Topic 9: Behavioral Exposure and CBT Case Formulation & Treatment Plan {by 11/8}

[Behavioral Exposure] – Watch PDA-6: Behavioral Exposure – Assessment of Anxious Patterns.  Answer the following (you can be brief): (1) What was the client’s primary negative automatic thought (possible cognitive distortion?) in response to this event?  (2) What was the client’s response to her associated automatic thoughts and physiological arousal (any safety behaviors?)?

[Case Formulation & Treatment Plan] – There are multiple readings due this week (J. Beck – 2 Chapters & Appendix A; Volungis – 1 Chapter; Persons & Tompkins [2006]; Academy of Cognitive Therapy: Candidate Handbook – Appendix D & E).  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 the beginning of class 11/8.  Have your two replies no later than 11/10.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

24 Comments (+add yours?)

  1. Becca Green
    Nov 04, 2018 @ 21:21:14

    Behavioral Exposure:

    Following the event the client reported feeling like a failure for not following through with grocery shopping. Although she made several big steps, perhaps ahead of where she was ready, she ignored those big steps and only focused on not completing her end goal of grocery shopping on her own. After she started having the panic attack in the store she felt as though she needed to get out of the store as soon as possible. She left the store and when she saw her husband she felt relieved, noting a safety behavior of having her husband there at times of increased distress. She later agreed that she often uses her husband as a safety behavior because he knows how to support her when she has panic attacks.

    Case Formulation & Treatment Plan:

    The case formulation is important for effective therapy for several reasons. Along with the information that it provides for the therapist to move forward with treatment planning and goal setting, it allows both the client and the therapist to be on common ground with why the client is there and what is hoped to be gained from therapy. This allows for the therapeutic relationship to evolve and offers a direct role in collaboration in the therapeutic process. Because of this it may help the client feel more motivated to work with the therapist in session and work on their own outside of session to work on the goals created as a team. When moving forward from the case formulation to create the treatment goals and interventions it can be helpful to have specific, concrete, and measurable treatment goals. This is helpful for several reasons, most importantly with it allowing you to more accurately track client progress towards the treatment goals. This can help the therapist and the client see what interventions are helping to meet the goals and if there should be any adjustments to the treatment plan if distress levels aren’t being improved. The use of different assessments can also help measure treatment progress. It also helps the client see improvement being made during times that they might not feel like they are improving at the rate they feel they should be.

    Reply

    • Amanda Russo-Folco
      Nov 05, 2018 @ 16:52:10

      Becca, I really liked how you said: “This allows for the therapeutic relationship to evolve and offers a direct role in collaboration in the therapeutic process”. This is very important because if the client and therapist work together, then the client will be more motivated like you said to actually follow through with their treatment planning and goals. They will have a better chance following through with what their supposed to do. Without collaboration, the results could turn out to be very different. I also talked about how treatment goals should be specific and concrete. Because if they are not, then the client would have a less chance of actually knowing what their treatment goal is. Overall, I really enjoyed reading your discussion post.

      Reply

    • Melissa Pope
      Nov 05, 2018 @ 20:04:27

      Becca,

      I liked your response to the importance to case formulations and treatment plans. Especially with your comment about how it keeps both client and therapist on common ground which will promote collaboration and hope to motivate them outside of session along with in session for better treatment outcomes

      Reply

    • Deanna Tortora
      Nov 05, 2018 @ 22:10:03

      “It also helps the client see improvement being made during times that they might not feel like they are improving at the rate they feel they should be.”
      Becca,
      You make an excellent point here. Having specific measurable goals can provide indisputable evidence to the client that they are improving. Clients like Lindsay tend to be hard on themselves. So having some proof that they are meeting goals and improving can provide contrary evidence to what they believe is lack of progress or “being a failure”. CBT therapy can sometimes be slow, but it is a rich process. Seeing goals be met can help clients see that they actually are improving, and can also give therapists the opportunity to point out that progress is being made at a pace that is beneficial for the client (not too slow or fast, but juuuuuussst right for the client!).

