
    Heavy breathing, rapid heart palpitation, and nervousness intensified my negative automatic thoughts and prolonged my physiological arousal state. This made me focus on a negative outcome which led me to think about the consequences of avoiding the situation but knowing that I couldn’t avoid the situation I resorted to trying to find coping skills. So I resorted to positive self-talk and deep breathing to help me relax. The anxiety-related behaviors were very powerful in impacting my thoughts and physiological response. When my anxiety-related behaviors were negative intense feelings, I envisioned a negative outcome. However, when my anxiety-related behaviors became more positive this helped to reduce my anxiety and physiological arousal symptoms a bit even though they were not totally gone.

    Watch PDA-11: Behavioral Techniques – In Vivo Exposure.
    (1) When the client was in the produce section, what was the most helpful technique to reduce her anxiety?
    Lindsay was reminded to pause and slow down her thoughts and was also reminded of coping skills that can be helpful in the moment. The most helpful technique that was used when Lindsay was in the produce aisle was DR.V normalizing the fight or flight response and associating the physiological symptoms with Lindsay’s panic disorder. Dr.V also reminded Lindsay to utilize her breathing techniques.

    (2) When having a panic attack in the aisle, how was it therapeutically beneficial for the client to try and “wait it out” for a few minutes rather than immediately leaving the grocery store?
    By waiting it out for a few minutes Lindsay can be reassured that the worst-case scenarios that she has in mind will not happen, this can aid in decatastrophizing the situation by reminding her that even though the symptoms might be uncomfortable she will not have a heart attack. On the other hand, if Lindsay immediately leaves then she will not go through the motions of overcoming the anxious symptoms by experiencing and enduring the distress associated with these physiological arousals and this will continue the cycle of avoidance. There is some truth in the fact that for you to overcome something you will have to go through it.

    (3) What were some indicators after the in vivo exposure technique that it was effective for the client?
    The in vivo exposure technique was very effective because Lindsays’ level of anxiety was reduced significantly after she completed the in vivo exposure task. She started at 7 and went up to 9 while in the store and then had a significant reduction to 3 once she was done with the activity. The exposure worked because it was powerful in helping Lindsay to realize that she might have some anxiety symptoms but they will pass and will not necessarily lead to a panic attack or a heart attack. Lindsay was very excited to have gone through the process and not running out or having a panic attack. She was so excited she started talking about being proud of herself and getting back her life which is very beneficial to her overall mood and believability that she can actually complete the task of grocery shopping.

    [Case Formulation & Treatment Plan] – For this discussion, share at least two main thoughts:
    (1) Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)?
    A CBT case formulation is vital for effective therapy that is individualized and caters to specific presenting concerns unique to the client. The CBT case formulation helps the therapist to understand their client’s difficulties in order to plan and implement effective treatment which is important for symptom reduction. It is also helpful to the therapists and the client to understand the origin, current status, and the maintaining factors that contribute to the clients’ problems. If the client is able to understand their diagnosis in terms of what the issues are, why they developed, and what is maintaining them this will be helpful in motivating the client to work towards their goals. The CBT formulation is essential to the client getting better because it lays out a specific and organized course of action that the client can follow in order to get better.

    (2) Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?
    CBT treatment is deemed to be empirically based therefore it is necessary to have specific, concrete, and measurable treatment goals because it allows both the therapist and client to be able to track the progress of the treatment. Specific, concrete or measurable short term and long term goals are necessary because it helps to keep the client motivated, due to the attainment of small goals that work towards the end goal. Specific, concrete, measurable goals help to eliminate the subjective nature of progress and help both the therapist and client to be on the same page about what constitutes goal attainment or advancement. For example, if a client needs to exercise more what does that really mean, for some people exercising once per week for 20 minutes might be considered exercising more however when the therapist comes up with specific concrete measurable goals such as Althea will exercise 3 times per week for 40 minutes. This is a more concrete description of what exercising more means. Client and therapist can track goal attainment based on the number of days Althea exercised and for how long.

    Reply

    • Pawel Zawistowski
      Mar 23, 2021 @ 04:39:34

      Althea,

      I also agree that Dr. V normalizing the flight or flight response and the physiological arousal that Lindsey was experiencing was a helpful technique demonstrated in this video. The combination of having someone that she can trust helping her process the experience and using coping skills such as taking a moment to pause, slow down, and breathe allowed Lindsey to resist the exposure to panic successfully.

      Reply

    • Beth Martin
      Mar 24, 2021 @ 12:10:50

      Hi Althea,

      I completely agree with you that the biggest sign of the success of in vivo exposure was Lindsay’s smile/demeanour at the end of the trip! It was genuinely lovely to see her so proud of herself, especially after seeing her struggle in the pet aisle. She also seemed completely up for cutting down her safety behaviors when Dr. V suggested that too, which gave me the impression that her elation wasn’t just a post-anxiety rush, but a genuine understanding of what she’d just achieved, and how she can continue to build on it.

      Thanks for sharing!
      Beth

      Reply

    • Tayler Weathers
      Mar 24, 2021 @ 13:12:45

      Hi Althea! I think you’re right that Dr. V reminding Lindsay of the psychoeducation makes a big difference. In panic attacks, the symptoms of “fear of dying” or “fear of losing control” often override the thoughts of “this is a normal response based in my amygdala.” I know when I have had a panic attack, trying to even remember the word amygdala would have been very difficult! So, it makes sense that it helped Lindsay to have that refresher course. I think this really shows the importance of psychoeducation, and also the importance of baby steps for behavioral activation – if Dr. V hadn’t been there, maybe Lindsay wouldn’t have remembered the information she had learned, and she might have panicked more or even left the store, which could have been a major setback. But since she did get that information again, she was able to stay and feel so accomplished, even with a safety behavior – so that she could be empowered for future attempts, like she seemed at the end. I think it’s easy to think of safety behaviors as wholly bad, but they do serve some purpose, and this was a good example of how to use them (and then work towards not needing them)!

      Reply

  3. Pawel Zawistowski
    Mar 23, 2021 @ 04:17:35

    Behavioral Exposure
    1. Yes, I was able to get a clearer picture of the relationship between the triggering event, negative automatic thought, and physiological response by practicing the anxious patterns record on myself. The triggering event for me was similar to last week’s blog post, addressing a group of people and giving them instructions for a task that needs to be completed. I often feel very anxious when I have to speak up and take charge in front of people. By doing this exercise, I feel like I am better at identifying negative automatic thoughts and dismissing them because I recognize that they are counterproductive toward my own adaptive functioning and will only increase my anxiety. However, I do notice that it is not just as easy as dismissing them and not allowing them to bother me. They can be persistent at times and it is not always so easy to just let them go. From my observation, it seems that the negative automatic thoughts that are most persistent are typically the ones I tend to believe hold a level of truth to them. The physiological response I experienced was that I would feel very tense and had an increased heart rate as well as an impact on my motor skills and speech.
    2. An anxiety related behavior I observed is taking a deep breath and also giving myself sometime to relax as a learned coping skill. I also notice that at times I stutter and mispronounce words which I can very easily pronounce when I am not under anxiety.
    3. I believe that these behaviors somewhat support my negative automatic thoughts. However, I also think it is not as bad and or as serious as I make it out to be. Also, some days I feel better than others and am able to successfully relax and functioning more adaptively. I also observe myself getting better being in a leadership role with more experience and get mostly positive feedback from my peers.

    Behavioral Techniques
    1. When Lindsey was in the produce section, the most helpful technique was taking a moment to pause, slow down her thoughts, and use breathing exercises to relax. I also believe it was helpful for Lindsey to process her thoughts and feelings regarding her panic with Dr. V. I think that Dr. V’s presence and expertise made Lindsey feel more comfortable with the situation knowing that she has someone with her that she can trust.
    2. It was beneficial for Lindsey to wait out her panic attack in the aisle because by doing so she was able to increase her exposure. By staying in the aisle and allowing the panic to pass she was able to condition herself to further decreasing feelings of panic. At the time Lindsey’s rating of anxiety peaked at 9, however after the exposure it decreased to just 3. This exposure was therapeutic and helped Lindsey learn that feelings of panic will pass and there is no real danger in being in the aisle at the super market.
    3. The indicators that this in vivo exposure technique was effective for the client is again the decrease in her anxiety rating at the time of exposure and after exposure. Also, Lindsey expressed being relieved and was excited to overcome her fear of panic attacks.

    Case Formulation & Treatment Plan
    1. CBT case formulation is important for effective therapy because it allows the clinician to be organized and apply purposeful treatment plans based on the client’s needs. It also allows to have a clearer understanding of their client and individualize their treatment goals. By building a case, the clinician can keep track of presenting problems, their frequency, its impact on daily life, maintaining factors, the things that work for the client and the things that do not. By building a case we are able to identify things about the client that prevent adaptive functioning such as cognitive distortions, escape/avoidance behaviors, and weaknesses in problem-solving skills. We can also keep records of their progress throughout their time in therapy and make appropriate adjustments when necessary.
    2. It is important to have specific, concrete, and measurable treatment goals whenever possible so that we can track the effectiveness of treatment. If we see that treatment is decreasing symptoms then we know it is effective. If we are able to measure that the treatment was working for a while, but improvement is no longer being made, then we know we have to adjust the treatment so that our clients can keep on making progress. It could also be the case that the treatment is causing further harm to the client, in that case we would have to be able to identify such problems early on and try out a different course of action. Additionally, the treatment plans have to be specific and concrete so that it does not create confusion. It should be clear to the client what is expected of them in order to execute their treatment. For example, if the client is to be exposed to an anxiety provoking trigger, they will have to know how much of that trigger they are to be exposed to, how often, and for how long.

    Reply

    • Althea Hermitt- Mcpherson
      Mar 24, 2021 @ 01:14:32

      Hi Pawel, I agree with you that it is vital to have specific, concrete, and measurable treatment goals whenever possible. Tracking the effectiveness of treatment helps the therapist to see that the therapy is working as well as it helps the client to feel motivated due to symptom remission. Also, I like that you mentioned being able to track treatment that is not working in order to make adjustments. The implementation of specific and concrete treatment plans helps to put everyone on the same page and help to eliminate the subjective nature of progress.

      Reply

    • Cassandra Miller
      Mar 24, 2021 @ 15:48:49

      Hi Pawel,

      Thank you for sharing! It seems as though this exercise was beneficial for you in further identifying the maladaptive associative nature that you have when putting necessary demands on others. I’m glad that this exercise allowed you to physically see the effects that these thoughts were having on your emotions and behaviors, specifically in how they restrict your own adaptive functioning. It seems that you were able to identify the reason behind certain negative automatic thoughts being more intrusive for you than others; they tend feel the most valid and truthful to you. Maybe you can focus on these thoughts the most and connect them to the core belief you identified earlier? By tackling these it may become easier to disengage from them, thus calming your physiological and behavioral responses.

      Reply

  4. Bibi
    Mar 23, 2021 @ 18:35:43

    [Behavioral Exposure]
    I was able to better understand how my thoughts helped trigger the emotions. The more I thought that I would be helpless in the event of a panic attack, the more worried I became about the possibility of the panic attack. I started to get nervous that I was going to have a panic attack and when that happened, I gradually started to get more and more overheated and slowly started to feel sick. It all happened very quickly before I even really realized what was happening. Originally, I thought about escaping the situation. I wanted to get out of there and into fresh air. This would’ve just negatively reinforced the situation. I knew that if I thought about it, that I would be ok. I took some deep breathes and understood that I wasn’t having a panic attack. Even if I was going to, it wouldn’t be the end of the world and I didn’t need to be so scared.

    [Behavioral exposure]
    1. He suggested pausing and working on slowing down the thoughts. I feel like this really helped her understand that she didn’t need to freak out in this moment. He reminded her that just because she’s thinking about having a panic attack doesn’t mean she is necessarily going to have one. She seemed to also really benefit from just taking a few breathes. She said that after taking some deep breathes that her anxiety didn’t feel like it was increasing anymore and even just going down a little bit.
    2. Leaving and escaping the grocery store would’ve provided negative reinforcement. She has done this in the past and it has resulted in continued avoidance of the store. Additionally, the therapist reminded her that it’s been a little bit since she first started feeling the panic symptoms and she was probably peaking in the panic attack. The reminded of the time that it takes for a panic attack to reach its peak allowed her to focus on that. She was able to not leave the store and even felt like she might be able to continue in the store. She was actually able to keep shopping in the end.
    3. Overall, her anxiety is reduced. Before going into the store, her anxiety was a 7, in the store, her anxiety was at a 9 at its peak. After completing the trip, she is feeling at a 3. She seems really proud of herself for having been able to complete the whole shopping trip. She didn’t have to run out of the store and was able to do all of her shopping.

    [Case Formulation and treatment Plan]
    1. The CBT case formulation is “a cognitive behavioral representation of the presenting problems, symptoms, and factors” (Volungis, p. 57). Basically, a case formulation is your road map to understanding everything about why your client came in to see you. Having a clear case formulation can help you plan what to do in treatment, determine how motivated your client is to receive that treatment, and evaluate the progress they are making. It can also tell you about other things that might not be considered to be part of the big picture that are helping to maintain the presenting problem.
    2. Treatment goals are desirable outcomes that your patient hopes to achieve as a result of being in therapy. Having clear goals allows you to see clearly where you want to go and some ways to get there. Each technique you use in therapy should be related to achieving those goals ultimately (even though it might not be clear how, eventually, it should lead to the final goal). Additionally, having clear goals can help you measure client progress throughout therapy. Is your client making active progress toward their goral? Do the goals need to be changed? Having clear goals sets a stage for the therapy process.

