Topic 9: Behavioral Exposure & Case Formulation and Treatment Plan {by 11/10}

[Behavioral Exposure] – Watch PDA-6: Behavioral Techniques – Assessment of Anxious Patterns.  Answer the following: (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?)?  {Highly Suggested: Complete an Anxious Patterns Record – this will be required for Exam 2.}

 

[Behavioral Exposure] – Watch PDA-9: Behavioral Techniques – Modifying Anxious Thoughts.  Practice a Decatastrophizing Worksheet on yourself. Answer the following (you can be brief): (1) Was it helpful starting with the worst-case scenario and ending with the most realistic scenario? (2) Did assessing the probability for each scenario provide supportive “data” to help modify your negative automatic thought? (3) Did this technique provide enough “convincing” information to develop an alternative thought?

 

[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?

 

Reminder: You will need to complete a core belief Behavioral Experiement for Exam 2.

 

Your original post should be posted by 11/10.  Have your two replies posted no later than 11/12.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

41 Comments (+add yours?)

  1. Rylee L Ferguson
    Nov 09, 2022 @ 11:15:55

    It seemed that the primary negative automatic thought was that she might have a heart attack in the store and be unable to get help. This thought persisted despite her trying to rationalize and tell herself she knew she was not having a heart attack. Her emotions caused her to accept the automatic thought despite some evidence against it. In terms of cognitive distortions this could be considered catastrophizing. It is very unlikely that the client would actually suffer a heart attack at that moment and still that the scenario would play out as she feared with no one being able to help her. Nonetheless she is committed to believing this worst case scenario as if it was bound to happen.

    She tried to reassure herself of her safety but felt so overwhelmed by her thoughts that she felt she was losing control and had to leave the store. She went to the car and seeing her husband helped relieve some symptoms. This immediate relief and our prior knowledge of the client suggest that her having her husband nearby is a safety behavior for her. She feels he can take care of her and meet her needs if something were to go wrong. Therefore she is not overcoming the aversive situations by confronting the negative emotions when she is with him.

    It was helpful to start in the worst-case scenario then end in most realistic scenarios. I think since the instinct in catastrophizing is to think in terms of extremes it is helpful to get those ideas out there before coming back to more realistic thinking. If you did it in a different order I think the worst case thoughts would be nagging at your mind preventing you from really shifting you perspective. Assessing the probability of my negative automatic thought did help me modify my thinking a bit because I had previously not considered its likelihood in regards to other possibilities. This helped me see there was a lot of probability that it would not happen how I thought too. It helped me modify my thought to a more nuanced alternative where things might not be the best scenario but also not the worst. My new thought was more in the gray area which is still a helpful improvement.

    CBT requires a good case formulation to be effective. The formulation helps provide direction to sessions, ensures time is spent well, and that treatment goals are pursued and monitored. It does so by providing an outline of the particular client’s existing symptoms and difficulties that should be addressed and how the therapist aims to treat them. This also involves checking up throughout therapy to see how much progress has been made and if the treatment is effective. The formulation begins in early therapy but is malleable and changes when new issues with the client come to light or it appears one technique would be better suited to their growth. A case formulation can be particularly helpful when it is created through collaboration with the client so they feel informed and empowered to move towards their goals. Without a formulation therapy could not be very effective as there would be no identified problems, goals, or ways to even measure progress.

    It is best to have specific, concrete, and measurable treatments goals because it makes monitoring progress all the more easy. If you can be more precise in a client’s starting point and end goal then you can better see how much progress they have made. Otherwise if you have a vague understanding of goals and no way to measure then the therapist might assume there has been progress even when the client feels the same. However, the concrete data can also act as motivation for the client to continue to grow. Even before the therapist sees that goals have been met they can share signs of forward progression to the client. This can show them that their effort in therapy is doing something and not a waste of time. It can give them the confidence to continue to work hard towards achieving their goals. Therapists should pursue specific, concrete, and measurable goals because it is what is best for the client and makes therapy more scientific and verifiable.

    Reply

    • Bekah Riley
      Nov 09, 2022 @ 19:08:34

      Hi Rylee,
      I thought you had a great response this week! I felt that overall, your response was very clear and precise! More specifically, I thought you did a good job at identifying the client’s specific automatic thought as well as her cognitive distortion in relation to the panic attack she was experiencing. I also really enjoyed reading your description of how starting at worst case-scenario and moving to the most realistic case-scenario is helpful. I agree that if the client had to envision the most realistic or best case-scenario first, it would be challenging for them to discard their persistent automatic thoughts about the possible worst case-scenario.
      Overall, great post!

      Reply

    • Tom Mandozzi
      Nov 10, 2022 @ 13:54:16

      Hi Rylee,

      I resonated with what you said about case formulation and how important it is in the therapeutic process. I think it is so often separated from the therapeutic process, but it is such an integral part of it. I agree that it provides an outline, or framework, for the therapist to follow so that they can ensure the therapeutic process is structured and conducive to reaching client treatment goals. Without creating a case formulation or referencing one, the therapist may be misguided and stray away from target treatment objectives for therapy. Without case formulation, it is difficult for the therapist to know how effective therapy is for their clients. Great post!

      Reply

  2. Amanda Bara
    Nov 09, 2022 @ 12:38:30

    The client’s primary negative automatic thought in response to the event in the grocery store was that she could not escape and she was having a heart attack. She felt that she was losing control and that she had to get out of the store. The client’s response to the feeling and thoughts made her leave the store and go to the parking lot. She kept telling herself that she was not having a heart attack but her feelings took over. The emotions were so high that the client had to escape in order to feel some relief physiologically. She engaged in a safety behavior of running to her husband when the panic attack was present. One type of cognitive distortion that is apparent in this situation is catastrophizing. It is catastrophizing because the client thought they were having a heart attack when in reality there was just a surge of adrenalin from the anxiety. The thoughts proceeding the event was that the client felt silly and like they failed. Even though the client was ambitious to going into the store the outcome was not what she had hoped for.