      Reply

  2. Melissa Pope
    Nov 05, 2018 @ 06:32:10

    In response to Lindsay going into the grocery store alone, her initial negative automatic-thought was “I can’t escape.” This thought was in response to the physiological effects of her body warming up, palms sweating and her chest tightening up. The primary and in my opinion, more intense negative automatic thought was “what happens if I have a heart attack”. Although she knew the reality that she was not having a heart attack, this could not relieve her distress because the emotional and physiological effects were too powerful. In response to these two thoughts Lindsay needed to escape the situation, because her distress at the time exceeded her coping skills and she left the cart in the aisle and ran out of the store. Once in the parking lot she felt a bit of relief and the even more relief once she saw her husband and knew that she would be going home. Her husband is a safety for Lindsay, and I also believe that her home could also be a safety. Although all people should feel safe in their homes, in Lindsay’s case could be maladaptive if “home” is perceived as an escape from her distress where she can engage in avoidant behavior.

    In CBT, the case formulation are the “stories” of the client from information gathered through intake, interview and any assessments given. Case formulations are ever changing, and it sets the stage for effective therapy. The more informative and detailed the case formulation the better sense the therapist has in knowing what direction they should be going in and where to start for the treatment plan. The main goal with any client is to ease their current distress while implementing adaptive coping skills so that the distress will continue to “lighten” and they eventually can continue progress on their own. The case formulation, pinpoints the presenting problems, how the came to be and what is continuing to have them manifest for client. I look at the case formulation as the information that is needed and necessary to be able to strategize, the divide and conquer of current issues.

    It is important for a good, effective therapist to have specific, concrete and measurable treatment goals for their clients because it sheds light on progress being made in and out of session and reflects upon the case formation that is made. Concrete and measurable goals also allow for the client to have feedback into their progress, which will hopefully continue throughout the process and even afterward. For example, if a client wants to feel more happy, although that is a great goal to have, the emotion of happy is nearly impossible to measure and from the day to day, the client may not be able to feel or see the progress even with the implementation of particular interventions. For the client to have the treatment goal to, have reduced negative depressed symptoms according to an assessment given, is much more concrete and measurable. Being able to see the decreased number on the scale and then reflect from where they started will motivate for continued progression even if they don’t feel happy everyday. Lastly, specific and concrete goals are needed for managed care companies to also see that progression is being made for sessions billed.

    Reply

    • Amanda Russo-Folco
      Nov 05, 2018 @ 16:38:53

      Melissa, I also agree with the client’s initial negative automatic thought being “I can’t escape”. This stuck out to me the most because she literally felt like she could not escape her situation and wanted to get out of the grocery store as fast as possible. I also really liked how you called the case formulation like “stories”. This makes sense because the more detailed a story is, the better it is. This also applies to a case formulation because the more detail the therapist has about the client, the better the therapist can help the client and see which direction to go in for treatment and goals. It is important for the client and the therapist to always be on the same page, so together they can work on the best possible outcome for treatment.

      Reply

    • Mikala Korbey
      Nov 07, 2018 @ 18:51:20

      Melissa, I really like that you mentioned that case formulations are ever changing because it is so true and I did not even mention that in my post. As the client and therapist progress through therapy, they can make changes to the case formulation as they gain more information. For example, if they choose a form of treatment, and it’s not working exactly as they would like, they can change their course of action and make changes to the case formulation. I can’t believe I didn’t think of that the first time, great post!

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  3. Alyce Almeida
    Nov 05, 2018 @ 14:37:47

    Exposure: The client discussed taking a big step with attempting to go to the grocery store which has been a difficult goal for her throughout therapy. When describing the situation, though at first she felt confident about giving this trip a chance she quickly regretted it and felt overwhelmed due to the crowdedness and ended up having a panic attack and ultimately left the store. She describes the physical response her body had during this time, like feeling as if she was choking and stating she felt like she was losing control. She initially reports she felt like she couldn’t escape the situation and even feeling like she could have a heart attack. Her response was to leave the store immediately and retreat back to her husband in the car. I think her husband giving her immediate relief can be an example as a safety behavior since he was able to ease these intense negative feelings and physiological responses.