    Reply

    • Althea Hermitt- Mcpherson
      Mar 24, 2021 @ 01:31:12

      I agree with you that Dr. V helps Lindsay to slow down her thoughts. He also reminded her about the physiological responses associated with panic disorder. He did so by normalizing the fight or flight response and reminded her to utilize her breathing technique. In the video, I realized how easy it is to forget coping skills in the moment when physiologically aroused. it is also easy for your automatic thoughts to spiral. So the guidance by Dr.V was really helpful for her. It was really nice to see how proud she was about herself at the end of the exposure.

      Reply

    • Brianna Walls
      Mar 24, 2021 @ 21:57:01

      Hi Bibi! I like how you referred to a case formulation as a road map. This idea really gave me a simple and clear picture of what a case formulation is, so thank you.
      Also, thank you for sharing your experience with the anxious pattern record. I’m glad it helped you better understand how your thoughts helped trigger your emotions. Your experience reminds me of Lindsay’s and how you were able to calm yourself down by paying attention to your breathing patterns. Also, I admire that you didn’t flee the situation, you were able to stay in the environment that was making you anxious which is a very big accomplishment so congrats!

      Reply

    • Michelle McClure
      Mar 25, 2021 @ 12:16:19

      Hi Bibi,
      I agree I was also able to better understand how my thoughts were triggering my emotions. I get panic attacks when I come across certain sever triggers and they are horrible. When I am having a sever anxiety attack I don’t just think about escaping the situation, I literally will retreat to my room the first chance I get to have some time to calm down, to process, to take a nap, whatever I need to do to help myself feel better. I feel like I just need to regain my strength to deal with the situation, if its a situation that I have to deal with, if its a situation I just have to let pass the same thing seems to help, just taking some time for me. This might be reinforcing behavior, safety behavior but it works for me and I rarely have anxiety attacks. I hope you have a nice weekend.

      Reply

  5. Lilly Brochu
    Mar 23, 2021 @ 21:44:12

    [Behavioral Exposure] – Anxious Patterns Record

    (1) Were you able to get a clearer picture of the relationship between the triggering event, negative automatic thought, and physiological response?

    For someone who experiences crippling anxiety, these types of exercises really help me. With my own anxiety, it is so easy to get caught up in the never ending negative automatic thoughts that lead to a complete distortion of my reality. It is easy for me to focus on those thoughts rather than my present experience. With activities like the NATR and the Anxious Patterns Record, it helps to pause and slow down my feelings of anxiety, and allows me to have more of a clear picture of how my own feelings are affecting my behaviors. It is interesting to see how everyone may respond differently to their triggering events, negative automatic thoughts, and the body’s physical response, but for me, I was surprised to see how self-sabotaging I can really be sometimes.

    (2) What were your anxiety related behaviors (only share what you are comfortable with)?

    I have noticed that in general, my anxiety related behaviors differ depending on what I am anxious about. I am either extremely focused and constantly having running thoughts about the triggering event or I completely blow it off and keep myself busy with other things to put off my anxious feelings. With this exercise, I focused on how I have been feeling very anxious about my current career path and how it will fit into other life aspirations. In response to feeling anxious and lost about this, I just put off my school responsibilities for the weekend and spent the weekend with my boyfriend as well as one of my closest friends who I can always lean on for support. In a way, I think it was what I needed to recharge and center myself even if it pressures me to get school work done in more of a time crunch.

    (3) How were these behaviors and the outcome reinforcing your thoughts and physiological response?

    Overall, I think putting off my studies and spending time with my closest support systems was beneficial, but only on a surface level. Deep down, I was still struggling and felt guilty that I was not doing work, but for the sake of my mental health, I just needed a break. In the short term, it made me feel better, but once Sunday night came, I was back to having highly anxious thoughts about my week to come and everything I had to complete. I think that when I feel my anxiety getting bad, one of my main safety behaviors is to go to my boyfriend or my close friends for support, reassurance, or direction.

    [Behavioral Exposure] – In Vivo Exposure

    (1) When the client was in the produce section, what was the most helpful technique to reduce her anxiety?

    For Lindsay, it seemed that grounding herself in some deep breathing techniques and shutting her eyes away from her surroundings seemed to really help reduce her anxiety (even if it lowered her anxiety rating by 1 or 2 points). Also, having Dr. V there to give her those reminders and reassurances of what they have discussed through psychoeducation during their sessions seemed to really help her. Towards the end of the video, she had mentioned that having those reminders that she has “never had a heart attack” and that “it is all in her head” seemed to help her focus and to push through the uncomfortable situation.

    (2) When having a panic attack in the aisle, how was it therapeutically beneficial for the client to try and “wait it out” for a few minutes rather than immediately leaving the grocery store?

    It was therapeutically beneficial for Lindsay to try her best at waiting it out rather than immediately leaving the grocery store because she was able to see the outcomes of what would happen if she were to stay in the store longer than planned. She was able to see that nothing bad happened and that she did not have a panic attack even though it felt like she was going to. She was able to see that her panic symptoms eventually subsided and that even though it seemed impossible for her anxiety to go away, it slowly decreased in intensity.

    (3) What were some indicators after the in vivo exposure technique that it was effective for the client?

    Following the in vivo exposure, Lindsay’s facial expressions and excitement in her voice was telling that the experience was effective for her. She was very proud of herself for sticking it out and seemed proud of her ability to stay in the store without having a panic attack. She was happy that she was able to complete it regardless of Dr. V being present. It seemed as if she was in a state of astonishment that she was able to finish the in vivo exposure technique through her comments (e.g., “I can’t believe I did that!”). From this experience and possibly other exposure techniques, I believe that Lindsay will be more motivated and hopeful that she will be able to overcome her panic disorder and/or the need for her husband or Dr. V to be present in public places, like the grocery store.

    [Case Formulation & Treatment Plan]

    (1) Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)?

    A CBT case formulation is important for effective therapy because it is essential before creating a solid treatment plan. The CBT case formulation includes collective information about the client’s presenting problems, associated symptoms, and any contributing factors to their distress from the very beginning of therapy and how it is modified throughout the therapeutic process. Also, due to the collaborative nature of CBT, clients can work alongside the therapists to develop their own conceptualization of their own distress and presenting problems. This can help the client to stay motivated and hopeful for change compared to clients who are not involved in the process. Additionally, the case formulation includes various other components that can be helpful to the therapist in identifying and treating areas of concern or distress, such as a cross-sectional and longitudinal view of the client’s cognitions, emotions, and behaviors. Moreover, a working hypothesis alongside a DSM diagnosis is included within the CBT case formulation as well. These help the therapist to understand the “how” and “why” the client has come to the current distress as well as what strengths and assets they have that can be used to significantly progress therapy and treatment. A DSM diagnosis can be helpful (especially for beginning therapists) to have direction about the treatment options used going forward in the therapeutic relationship.

    (2) Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?

    It is necessary to have specific, concrete, and measurable goals whenever possible so that the client can understand the steps clearly and can see that they are possible to complete. Moreover, the clearer the goals, the easier it is for the client and the therapist to look at any progress made. If the treatment goals are unclear, the client may become overwhelmed and may not be able to follow through or understand what needs to be done to meet their therapy goals. Moreover, it is important to link treatment goals to specific interventions that must be done. This ensures that both parties have a clear picture of how therapy will proceed forward in completing the client’s treatment goals.

    Reply

    • Beth Martin
      Mar 24, 2021 @ 12:06:50

      Hi Lilly,

      Thank you so much for sharing your experience – I’m glad that it was able to help you hone in on behaviors that you weren’t aware of before! Your mention of how your anxiety behaviors differ depending on the trigger really hit home for me, as that’s something I experience too. It makes dealing with anxiety as a “general” concept really difficult, as you have to essentially shift through coping mechanisms to find the right one for this particular expression of symptoms, and that can be extremely hard to do when you’re catastrophizing or feel like you’re overheating etc. It sounds like spending time with your boyfriend and friend gave you a much needed recharge; when you can’t remove the anxiety about school, I think doing what you can to give yourself energy and motivation to push through sounds like a great idea!

      Beth

      Reply

    • Tayler Weathers
      Mar 24, 2021 @ 13:08:46

      Hi Lilly! I completely relate to your thoughts about your career goals and other life aspirations. I also think it’s interesting that you note that taking time off to recharge didn’t feel like it “fixed” the problem – I feel like that is something that so many clients (and practitioners and students and maybe everyone!) experience, because it feels like avoidance. I wonder if the difference between avoidance and “self-care” is that self-care should seek to address thoughts as well as allow time away from them. For example, taking two days off and then having a night where you just contemplate. I find that for myself, being really stressed and taking a break does help my stress, and sometimes it makes me feel recharged and ready to tackle problems; other times, it makes me feel worse because “now I wasted two days” or some other such thought. I wonder if the alleviation of physical symptoms from a recharge day allows more thought or if, like with some relaxation exercises and panic disorder, can become a safety behavior. In any case, I totally understand the struggle, and I’m rooting for you 🙂

      Reply

    • Cailee Norton
      Mar 25, 2021 @ 15:02:05

      Lily,

      I’m really glad that you took the weekend to recharge. I know it’s hard to allow ourselves to stop and take a weekend for ourselves when we have responsibilities, and that can be a source of anxiety in itself (I’m definitely feeling anxious that I’m celebrating birthdays this weekend rather than working on school stuff), but your ability to recognize the utility in giving yourself a break is so important. I’m glad you found this worksheet so helpful. I think you make some excellent points about the importance of the CBT case formulation process and how it’s so important to use this to understand both the how and why rather than running to a diagnosis and standard type treatment plan. Being able to evaluate each unique client and their resources, past, etc., is so important to providing an opportunity for a helpful and achievable treatment plan for motivated clients. Great job!

      Reply

    • Laura Wheeler
      Apr 15, 2021 @ 22:59:07

      Hi Lilly! I appreciate your honesty about the anxiety that you experience, and find it kind of reassuring to see that so many people experience the same difficulties and are also working through them. I also really relate to your experience of trying to take the weekend off and just relax and enjoy the people close to you- I often deal with the same situation and its so frustrating! Sometimes I will think to myself “okay, I am going to spend all of Saturday just hanging out with my son and enjoying the weekend, not worrying about school” but ultimately I worry about school the entire time so it doesnt end up being worth while- and then I feel more stressed that I potentially wasted valuable time! I am glad you seem to have worked through it all during this experience. I have definitely found through these activities that my best bet is to schedule specific time for homework so that I know I have that time set aside and I can enjoy my free time outside of that.

      Reply

  6. Beth Martin
    Mar 24, 2021 @ 12:01:38

    Behavioral Exposure – Part 1
    1) I was definitely able to get a clearer picture of the relationship between my anxiety trigger, the negative automatic thought and how I respond to both. I find it really easy to get caught up in my anxiety, and after I’ve had an anxious event or an anxiety attack, I genuinely struggle to remember what started it, or how I felt. I’m only ever really aware of the resulting symptoms (feeling exhausted, wired up etc.), and I tend to avoid thinking too deeply in case it’ll trigger another period of anxiety. Being able to sit down and work backwards was incredibly helpful to track what actually happened, and having guided questions stopped me from rabbit-holing and getting worked up on the “what if’s” that I tend to do when I catastrophize.

    2) My anxiety-related behaviors are to essentially shut down for a few minutes, whilst also flapping around like a headless chicken. I withdraw from whatever it is I’m doing, and completely start to focus in on the trigger (in this case, an email). I’m not so great at the reducing/preventing, for some reason – I seemed to choose to make it worse this time around. I’m trying to get better at not shutting the world out when I’m extremely anxious, so I definitely engage in what I think is a safety behavior – venting/word-vomiting at my partner. He’s understanding, and tends to let me just get everything out, but he’s also pretty good at rationalizing out how unrealistic my anxieties are (that I’ll never get an internship, so I won’t graduate, and therefore I’m going to be homeless, for some reason). He does the rationalizing for me at the moment, so I’d definitely consider him a safety behavior, as I don’t actually have to go through that thought process myself.

    3) I think my safety behavior in particular is reinforcing my negative thoughts. I sort of shift the responsibility of dealing with my anxiety off on to another person, rather than working through the actual issue that’s causing the negative thoughts in the first place. Being able to get relief and soothing from my anxiety symptoms doesn’t actively encourage me to work on them, and I think I need to start working through things by myself a bit more. It wasn’t something I’d considered beforehand, so this exercise genuinely helped!

    Behavioral Exposure – Part 2
    1) The most helpful technique that seemed to help reduce Lindsay’s anxiety was the grounding/pausing and breathing deeply. It seemed to be something she was great at doing, and it looked like her shoulders un-hunched ever so slightly and her breathing slowed down. Lindsay also stated that she thought it wasn’t getting worse after the first round, and it seemed to decrease after the second time she focused on her breathing, which definitely suggests it worked! I don’t know if it’s a technique or not, but the positive feedback on how she was doing seemed to bolster her too.

    (2) It was more therapeutically beneficial for Lindsay to try to wait out her panic/anxiety symptoms than to immediately leave as it gave her proof that she can endure, and that her breathing exercises can help. While it may not have been immediately and completely successful, removing all of her symptoms, she did spend two or three minutes actively calming down and rationalizing her fear of a heart attack that she can use for future instances in the store when she’s panicking – there’s proof that she can fight her symptoms, and that she can continue shopping, which will hopefully help her fight any negative automatic thoughts that suggest she can’t.