    I thought it was helpful to start at the worst-case scenario and ending at the most realistic scenario. It helped me to understand that there are more possibilities for a good outcome than a bad outcome. It allows you to look at strategies in order to achieve a realistic or best outcome. Catastrophizing blocks out the ability to think strategically therefore, this technique allows you to break down situations and see them for what they really are. Assessing the probability of each scenario in my case did provide supportive “data” to help modify my negative automatic thought. It allowed me to see that there are other possibilities than just a bad outcome and there are ways to get to a more realistic scenario. In my case, this technique did provide enough “convincing” information to develop an alternative thought. However, I think depending on what the negative automatic thought is and the reality of each situation is different so this technique may not work for everyone. There may need to be different types of behavioral techniques or thought modifications that need to be done in addition to this strategy.

    CBT case formulation provides clients and therapists with a depiction of why the client is distressed and what events have led to where they are. It allows the client to be seen from a bigger perspective than just their issues. It incorporates all elements of the client including their background, medical history, and significant life events that have impacted their identity as an individual. Case formulation is important for therapy as it depicts certain treatment goals and allows the therapist to hypothesize how clients have come to their certain type of distress. Without case formulation there would be no basis for a formal DSM diagnosis which is crucial for the guidance of treatment direction. There would be no structure or direction without a case formulation which could prevent any substantial progress for therapy. It is necessary to have specific, concrete, and measurable treatment goals whenever possible in order to see what is working for a client and what is not working. Treatment goals help to provide a sense of hope and desired outcomes. They help to indicate how the therapeutic process is going by reducing symptom distress and improving one’s quality of life.

    Reply

    • NikkiAnn Ryan
      Nov 10, 2022 @ 10:08:33

      Hi Amanda,

      I think you did a great job with your post, I particularly liked your description of the importance of CBT case formulations and having specific treatment goals. I appreciated your point about how a CBT case formulation helps to see the client as a whole person rather than just their presenting problems. Looking at the client as a whole person including their background, medical history, and significant life events may help the therapist catch important factors that are contributing to the client’s distress that they may have otherwise missed.

      Reply

    • Yoana Catano
      Nov 12, 2022 @ 12:02:00

      Hi Amanda,
      I agree with the way you explained how the psychological relief comes from avoidance, the client escapes the situation, and this reduces the symptoms in short term, using her husband as the copying skill. However, in a long term, the client will feel disappointed of not being able to achieve her goal. She can see that the outcome resulted in failure if she was no able to complete it. The catastrophizing distortion is bringing those negative emotions and feeding her core belief. That’s why it is important in therapy to help her to see other evidence that shows how the little steps are progress and not just the outcome.

      Reply

  3. Tom Mandozzi
    Nov 09, 2022 @ 12:46:07

    I think the client’s primary negative thought was about expecting or thinking that she will experience a panic attack while grocery shopping, and initially the cognitive distortion seems to be that the symptoms of the panic attack signify medical danger that may threaten her life. I thought it was interesting that even though she was able to remember some of the psychoeducation. Dr. V discussed in previous sessions during this experience, she still found it difficult to really “feel” this. I think it was great that Dr. V highlighted this during the session to provide some insight for the client. Even though she was reminding herself that she was going to be alright, her overwhelming symptoms of anxiety contributed to her anxiety made it even more challenging to overcome the automatic thought. I thought she demonstrated great insight into her own experience and was very self-aware when describing what happened and the cognitive and emotional processes that took place. In response to the event, the client experiences elevated heart rate, chest tightness, sweating, and other physiological symptoms of anxiety. She leaves the store and feels comfort and relief from her symptoms when she is with her husband. Even though one of her strengths was to remind herself of what she learned in therapy, she became so overwhelmed that it was hard to access and truly believe this information during the event. She experienced immediate relief when she left the store and was able to be with her husband, which seems to reinforce that she has returned to “safety” and that the experience of shopping at the store is a danger. Treatment interventions that support gradual exposure to this stressor will empower the client to overcome her anxiety symptoms and develop skills to manage thoughts and feelings while in the store.

    I think it was helpful to start with the worst-case scenario because in a situation in which a person is catastrophizing, they will most likely find it easiest to come up with the worst-case scenario as opposed to the best-case scenario or most realistic. This makes the start of the worksheet easier, because when we are anxious about a particular event or situation, we often get stuck thinking about the negative potential outcomes. By starting with the worst-case scenario, we can use this framework to develop positive or realistic outcomes after reflecting on what we believe is the worst-case scenario. I think it ends the exercise on a positive note by focusing on positive and realistic outcomes at the end that can build upon the worst-case potential outcomes that the client comes up with. Assessing the probability for the scenarios I came up with in response to my thought was very helpful because it allowed me to look at the situation from multiple perspectives. I think it’s so easy for people to experience a negative automatic thought and then immediately assume the worst-case scenarios will happen. By assessing potential outcomes (both positive and negative), I was able to open my mind to all the possibilities instead of just focusing so strongly on the negative. This technique did provide enough convincing information to develop and alternative thought. I think it is important to keep in mind that the goal isn’t to just start believing the best-possible outcomes will take place, but to look at the situation more realistically and neutrally.

    Case formulation is a critically important part of therapy and is often overlooked when it comes to treatment planning and assisting clients in treatment goals. Before a clinician can develop an in depth understanding of steps to take in treatment, they must develop a solid and comprehensive case formulation based on the client’s clinical presentation and personal experiences and history. Jumping into treatment interventions and targeting issues that the client is dealing with will not be as effective without a plan for their course of action. The case formulation should be an ongoing process for the therapist and should be shifted and adapted throughout the treatment process. It is necessary to have specific, concrete and measurable goals to determine progress and adapt the approach for both the client and clinician. As we have discussed in class, the goal of CBT is for the client to eventually discharge services and use the skills they learned on their own. Without measurable and specific goals, the therapist will have a hard time knowing when it is appropriate to close services or change goals as needed. If the goal is “the client will be less anxious”, then it is hard to know how much the client is progressing toward this goal. Though this may be the overall therapeutic goal for the client, this broad goal is not going to be conducive to positive treatment outcomes. The client may feel less motivated by this goal and ultimately be reluctant to want to close services. By creating a more specific goal (i.e. “The client’s panic attacks will be reduced from 6 times per week to 3 times per week or less by {insert target date}”, the client will be able to gauge readiness for termination of treatment or for when it will be appropriate tom move on to a new goal to work toward. By evaluating whether the client reaches this goal specifically, both the therapist and client can adapt their approach or shift the goal to something more appropriate if needed.