    Case Formulation and Treatment Planning: Case formulation is important for effective therapy since it not only provides detailed information about the client, but is useful when figuring out the direction of treatment and ultimately produce a treatment plan that you and your client agree on. I think this is important because it helps give more insight on the client for therapists, but also points out client problems, how such problems came about, and ways to shift problems into steps towards progress. Case formulation is crucial for treatment planning, and a great way to plan ahead, whether it be setting goals, or how one can take the steps to achieve such goals. This helps clients be realistic, and practice problem solving and prepares them for the goal they plan to work on. It’s important to have measurable and specific treatment goals because you want to make goals attainable for clients, giving them unrealistic goals that set them up for failure would have them going backwards. Having concrete goals helps measure progress of clients, providing not only the therapist this assessment, but the client themselves to track their own accomplishments and note changes they’ve seen since starting therapy. This can also act as a chance to alter any steps or goals to better fit the clients needs and produce more attainable tasks that will hopefully show the client their improvement. This could then foster more motivation to set and achieve more goals!

    Reply

    • Deanna Tortora
      Nov 05, 2018 @ 22:17:25

      “I think this is important because it helps give more insight on the client for therapists, but also points out client problems, how such problems came about, and ways to shift problems into steps towards progress.”
      Alyce,
      I like what you say here. I completely agree. The case formulation really does give deeper insight on the client because you and the client find the connections between their distress, presenting problems, cognitions, emotions, and symptoms etc. Working it out together can really paint a more detailed picture of the situation. The case formulation is (obviously) deeply personal, but I think this can allow for better personalized and effective treatment that keeps all of these things in mind when making the plan and goals. The case formulation is almost like a part of the foundation for effective CBT!

      Reply

  4. Amanda Russo-Folco
    Nov 05, 2018 @ 16:33:13

    The client’s primary negative automatic thought in response to this event is that “I can’t escape”. She wanted to leave the grocery store because she was having a panic attack and felt that she could not escape the situation. However, she did feel these sensations happening beforehand. A possible cognitive distortion she was having was catastrophizing because she was making the situation far much worse than it actually was and she knew that too. Although, as soon she left and saw her husband, she felt a sense of relief and her symptoms started to decrease. The client’s response to her associated automatic thoughts and physiological arousal is that she knows intellectually what is happening, but emotionally she cannot control her physiological symptoms. However, whenever she sees her husband, she feels a sense of relief and does not feel any anxiety symptoms. She uses her husband as a safety behavior because it helps her to feel better. Throughout time though, it is important to not have this safety behavior because then she will not be able to get over her fear on her own.

    A CBT case formulation is important for effective therapy because it helps the therapist figure out which direction to go in for treatment planning. It has three key elements such as assessment, formulation, and intervention. The information that is obtained during the assessment is used to develop a formulation. A formulation is a hypothesis about the causes of the patient’s disorders and problems. This hypothesis is used as the basis for intervention. Throughout the treatment process, the therapist will repeatedly come back to the assessment phase to monitor and collect data of the process and progress of the therapy session. The therapist then uses this data collected to revise the formulation and intervention as needed for the patient. Each individual has their own case formulation, so it helps the therapist keep track of that one particular client. It also helps to see if the client is improving or not with their symptoms and it gives room for changing the hypothesis or the intervention that is being used. It is important to keep all the data of the individual organized. According to Appendix A in Judy Becks book, the case formulation begins with precipitants. Then, a cross-sectional view of current cognitions and behaviors, then longitudinal view of cognitions and behaviors, strengths and assets, and lastly a working hypothesis which is a summary of conceptualization. It is important to know the important details of the client. A case formulation is effective because the therapist and client are still working together to gather all the information that is needed and to explain the issues the client is having in therapy. A case formulation is meant to relieve some distress from the client and for them to get better by reaching towards their goal. It is necessary to have specific, concrete, and measurable treatment goals whenever possible because this is how the client will follow through with their goals. If their treatment goals are all over the place, then they will not follow through with it because they do not know which goal to follow. It is important for the client to follow their concrete treatment goal to prevent relapse and the client will become their own therapist, so they do not need to go to therapy anymore.

    Reply

    • Melissa Pope
      Nov 05, 2018 @ 19:55:47

      Amanda,

      I completely agree that the client’s automatic thought that started her panic attack was “ I can’t escape”. After that I also wrote down that her thinking about having a heart attack was also crucial to the situation. I think the two worked together and the second tipped the iceberg and continued to fuel her physiological effects and her negative automatic thoughts. I also agree that her cognitive distortion was catastrophizing.