    3) I’d say the biggest indicator that this was effective is that Lindsay got through her shopping experience! She was able to use her coping techniques/mechanisms in the store, such as her breathing and rationalization to actively reduce her symptoms, and to continue to fight her automatic thoughts and carry on shopping. The fact that Lindsay managed to get her shopping done, and felt her anxiety drop when she was done with a huge smile on her face suggests that this in vivo exposure reduces her anxiety about the store.

    Case Formulation & Treatment Plan
    1)CBT case formulation is important for effective therapy in that it gives the clinician a clear, written guide on the client’s presenting problem, how it impacts their day-to-day life, their symptoms, and what factors may be contributed to or reinforcing their distress. It helps clients to get “better” as clinicians have a clear document that they can refer to throughout treatment to make sure they’re targeting the correct behaviors (and perhaps look back at to judge progress informally), how often symptoms occur etc. when it comes to coming up with a treatment plan, and clients can actively contribute to the formulation too. This helps build therapeutic rapport, which is hugely beneficial for treatment, and it allows a client to become more invested as they’re an active partner in their goals, rather than an individual who is having therapy “happen” to them.

    2) It is important to have a specific and measurable treatment goal when possible as it’s crucial to track how successful treatment is. Ideally, clinicians will check in to assess whether their current tactics and therapy is working to help their client, and that’s extremely difficult to do if there isn’t a set goal to measure their current presentation off of. Having a concrete goal means that clinicians can assess how much, or how little, progress is being made, and if they need to switch tactics in order for to achieve better treatment outcomes. Furthermore, it also makes sure that the clinician is targeting one or two specific goals, and does not over-extend themselves into other areas that, while they may cause distress, aren’t the primary causes of concern for the client. Many people have multiple concerns or issues with their mental health, so picking one or two that seem to contribute most to their distress, rather than focusing on all of them, makes treatment more efficient too.

    Reply

    • Cassandra Miller
      Mar 24, 2021 @ 16:01:21

      Hi Beth,

      First, I wanted to say thank you for being so vulnerable because worrying about the thoughts of others is something that I can relate to. I found a connection with my own safety behavior; in that I have a tendency to unload on the others in my life when I am upset instead of using my own self-regulation strategies. This does feel like it helps in the short-term, but then the behavior just continues to happen, which doesn’t solve the original issue. It can also be so difficult not to focus on the “what if’s” or “worst-case scenarios” because it almost creates a barrier for you in case it does happen. However, it does not allow you to move forward and focus on what you can control, so I think the behavior you are working on changing will be so beneficial for you in the long run 🙂

      Reply

    • Michelle McClure
      Mar 25, 2021 @ 12:04:47

      Hi Beth! I also sometimes shut down or in my own words, escape from the world for a few minutes to a few hours until my anxiety goes back down. I find it helpful when I have time to process what I am feeling when at first it is just too overwhelming to do so. I admit there may be some catastrophic thinking or I probably wouldn’t be having the anxiety reaction in the first place. I also found this to be very helpful in identifying how my thoughts and emotions are connected and influence each other. I hope you have a great weekend.

      Reply

    • Cailee Norton
      Mar 25, 2021 @ 14:57:48

      Beth,

      I can completely sympathize with the headless chicken shut down, it’s definitely one of my go to anxiety phases. I think sometimes getting it out can be a safety behavior, however I think that processing it is also necessary. I definitely get in my head and go to catastrophizing things (if I don’t make this thing that no one really asked for, all my friends will hate me and I’ll be friendless forever). Obviously that’s not the case, but in the moment I know how real it feels. For me sometimes just going through the events and trying to think them through rationally is the best way for me to handle my anxieties. I also think you did a great job in conceptualizing the entire experience with the grocery store and Lindsey. Her being able to complete the task is monumental, even if she had anxiety during the event. Great job!

      Reply

    • Christina DeMalia
      Mar 27, 2021 @ 11:53:31

      Hi Beth,

      I think you made a great point about how sometimes even trying to think back on anxiety can be anxiety provoking. If a certain event or thought was bad enough to trigger an anxiety response, it is understandable that people may be hesitant to revisit that event or thought in their mind. I agree that this exercise seems to give more of a guided structure to go through the process step by step. As you mentioned, it lets you work backwards so you can follow what happened, and what event or thought it was that triggered the chain reaction. Just like how we trace thoughts all the way down to core beliefs, we can trace experiences of anxiety back to the cause. This makes it easier to understand the cause and break up the path that leads from it to full blown experiences of anxiety.

      Reply

  7. Tayler Weathers
    Mar 24, 2021 @ 13:04:08

    [Anxious Patterns Record] 1. I don’t know that the record created a more clear picture of the relationship because I’ve been doing this work in therapy, but it did reiterate it. I knew in the moment roughly what was happening but it was still difficult to think about while feeling anxious/panicked. 2. My anxiety related behaviors were mostly fidgeting to center/calm myself, though it was not super effective. 3. I felt very out of control, and so the fidgeting to calm myself (which didn’t work) seemed to reinforce that feeling of being out of control. In addition, my catastrophic thoughts seemed reinforced by my feelings of anxiety and physical discomfort because they felt like they matched – like, “I would feel this way if the negative outcome were occurring right now,” rather than “I feel this way, but that doesn’t mean the negative outcome is happening.”
    [Behavioral Exposure] 1. The most helpful technique it seemed was the diaphragm breathing. Lindsey seemed like it helped her press pause on the panic and focus on the inner experience rather than the outward factors that seem to confirm her inner experience. 2. “Waiting it out” was beneficial because it showed that the panic can and will pass, that it isn’t going to result in an ambulance ride or a hospital visit, and that even if she does panic in the grocery store it’s okay. 3. I think the main indicator that it was effective was Lindsey’s ratings of anxiety. Just after, she said it was reduced to a 6, and then outside the store it was a 3. She seemed lighter and seemed to find some humor and relief in the debrief. She said she was proud, which is awesome – it makes me think that she does feel the hope and possibility after the exposure.
    [Case Formulation & Treatment Plan] 1. Case formulation is important for effective therapy because you can’t treat something you don’t understand. Being thorough and considering all the angles is important for any scientific process, and especially important when one deviation or error can negatively impact the therapeutic relationship. Also, case formulation is important because it helps the therapist and the client consolidate and clarify the info they have to look for cause/effect and important pieces. Without this, it’s tough to evaluate what should be addressed in therapy, or really how to address it. Knowing someone is depressed is a very overarching, general term that doesn’t give any client-specific information. Treating all clients with depression the exact same wouldn’t work; the treatment has to adjust for and accommodate all the client’s specific features and strengths and quirks. Even two clients with the exact same symptoms might have important differences, such as external factors. So understanding the holistic view of the client’s internal and external system is crucial to being able to effect any change in that system. 2. We need specific, concrete, and measurable treatment goals because, without them, there can be a great deal of variation in what the therapist initially thinks they should do or plans to do and what is actually done. In addition, creating a vague goal might lead the therapist or client to be unjustifiably satisfied or unjustifiably dissatisfied at the end of therapy. For example, if the goal is “be happier,” and the client meets a new significant other and is in the honeymoon phase at the end of therapy, they may think they are happier because of treatment when really treatment had no effect. So a goal like “limit negative episodes to once a week” is more measurable to be able to prove/disprove the happiness. Or, if the goals was something like “don’t be sad,” then a client who still has bouts of sadness might be dissatisfied with treatment because they unrealistically expected it to remove all sadness, rather than just limit it or decrease the severity of the bouts of sadness.

    Reply

    • Brianna Walls
      Mar 24, 2021 @ 21:47:29

      Hi Tayler! I completely agree with your first statement, “You can’t treat something you don’t understand.” This is so important! If you as the therapist do not understand your client and their presenting problems how will you ever be able to treat them? I also agree with your comment, “Knowing someone is depressed is a very overarching, general term that doesn’t give any client-specific information.” This is an elaboration on your first statement but it is so true, if you just have the same case formulation for every client that presents depressive symptoms you are not going to be able to treat all of them because a case formulation is NOT one size fits all. The therapist needs to adjust and accommodate each of their clients because they all react and learn in different ways.

      Reply

    • Anne Marie
      Mar 24, 2021 @ 22:20:22

      Hi Tayler, I like how you mentioned the importance of viewing clients individually despite having the same diagnosis. People are not their diagnosis and need to be treated in a holistic approach, as you mentioned. I also liked that you therapist talked about the importance of the client and the therapist working together to clarify the goal. I thought it was smart to recognize the ongoing collaboration that is occurring between the client and therapist to accurately identify a concrete measurable goal and reassess it is needed. Thank you for your comments.

      Reply

  8. Brianna Walls
    Mar 24, 2021 @ 21:32:33

    1. After completing the anxious patterns record I was able to get a clearer picture of the relationship between the triggering event, automatic thought, and physiological response. For instance, while I was completing it I was able to work through my anxiety. I was able to see the bigger picture or the whole picture sort of speak. I was able to see just how the triggering event caused me to have a negative automatic thought which then resulted in a physical response. It was very helpful and overall it just gave me a better understanding of how my anxiety typically works.
    2. My anxiety-related behaviors related to this activity are sweating, clammy hands, and got a little nauseous. At other times I can sometimes feel like I am going to pass out and I get lightheaded. Also, if I am anxious and I am with another person I tend to talk a lot, I ramble. However, in different situations, I will stay completely quiet when I am anxious. I guess it all depends on where I am and/or who I am with.
    3. These behaviors and the outcome reinforced my thoughts and physiological response by making me feel like I wasn’t in control. When I got anxious I couldn’t stop the sweating or the feeling of being nauseous which therefore caused me to believe that I had no control over the situation I was anxious about in the first place. In other words, it becomes a never-ending circle of negative thoughts, physiological responses, and behavioral responses that are not at all helpful to the situation.
    1. When Lindsay was in the produce section it was most helpful for her to slow down her thoughts and breathing. However, it did help that Dr. V was helping her realize that her feelings are normal due to the fight or flight response. In addition, he reminded her of how far she has come in therapy.
    2. When Lindsay was having a panic attack in the aisle it was therapeutically beneficial for her to try and “wait it out” because it gave her the reassurance that the feelings do pass with time and she can calm herself down by slowing her breathing and her thoughts. In addition, Dr. V reminds her that even though she feels like she is having a heart attack, she isn’t, and she has never had one before. This gives her even more reassurance. If Lindsay did choose to leave the store she would have never got that reassurance and she wouldn’t know that she would be able to get through her panic attack without leaving.
    3. Some indicators that showed Lindsay had an effective experience after the in Vivo exposure technique were for one she showed an overall decrease in her anxiety after completing grocery shopping. At first, she rated her anxiety level a 7 but as soon as she finished the exposure technique she rated her anxiety a 3 which shows she had an effective experience. Also, she was able to realize that even though she might start to experience some anxiety symptoms it does not mean that she is going to have a panic attack. In addition, she realized even if she does have a panic attack she is able to conquer those feelings and symptoms and continue to shop. She was overall reassured that even if the worst happened (having a panic attack) she was able to control it. Lastly, at the end of the video, you could see how happy and excited she was that she was able to grocery shop. You can tell she is excited to conquer her anxiety and go back to living her normal happy life.
    1. CBT case formulation is important for effective therapy because it is vital for purposeful, efficient, and effective treatment planning. Each case formulation will be different depending on the person, it’s not one size fits all. A case formulation is cognitive-behavioral conceptualization of the client’s presenting problems, their associated symptoms, and their contributing factors. Because of this, the client’s case formulation will be modified throughout treatment due to new information being gathered and clients will start to make progress/change. In order to have a “good” case formulation, it is important that the therapist allows their client to have some level of input and involvement when developing their case formulation and treatment plan. This can help the client become motivated to change and allow them to stay hopeful throughout therapy. Overall a CBT case formulation will lay out an organized and specific course of action that the therapist and client can follow.
    2. It is necessary to have specific, concrete, and measurable treatment goals when possible because it is important that the therapist AND client are able to see if treatment is effective or not. They need to see if there is change, are they getting better, worse, or if things are staying the same so that the therapist can continue with the same treatment or modify it. In addition, having specific, concrete, and measurable treatment goals it will allow the client to keep up with their treatment and be aware of what is going on and what to expect in their future. In other words, it will give the client motivation and hope to continue with treatment if they have concrete and specific goals that they understand.

    Reply

    • Anne Marie
      Mar 24, 2021 @ 22:14:02

      Hi Brianna, I liked how you recognized that if Lindsay left the store prematurely she not only would have met her goal. It certainly could have inadvertently reinforced her skewed thinking about the threat level at the grocery store, making it that much harder to break the pattern of behavior. Thanks for your comments

      Reply

  9. Anne Marie
    Mar 24, 2021 @ 22:07:36

    By nature I am not an anxious person unless I am faced with a novel situation where the consequences are high. If anything I may underreact to situations that might require a larger response. Therefore, I found this assignment very challenging to do myself, as my life is pretty routine currently. So I decided to have my daughter participate in it. She has a lot of anxiety about arriving late for school. It is to the point that if we leave 30 minutes earlier than we need to, to avoid her anxiety levels rising. If they do she begins yelling, stating that she will not go to school at all, or even cry. We started slowly increasing leaving later. Initially by only 3 minutes and building from that. I also had her rate her anxiety before we left and once we arrived. We still leave early by the end of the week, she was able to leave 15 minutes later than before with little anxiety. She actually prefers it now as she is closer to the entrance and has recognized that she can leave later without negative consequences.