    Reply

    • Bekah Riley
      Nov 09, 2022 @ 19:02:04

      Hi Tom,
      I really enjoyed reading your response this week! I thought you did a great job at recognizing that the client felt the physiological symptoms of her panic attack were medically dangerous. I also found it very interesting that although her somatic symptoms were so extreme, she was still able to bring herself down in the sense that she identified it was not a heart attack she was experiencing. This would be something that I would highlight in session as a strength and motivation for behavioral exposure moving forward! In reading your description of the importance of case formulation in CBT, I completely agree that jumping into a treatment plan without fully having a conceptualized understanding on the client’s presentation and history is not beneficial for the client!
      Overall, great post!

      Reply

  4. Bekah Riley
    Nov 09, 2022 @ 18:52:46

    After watching the session between Dr. V and his client, I was able to identify the client’s primary negative automatic thought. This particular client has been struggling with panic attacks upon being exposed to what she perceives as very distressing situations or environments. During the session, the client described feeling particularly ambitious and wanted to go into a distressing environment, a grocery store, by herself and began to have a panic attack. After experiencing a number of extreme physiological and psychological symptoms, it appears that the client’s primary negative automatic thought was that she was going to have a heart attack. The client’s response to her associated automatic thoughts and physiological arousal led to her leaving her grocery cart in the store and going back outside to her car where her husband was waiting. The client described feeling as though she was having a heart attack in the store although she was able to recognize deep down that she would be okay. Upon leaving the distressing environment, the client was able to feel relief.

    When starting with the worst-case scenario and ending with the most realistic scenario in terms of the client’s success in her graduate courses, it was helpful for the client in recognizing different outcomes. The client tends to catastrophize, so it is easier for her to list the worst-case scenario right off the bat, and hard for her to see the best-case scenario or most realistic case-scenario. However, when ending on the most realistic case-scenario, as well as tying in previous experience, it helped the client identify that the most realistic case-scenario is more likely to be the outcome than she originally perceived. Even if the outcome was not quite the most realistic, the client began to move away from the worst case-scenario thinking to more realistic thinking. In addition, assessing the probability of each case scenario provided supportive data in terms of helping the client to modify her negative automatic thought. Specifically, the client was able to look back on how well she has done in the program so far and assess that the probability she will fail her next exam is not as likely as she thought. In addition, the client was able to assess that passing the exam would be the most realistic case-scenario, while doing very well would be best case-scenario. This overall guided the client to see that when assessing the probability, she is most likely to pass. I believe that this technique did provide convincing information to help the client begin forming an alternative thought. As the client stated, she was able to think about the exam more realistically and adaptively when assessing the probability of each scenario. This may be a good technique to help the client work towards developing more adaptive thoughts as opposed to catastrophizing.

    CBT case formulation is important in implementing effective therapy for many reasons. Specifically, it helps further identify and conceptualize the client’s presenting problems, related symptoms, and different contributing factors. In addition, it allows the client and therapist to work together in order to eventually move forward in creating a treatment plan that is individualized to that particular client. As the therapist and client continue to collaborate, appropriate and meaningful changes to the case formulation will help to incorporate the client wholistically when creating the treatment plan. Additionally, it is important to have specific, concrete, and measurable treatment goals whenever possible because it is easier for both the client and therapist to track the goals and see the treatment progress.

    Reply

    • Ashley Torres
      Nov 10, 2022 @ 12:35:07

      Hi Bekah, I really enjoyed reading your response. I like how you mentioned that clients tend to catastrophize so it is easier for them to list the worst-case scenarios first. I agree with you because it helps them express themselves and get their negative thoughts out of their system. I also enjoyed how you said ending on the most realistic case scenario is more likely the outcome she will receive. I believe this technique sets the client up for success in many ways including what you wrote in your response. The client gets out all of the negative automatic thoughts, they reflect on more realistic experiences, and end up realizing the probability of them all. You did a great job explaining how this technique works in a session.

      Reply

    • Tuyen Phung
      Nov 11, 2022 @ 21:15:34

      Hi Bekah,
      Your post explains specifically each question. I like your idea of creating a CBT case formulation that allows clients and therapists to work together to move forward and the plan is individualized. This step makes CBT special in collaborative characteristics between both sides. I also think that there is no specific treatment for all clients with the same disorder. On the one hand, each client is different and lives in various situations. On the other hand, case formulation can be adjusted with each client so that they are effectively treated. Overall, your rationale for the case formulation is very convincing.

      Reply

    • Yoana Catano
      Nov 12, 2022 @ 12:13:17

      Hi Bekah,
      I agree on the idea that the client starts with the worst-case scenario so she can start moving away from it, and as you said, it is easy for her to explain the worst since the cognitive distortion is catastrophizing, but after that, what she is doing is building new information and recreating evidence that will help to decatastrophize. Also, I agree with you that this technique provided convincing information to work on an alternative thought on a more realistic scenario.

      Reply

    • Teresia Maina
      Nov 13, 2022 @ 00:34:36

      Hi Bekah,
      Amazing discussion post! You brought up a critical point that clients tend to catastrophize the situation. Starting with the worst-case scenario is easier since we all tend to think about the worst-case first. After that, it becomes easier to think about other possible scenarios that are more realistic. When it comes to probability, after listing all the possible scenarios, clients receive data showing how the worst-case scenario is invalid. I enjoyed reading your post!

      Reply

  5. NikkiAnn Ryan
    Nov 09, 2022 @ 21:33:34

    The client wanted to see if she would be able to go into the grocery store by herself. She explained that when she first got to the grocery store, she thought to herself, “I’ve got this,” however, she eventually experienced several physiological changes and had a panic attack. The client identified that she had thoughts that she could not escape and wondered how she would get help if she were to have a heart attack in the grocery store. She also expressed feeling like she was losing control and “knew [she] had to get out.” During the therapy session, the client also acknowledged that she felt like she had failed because she did not complete her shopping. This is an example of dichotomous thinking in which she viewed the trip as only being a success or a failure. However, with therapeutic guidance, she was able to see that rather than being one or the other, there were parts of the experience that were successful such as the fact that she went into the store at all and gathered some items even if she did not finish her shopping. After experiencing these negative thoughts and physiological symptoms, the client ran to the parking lot and stated that she felt relieved when she saw her husband. It appears that her husband serves as a safety behavior for the client because he helped her cope with her anxiety. The client’s avoidance, as evidenced by her running out of the store, also appears to serve as a safety behavior because she experienced temporary relief by removing the aversive stimulus, the crowded grocery store.