      Reply

    • Alyce Almeida
      Nov 07, 2018 @ 18:10:33

      Amanda you did a great job at discussing case formulation. You focused a lot on the importance of the collaborative approach to really diving into what the client is truly struggling with. Just like you stated, if it’s all over the place there won’t be an organized way to work on therapy

      Reply

    • Mikala Korbey
      Nov 07, 2018 @ 18:37:17

      Amanda, I did not even think about or mention the negative automatic thought of “I can’t escape” that you mentioned in your post. How did I miss that one? I’m so glad you mentioned it because I feel like this is a good thought that highly relates to her panic attacks and are the potential root for why they start in those situations. I think this thought also feeds into what you mentioned, her catastrophizing. She thinks the worst possible situation is happening and she can’t get out. I am really glad you mentioned this automatic thought.

      Reply

    • Shannon O'Brien
      Nov 10, 2018 @ 10:20:48

      Amanda, I liked your comments on case formulation. Especially the last few about how organization plays a role in decreasing client distress.I couldn’t agree more! As we have discussed in the past, the balance between structure and flexibility/adaptability is crucial for a therapist to create. With case formulation a more structured and organized approach seems important in order for clients to clearly see the plan ahead. Like you stated, if things were all over the place, the view of the goal would be diminished. This could potentially cause more distress for the client or inhibit progress as expectations are unclear.

      Reply

  5. Shannon O'Brien
    Nov 05, 2018 @ 18:38:26

    I believe that Lindsay’s automatic though was that she was out of control of the situation or was about to have a heart attack because she felt like she could not escape. I believe her physiological symptoms and responses really contributed to these thoughts because they were so intense and came on very quickly. As the therapist stated, “the emotions were so intense it is hard to think rationally.” The response in session to the experience seemed to be defeat or failure. Both Lindsay and the therapist acknowledge the drive and ambition that Lindsay exhibited, however she stated in many different ways that she felt like she failed or was completely out of control despite remembering certain aspects of therapy that would have benefited her. A safety behavior that she displayed was immediately leaving the store in order to seek out her husband. She also stated that after this experience they both went home in order for her to recover, but she began to feel relief the second she was out of the store and in the presence of her husband.

    CBT case formulation is important as is aids in the development and testing of hypotheses for conceptualizing and treating clients’ difficulties and distress. It helps clients get better by taking information from intake interviews (background info, presenting concerns, strengths and assets, etc…) and using it to form a purposeful assessment of the presenting symptoms. The ability to create a strong therapeutic alliance, the ability to identify automatic thoughts and emotions, and the ability to work within a goal and problem oriented focus are all skills that therapists need in order to make case formulation effective. For the client, I think it provides an outline of all the progress and goals they have achieved as well as what is in store for future treatment. It is necessary to have specific, concrete, and measurable goals during this process in order to foster and maintain and collaborative approach to therapy as well as make a clear and correct DSM diagnosis. Additionally, I also think that having measurable goals will help identify and differentiate between any obstacles such as the therapeutic relationship, client-specific factors, or external factors.

    Reply

    • Alyce Almeida
      Nov 07, 2018 @ 18:14:33

      Shannon, you mentioned the clients feeling at the moment while at therapy when discussing the incident in the grocery store seemed like defeat or failure. I liked your empathy here, as you pointed this out and I realized I didn’t even see it in that way when I initially responded. I think this makes a good point to understand how clients can be feeling around their attempts while going through therapy and how if such attempts aren’t successful, how distressing it could be to them

      Reply

  6. Mikala Korbey
    Nov 05, 2018 @ 19:04:13

    Lindsey’s primary negative automatic thought that she verbalized during the session was that she feels like she failed and she said that it “should be so easy to go into a grocery store”, but that it is not easy for her. She failed to recognize that going to the grocery store was a big step for her, especially because it was something she decided to do on her own. Once she began to feel her panic attack come on, she just left the store and went straight to the car where her husband was waiting for her and they went straight home. Once she saw him her physiological symptoms because to go away and by the time she got home her symptoms were gone. This was her safety behavior, fleeing from the situation to her husband once she began to feel the panic symptoms set in.