    While in the produce section it appeared to be helpful for the client to be verbally reminded to examine the evidence from her past experiences in a supportive way. It was just as beneficial to practice her breathing techniques that she had previously learned. The client found success by specifically reminding the client that she had never had a heart attack before and that the physiological symptoms were a natural response to anxiety. She was also reminding that she has gotten to the other side of a panic attack before and she can again. This positive encouragement paired with in vivo techniques allowed her to push through her uncomfortable symptomatology. In being able to “wait it out” she was able to have her anxiety levels reduced and obtain her goal of being able to get her shopping done.

    Case formulation is important to clients getting better because it synthesizes complicated information in an organized way so that likely explanations of the presenting issues can result in a hypothesis, which in turn will lead to setting appropriate treatment goals. There is a saying based off of Alice in Wonderland that states “If you don’t know where you are going, any road will get you there.” Lewis Carroll. Meaning if there are not set intentions with specific, concrete, measurable treatment goals, you won’t recognize when you’ve steered away from your initial intention. In having measurable outcomes it reduces the influence of subjective interpretation of the outcomes. It becomes easier to assess if you have met your benchmarks if they are concrete and data driven.

    Reply

    • Maya Lopez
      Mar 25, 2021 @ 11:48:24

      Hey Anne Marie,

      Wow, I think that’s fantastic you involved your daughter and were able to reduce the time she leaves by half! Since you are already mother and daughter you don’t need a therapeutic bond because she already trusts you will do what’s best for her and that is lovely. I agree in the video, the encouragement and evidence showing she has not had a heart attack before strongly contributed to her reduction in anxious feelings. While the deep breathing helped reduce her physiological reaction because it’s one thing for her to believe okay “I’m going to get through this”, but another for her body to come to the same conclusion.

      Reply

  10. Elizabeth Baker
    Mar 24, 2021 @ 22:16:31

    [Behavioral Exposure]
    I was able to easily connect the relationship between the triggering event, negative automatic thought, and physiological response. The triggering event I decided to use for this exercise has been a more common event I have been experiencing, so I think that played a huge role in my quick connection of the three factors above. In response to the triggering event, some of my anxiety-related behaviors were rapid or deep breathing (trying to lift the weight off my chest) and ENDLESS negative automatic thoughts. These behaviors definitely intensified my physical and mental distress since I was just sitting there wallowing in my upset mood and allowing these negative automatic thoughts to continue weighing down my mood. Although I allowed myself (and I say allow because this wallowing behavior was completely voluntary) to stay like this for a few minutes or so, I then tried switching my mood around completely. I literally bounced out of bed and started to shake off my negative emotions and negative thoughts and talk myself into a better mood. I was getting annoyed that I was allowing myself to feel this way and that I was being affected by the event. I instead tried to let the event slide off my back, and prepared respectful comebacks for when I have another negative encounter. Although I was still upset from the encounter, I feel that I increased my confidence a little with responding, instead of backing down, during these negative encounters. So the outcome for me was both negative and positive as I tried to bring myself out of this upset mood.

    [Behavioral Exposure]
    When Lindsey was in the produce section, it seemed that some deep breathing exercises and explaining how she was feeling (before and after the breathing exercise) helped her reduce her anxiety. Being reminded that she was not alone during this experience seemed to help her ease the intensity of her symptoms as well, as she found some comfort in remembering her relaxation techniques and that her therapist was there to support her. When Lindsey agreed to wait out her panic attack instead of immediately leaving the grocery store boosted her self-efficacy and confidence to get through similar experiences. It allowed her to see that she could and DID complete her goal of successfully grocery shopping. It also reminded her that her symptoms will eventually pass, and that she can use her learned skills to cope through the duration of her panic attack. If she had not waited out her panic attack, she would have never realized that she could get through her discomfort and successfully fulfill her goal of grocery shopping. Some indicators of the effectiveness of the in vivo exposure technique are that her anxiety rating, which initially started at a 6 and rose to 9, had dropped to a 3 after she pushed through the experience. She visibly seemed proud of herself as she was smiling and verbally expressing how proud she was that she accomplished her goal. With this experience, she may feel more confident in herself to continue this exposure technique until she is able to go to the grocery store on her own.

    [Case Formulation & Treatment Plan]
    (1) A CBT case formulation is extremely important for effective therapy because it allows therapists to organize and have a general overview of various aspects of the client. Using this information allows clinicians to diagnose the client, and for clinicians and clients to collaboratively organize effective treatment plans. Clinicians can also update their case formulations as they receive new information, and are able to collaboratively modify treatment plans to best provide the most effective treatment to their clients if need be. Being able to look back at the presenting problems also allows clinicians to make connections between events, thoughts, and emotions, and make mental notes of this before they start their session. For example, clinicians are able to prepare themselves before a session by quickly overviewing what the client last spoke about (e.g., the triggering event, thoughts, emotions) and are ready to engage with their client (if the client feels that the triggering event is still something they want to continue working through, of course).
    (2) Having specific, concrete, and measurable treatment goals is extremely important throughout the therapeutic process. Clients may come to therapy with multiple distressing situations that they would like to overcome but not know how to begin. Generalizing their goals of overcoming those situations would not help the client in taking the steps to overcome them, because they do not have specific steps in place to begin with. Clients may know the general goal they want to achieve, having more friends for example, but they need steps to help them get to that goal because just saying “be friendly” will not help nor encourage the client to achieve the goal of having more friends. Working to identify specific goals to support the client towards their end goal allows the client to understand and practice the parts in-between achieving an end goal; for example, a step to having more friends may be to socialize with at least two or three people when they are in a public space (e.g., school, parks, etc.), thus increasing their skills to hold conversations, making this communication process more familiar and potentially less nerve-wracking. It also allows both clients and clinicians to assess any difficulties the client may have with achieving these steps, and work to overcome those difficulties before resuming to work towards their goal.

    Reply

    • Maya Lopez
      Mar 25, 2021 @ 11:59:00

      Hey Liz,

      I understand what you mean when you say “endless” automatic thoughts, hence the name, they are terribly hard to “shut off”! Sometimes I think learning about the cognitive model has made me too self-aware because all I do is hear my negative automatic thoughts loud and clear. I think it’s notable you mentioned you “allowed” yourself to wallow because it seems like that is the first step with clients is to show them, “okay you HAVE the voluntary power to stop, change, or address these thoughts” and it shows you understand that. I also like you mentioned you shook your body to get rid of the thoughts, I think it’s great for 2 reasons, 1. You had increased arousal and that energy needed to be put somewhere so you used it as you shook your body which would increase physiological arousal anyways. 2. By doing something by standing up and giving your body a new sensation from laying down you may have forced your mind to focus more on that and less on the automatic thoughts themselves. Overall it is great you made an effort as you said to pull yourself out of a bad mood and didn’t let it completely consume you.

      Reply

  11. Yen Pham
    Mar 25, 2021 @ 07:05:36

    Behavioral Exposure

    The assessment of anxious and fearful patterns was useful for me because it helped me to get a clearer picture of the relationship between the triggering event, negative automatic thought, and physiological response. I understand that triggering events identify any events or related factors that may have initiated the anxious/fearful experience. Associated automatic thoughts often, there are patterns of thoughts that occur right before the anxious event. There can also be thoughts during and after the anxious event/physiological response. There is common cognitive distortions such as catastrophizing, magnification (of risk), minimization (of own skills to cope). There may also be underlying core beliefs if significant past experiences. For physiological responses, although they can be associated with any event or thought, the nature and intensity is generally most relevant when focused around anxious experiences. For this assessment the focus is mainly on rating the intensity of the anxiety (i.e., 0-10) and identifying specific body sensations. Physiological response information will be useful in implementing relaxation strategies (e.g., diaphragm breathing or progressive muscle relaxation) and identifying anxiety-related cues. My anxiety-related behaviors were heart palpitations, trembling hands, and deep breathing. I felt heart palpitations in your throat or neck as well as my chest. These behaviors and the outcome were reinforcing my thoughts and physiological response in some ways. I thought, I wouldn’t give a good presentation, although I was well prepared. At that time, it was difficult for me to focus on what I was presenting. Deep breathing is a technique that I used when I got nervous and anxious. It was very helpful and helped me regain confidence to complete my presentation.

    Behavioral Exposure

    1.When Lindsey was in the produce section, the most helpful technique was taking the time to pause a little bit. If Lindsey can, just take some time to slow down her thoughts and breathing a little bit on her own. Diaphragm breathing is the best technique, we can use for Lindsey. The diaphragm is a large muscle located between the chest and the abdomen. Breathing through the diaphragm, or stomach, regulates breathing by being slower and deeper .Diaphragm breathing helps clients cope with thoughts of fear/anxiety in the moment, resulting in more stable breathing and less distress. Ultimately, the primary goal here is to increase self-awareness of voluntary control over breathing and associated thoughts and emotions.

    2. When I have panic in the aisle, I think it would be better for Lindsey if she doesn’t leave the grocery and continue there. She can stop and continue using the diaphragmatic breathing relaxation method. This non-departure gives Lindsey a chance to get more out of the crowd and is also a good opportunity to challenge her negative core beliefs such as “I will get panic attack if I am going to the grocery.” If Lindsey can do so, she may gain a new core belief such as “I can go to the grocery without panic attack.”

    3. The in vivo exposure technique was effective for Lindsey because it reduces Lindsey’s anxiety at the time to exposure and after exposure. She is cheerful and excited and exclaimed “I just can’t believe I did it. I do feel pretty proud of myself right now.”

    Case Formulation & Treatment Plan

    1. A CBT case formulation is important for effective therapy because it is helpful to the cognitive behavioral therapists use individually tailored formulations as a framework with which to understand their patients’ difficulties and to plan effective treatment. A case formulation helps therapists and patients to understand the origin, current status, and maintenance of a problem. A case formulation can be useful when: A client has several disorders or problems. No treatment manual exists for a particular disorder or problem. A client has numerous treatment providers. Problems arise that are not addressed in a manual- no adherence or therapeutic relationship ruptures.

    2. It is important to have specific, concrete, and measurable treatment goals whenever possible because these factors will help therapists can track the effectiveness of treatment. The therapists will know which method is most useful to clients, and if so, will apply and develop it. Besides, it also helps the therapist to know which treatments are not suitable and ineffective for clients. Creating a new treatment plan is necessary, because treatment plan addresses problems identified in the client assessment process. Additionally, treatment plan also offers a measurable indication of the client’s progress in treatment.

    Reply

  12. Maya Lopez
    Mar 25, 2021 @ 11:35:32

    [Behavioral Exposure]

    (1) Were you able to get a clearer picture of the relationship between the triggering event, negative automatic thought, and physiological response?
    I had already felt the relationship between the triggering event to the negative thoughts and arousal because I have become very self-aware but nonetheless the automatic thoughts kept coming. The record did help me realize my coping strategies though, adaptive and maladaptive ones.

    2) What were your anxiety-related behaviors (only share what you are comfortable with)?
    My only behavior was to walk into another room from where the triggering event happened and begin a new assignment.

    3) How were these behaviors and the outcome reinforcing your thoughts and physiological response?
    I do believe standing up and walking around even if to another room helped my physiological response balance out and the behavior reinforced the avoidance of me not wanting to think about the negative thoughts or challenge them.

    [Behavioral Exposure]

    (1) When the client was in the produce section, what was the most helpful technique to reduce her anxiety?
    The most helpful technique for the client was to do some deep breathing exercises and remind herself that she has not had a heart attack in the past.

    2) When having a panic attack in the aisle, how was it therapeutically beneficial for the client to try and “wait it out” for a few minutes rather than immediately leaving the grocery store?
    It is better for the client to see they will not die and can get through their fear by “waiting it out” in the isle even though it is very hard. It also will not allow the client to “be right” haha or in others, words cannot reinforce the fear of being in a grocery store and that they cannot handle it. I think she did a great job just holding on a bit longer to practice more coping skills and heavy breathing and found that she was actually starting to calm down and was able to get through it.

    (3) What were some indicators after the in vivo exposure technique that it was effective for the client?
    Some indicators that the exposure was effective were that the client rated her anxiety even lower than she did when she was in the parking lot before, some of that could be from the anticipation she was feeling but still, the fact that she had come out of the store at a 3 and felt happy and accomplished is a good sign. She also was no longer breathing heavy, shaking, or looking scared showing she had decreased her physical arousal.

    [Case Formulation & Treatment Plan]

    (1) Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)?
    A CBT case formulation is important for effective therapy so that clinicians can stay organized and will see their initial treatment thoughts/ hypothesis and view how they change. It is important they have a plan that encompasses the client’s history and formulate how their disorder occurs in terms of the cognitive model, with this understanding we avoid fruit loop therapists who make things up as they come and don’t know what they will want to work on next. The effective therapist will communicate to the client, “this is what I think is going on, this is how I want to proceed with thesis goals in mind” and can collaboratively work with the client to see if their presumptions are correct. By working together and setting goals together it can help the client stay motivated and see there is a clear plan for treatment.

    (2) Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?
    It is necessary to have concrete and measurable treatment goals so that improvements aren’t subjective. Clients and therapists should have real data/ evidence their interventions are working and clients are improving without this, therapists would have to rely on assuming the client seems better which is obviously not proper. In the example we watched, Dr. V asked his client many times to rate her anxiety, without this data he would not truly know how anxious she is feeling or if she is feeling better or worse.