    I found it helpful to start with the worst-case scenario because it allowed me to get all my worst-case thoughts out of my head and onto the paper which helped me focus more on the more realistic scenarios. Additionally, while reviewing the worst-case scenario, I thought to myself “well that’s probably not realistic” which actually helped me develop the more realistic scenarios. Assessing the probability for each scenario helped me realize that the probability of the worst-case scenario was equal to that of the best-case scenario. This helped me recognize that the only difference between the worst-case scenario and the best-case scenario was that my thoughts associated with the worst-case scenario were more prominent. Going through the decatastrophizing worksheet helped me develop an alternative thought because this technique assisted with developing a more realistic scenario of what will likely happen, and it guided the creation of a coping plan which contributed to a thought that even if the worst-case scenario occurs, I will be able to manage it.

    A CBT case formulation is an important component of effective therapy. It is a process of gathering and organizing important information about the client which is used to better understand the client and why they are seeking treatment and to create a “road map” to help the client achieve their goals and reduce distress. Moreover, a CBT case formulation is a way of understanding the client’s presenting problems, the origins of such problems, what factors are maintaining the problems, and how different problems are connected in the case of clients with multiple presenting problems. Understanding these factors helps the counselor conceptualize the client’s distress and symptoms and guides the treatment plan and intervention process. Not every intervention will be helpful or necessary for every client, so understanding the clients’ problems and goals guides the process of selecting the most appropriate and effective treatment approaches for each individual. The CBT case formulation process also assists with structuring individual sessions and treatment overall so that goals are achieved in a systematic manner. This is particularly important for clients that may have limited time in therapy due to financial or insurance-related constraints. While a non-structured therapeutic approach may eventually help clients experience less distress, the case formulation process makes the journey to the goal and distress reduction more efficient and purposeful. Finally, the case formulation is a great opportunity to determine potential obstacles to achieving therapeutic goals so that problem-solving can begin before the obstacles arise as well as an opportunity to determine clients’ strengths so that counselors can incorporate what the client already knows how to do into the treatment plan. Treatment goals should be specific, concrete, and measurable to ensure that they are purposeful and geared toward the goal(s) that the client is working on. Just as a case conceptualization makes the therapeutic process more efficient and effective, goals that are specific, concrete, and measurable are also achieved more efficiently rather than loose, vague goals. When a goal is too vague it can be difficult to tell if it has been achieved or it can seem like it can never be achieved which may make the client feel doubtful about therapy. Therefore, to foster a sense of accomplishment and hope, it is important for goals to have clear, measurable steps so that progress can be monitored. This also helps ensure that the therapeutic process stays on track. If a therapist cannot think of anything that was done in the session that contributed to progress on one of the client’s treatment goals, they can reevaluate what they are doing in sessions and prepare to make progress during future sessions in order to make the most out of session time.

    Reply

    • Tom Mandozzi
      Nov 10, 2022 @ 13:46:51

      Hi NikkiAnn,

      I had the same feeling about doing the worst-case scenario first. I feel like if I had started with the more positive or realistic scenarios and then focused on the negative ones. Firstly, I think this would have made it more difficult to think about positive outcomes because I would be so heavily focused on catastrophizing about the negative possibilities. I feel like doing this technique in this order allows for a more well-rounded perspective for the client to evaluate possible outcomes in a more objective way. Ending the exercise on a realistic note allows the client to have an understanding of the event and outcomes in a more realistic way that can evoke change and use of appropriate skills learned in therapy. Forming realistic outcomes was much easier after reflecting on the more unrealistic negative possibilities. Great insight on this!

      Reply

    • Sam Keller
      Nov 10, 2022 @ 13:53:11

      Hi NikkiAnn!

      I really liked that you pointed out that the client feeling like they were ‘losing control’ had a lot to do with why they panicked. Especially because she felt like she was losing control and she was perceiving that other people were noticing (and maybe judging her?). This can really hint to us one reason why the experience becomes so distressing for her and why one of her main coping mechanisms is escape.I also like how you mentioned that case formulation can help us predict and prevent some obstacles that can come up in therapy.

      Reply

  6. Rachel Marsh
    Nov 09, 2022 @ 21:42:28

    Behavioral Exposure-PDA-6

    Question 1

    Lindsey had two possible automatic negative thoughts that can also be related to cognitive distortions. Firstly, Lindsey had the automatic negative thought, “I can’t escape,” while she was experiencing her panic attack in the grocery store. After this thought, Lindsey thought she was going to experience a heart attack and began wondering what would happen to her if one did happen to her in the store. This could be considered catastrophizing. Catastrophizing occurs when an individual tends to assume the worst. Though Lindsey knew she didn’t have a heart attack, she assumed the worst about her panic attack symptoms. Moreover, the thought of not being able to escape could be viewed as catastrophizing, as Lindsey was able to leave the store while experiencing her panic attack.

    Secondly, Lindsey had the automatic negative thought that she was “stupid” and “a failure” for not being able to complete her grocery shopping trip. With this thought, several cognitive distortions come to mind. Firstly, this could be considered all-or-nothing thinking. This occurs when the client believes things are either all good or all bad. For example, Lindsey feels as though she must go into the grocery store and successfully complete a purchase, or she is a failure. As Dr. V and Lindsey discussed after, it might be more beneficial for Lindsey to do grocery shopping in steps. Rather than viewing her trip as a failure, she views it as partially successful, given that Lindsey was able to enter the store and start shopping. This could also be considered minimizing in that Lindsey downplays the positive aspect of her experience. Lindsey failed to give herself credit for having the courage to go into the store by herself and begin to shop.

    Question 2

    In addition to her thoughts, Lindsey exhibited symptoms such as heart racing, sweaty palms, chest tightness, nausea, and a feeling of losing control. As Lindsey began to feel the intensity of her symptoms increasing, she noticed other people around her picking up on her anxiety. As a result, she felt anxious about being anxious in front of other people.
    In response to her anxiety, Lindsey left the grocery store and went into the parking lot to see her husband. Before leaving the store, Lindsey attempted to reassure herself that she was only having a panic attack but was overwhelmed by the increased physiological arousal. As highlighted in the video, Lindsey tends to bring her husband along as a safety behavior, even if he does not go into the store. In addition, Lindsey’s escape from the grocery store could be viewed as a safety behavior.