    A case formulation is crucial for effective therapy because contains most, if not all, of the information that was gathered by the therapist during the evaluation session. It is used as the basis for choosing which interventions to use and guides the individual’s treatment plan. A case formulation allows the therapist to consider all of the factors at play, such as automatic thoughts, emotions and behaviors, and the relationship that these factors have with the client’s symptoms/problems. The formulation contains a description about what is causing and maintaining the client’s problems, a description about what seems to have caused the problem (i.e the origin), any other potential life events or circumstances that may be contributing to the problem, and and overall summary including strengths and assets. It ties all of the information together and is a guide for the rest of therapy because it gives a framework for how the factors and problems are related. Without the case formulation, the therapist may have a more difficult time in planning how therapy will go. This formulation acts as a guide for the therapist and helps them be able to determine where the treatment needs to go in order to be most effective for the client. The information within the case formulation helps the therapist and the client decide what the individual’s goals are going to be. Treatment goals are the desired outcomes for the patient and also are indicators of the therapeutic progress. The goals need to be specific, objective and measurable because they will be easier and more clear to track over time. If they are too vague, the therapist and client will have a difficult time providing feedback on how things are going, and will have a more difficult time knowing if and when the goals are met. By having clear, measurable goals, the therapist can better implement the appropriate interventions required to meet those goals.

    Reply

    • Sam
      Nov 07, 2018 @ 20:44:09

      Mikala,
      Something I failed to mention in regards to the clients safety behaviors was that her symptoms nearly diminished after being in the car with her husband. At first, I thought it could be normal to have her husband there as she was taking a big step, but because her symptoms were essentially gone just because she was in the car with him, really does indicate a safety behavior that should be further analyzed. Nice comment.

      Reply

  7. Deanna Tortora
    Nov 05, 2018 @ 21:55:59

    [Behavioral Exposure]
    (1) The client’s primary negative automatic thought in response to the event was that she is a failure. The client said she “…felt like a failure”. She displays the cognitive distortion of all or nothing thinking. The client felt that even though she was ambitious and attempted to do something normally very difficult for her, she was a failure because she didn’t finish what she had set out to do (her shopping). She does not see that her attempt is a success on its own, and because she has the all or nothing distortion, she feels she failed entirely.

    (2) The client’s response to her associated automatic thoughts and physiological arousal was to leave her shopping cart (escape the crowded grocery store and the situation that was triggering her attack), go back to her husband in the car, and go home. The client experienced the physiological arousal of her heart beating fast, feeling warm, and having sweaty palms, and the associated thoughts of feeling the need to leave the crowded store. The client decided to leave and rejoin her husband in the car. The client had taken her husband with her on the shopping trip and when she had a panic attack, she retreated to him and her home. She mentioned that she felt much more relaxed and better with her husband around, and this allowed her to attempt shopping. After the attack she felt he helped her to calm down. Being with her husband is very clearly a safety behavior.

    [Case Formulation & Treatment Plan]
    (1) A CBT case formulation is important for effective therapy for several reasons. The case formulation includes: a precipitating and maintaining factors summary, cross-sectional view of cognitions, emotions, and behaviors, longitudinal view of cognitions, emotions, and behaviors, nomothetic formulation, working hypothesis (Idiographic Formulation), and a DSM diagnosis. A CBT case formulation helps to encapsulate the therapeutic process, relationship, client goals, presenting problems and symptoms, contributing factors, and provide the opportunity for collaborative planning. That is, a case formulation includes all of the elements interacting with the client and their disorder, their symptoms, cognitions, and emotions. It is a running document throughout therapy that can be modified to include new information, as well as all the involved factors in the case. Having all of this information in one document is not only important for record keeping, but it can be useful in other ways; a therapist can use it for treatment planning and setting goals, it allows for therapeutic rapport to be built upon through collaborative involvement with the client when developing the case formulation together, it can in part allow the client to see where they have started and how they have improved (based on seeing the presenting problems in the beginning of therapy and how they have changed or improved through therapy), as well as it can help give the client some motivation and hope for change. The formulation itself can even show the client that you are a professional and are considering all elements of their presenting problem and have a plan for treatment. The case formulation is not a treatment plan, but the client can see that you are working together to make a document that includes many key elements involved in the client’s presenting problem, diagnosis, and the therapist’s hypotheses of all the interactions. Overall, having this document can act as a springboard for the treatment plan and goals to be set by therapist and client, and act as a running document of any changes and/or new information that can assist further in the therapy. It helps clients “get better” because they collaborate with the therapist on the case formulation and gain understanding and motivation. The collaboration on the case formulation allows the client to develop an understanding of their diagnosis, cognitions, emotions, and the other elements that are interlaced and involved. Having an awareness and developing an understanding of their situation is one of the parts of CBT that is effective for clients. The collaboration keeps them involved in their own therapy, so that they may be proactive and learn how to help themselves. An understanding of interactions and conceptualization of their distress, symptoms, and the process of treatment, will help keep them in the loop and even motivated and hopeful for change. In all, the case formulation helps keep the important component of collaboration between therapist and client, can help give the client hope and motivation for change, keep the client cognizant of the interacting components, can keep track of symptoms, cognitions, and emotions, and can keep track of other aforementioned components.