    Reply

  13. Michelle McClure
    Mar 25, 2021 @ 11:57:49

    Behavioral Exposure
    1. I was able to better understand how my automatic thoughts were triggering my emotions and how my thoughts either intensified or could also lessen the extent of the emotions. When my anxiety is triggered it is usually because of something triggering my fear of loss. I get very anxious when I think I am losing someone important to me even when that is not the case and it just feels like I am. 2. I have worked very hard at controlling my anxious feelings and sometimes I do really well and other times I experience a big enough triggering event and then my anxiety becomes almost unbearable and not easy at all to control. When my anxiety is that bad I feel like I can barely function, I can’t eat, and my chest hurts. I feel like it’s the end of the world and if at all possible I retreat from the world and just lay down till I feel better. A cup of tea and a nap sometimes really helps. Thankfully my anxiety is rarely so severe. Most of the time it’s a much smaller triggering event and I can notice the anxiety start and talk myself out of it or breath or write until the anxiety is gone. 3. I think maybe taking time away from everyone and everything making me anxious or not is reinforcing just because it is nice to have some time alone. I think even if it is just a couple hours having that time alone to nap or watch a movie is like helping me to be able to process whatever is feeling so overwhelming. I like to think that when I am ready to face the world again I am more capable because I took some time for myself first.

    Behavioral Exposure

    1. Lindsey seemed to ground herself in the food store by taking deep breaths and shutting her eyes. Lindsey said things to suggest that she found the breathing especially helpful and also the encouragement and reminders from Dr. V.
    2. 2. It was more beneficial for Lindsey to endure her anxiety and remain in the store while she did techniques to lessen her anxiety because then she could see that her anxiety would lessen. By doing this Lindsey would prove to herself that she can endure the discomfort of the anxiety and that it would lessen and be easier to endure over time.
    3. I think the biggest indicator that this was effective is that Lindsey was able to rate her anxiety level after the experience a 3 and she was smiling and she was expressing that she was proud of herself.

    Case Formulation and Treatment Plan
    1.A case formulation is important for effective therapy in that it gives the clinician a “gold thread” that links and includes important information about the client’s current situation, the biological, social, environmental, and psychological historical information that has an impact on the current situation (s). When a clinician has a good case formulation they can use that to create a solid treatment plan that meets the client’s needs and addresses the issues that the client wants to resolve.
    2. It is important for treatment goals to be specific, concrete and measurable, or in another acronym, treatment goals should be S. M. A. R. T. Smart treatment goals are specific, measurable, attainable, relevant, and time based. A treatment plan with SMART goals is a treatment plan that the client and the clinician can work through together with clear direction and purpose. The clinician can tell based on how well the client is meeting the goals on the treatment plan how effective their treatment plan actually is and can modify it as needed to meet the client’s needs and to make the treatment more effective.

    Reply

    • Elizabeth Baker
      Mar 26, 2021 @ 03:04:22

      Hello Michelle,
      Wow, it is good to hear that you have identified your triggers, it sounds like it can be an extremely debilitating experience for you. I agree that taking time to tend to yourself would not necessarily be a safety behavior, as long as you are not avoiding the situations/persons that triggered your anxiety. You are definitely not alone with taking breaks to recharge and refocus after an event that may drain your energy or increase your symptomology. Overall, it sounds like you have some great coping skills to help you during and after those distressing moments, it is great that you have identified what helps you not only decrease your anxiety but process what triggered your anxiety symptoms. Thank you for sharing your experience!

      Reply

  14. Christina DeMalia
    Mar 25, 2021 @ 12:52:25

    [Behavioral Exposure] (1)
    For my anxious patterns record, I didn’t have any real moments of anxiety this week, but did want to personalize the exercise. As someone who previously had sever PTSD (but now no longer qualifies for a diagnosis!!) I have several vivid memories of times when I experienced anxiety and physiological arousal and used safety behaviors in response. So even though it was not very recent, I looked back at a clear memory of when I had experienced a triggering event. This exercise helped me to see how the thoughts I had in that moment led to my response. I believed I was about to have a panic attack in front of a whole classroom of people, and that I would make a fool of myself. Because I was so scared about the panic attack happening, I wound up increasing anxiety even more, worsening all of the physiological symptoms. Ultimately, they were so intense that I engaged in my safety behavior to try to avoid having a panic attack in front of people.
    (2)
    When I would experience that level of anxiety, I would use some techniques such as imagining a scene where I felt safe, down to the sights, sounds, and smells. I also would use a water bottle that I would tip back and forth to calm down. However, neither of those really made any difference in this case, so instead I used my common safety behavior of fleeing to the nearest bathroom stall to escape the situation and hide from any other people.
    (3)
    The act of getting up and rushing out the classroom ended up increasing my heart rate and feelings of anxiety to the point that I did have a panic attack. So in a way, I created a self-fulfilling prophecy in which I was so scared about having a panic attack and experiencing flashbacks that I did end up having one. This made it so I missed the majority of the class and felt paranoid that people had noticed and were judging me. It reinforced that idea in my head that if I am triggered at all, I will end up having a panic attack and feeling embarrassed about it.

    [Behavioral Exposure] – Watch PDA-11: Behavioral Techniques (1)
    It seemed helpful for Lindsay to take a break to check in about how she was feeling, slow down her thoughts, and use breathing exercises to try to calm down some of her physiological arousal.
    (2)
    If Lindsay had left the store immediately, she would have reinforced her believes that if she stays in the grocery store, she will have a panic attack, and that the only way to avoid it is by fleeing. It was important that Lindsay know she can leave at any time. However, it was also important that she took a few minutes to calm down and wait it out so that she could at least give the exercise a chance. In the end she was able to complete the whole task, so it was beneficial that she didn’t immediately give up. Instead she proved to herself that she could shop in the grocery store without having a panic attack or heart attack. She also got to experience the feelings of accomplishment for following through with the exposure activity.
    (3)
    One clear indicator of the success of the exposure was that Lindsay had a lower anxiety level than before she went into the store and while she was in the store. This showed her that although her anxiety might be released when she flees from a situation, it can also be reduced once getting through the task. She seemed proud of her accomplishment and happy that she was able to get through it. This experience offered Lindsay valuable evidence against her previous safety behaviors.

    [Case Formulation & Treatment Plan] –(1)
    The CBT case formulation is important to the effectiveness of therapy because it creates a type of guide/map for the therapeutic process. It lays out where the client has previously been (development, life, medical, and mental health history, and precipitating factors), where they are now (presenting concerns, relationships, current presentation, strengths and assets, sociocultural factors, and symptoms), and where they was to be going next (motivation for change, working hypothesis). This lays out the ground work for the CBT treatment plan, and helps to establish a more complete picture of who the client is and what their needs are. By laying this ground work, the case formulation acts as a sturdy foundation for the treatment plan to be built upon, and leads to more effective therapy.
    (2)
    It is important for goals to be specific, concrete, and measurable because these aspects contribute to the ability to be able to track the client’s progress over time. Frequent assessment of a client’s progress plays a large role in how effective the treatment will be. By creating these types of goals, they can be used to see if the client is making progress towards them, how much progress is being made, and when a goal has been met. It is also useful to demonstrate in managed care that progress is being made, so these specific measurable goals help to meet that need as well.

    Reply

    • Abby Robinson
      Mar 29, 2021 @ 13:08:58

      Hi Christina!
      I liked how you explain the importance of case formulation as a road map to successful goals and treatment. I think this is important because even though the progress is important in treatment, it is also just as important to get the history part as well. This map allows for a complete, in depth understanding of the client while building a relationship to create a proper treatment plan with goals that will hopefully set them up successfully.
      See you in class 🙂

      Reply

  15. Carly Moris
    Mar 25, 2021 @ 14:14:41

    1) I feel like I already had an idea about the relationship between the triggering event, negative automatic thought, and my physiological response. Though I think this was because of the other techniques we have used this semester. Most of my anxiety has been related to school and finding an internship position. Ive noticed that as the semester goes on my level of anxiety has been gradually increasing. Even though I can recognize the relationship between the event, thoughts, and arousal I have still been feeling anxious about school, and being able to complete assignments correctly and on time. This past week I ended up getting fairly upset when my iPad stopped working while I was in the middle of an assignment. I felt myself getting more and more frustrated as I couldn’t get it to work. I was worried that I would need to take it in to get fixed and what that would cost, and how I would be able to complete my work if that was the case. I realized that the more I tried to figure out what was wrong then the more frustrated I got and the less likely I was to figure out a solution.

    2) I noticed that the more frustrated I got the more I started to swear at my iPad, and honestly the more I felt like I was going to cry. A lot of times when I get very frustrated or anxious I feel like im going to start crying, which tends to make me feel more frustrated and it doesn’t help the situation. Ive learned that stepping back for a second and taking a few deep breaths tends to help me calm down. Though in this situation it didn’t really work and I still felt very anxious. I realized that me trying to fix the problem in that moment wasn’t going to be productive so I ended up walking away from it for a bit. I think would be considered a safety behavior because I removed myself from the situation that made me anxious, and this didn’t lead to a resolution of the thing that made me anxious. I ended up deciding to take a shower to help relax and to help try to let go of the tension that I was feeling. While I was in the shower I did some breathing exercises until I felt my anxiety and tension go away. Then I went back and used my phone to look up ways to fix the problem, and I managed to have it fixed within about 15 minutes.
    3)
    I don’t think that the behavior reinforced the negative automatic thoughts I was having about school. But I think it reinforced the idea that when I get frustrated to that extent I need to walk away from the situation for awhile in order to deal with it. That in order for me to reduce my physiological arousal I needed to leave the situation. Instead of calming down and working on a more realistic solution in that moment. I could have searched for ways to fix it before I walked away and took a shower, because it ended up taking me less then 15 minutes once I did.

    [Behavioral Exposure]

    1. The technique that was most helpful for Lindsey to reduce her anxiety were breathing techniques. As they were in the produce aisle Lindsey began to feel more anxious, but Dr. V reminded her to take a second to breath and try and slow down her thoughts. They ended up growing through a few rounds of breathing here until Lindsey felt comfortable moving on. After doing this breathing technique she went from saying that her anxiety was at an 8 to a 7.
    2.
    It was therapeutically beneficial to have Lindsey wait it it out for a few minutes in the grocery store because it helped to break her cycle of a avoidant behaviors. Before, leaving the situation would negatively reinforce the avoidant behavior by removing her from the situation that is causing anxiety. This time Dr. V was there to remind her that what she was feeling was part of the bodies fight or flight response and that it would normally peak after 15 minutes. When she mentioned that she was afraid of having a heart attack, he reminded her that she had not had one before. By staying in the situation she was able to see that she was not going to have a heart attack. By staying in the situation she was also able to engage in some breathing techniques that helped her to reduce her anxiety. In the end she was able to reduce her anxiety from an 8 to a 7/6. While she still said she felt anxious and would rather not be in the situation she no longer felt that she had to leave in that moment. This was very beneficial because it helped to break her avoidance cycle and helped her to realize that she would not have a heart attack if she stayed in the store while feeling like this.
    3.
    I think one of the indicators that the in vivo exposure was beneficial for Lindsey was the fact that at the end of the exposure when she was in the parking lot talking with Dr. V, she said that she cant believe she did that and how it was something she never thought she would have been able to do. She was clearly very proud of herself and happy that she was able to make it through the store. Even though she was very nervous about it and had doubts that it would go well, she was glad that she did it in the end. Especially considering the fact that her anxiety was an eight before going into the store and it was a three when they finished.

    [Case Formulation & Treatment Plan]

    1.
    CBT case formulation is important for effective therapy because it helps us understand the clients presenting problem and what other factors may be contributing to or influencing it. This understanding of the clients presenting problem and the factors effecting it are needed for effective treatment planning. You can not plan effective treatments and interventions if you do not have a thorough understanding of the client and their presenting problem. CBT case formulation helps us understand a clients presenting problem, their symptoms, and other factors that may be contributing to it. A case formulation helps to lay out all of the relevant information you have gathered about your client from previous sessions and assessments. One of the most important parts of your CBT case formulation is your working hypothesis. The working hypothesis is an overall summary of your CBT case formulation and is meant to be continually tested and modified throughout the course of treatment so that it is an accurate representation of the client and their presenting problem so that it can be used to make an accurate treatment plan.
    2.
    It is necessary to have specific, measurable, and concrete treatment goals whenever possible. Specific and measure able goals are important for both the client and the counselor. If the goals are not specific and measurable then it would be hard to tell if the client is making progress. This is why it is important to break larger goals up into smaller ones so that you can measure your progress toward the larger goal by the completion of the smaller goals that lead up to it. This also helps the client stay motivated in the therapeutic process. Completing goals they have set helps to instill a sense of hope, increase motivation for change, and helps to increase the client’s confidence toward achieving larger goals. If the goals are vague or something that can not be measured than it will be hard for the client to know when they have achieved that goal. You also want the goal to be concrete and no something that is subject to change because that can make it hard to achieve or to know when you achieve the goal. Setting up specific, measurable, and concrete goals also helps to set up an outline or a plan for therapy and to work off of for your treatment planning. If you and the client work together to set up specific goals, then you as a counselor will have an idea of what to work on each session in-order to achieve those goals. Working with the client to set up specific, measurable, and concrete goals also helps to build the therapeutic relationship and demonstrate that you are a professional.