    Behavioral Exposure PDA-9

    Question 1

    For my decatastrophizing worksheet, I used an event that happened to me at the gym the other day. When I went to the gym, another gym member kept looking at me oddly. My automatic thought was that I must be working out strangely or looking weird. The person approached me and said I looked familiar. After talking, we figured out that this individual was a frequent customer from my previous job. They were only looking at me because they couldn’t figure out where they had seen me before.

    I did find it helpful to start with the worst-case scenario and end with the most realistic one. With my experience, it was easier for me to think of the worst-case scenario first. With automatic thoughts, the worst scenario often comes to mind easily compared to an alternative explanation. By identifying more realistic events after the worst case scenario, I felt I spent more time thinking about a more realistic scenario. Spending more time thinking about realistic scenarios made me realize how much less likely the worst-case scenario was to occur.

    Question 2

    Assessing the probability for each scenario was also helpful in modifying my automatic thought. Had I not known that this person was looking at me because they couldn’t figure out where they knew me from, I would have gone with the worst-case scenario. But after taking a step back to reassess the situation and rate the probability of each scenario occurring, I realized that even if the worst-case scenario were to occur, it wouldn’t be the end of the world.

    Question 3

    Though I discovered why this individual was staring at me at the gym, this technique provided enough convincing information to develop an alternative thought. I went through this exercise with the mindset that I did not know why this person was staring at me. That is, if it ended up that I did not know this person from somewhere, I could find alternative explanations for them staring other than “I must look silly/stupid.”

    Case Formulation & Treatment Plan

    Question 1

    Case formulation is integral to CBT treatment for several reasons. Firstly, having an accurate understanding of the client is imperative to treatment planning. If a therapist fails to acquire an accurate understanding of their client, this might lead them to set goals that are irrelevant to the client or choose interventions that do not pertain to the client. For example, based on their case formulation, a therapist might propose that a client is dealing with anxiety, but the client more accurately meets the criteria for depression. Interventions and treatment goals differ between these two disorders and would do a disservice to the client by choosing interventions that do not pertain to their situation.
    Additionally, CBT case formulation can help tailor treatment to the client. A CBT case formulation goes beyond the client’s thoughts and beliefs. It also aims to ascertain the client’s goals, values, aspirations, interests, and personal characteristics. By understanding these factors of the client, the therapist can get a better idea of how to individualize treatment. For example, two clients with the same disorder might have different goals. Though the approach might be similar, how the treatment is executed might differ. For example, one client like Lindsey with panic disorder/agoraphobia might have the goal of completing a shopping trip independently without having her husband nearby to escape to. Another client with the same disorder might have the goal of just getting out of the house and driving to another family member’s house rather than going to the grocery store.
    Overall, CBT case formulation is integral to therapy to ensure a relevant choice of goals and interventions as well as individualized treatment to clients contingent upon their personal, cultural, and other characteristics.

    Question 2

    Having specific, concrete, measurable goals is essential for several reasons. Firstly, this helps both the client and the clinician have a specific benchmark as an indicator that the client is attaining the goals they aim to achieve. For example, a client might have the goal of finding more adaptive coping behaviors. To measure this specifically, a benchmark to use might be “client will engage in at least 10 minutes of guided imagery each day”. Without having the benchmark of time, the client might not know how long they should participate in the coping to be effective.
    Moreover, specific, measurable goals can make it easier to refine goals as needed if the goal is too simple or too complex for the client. Going back to the previous example, after a week of engaging in guided imagery, the client may find that 10 minutes is not yet attainable for them. In this case, the clinician and client may collaboratively decide that a more appropriate time to spend each day maybe 5 minutes instead of 10. On the opposite end, a client may find that this time is not enough for them. The clinician and client may collaboratively decide that a more sufficient time to spend on this technique could be 15-20 minutes a day. Alternatively, this information may indicate that guided imagery is not the best choice for the client, leading to teaching the client a different coping skill.
    Overall, having measurable, concrete, specific goals provide guidelines for refining approaches and indicates whether or not a client is achieving their goals.

    Reply

    • Sam Keller
      Nov 10, 2022 @ 13:49:31

      Hi Rachel!

      I like that you drew in catastrophizing about having a heart attack as an automatic negative thought. Even knowing intellectually that she was not having a heart attack, this was still so concerning to the client that they had to decide whether or not they wanted to go to urgent care. I also liked what you shared about your own decatastrophizing worksheet. Unexpected social interactions with people you don’t remember can be very stressful!

      Reply

  7. Patricia Ortiz
    Nov 09, 2022 @ 22:40:01

    [Behavioral Exposure] – Watch PDA-6: Behavioral Techniques – Assessment of Anxious Patterns. Answer the following:
    (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?)?

    I believe that this client’s primary negative automatic thought in response to the panic attack she had was that she was going to have a heart attack and that people might see that she was going through one. She said that she felt like she was not going to be able to escape and therefore felt the urge to leave. After the event, she felt like she “failed” and like she was “silly.” She felt that way because she stated that going to the grocery store should be an easy and everyday task, but it was not the case for her. I think her safety behaviors could be that she chose her husband to take her to the grocery store and that she went to the car immediately after leaving the grocery store. The goal would be that she does not have her husband around every time and find the skills to cope with the situation by herself adaptively.

    [Behavioral Exposure] – Watch PDA-9: Behavioral Techniques – Modifying Anxious Thoughts. Practice a Decatastrophizing Worksheet on yourself. Answer the following (you can be brief):

    (1) Was it helpful starting with the worst-case scenario and ending with the most realistic scenario?
    I believe it was helpful because it made me think of everything that came to my mind and that “supported” that thought, and I could really write everything that was going through my mind at that moment. Then I could see all those things from another perspective and where I might have been thinking irrationally.

    (2) Did assessing the probability for each scenario provide supportive “data” to help modify your negative automatic thought?
    Assessing the probability for each scenario provided supportive data to help me modify my negative automatic thoughts because it made me realize that I believed some of the thoughts until I did the exercise and realized that they were not true 100%. Also, by asking myself what has not worked and what has worked in the past was a good strategy that I used, and I could see what could help me in coping with the situations. Also, by imagining the worst scenario, I could objectively analyze the severity of its real consequences. By focusing on the next steps after the worst possible scenario, one can come up with a plan and potentially come to the conclusion that it wouldn’t be as scary as one could imagine.