    (2) It is necessary to have specific, concrete, and measurable treatment goals whenever possible so as to be able to track treatment progress (both by client and therapist). If treatment goals are not specific, concrete, nor measurable enough, the client and therapist will be unable to determine if they have met the goal. Making a specific concrete goals can help narrow down behaviors and/or cognitions to increase or decrease, so that the client can tell their symptoms and distress have decreased. Making measurable treatment goals can also help the client and therapist tell if the desired goal has been met and how much so. That is, they can have definitive evidence of measurable progress or lack thereof. This can help with the development or modification of future or current goals. It yet again helps a client and therapist to witness and observe concrete progress (or lack of progress). Being able to track client progress, symptoms, cognitions, emotions, and distress levels helps with modification of treatment goals, as well as can show a client their success and improvement from where they began. Allowing the client to see how they have improved is very useful for motivation in therapy and even with improving distress. Having specific, concrete, and measurable treatment goals can help clients see their progress in therapy, what works, what does not work, and what other goals need to be made. If goals are or are not being met, treatment goals can be modified to best suit client therapy.

    Reply

    • Sam
      Nov 07, 2018 @ 20:38:46

      Deanna,
      I liked that you included in your response for the case formulation that “The formulation itself can even show the client that you are a professional and are considering all elements of their presenting problem and have a plan for treatment”. I agree with this and think that it is so important to have the client feel that their therapist is working to tailor everything to their specific needs. It can be discouraging for a client to feel that they are working working with a therapist who is using a certain form of treatment just because they used it with another client and it worked. Coming off as a professional, especially a caring professional, is crucial in establishing therapeutic rapport. So, I believe this one small comment is important because a therapist should always want to show that they are considering all the information provided in establishing a treatment plan to ensure a positive therapeutic relationship. Great post.

      Reply

    • Shannon O'Brien
      Nov 10, 2018 @ 10:30:23

      Deanna, i really liked how to pieced the “all or nothing” distortion title into your response, It was a very fitting piece of information from previous readings and lecture (it really helped to bring back some of that content for me!) I totally agree with your thoughts on this. She viewed the entire process as a failure despite her great efforts and ambition to give it a try in the first place. I think that this is such an important aspect of Lindsay’s distress that should be a top priority during her time in therapy. Even thought the end result was not what he hoped for, smaller accomplishments can still be recognized and applauded (kind of reminds me of the GTA form!)

      Reply

  8. Sam
    Nov 07, 2018 @ 20:30:56

    [Behavioral Exposure]

    Although the client expressed many negative automatic thoughts that seemed to exacerbate her emotions and physiological symptoms, such as: “I felt like I couldn’t escape” or “what happens if I have a heart attack”, I believe the primary or key negative automatic thought was expressed after the event where she mentions: “I feel like I failed”. In this case, potential cognitive distortions are present. For example, she may be engaging in dichotomous thinking or “all or nothing” thinking in which she may believe that, “because I could not complete my grocery shopping, I am a failure”. In considering her other negative thoughts about feeling as though she could not lose escape, she expressed that she felt as though she began to lose control and needed to get out. Therefore, her response to these thoughts was to leave the store and return to her husband. During this event, the client experienced physiological arousal in the form of sweaty palms, racing heart and nausea. Although finding comfort in a loved one is often normal, it seems to come across as a safety behavior for this client. This was her first time entering the grocery store alone, so it is normal to bring her husband along, however, it is not likely that every time they need to go grocery shopping that he will be able to sit in the car waiting for her. Thus, retreating to him after her panic attack insinuates some safety behaviors, more effective coping skills should be identified and utilized.