    Reply

    • Lilly Brochu
      Mar 25, 2021 @ 20:22:54

      Hi Carly,

      Your post resonated with me because I connected it to several times in which I felt frustrated and anxious that something did not go the way I had planned it to – especially experiences that were related to school. Moreover, it is so easy to catastrophize and think the worst of situations when you are under a great deal of stress and/or if you are like me and consider yourself “unlucky” for the random and annoying things that happen to the best of us! I applaud you from stepping back from the situation to recenter yourself in a better mindset to figure out the problem at hand instead of exploding or giving up all together.

      I am glad that you were able to solve the problem with your iPad – Google is always the answer!!! Thanks for sharing, Carly. 😊

      Reply

  16. Cailee Norton
    Mar 25, 2021 @ 14:51:40

    Behavioral Exposure
    1. I feel like in the moment for when I experience anxiety I’m not really aware of these things individually, but when you questioned on their occurrence you can really see how this series of events (event -> negative automatic thought -> physiological response -> behaviors -> outcomes) and how they really feed into each other. I feel like seeing my anxieties written down in this format helps me to understand where I can make changes so that they don’t impact me so strongly. Being able to stop the anxiety and examine it before it gets to avoidant behavior or escape will significantly help in calming that anxiety to a more normative response. The only way to do this however is to lay it out in the way that a anxious pattern record does and working from it.
    2. It didn’t help that I was driving when the anxiety provoking event occurred (basically in a call), so I definitely feel like I was avoiding and escaping the situation by hanging up and continuing to drive. Obviously I was going somewhere, and I was going somewhere that I enjoy going so that ended up being somewhat of an accidental positive coping skill. Typically though I avoid the situation and try to distract myself and then ignore the problem. That’s not done me much good in the past, but I’ve definitely adapted to a few better techniques like breaking, trying to do something with my hands/creative, and even trying something new (something like trying a new recipe to bake or cook, going to get a new type of coffee, etc.). While these things are all good, I still can use them in a negative way in which I ignore my problem/source of anxiety.
    3. For this specific situation, I feel that my actions of going somewhere I really liked and calming down from the situation allowed me to become a bit more level headed in determining what to do next. My event presented an obstacle, and so for me I needed figure out the best way to move forward and make everyone happy. In order to do that I needed to calm down, and going to that place let me do that and distracted me for a bit to address the problem and figure out next steps immediately after rather than ignoring the problem or avoiding it in some way.

    Behavioral Exposure
    1. When Lindsey was in the produce section it seemed that the most helpful technique in reducing her anxiety was to stop and breathe and pause from the situation. By doing this she was able to focus on slowing down the thoughts that were increasing her anxiety, as well as thinking back to the previous occasions of behavior exposure going well and really centering the physical feelings she is having as being normal.
    2. Therapeutically it was beneficial for her to “wait it out” because it showed her that she could accomplish her goal of staying in there. By not leaving she was facing her anxieties and showing herself she could complete the task no matter how anxious it made her feel. If she had left the grocery store and the anxiety provoking situation, then the anxiety would have “won” and for her it would be an escape from the anxiety and allowing that anxiety to dig in deeper to her beliefs about her ability to “defeat” such feelings.
    3. Some indications that the experience was a success for her was her ability to slow down from a 9 to a 6/7 in the aisle, and her ability to continue shopping. She was able to get what she needed and leave the store with you, and upon being outside she was at a 3. She was able to celebrate the victory of facing the fear, not running out of the store, and completing the task to its entirety. Her relief it was over allows her to see she won’t have a heart attack in the store, and that she can do it.

    Case Formulation & Treatment Plan
    1. CBT case formulation assists in clients ability to “get better” by laying out all the information possible and really deciding what course of action is best suited to that specific client. Having a case formulation, each one is unique to the individual and this can account for difficulties, strengths, and past experiences that all come together to create the individual we are seeing as a client. With the case formulation we are able to organize and methodically understand our clients, that allows for better treatment formulation and more efficient and focused clinicians. Without having a case formulation, clinicians can’t get to a working hypothesis because they may not have covered all of the important factors that create case formulations (the demographics, strengths, interpersonal relationships, developmental history, etc.). Making any kind of hypothesis or diagnosis without having such a clear background, wouldn’t be in our clients best interest and could lead them down a path of treatment that may not have worked in the past, can make things worse for the client, or be incompatible for our client and their resources, all of which would damage the therapeutic alliance and make the therapy quite problematic.
    2. It’s really quite necessary to have specific and concrete treatment goals simply for the fact of having something to work towards gives a sense of purpose and motivation to clients for things to change. In clients with little hope, this can provide the motivation to move ahead as they make specific small goals to reach larger ones, somewhat gaining the momentum of therapy to becoming less distressed and more autonomously functioning. Having measurable goals is a way in which to show clients the changes they are making, because often maladaptively functioning clients will minimize the good and maximize the bad of their problems, so being able to show measurable differences in assessment scores, comparing starting behaviors/skills to current behaviors and skills will be able to again motivate the client to move forward. Without the specific, concrete, and measurable treatment goals, it can leave clients lost and feeling as though they may be going through the motions, but without much conviction or end plan.

    Reply

    • Tim Cody
      Mar 26, 2021 @ 16:05:13

      Hi Cailee,

      I agree that ignoring the problem could potentially do more harm than good, but I am glad you were able to distract yourself in a healthy fashion and return to the problem when you were more level headed and focused. Perhaps that is a sign that ignoring the problem or postponing it for the moment can aid one’s anxiety, however this should not be a habit to fall into. I think that ignoring the problem and relying on safety behaviors in the wrong circumstances could potentially do more harm than good. Sometimes you can’t just walk away (or in your case drive away) from the issue and return to it when you are ready. It is best to be able to face the issue no matter how hard it may seem, allow the anxiety to run its course like Lindsay did, and be able to return to a more regular routine and normative behavior.

      Reply

  17. Alexa Berry
    Mar 25, 2021 @ 14:53:21

    1. Completing the anxious patterns record was very similar to the negative automatic thoughts record for me because my NAT tend to be anxiety related. Because of this, I felt like I did not necessarily gain more insight into events that occurred, but I did have a preference in completing the anxious patterns record because naturally the language for it is more anxiety related (for obvious reasons). Due to the fact that I was already familiar with the patterns of relationships between triggering events, NAT, and physiological response, in completing the anxious patterns record I was able to focus more on my specific anxiety related behaviors. I was already aware that my anxious thoughts tend to lead to me engaging in safety behaviors to remove negative physical sensations, but I was able to pin down safety behaviors I was not necessarily aware of. Prior to this exercise, I was aware that my primary safety behavior was leaving a place I was uncomfortable in (i.e. a crowded store, visiting a friend’s house) to return home. Although it is much easier to manage anxiety and corresponding symptoms when in a comfortable environment like home, over time this has led to a fleeing safety behavior in which the only thing that can calm my anxious responses is returning home, even if I am far away from home. As stated before, I was aware of this safety behavior, but a new one I became aware of in doing this exercise was withdrawal. So, even before I reached a point of deciding I just needed to go home, I realized a pattern of me going into other rooms to be away from people I was around, or alternatively went into a room alone at home to deal with anxiety-related physical symptoms. By fleeing or using my home as a “safe base”, each time I do this I am reinforcing the idea that I cannot tolerate being away from home due to risk of anxiety. It is a goal of mine to deal with this so it does not evolve into further agoraphobia like avoiding going places for fear of anxiety. Even though engaging in safety behaviors makes me feel better in the short-term, in the long-term it is going to cause more problems for me dealing with anxious symptoms.

    2. When the client was in the produce section, a technique that was effective in reducing her anxiety was to do some deep breathing exercises while being reminded of the fact that what she was experiencing was a normal physiological response. Taking time to slow things down paired with deep breathing resulted in Lindsey not escalating further towards having a panic attack, although she was still significantly distressed. Similarly, having Lindsey wait it out for a few minutes when she is at peak distress levels also led to her calming a bit and feeling like she could proceed with her shopping and finish the trip. If she had reacted to her initial thought of wanting to leave right away due to her symptoms worsening, this safety behavior would have reinforced her idea that she is unable to get through these types of events without experiencing panic attacks. By waiting it out for a few minutes, Lindsey was able to de-escalate and finish her shopping trip, which will act as an experience to reinforce new ideas that she is able to get through distressing events without experiencing panic attacks (or if she does she can get through them). Following the in vivo exposure, the client was very pleased with her results and expressed statements that she felt she could do this now and was getting better. This event contributed to an increase in Lindsey’s self-efficacy regarding her ability to cope with anxiety provoking events.

    3. CBT case formulation is important for effective treatment planning because it is essentially a cognitive-behavioral conceptualization of presenting problems, associated symptoms, and contributing factors. All of this information is integrated into a case formulation, and notes about automatic thoughts, emotions and behaviors can be helpful for considerations of interactions between the individual’s symptoms, problems and environment. Additionally, since clients participate in their case conceptualization process, this contributes to their motivation and hope for change when compared with clients who are not involved in this process. In other words, a case conceptualization can provide useful information for effective treatment, but also contributes to the therapeutic alliance, in which the client feels confident in the clinicians ability to help them based on their assessment. In using CBT case formulation for effective treatment planning, it is also important to have specific, measurable, and concrete treatment goals when possible. This is because it ensures that interventions are purposeful as well as allows you to more accurately track treatment progress. Thus, these qualities make a difference in monitoring progress and providing clients with feedback, since they will know what to expect with specific goals.

    Reply

  18. Lina Boothby-Zapata
    Mar 25, 2021 @ 15:17:17

    [Behavioral Exposure] – Practice an Anxious Patterns Record on yourself.

    During the Covid19 pandemic, DCF moved to telework, and all the settings and habits we had changed. It was necessary to create a new routine to execute our work. One of the challenges that I faced in teleworking was email. At least for our office became the best way of communication and reaching out people even tough for short questions or complex situations. I believe this was the setting that triggers my anxiety. After several months of doing it, I found myself compulsively checking my emails all day at a point that I realized that I was doing my actual work.

    Doing the Anxious Pattern Record, I could identify a relationship between the triggering event, automatic thoughts, and physiological response. The triggering event was compulsively checking my email during the day. The negative automatic thoughts were; “the only way that they know I am working is answering all these emails”, “I have to answer right way,” “They are going to think that I am not doing my job”, “what is coming next?”, “I am sure bad news about X family will come soon”. The physiological response was having unpleasant butterflies in my stomach or feeling hungry, but I knew I was satisfied. My anxiety behaviors were checking my email constantly. This was a situation that was building up until I couldn’t control it and I found myself spending my all day just doing it. The outcome of the case was that I lost concentration and I couldn’t focus on any other task or stop and give a pause, meaning detach myself and do a different task. My thoughts about this outcome were; “Something is wrong and I need to detach from the media,” “I am not different from using any other social media such as Facebook or Instagram, etc”. I see the relationship of each separate element of the Anxious Pattern Record from the Social Learning theoretical perspective and psychological functioning. is composed of three elements: behavior, Personal Factors, and environment. These factors have a continuous reciprocal interaction or are interwoven with each other.

    [Behavioral Exposure] – Watch PDA-11: Behavioral Techniques – In Vivo Exposure [PDA-10 is helpful, too].

    1)I think that one of the most useful techniques as a Counselor is rating anxiety. This was a constant tool that Dr. V introduced. It was very effective because this allows the counselor to assess if it is necessary to pause and introduce any technique or all of them at the moment; breathing relaxation, thinking skills, or identifying physiological emotions. Also, the rating technique allows identifying when is time to move to the next aisle. Based on what was observed these were appropriate techniques to introduce in the Vivo exposure and supported the client to complete the exposure without being too rough but giving a gentle push to do all exercise. I found that the three techniques were useful and effective; Addressing cognitive skills such as “the evidence shows that you are not going to have a heart attack”. The diaphragming technique helps the client focus on herself.

    2) I think that was the “big/crucial moment” that the counselor and client were preparing for. Thinking skills, breathing skills, and identifying physiological emotions. Helping the client to let her pass her panic attack and “experience” her panic attack instead of using safety behaviors or avoiding behaviors such as leaving the store was the main purpose of the exposure. Because this is the only way Lindsay can confirm with her evidence that she will not have a heart attack. This will allow her to break down with her cycle (P), (B), (E) and learn new behaviors. This was recently learned when The Behavioral Exposure experiences what offers is to confront the source of stress, to break the avoidance pattern, it is necessary that the client is being confronted with the source of anxiety/distress. The benefits of confronting the source of stress are that the avoidance patterns that maintain avoid/flee behavior will be broken. The client will have the opportunity to learn new behaviors and cognitions to resolve or dissolve the stress source. This is the clinical example.

    (3)
    • Rating the client’s feeling and level of anxiety; How are you feeling right now? 3
    • Reviewing thinking skills/Initial prediction: Panic Attack and I didn’t happen and Heart Attack, or running out of the store and exposure.
    • Her anxiety went down and she was collected.
    • Homework: If she feels comfortable and it is okay start just try doing on your own.

    [Case Formulation & Treatment Plan] – For this discussion, share at least two main thoughts:

    A Case formulation is a common and regular practice that the counselor needs to learn to apply in the clinical setting. There are different forms of case formulation, even though each therapeutic agency can have its own format. In particular, CBT case formulation has the following components: first cross-sectional view cognitions, emotions, behaviors, second Longitudinal view of cognitions, emotions, behaviors, third Nomothetic Formulation, fourth Working hypothesis, and finally DMS 5 diagnosis. It is recommended to update the case formulation every two months due to the client’s new information and goals met during the sessions. The changes made in the case formulation/hypothesis will bring to the therapy individualized goals and treatment plan, in other words, the therapist will answer the client’s needs, personal and assertive techniques of intervention. A suitable case formulation will provide the foundation for the proposal of the goals and treatment plan. Also, the Case Formulation should how a coherent relationship between; goals and treatment.