    (3) Did this technique provide enough “convincing” information to develop an alternative thought?
    I believe this technique provided enough convincing information to develop an alternative thought because I could decrease my thought’s level of believability and therefore develop different ways of thinking from another perspective. It helped me learn and understand how to manage emotions, feelings, and thoughts from another position, moving away from pessimism and approaching optimism. I find this technique very interesting and helpful because it also allows us to deal with everyday life problems effectively.

    [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”)?

    CBT case formulation is essential in therapy because it helps therapists and clients to understand the origin, current status, and maintenance of a problem. In the course of therapy, case formulations can be created by the therapist and the client during the evaluation phase, and they are altered as new information is learned. It helps clients get better because they can better understand their distress and have another perspective that maybe they would not have seen without a bit of help. For instance, they know they are suffering from anxiety and panic attacks, but with a suitable case formulation, they could learn about their disorder and what are the triggers for their attacks; they can have a better understanding and therefore learn the tools and skills that they need to improve and get better.

    (2) Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?
    Therapeutic goals allow clients to move from a present state to a desired state. It is the opposite of thinking about a problem and focusing on what they want to achieve and moving towards it. Goals and objectives in Cognitive Behavioral Therapy help organize and direct the intervention strategies. Thus, the interviews are not impromptu talks on the fly but instead revolve around axes previously agreed upon between client and therapist, taking into consideration that CBT is a structured, goal-oriented type of talk therapy.
    They need to be specific because each client is different and has different needs. Not every technique is going to work the same for all clients (each person knows their capabilities and knows more or less how far they can go). Also, they need to be concrete because therapy and CBT specifically work towards helping identify and change thought patterns that negatively influence behavior and emotions. So, in order for it to be effective, we must know and identify precisely what we want to modify (through CBT, faulty thoughts are identified, challenged, and replaced with more objective, realistic thoughts). Finally, the goals need to be measurable because we cannot expect to make changes and change thinking patterns in one day; when we have measurable therapy goals, it allows us to establish concrete criteria to measure and evaluate the progress in order to make the necessary modifications.

    Reply

    • Rylee L Ferguson
      Nov 12, 2022 @ 13:10:04

      Hi Patricia. I liked how you mentioned that starting with worst case scenarios allows you to get all the thoughts out so that after you can have better perspective. I agree that this an important feature as we cannot begin to disprove or invalidate the evidence until we first pour it out on the page. Seeing it in front of us can really help begin the process of seeing the little irrationalities that can feel so real inside our heads. Great point!

      Reply

    • Tayler Shea
      Nov 12, 2022 @ 23:56:58

      Hi Patricia,

      I loved reading your post this week. I really related to you when you said that writing down what could happen from worst to best outcome really helped you understand your own thoughts. It can be so easy for us to get wrapped up in our core beliefs or anxieties. I found this exercise very helpful while evaluating a situation! The data also helped me realize that my thoughts are not always accurate and also provided me with the evidence to know that those feelings or thoughts are not true. When evaluating my own worse-case scenario I realized that the worst-case really isn’t THAT bad and I was also able to develop an alternative thought.

      Reply

  8. Yoana Catano
    Nov 09, 2022 @ 23:32:34

    (1) The client mentioned some automatic thoughts about the event: “other people can see I’m struggling”, “I am losing control”, “I can’t escape”, “my symptoms are getting worse”, “what happens if I have a panic attack”, “how am I gonna get help”. The main distortion could be mindreading, in the sense that she knew or believed she knew what other people were thinking about her, which elicited other automatic thoughts as part of the self-perpetuating characteristics.

    (2) The response to her associated automatic thoughts and physiological arousal, was avoidance. Leaving the place is her first response and being with her husband is part of her safety behavior. According to her: “I know he is there for me, and he knows how to respond”. It is the short-term anxiety relief that perpetuates the avoidance.

    [Behavioral Exposure] It is helpful because the stress is put out there first, then at the end it doesn’t seem that valid when you check the percentage. Clients usually come with a problem, and they want to express how bad it is from their own perspective. Putting the worst scenario first also has that cathartic feeling. I would say, after all the bad that could happen, the only thing left would be the good possible. But it doesn’t end up just there, after all the good and bad is said, it is interesting how a third option can come into the picture, the realistic scenario, so it means that the therapist is not trying to convince with fake positivism. The positive is as bad as the negative, and bringing all the stress back to reality, really helps to modify the negative automatic thoughts. It is different when evidence shows that it doesn’t need to be only black or white, it can be a problem that could be solved or tolerated. We can work with it or just cope. In this sense, it is definitely a good way to obtain evidence for more realistic thoughts.

    [Case Formulation & Treatment Plan] Understanding the client’s problem is the first step to providing effective therapy is not “one size fits all” in therapy, even when treatments are available for specific diagnoses, it needs to be adapted to every individual. With the case formulation, the therapist builds a CBT conceptualization of the presenting problems, associated symptoms, and contributing factors. With this information, the therapist can formulate a treatment plan and identify indicators of achievement. Without it, it would not be possible to determine if the treatment has been effective or not.

    Respect to treatment goals, it is important to highlight the statement: “if you don’t know where you are going, how will you know when you have got there”. Treatment goals provide clarity of the treatment and make change realistic and achievable. But treatment goals need to be formulated in a way that can be measurable or easy to track, not only for the therapist in the way to see if the treatment is working, but also for the client who needs to see their progress in a collaborative way; also, for external intervention such as healthcare system, audits, research, or payor.

    Reply

    • NikkiAnn Ryan
      Nov 10, 2022 @ 09:58:50

      Hi Yoana,

      I like how you described your reaction to the behavioral exposure/anxious patterns record. I agree that starting with the worst-case scenario almost has a cathartic feeling because all the worst-case scenario options tend to pop into our minds first when we are feeling anxious about something so it can feel almost like a relief to get those thoughts out of our minds first! I also agree with you that it is beneficial for the therapist not to try to convince the client that the best-case scenario option is what will necessarily occur because that may feel false and not sensible. Coming up with the realistic scenario, on the other hand, helps the client see that the worst-case scenario is probably unlikely without trying to be overly optimistic that the best-case scenario will happen instead because that would be unhelpful. Overall, I think you had a great post!