    [Case Formulation & Treatment Plan]

    Case formulation is necessary for effective CBT. This is because the case formulation essentially allows the client and therapist to identify what is causing and maintaining a specific problem. By doing so, a client get can “get better” because they are able to collaboratively develop a working hypothesis and establish treatment plan that is specifically tailored to their needs. The therapist can then use the formulation and treatment plan during sessions as a guide to make clinical decisions and how to proceed with treatment. It is important to have specific treatment goals, because the treatment plan also serves as sort of a record for progress where both the client and therapist can identify what progress has been made and whether or not their hypothesis has been supported. In being able to keep track of progress, the therapist and client will know when the treatment goals have been met, and therapy can be terminated, as opposed to continuing with unnecessary sessions. On the other hand, having this formulation and measurable treatment goals is also important because if a client is doing poorly and they are not progressing, both the therapist and client can then stop and work together to problem solve and determine what steps should be taken to help the client progress.

    Reply

  9. Jayson Hidalgo
    Nov 08, 2018 @ 00:22:18

    The client felt like a failure after the grocery store trip did not go as planned. She stated how easy it is for someone to go to the grocery store and since she could not do it, the client seemed defeated. The client does not see this as a success because the overall result was that she fled the market, but the therapist is validating her efforts to actually trying it on her own and validate how much progress she has made. The client’s response to the automatic thoughts and physiological arousal was to rapidly get outside of the grocery store to her husband who was waiting out for her. Her husband is her safety behavior because she claimed he is always there for her when she feels the tensions of a panic attack. The husband provides her with a sense of relief.

    CBT case formulation is very important because it provides the direction of how the individual will get better. It pretty much integrates the information gathered from the intake assessment and CBT assessment to formulate certain key points to focus on. The CBT case formulation is sort of like a story gathered from the assessments of the client that describes exactly how an individual got their presenting problems and their symptoms. It shows what contributed to their problems. It helps the client get better by essentially allowing the therapist determine a treatment plan by using the client’s information. The more information the therapist can obtain from the client, the better the case formulation will be along with the therapist’s hypothesis, and thus it will impact how well the treatment plan will be. It pretty much sums up everything and the therapist has information to support why he or she thinks this way and supports why they are thinking about selecting a specific treatment plan that will benefit the client in terms of best fitting with the client’s characteristics. It is necessary to have specific, concrete, and measurable treatment goals because without them, there will be no proof of improvement. The goals are what shows what the client has been proving on and it also shows how much the client is making progress. It also allows the client to see how well he or she is performing and it also shows the therapist how well their intervention they have chosen is working. If the client is not showing any improvements by not fulfilling any of the treatment goals then the therapist is given the chance to alter the treatment plan to benefit the client more.

    Reply

  10. Nicole Plona
    Nov 08, 2018 @ 15:57:06

    Behavioral Exposure:
    In response to the event the client’s primary negative automatic thought was that she wouldn’t be able to escape or handle going into the grocery store. The client ended up having a panic attack in the store and was not able to fully compete the task at hand. The safety behavior that was involved was her running away from the situation instead of facing the grocery store and calming herself down in the moment. Her husband could also be considered a safety token because after seeing him she was able to calm down. If this becomes a reoccurring action in time of distress, seeking out her husband would then become a safety behavior which was the case in this client’s situation.

    Case Formulation and Treatment Plan:
    A CBT case formulation is important for effective therapy because it is the one of the focal points to helping a client getting better. To begin, a CBT case formulation supplies the counselor with crucial information about the client that will allow them to plan appropriately and set attainable goals. A therapist having this type of information also allows a counselor and client to work collaboratively together to create the goals that are being set. And it can also make a client feel more as an equal in the relationship instead of the counselor just controlling and adjusting the entire therapy sessions. Being more involved in the planning process can increase involvement and motivation in the client throughout all of the sessions as well. It is necessary to have specific, concrete, and measurable treatment goals when possible because it allows for easy progress tracking for a client. When looking back on the progress that is being made a therapist and client will be able to see what was able to be and not to be completed by the client. With that information the treatment can be adjusted to further benefit the client in a more attainable and appropriate way.

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Adam M. Volungis, PhD, LMHC

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