    Specific, concrete and measurable treatment goals are necessary because goals mark the direction of the treatment, meaning that they will tell us what we need to accomplish with the client to respond to the client’s specific needs or support the client in resolving their symptoms. As a counselor, we want to make sure that these goals are met, they need to be described in terms of being achievable and workable. Subjective goals such as “being happy”, “no having tantrums”, “being successful in life” are untangled, and it doesn’t say anything about how we can get there, or how we accomplish it. Hence, treatment goals need to be concrete, specific, and measurable. For example, “reduce panic attacks to a 50% during the first 3 months of therapy”, or “engage in an extracurricular activity to enjoy free time”. Usually, two or four intervention pergola is the expected. Also, goals build up upon each other, meaning that reaching a general goal can be beak down into more achievable goals to reach the general goal.

    Reply

    • Zoe DiPinto
      Mar 25, 2021 @ 17:34:44

      Hey Lina!

      You made a great point about how treatment goals can be broken down into smaller, more achievable goals. I remember we also talked about this when discussing behavioral activation and interventions specifically for depressed individuals. I wonder what qualities a clinician should look for when deciding to split a large goal into smaller goals. I believe a lack of motivation is likely one aspect that will indicate a client will have trouble completing a large goal. Self efficacy and anxiety are others that may make the goal seem less achievable than it is. Can you think of any others? This is also making me think about how positive reinforcement could be a beneficial tool in keeping the client engaged in completing goals.

      Reply

    • Abby Robinson
      Mar 29, 2021 @ 13:05:32

      Hi Lina,
      Thank you for sharing your experience! I have found myself doing the same thing with checking emails. I realized that part of my anxiety about learning remotely is that it’s the waiting for a reply or not replying fast enough to emails. It’s a completely different experience than just going to someone’s office to ask a clarify question where you’d get an immediate answer. I like how you mentioned how all the factors of this have been intertwined, I think that is a great way to explain how these anxious patterns create more than just emotions but also behaviors, thoughts, as well as physiological feelings as well.
      See you in class 🙂

      Reply

  19. Nicole Giannetto
    Mar 25, 2021 @ 15:40:13

    Anxious Patterns Record

    (1)
    Completing the Anxious Patterns Records helped me visualize my experience and connect the dots between the event, the negative automatic thoughts that came up, and then the physiological response I observed my body experiencing.

    (2)
    For anxiety related behaviors to this experience, I noticed myself engaging in avoidance to reduce my feelings of anxiety. For work, counselors are responsible for running group therapy sessions on the weekends (group therapists are only on during the week), and I have ran a few groups, which have gone well, but one group that I haven’t run is community meeting. The reason this experience produces anxious feelings in me is because this meeting is held in the millue instead of a private group room, so I imagine it as being on center stage in a way. There have been opportunities for me to run community meeting before, but I did manage to get out of it by offering to run other groups during the shift. I keep telling myself I need to do this to overcome my fear, and I have decided to try my hand at running this group this coming weekend which is anxiety provoking.

    (3)
    My avoidance behaviors reinforced my thoughts that I wouldn’t be good at running community meeting and would sound nervous and that the patients and my coworkers would sense that. By switching my tasks with coworkers, I confirmed my belief that I am not capable of running this group to myself and to my coworkers in a way which definitely added to the feelings of anxiety. My physiological response that I noticed the most was a stomach-dropping sensation, like what one would experience while on a roller coaster. If I heard the sentence, “We need someone to do community meeting”, this feeling would occur and my heart would start racing.

    [Behavioral Exposure]

    (1)
    Practicing breathing and grounding techniques was a bit helpful for reducing her anxiety. Reminding herself that this moment will pass also seemed to be helpful, and was a good technique that she could use once she tries this by herself. She also mentioned that having Dr. V there was comforting, because it reminded her she is not alone. In the future, it will be good for her to try and do this experiment by herself, but for now, she did a great job with it.

    (2)
    It was good to wait it out for a few minutes before leaving because it challenges safety behaviors the client has which include escaping the environment that she is feeling panic in. Although it is uncomfortable, it is a good technique because afterwards, the client can reflect on those few minutes and hopefully identify that she was still ok and safe despite feeling anxious.

    (3)
    After completing this exposure technique in the grocery store, Lindsay acknowledged that she felt okay afterwards and couldn’t believe she was able to do that. She felt proud of herself, and this shows that challenging herself to stay in the moment of discomfort paid off for her. She also utilized coping skills during the experience which is great practice to see how effective those skills can be in managing the panic symptoms.

    [Case Formulation & Treatment Plan]

    (1)
    CBT case formulation is important for effective therapy because it incorporates information obtained during the initial intake assessment to produce a summary of the series of events and contributing factors that led to the client’s current problems. An important aspect of CBT case formulation is that it includes the client’s strengths and assets. For effective treatment, its important to utilize both the weaknesses as well as strengths to guide the direction. Another factor that makes CBT case formulation so effective is that it is a working and malleable document that is expected to change throughout the therapeutic process to match where the client is at on their journey.

    (2)
    It is necessary to have specific, concrete, and measurable treatment goals whenever possible during CBT treatment, so that the clinician and client can monitor progress and adapt the process in a way that fits best. Tracking progress throughout treatment is important because it can offer information to the sessions that may have not been verbally discussed. Incorporating evidence into the sessions makes CBT effective, because it adds to the discussion and the client can view their progress on paper instead of basing it off how they are feeling week to week. Another great aspect of utilizing evidence based treatment goals is that they serve as a kind of checklist, that the client and clinician can check off once the goals have shown to be effective, allowing then for the sessions to move onto another aspect or goal in treatment.

    Reply

    • Zoe DiPinto
      Mar 25, 2021 @ 17:20:21

      Hi Nicole!
      Thanks for sharing your experience in avoiding leading community meetings. That seems like a stressful weekly experience, I’m sorry that happens! You did a great job describing your experience and recognizing how the avoidance behavior affects the outcome of not believing you are as capable of running the meeting as well as your colleagues. I wonder what effect recognizing the physical symptoms of anxiety has on your thoughts in the moment. When you hear that question and feel the roller coaster stomach feeling, what are your thoughts? Do the thoughts change when you recognize the physical symptoms as separate from anxiety? I know for my experience, it really helped gain feelings of control to view physical symptoms as a helpful external response instead of building anxiety. However, it is likely different for everyone. Thanks again!

      Reply

    • Lina Boothby-Zapata
      Mar 27, 2021 @ 19:56:34

      Hi Nicole,

      I like the way that you introduced treatment goals thinking that they can be seen as a checklist during the treatment. I think another element to see in the treatment goals is that they need to be reachable and concrete. In that way, the client and the therapist can review together if they meet the goals. I am thinking that with this permanent assessment, the therapist modifies the case formulation and new treatment goals can come up. I was wondering if it is possible to have a general treatment goal and breakdown into subgoals to support the client to reach the main goal. What are your thoughts?

      Reply

  20. Zoe DiPinto
    Mar 25, 2021 @ 15:43:14

    The Anxious Patterns Record was especially helpful in helping me separate the physiological response from the emotional anxiety that I felt. This separation made the emotion feel much more manageable. It prevented a loop of arousal. I find that I often will experience physiological symptoms that cause thoughts like “wow, I feel really anxious” which will cause more anxiety. Awareness of physical symptoms as an outcome of emotion gave them less power in causing maladaptive thoughts. I believe this prevents “spiraling.” I acknowledged that drinking a coffee made my heart rate speed up and made me feel jittery. Realizing these symptoms as physical and not emotional helped me perceive myself to be more in control. Hopefully exposure to these uncomfortable sensations will lessen avoidance outcomes in the future.
    In the produce section, we saw the client use a breathing technique to combat her physical symptoms of anxiety. Slowing down her breathing and talking out her thoughts and emotions slowed down the escalation of catastrophizing. The anxiety peaked later in the aisle as the client believed he was going to have a panic attack or a heart attack. Understandably, she wanted to remove herself from the situation that was giving her anxiety. However, it was very beneficial for her to wait it out for a minute to show that the symptoms were temporary and can not actually do any damage to her. She knew the symptoms were going to pass, and when they did, the exposure was successful. She got to gather more in vivo evidence that she was safe in a crowded place. We can assume it was successful from her reaction in the parking lot. Her anxiety had subsided and she felt a newfound sense of autonomy. She said “I feel like I can get my life back.” This hope will likely carry her to the rest of her progress.
    CBT case formulation is very important for effective therapy because it provides a focus and direction for progress. The case formulation is the story of where the client currently is and where they have been. A thorough understanding of the presenting problems and characteristics of the client should provide direct influence on a treatment plan. Having specific and measurable treatment goals is very important. Goals are desired client outcomes. Good goals will inspire specific interventions to achieve specific outcomes. This makes progress much more achievable and increases motivation in the client. Vague goals will not inspire change. Well-thought out and measurable goals will be more likely to instill action and provide a feeling of progress.

    Reply

    • Tim Cody
      Mar 26, 2021 @ 14:54:36

      Hi Zoe,

      I appreciate your comments on the Anxiety Patterns Record. I am curious, were you able to pin point your anxiety to a specific event or situation, whether anticipated or not? I found that when I connected my own anxiety to a particular event, whether it already happened or will happen in the future, that I was able to further cope with my anxiety and analyze it further. I wonder if you were able to do the same when completing the Anxiety Patterns Record.

      Reply

  21. Abby Robinson
    Mar 25, 2021 @ 15:43:18

    Behavioral Exposure
    1. I was able to get a clearer picture of the relationship between the event and negative automatic though and physiological response. It was interesting because usually the response is intense enough where I don’t even think about what the trigger was, and only focus on my physiological response because it’s uncomfortable feeling. But writing down the event first, then the thought and the response made it clearer.
    2. My anxiety related behavior is to just avoid the event/trigger all together. Or, bring along a close family member or friend as a safety behavior in case. I think that avoiding the trigger, for me, allows me to sit and dwell on the fact that I avoided it, which then makes the anxiety worse.
    3.Avoiding the trigger makes me anxiety worse because I know that I am supposed to be accomplishing a certain task, but if my anxiety is bad, I just won’t do it. Then I’ll feel even worse because I didn’t get done what I needed to.
    Behavioral Exposure PD 11
    1. For this client, the best technique that seems to help control and calm her anxiety, the breathing techniques seemed help. She mentioned it wasn’t going significantly down, but that the breathing was making it so the anxiety wasn’t getting any worse.
    2. I think the it was important for Lindsey to wait it out because she thought she was going to have a heart attack and needed to get out of the store immediately. But after waiting just a minute, the anxiety peaked and then started to come back down. She realized it was over and that she did not have a heart attack and was able to continue shopping.
    3. For Lindsey, the in vivo exposure helped her because she was able to complete the task all the way through. I think this helped her realize it is possible to come to the store without having a heart attack and that she made it out to the parking lot okay. This exposure worked for her because her anxiety at the end of the session was significantly lower than when they started.
    Case Formulation
    1. CBT case formulation is important for effective therapy because it starts off by building a therapeutic alliance and relationship. Getting all the appropriate history, presenting symptoms and maintaining factors allows the therapist to create an appropriate treatment plan and goals that are attainable and helps motivate the client. This helps motivate the client to become active throughout the therapeutic process and creates a collaborative approach for their treatment.
    2. There needs to be measurable goals because then the therapist can properly track the progress through the therapy process. By having the goals be measurable and objective, the therapist can note whether the client has improved or declined based on the scores from previous measured goals. This way, the therapist can know if the goals need to be changed or not because if there is no change or a decline for the client, something needs to change. But if the client is improving and the therapist can notably see the positive change, then they know the goals are appropriate and working.

    Reply

    • Yen Pham
      Mar 25, 2021 @ 22:32:47

      Hi Abby,
      Although each of us has a different experience of the trigger event, we automatically think and react to an event. Like you I clearly felt the relationship between the triggering event, negative automatic thought, and physiological response. I thank you for sharing your experience of avoiding triggers that make you worry and fear which is understandable because in front of an event everyone reacts and handle the event is different. I believe you are not alone. The good news is that you have realized that the avoidance event triggers not stop your worry but they make your anxiety worse. Finding yourself a suitable solution to overcome the fear of harm is what we should do. Myself, if an event happened in expected or unexpected, I just took a deep breathing and talk to myself “I can do it.” 🙂

      Reply

    • Elizabeth Baker
      Mar 26, 2021 @ 22:03:11

      Hello Abby,

      Thank you for sharing your experience with this exercise. Going through these exercises are beneficial because not only are we experiencing doing the activity ourselves, but we also have somewhat of an insight of what our clients will be going through as they complete this exercise as well (if you choose to use this activity that is). Not that I am saying everyone experiences the same physiological response to similar triggers, but since we have worked through the process ourselves, we slightly understand how our clients may be processing their triggering events.
      Also when Lindsey expressed that her symptoms did not necessarily decrease, but her deep breathing techniques helped keep her symptoms from intensifying, I think this is helpful advice when psychoeducating our clients on relaxation/deep breathing exercises. That is, notifying our clients that these relaxation techniques may have various outcomes, and that it works differently for each person. One may experience one’s symptoms decreasing, another may experience the technique(s) keeping their symptoms from intensifying, and another may not experience any changes at the time. This information, of course, should not be used to discourage clients, but to instead keep their minds open for various outcomes and to continue practicing the techniques until they find a technique(s) that works best for them.