      Reply

    • Tayler Shea
      Nov 12, 2022 @ 23:52:54

      Hi Yoana,

      Great post! I really like how you stated that understanding the client is the first step in effective therapy. I think that it can be so easy for therapists to forget how important that can be! I agree that although there are outlines for clients with specific diagnoses or disorders, all therapies need to be customized to what works best for the individual and their life style/history. I also agree that this is a vital part of the client getting better both therapist and client being able to see the progress. Very insightful!

      Reply

  9. Tuyen Phung
    Nov 10, 2022 @ 08:20:15

    Behavioral Exposure

    In the video, the client described her experience of a panic attack. Her primary negative automatic thought can be one of the causes of the panic attack. She thought that when she had a panic attack among the crowd at the grocery store with various symptoms such as pounding heart, sweating, shaking, and difficulty breathing, no one comes to help her and she might be at risk in the situation. The automatic thought causes her resistance or avoidance to get into the grocery store. In other words, the grocery store becomes her triggering event as expected. In her case, her cognitive distortion was a catastrophizing in which she exaggerated her fear and situation in a negative way. With this thought, the client used avoidance as her safety behavior when she tried to ask her husband to buy groceries, and even if she had to, she asked him to go with her. Her husband became her safety behavior so that she could limit her exposure to the situation. When the client talked about her event of getting into the grocery, her automatic thought triggered her core beliefs and her physiological arousal. As a result, she had a panic attack and ran out of the store as soon as possible. When she used her safety behaviors as a solution, her anxiety could be reduced. However, her outcome was her acquittance with her avoidance and needs it for the next time. Consequently, her fear and anxiety were not effectively resolved.
    Personally, I see that it is very helpful to start with the worst-case scenario and end with the most realistic scenario. First of all, the worst-case scenario can be my initial thoughts when I have issues because distress or anxiety emerges from the thought of the worst case. Second, thinking of the best case can be out of touch when I have obvious obstacles to reaching a goal. Therefore, thinking of the most realistic scenario after listing the worst-case scenario can see how negatively I see the situation, and my thought of the worst case can be illogical. I also think that assessing the probability for each scenario can provide supportive evidence to modify my negative thought. Specifically, when I rate my worst case at a high level of probability and my best-case scenario at a lower level of probability, I can see how I underestimate the evidence of the best-case scenario and overestimate the worst-case scenario. Also, assessing the probability of the realistic-case scenario can be balanced and based on the awareness of the under and over-estimation. Even though the technique of understanding decatastrophizing is helpful in recognizing the realistic-case scenario, it needs other factors to have more convincing information to develop an alternative thought such as Socratic techniques.

    Case Formulation & Treatment Plan.

    CBT case formulation is important for effective therapy for several reasons. First, when clients understand accurately case formulation for their own issues, it is easier to build therapeutic collaboration, which is the nature of the CBT approach. Second, additional information is added into case formulation throughout the therapy can help the clients understand that they are cared for in every detail. As a result, they are motivated to change. Moreover, it is better for them to know what they will work on for a specific session for their own sake. They will get better when knowing their specific goals. It is necessary to have specific, concrete, and measurable treatment goals whenever possible because it helps to modify what goals need to be prioritized over the course of treatment and what goals can be set aside for later intervention. Even though there will be a lot of changes, update, or new information along the treatment, having specific goals keep both therapist and client in the right track of treatment.

    Reply

    • Ashley Torres
      Nov 10, 2022 @ 12:55:21

      Hi Tuyen, your response this week was very informative! I like how you mentioned that once a client understands their case formulation, it will help the pair build therapeutic collaboration. I understand how important and effective a case formulation is but I did not pay much mind on how it aids rapport. It is like a bonus that comes out of the formulation because in order for the client to be fully engaged in sessions, they have to trust their therapist. I also agree with you that creating these formulations ensures the client is being taken care of. Lots of information is being asked and incorporated into the treatment plan. Instead of jumping into therapy, the therapist gets as much information they can about them, their distress, and their history.

      Reply

    • Patricia Ortiz
      Nov 11, 2022 @ 18:25:36

      Hi Tuyen, establishing therapeutic goals definitely is a way to build therapeutic collaboration, as you said is the nature of the CBT approach. I also like how you mentioned that when additional information is added to case formulation throughout the therapy can help the clients understand that they are cared for in every detail, this is essential because this way clients are motivated and they look forward to making the desired changes.

      Reply

  10. Ashley Torres
    Nov 10, 2022 @ 12:26:51

    The client’s negative automatic thought during the event is that she’s having a heart attack. When the client noticed the grocery store was crowded, she felt her body get hot, her chest felt tight, and her heart started racing. The client mentioned she tried to use techniques she learned in session and told herself she wasn’t having a heart attack. Unfortunately, she had to leave the store because her physical symptoms were intense and she believed the worst was going to happen, for example a heart attack. The client then left the grocery store and reconnected with her husband because that is her safety behavior. The client uses her husband as a security outlet and stated she felt relaxed when she reunited with him. All she wanted to do was be with her husband and go home because those familiar environments made her feel safe. After the event she had thoughts of being a failure because she did not complete her grocery shopping. The client was able to go inside the grocery store and put a few items in her cart but then she started noticing people around her. The client had a panic attack and didn’t continue with her original plan.

    Using a decatastrophizing worksheet was helpful because it starts with the worst-case scenario and ends with the most realistic. I think starting with the worst possible outcome helped flush out all the negative automatic thoughts and get them out of the way. It is hard to focus on realistic outcomes when someone is catastrophizing in the moment. Once we get that out of the way, we can analyze the scenario and come up with a more realistic outcome. I think it is also motivating to end on the most realistic outcome because it reminds us that not everything is a negative experience. I believe accessing probability for each scenario provided supportive data to help modify negative automatic thoughts because it was a visual of how likely something could happen. It gave me a different lens on the scenario which helped me understand and modify my negative automatic thoughts. It is a great layout to encourage progress and realize what is most likely to happen. I believe this technique provides enough convincing information to develop an alternative thought because it explores different scenarios and their probability. It is helpful to open the mind to other possibilities but if the probability is not considered then it brings up back to the beginning. Once we decide on probabilities, it helps us alter our thoughts even if it’s not the best-case scenario.