      Reply

  22. :Laura Wheeler
    Mar 25, 2021 @ 15:49:03

    As someone who genuinely does deal with anxiety, I found this exercise difficult and frustrating as I struggle to ever identify triggering events. In my adult life I have come to accept that it must be stress related, but there is never a concrete event like we saw in the video (for example, going to the grocery store). With that said, it was really helpful in consciously evaluating the negative automatic thoughts and the physiological response. I am definitely one to catastrophize and just like we saw in the video, jump to the worst possible outcome (usually that I’ll die). Although I didn’t experience panic or anxiety during this past week, I was still able to think about past experiences and go through the motions of when the physiological symptoms start, what my thoughts are when that happens, and identify coping mechanisms that I can utilize during those moments. In general, the outcome of my anxiety never reinforces my thoughts or physiological response because the outcomes I become anxious about (dying) never happen.

    In the produce section, the client seemed to benefit from talking through her feelings in the moment and taking a second to stop and take some deep breaths. When her emotions started to escalate, the client was able to think through what was happening, rationalize why it was okay for her to continue shopping, and utilize her coping strategies to get through it. Staying and waiting out her difficult emotions was therapeutically beneficial because it helped to confirm for her that she can do these anxiety provoking things, like going to the busy grocery store, and get through it without anything catastrophic happening. The experience helped to reinforce for the client that she is more than capable of utilizing her coping skills during difficult situations and to de-escalate and get through it. After the client left the grocery store she expressed being proud of herself and in disbelief that she was able to complete the task she set out to complete. The client also reported that her anxiety was down to a 3 after the exposure technique, while it was between a 6-8 before and during the experience.

    A CBT case formulation is important for therapy because it outlines specific techniques that the client will move through to identify problem behaviors, learn how to modify them, develop effective coping strategies, and practice putting those into practice. This helps clients to “get better” because they are not only able to pinpoint the cause of their distress but are also able to specifically address and modify it. Further, it is important to have specific, concrete, and measurable treatment goals because it gives you a clear and indisputable way to gauge progress in treatment. In using measurable and specific goals you have a starting point that you and the client can refer to and can then track progress; it is also helpful for clients to have goals to work towards that encourage their hard work in therapy.

    Reply

    • Yen Pham
      Mar 25, 2021 @ 22:13:20

      Hi Laura,
      I agree with you that Lindsey benefited from a grocery stop stop and take a deep breath. I like the way you mention that the client that has experience what she’s doing is to challenge herself again to stay in the grocery store instead of leaving. A good result happened, benefiting both the client and the therapist, Lindsey finally lowered her fear score and she was happy because she won her fear.

      Reply

    • Connor Belland
      Mar 27, 2021 @ 22:32:11

      Hi Laura, I agree with you that it is hard to identify specific a specific evene tor thought that is causing anxious thoughts because they are so constant and are kind of just expected at this point. But identifying these specific negative automatic thoughts can be helpful when trying to feel better, maybe we can do this with the really tough anxious thoughts but just deal with the little ones as they come.

      Reply

  23. Anna Lindgren
    Mar 25, 2021 @ 15:54:30

    [Behavioral Exposure]
    1. I experienced feeling hot, getting a lump in my throat, and starting to tear up seemingly out of nowhere the other day. While I was initially unsure about why I was having a physiological response, completing the APR helped me link the event with my negative automatic thoughts and following emotions that triggered my physiological response.
    2. My anxiety behaviors were a combination of withdrawal and emotion-based coping. However, once I realized what I was doing and that I could better help myself by talking to my partner about it instead of withdrawing, I chose that action later and was able to talk things through and decatastrophize the event.
    3. At first when I was experiencing my heightened physiological response of feeling hot, feeling a lump in my throat, and beginning to cry, I withdrew from the situation. I realized that staying away would only reinforce my negative experience, practiced some breathing exercises, and came back when I was calm again. Had I remained withdrawn from the situation instead of coming back to it when I was ready, it may have hurt my self-efficacy in that area or reinforced my negative emotions tied to the event.

    [Behavioral Exposure]
    1. The most helpful technique in the produce aisle seemed to be the relaxation breathing techniques as well as closing her eyes to slow down her thoughts. It seems to me like the simple act of closing her eyes really helped her to get out of her mind and try and just focus on calming her body’s responses down before proceeding.
    2. Lindsay sticking with it when she was having physiological symptoms allowed her to break the avoidance cycle that was contributing to her panic attacks. By pushing herself to stay in the store even when she wanted to leave, she is experienced first-hand how her panic symptoms don’t last as long as she is in the store. Eventually, they pass and she can complete the task of completing her shopping trip.
    3. The biggest indicator of the in vivo exposure’s success was that she rated her anxiety at a 3 when it had been at 6 and up to 9 over the course of the grocery trip up until that point. It was also really moving when she said she felt like she could get her life back. She seemed really happy that her hard work was starting to pay off and that she was close to reaching her treatment goals.

    [Case Formulation & Treatment Plan]
    1. A CBT case formulation is important to effective therapy because it takes the whole client into account. Their diagnosis, presenting concerns, their origin, the maintaining factors, and the areas in most need of intervention. Once the therapist understands the case formulation, they can help the client to make sense of the cycle of behavior they are caught in due to their thoughts and emotions, and over time learn to change those negative thoughts and associated emotions and behaviors.
    2. Having specific, measurable, and concrete goals makes the idea of “getting better” less elusive or daunting. Someone suffering from a mental illness may have doubts about being able to incorporate big, sweeping changes in their life and this can lend itself to dichotomous thinking: either I succeed, or I fail. Breaking the overall big picture into smaller, more achievable goals is going to set the client up for success because they will see that they can do it one step at a time. It also makes it easier to track treatment progress.

    Reply

    • Lilly Brochu
      Mar 25, 2021 @ 20:10:18

      Hi Anna!

      I appreciate you sharing your experiences with anxiety. Similarly, I can relate to how you handle your distress as I too withdraw from those closest to me and tend to use emotion-based coping rather than exploring the problem or distress head on. However, once we center ourselves, we know what will help us in the long-term (like chatting with a partner or a close friend) rather than isolating ourselves. Withdrawing from everyone and everything always seems like a good idea at first, but then we tend to miss the support we have from those closest to us.

      Besides breathing techniques, what other coping skills are helpful for you when you are experiencing anxiety? I find that journaling, taking a bath or shower, or listening to calming music helps me ground myself. Great post! 😊

      Reply

      • Anna Lindgren
        Mar 26, 2021 @ 14:01:34

        Thanks for the reply, Lilly! In addition to breathing exercises, I’ve also utilized calming music, yoga, and going for a walk when I’m feeling anxious. Sometimes having a physical outlet can help to work through the physiological responses and come out calmer and more clear-headed on the other side. I also journal sometimes and find that really helpful.

        Reply

    • Christina DeMalia
      Mar 27, 2021 @ 11:48:53

      Hi Anna,

      The point you made about physiological anxiety symptoms coming up seemingly from nowhere is really important. In Lindsey’s example, she has recognized that going to the grocery store is a trigger, and therefore knows that if she tries going there, she will experience symptoms of anxiety. However, a lot of people will not necessarily recognize what their triggers are, or the triggers may be had to pin down. I’m sure that for many clients, they may also experience symptoms of anxiety without any warning or idea it’s coming. I also think your example shows how useful this exercise can be. By paying close attention to your behaviors that followed, you were able to recognize your tendency to withdraw. I think this can be a lot of people’s safety behaviors, but can also be one of the most problematic. Leaving a situation and withdrawing can relieve symptoms momentarily, but leaving or withdrawing is not always an option in every situation, so developing more adaptive ways to cope seems like an important part of minimizing the negative effects of the anxiety.

      Reply

    • Lina Boothby-Zapata
      Mar 27, 2021 @ 20:11:15

      Hi Anna,
      I agreed with you that one of Lindsay’s indicators was that she rated herself at the parking lot 3, knowing that during the trip at the grocery store she was going back and forth between and 7 and her pick was 9. One of the elements that I really appreciated in this video was that Dr.V in this Vivo exposure was constantly using the rating scale with Lindsay allow him to assess when was the appropriate moment “to switch gears” meaning to introduced breathing skills, thinking skills, or identify psychological arousal, furthermore will help him to decide when is the appropriate moment to wait it out and wait or finish the exposure. This was amusing for me 🙂

      Reply

  24. Tim Cody
    Mar 25, 2021 @ 15:58:42

    [Behavioral Exposure] – Practice an Anxious Patterns Record on yourself.
    Identifying the triggering event was enough for me to determine the source of my anxious thoughts. Now that I have done that, I can do a better job of getting ahead of my anxiety and reacting to it in a different way. Some of the physiological indicators that I felt were feeling tense, distracted, and irritated. I did not find pleasure in the activity and I wanted to quit and do other things that were more enjoyable. I wanted to watch YouTube, TV, play games and go for a walk instead of doing the things that I needed to do. The longer I turned to safety behaviors (i.e., watch YouTube and play games on my phone), the more my anxiety about not finishing my homework was pronounced. In fact, I found that my immediate behaviors following the physiological symptoms of the panic were reinforcing my anxious thoughts.

    [Behavioral Exposure] – Watch PDA-11: Behavioral Techniques – In Vivo Exposure
    Lindsay was able to do some breathing exercises to control her anxiety and receive some encouragement from Dr. V. Instead of leaving the story in a flight (safety behavior), Lindsay was able to wait it out and fight her anxious feelings. This was therapeutically beneficial because Lindsay was able to see that her anxious feelings were temporary and she can function properly with her anxiety. If she runs away every time that she feels like she is going to have a heart attack, even though she has never had one before, she will not be able to cognitively function and complete everyday tasks. At the end of the exposure, she felt jubilated that she was able to complete the task. Even though the experience in the moment was horrifying, she indicated at the end that she “felt that she could get her life back.” She was excited to try and do something like this again, whether with or without Dr. V. help guide her.

    [Case Formulation & Treatment Plan]
    CBT case formulation is what encompasses all the information gathered in the Initial Interview Basics and CBT Assessment. It is a summarization of all the information about the client, including their automatic thoughts, emotions, and behaviors. This is especially important for effective therapy because it paves the way for further diagnosis, session structure, intervention and treatment plans. The client also is able to work alongside the therapist in constructing their case formulation, motivating them to be more involved in the therapeutic process. The treatment goals are meant to be therapeutic indicators of reduced symptom distress and improved quality of life. The more measurable the treatment goals are, the more likely you are able to measure an accurate progression of one’s symptoms. The more specific the goals are, the more desirable the anticipated outcomes as well.

    Reply

    • Anna Lindgren
      Mar 26, 2021 @ 14:07:07

      Hi Tim!
      Thanks for sharing your experience with anxiety and procrastination. I’ve found this to be a tough cycle to break at times, and I actually just read an interesting article about the philosophy of why people might procrastinate. The basic idea is that we don’t think of our future selves as an extension of us but more like strangers we haven’t met yet, and therefore it’s easy for the current version of ourselves to push our workload onto that person. Here’s the link in case you want to check it out! http://m.nautil.us/issue/9/time/why-we-procrastinate

      Reply

    • Connor Belland
      Mar 27, 2021 @ 21:54:19

      Hi Tim, I totally feel you on always getting distracted from the task at hand and getting more enjoyment out of other things so choosing to do them when i shouldn’t be. But doing those things and putting off my work just makes me more anxious because their less time to get it done, so at this point i just use safety behaviors like that as a reward system for finishing my work which makes them that much more rewarding.

      Reply

  25. Connor Belland
    Mar 26, 2021 @ 17:36:38

    The Anxious patterns record definitely helped me to visualize what was making me anxious and the negative automatic thought that was causing it and helped me to rationalize the thought even more and learn about it to the point where I wasn’t as anxious anymore. I was anxious about an upcoming presentation I had for another class and was able to use the anxious though record to sort of deconstruct the thought and see the root of the problem which helped me rationalize it better. Before the presentation I was getting sweaty and my stomach hurt frim anxiety but the more I practiced the presentation the better I felt about it and more prepared I was, and once the presentation was over with I felt an immense feeling of relief and was able to relax.
    When Lindsay was in the produce section and starting to become more distressed it was helpful for her to kind of take a step back and slow everything down. She shut her eyes and did some deep breaths and tried to understand the thoughts that were going through her head and rationalize them. The reminders that this feeling will pass and that she won’t have a heart attack seemed to reassure her as well. In the aisle it was helpful for her to wait out the panic attack feelings and really try to push herself because she had been working hard to get to this point so it wouldn’t have been productive to just immediately walk out of the store. As she practiced breathing she reminded herself how far she has come. She kind of forgot her nervous feelings the more she waited it out and was able to continue on. After she finished shopping she was extremely excited and relieved. Her anxiety had gone back down and she was feeling accomplished with herself which helped to show her that this was something she could actually do now.
    A case formulation can be very helpful in therapy. It is a written summary of an individual case and can be changed as more information is learned and helps the clinician visualize the case by seeing it on paper. They can use it as a reference in therapy and to remind themselves about certain details of a client that they might not remember. Marking progress is important therapy and setting attainable concrete goals can help with that. The client should have something that they are working towards and want to accomplish in therapy. Setting these goals can help the client have hope and something to work towards. They can also be a reference point for clinicians to check back and see how much progress is being made and adjust therapy to work towards them.

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Adam M. Volungis, PhD, LMHC

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