    A CBT case formulation is extremely important to help a client get better because it is a specific treatment plan designed with the client to reach their goals. It encourages collaboration and uses measurable goals to examine progress. It informs the client what to expect from the services and provides structure. The formulation includes the client’s symptoms, distress, background information, medical history and other information that will help the clinician understand their client. It’s important to have specific, concrete, and measurable treatment goals because it sets a foundation for the therapy. It gives the pair a starting point and then they can measure how well or not they are progressing. If no improvements are being observed, the therapist can stop and come up with a different plan. This is very important because if a therapist does not know how well and at what rate the client is improving, it makes it hard to identify what needs to be changed. Measurable goals are also great because it informs the clinician when the client is ready to stop services. The client will become independent and have learned to deal with their distress on their own.

    Reply

    • Rachel Marsh
      Nov 11, 2022 @ 09:40:19

      Hey Ashley,

      I loved reading your post. I especially appreciate your insights on the decatastrophizing worksheet. You make a great point when you say that addressing the worst possible outcome first can help minimize some of the automatic thoughts. When doing the worksheet, I had a similar experience. I did find it easier to come up with some realistic scenarios after thinking of the worst case. In addition, I found that as I was listing the more realistic scenarios, it made me realize that even if the worst case were to occur, it would be something I can still handle.
      In addition, I like some of the things you said about case formulation. Specifically, I like what you said about measurable goals in terms of knowing when the client is ready to stop services. The goal of CBT is to help clients become their own therapists. By giving clients the skills and resources they need to become independent, we can empower them to solve their own problems as well as monitor and refine their thoughts and beliefs.
      Overall, great post!

      Reply

    • Patricia Ortiz
      Nov 11, 2022 @ 18:41:32

      Hi Ashley, I think the same as you; it is hard to focus on realistic outcomes when someone is catastrophizing at the moment. It is helpful to get rid of all the negative automatic thoughts by beginning with the worst scenario. I also believe that ending with the most realistic outcome is motivating because it reminds us that not everything is a negative experience; being aware of our catastrophic thinking can help us to put steps in place to manage it going forward. Also, in this exercise asking myself, “what is the worst that can happen? what is the best thing that could happen? what is the most likely thing to happen?” for instance, could help me shift my thinking as I built up a more balanced view of the particular situation.

      Reply

  11. Sam Keller
    Nov 10, 2022 @ 13:45:06

    [Behavioral Exposure] – PDA-6: Behavioral Techniques

    1)The client’s primary worries during this experience were that she might have a heart attack and that people might notice her lack of control. She mentioned having the automatic negative thought that she really thought she could handle this and that she was disappointed in herself for not being able to handle it. She had to remind herself that there is a difference between intellectually knowing why she was having those responses and being able to physically not react. Other negative thoughts were that she should be able to just go to the store without having these reactions. She viewed this as something that is easy for other people to do so she should be able to do it easily as well.
    2) During her panic attack, she got hot, had sweaty palms, tight chest, racing heart, hyper aware of other people noticing her, and a sense of losing control. Her main safety behavior was to leave the store and go to her partner in the car. She said that once she saw her husband her symptoms began to get better and she began to calm down. Later while processing in session she needed to remind herself to give herself credit for attempting something she had not done in a long time.

    [Behavioral Exposure] –PDA-9: Behavioral Techniques – Modifying Anxious Thoughts.

    I think working from the worst case scenario and working backwards can be helpful because you start with the negative and end with the positive. It also allows you to acknowledge the trustful parts of the worst case scenario so you can determine how valid it is. Then looking at the best case scenario makes you look for the positive deliberately to maybe disprove the worst case scenario. Then by ending on the most realistic you kind of blend the two into something that will probably happen. Working through it this way makes you acknowledge the bad, then the good, and then take parts of both for a more realistic view.
    Assessing the data for each scenario really helps put it in perspective how likely each scenario is. It can show you how far off from a realistic probability your worst or best example is. It can also help prevent black and white thinking by making you evaluate each scenario on a scale. This also helps you argue those points to yourself when you are trying to accept the more realistic version or disprove to yourself that the worst case will happen.
    I think this technique was very grounding. It really forces you to think it through and come to a new conclusion. I don’t think you will magically believe the more realistic version right away but it helps you move closer to believing it. You can go from believing the realistic version 20% to believing it 70%. It’s not perfect but it is better than it was. I do think it gives you enough information to form new thoughts because of the way you go through and think it out piece by piece.

    [Case Formulation & Treatment Plan]

    Having a case formulation helps immensely with treatment because when choosing treatment goals or methods you first need to know what the major issues are. You get lots of information on the client, what they view as pressing needs, some of their history, what other treatment they may have received in the past, which allows you to form an initial diagnosis. That theory of a diagnosis then helps you narrow down how you will treat that specific disorder and helps you figure out what might be most beneficial to that client.
    Having specific and measurable treatment goals is beneficial because it allows you to measure progress and see greater trends over time. We work with the mind, and there is no machine that can spit out numbers about how bad a patient’s depression is the same way we can measure cholesterol. This also makes it harder to determine whether or not a client’s mood is back to non-clinical levels without some way to measure this. This also lets the client see their progress, which might be hard for them to do initially due to having a distorted view of the world. In that case it helps to be able to point to something measurable and show them the changes that have occurred over time.

    Reply

    • Kristin Blair
      Nov 10, 2022 @ 16:00:41

      Hi Sam,

      I really enjoyed your post this week. I liked how you described not being able to measure someone’s depression in numbers as we do with cholesterol levels. I thought this helped put that point into perspective in a relatable way. Imagine if we COULD do that, though! Hahaha

      Reply

    • Rylee L Ferguson
      Nov 12, 2022 @ 13:14:51

      Hi Sam, I am glad you mentioned some of the clients other negative automatic thoughts about how easy it is for others to go to the grocery store. This is not something I had considered too strongly but it may really play a role in how she views the situation. She may see the disparity in her reaction to the grocery store in comparison to others and be excessively harsh on herself. These negative feelings could exacerbate her feelings of low self-efficacy and mess with her head as she tries to gain confidence and replace her negative thoughts. This makes me think normalizing her response in some sense might help reduce her negative comparison and be an important step towards her goals.

      Reply

    • Teresia Maina
      Nov 13, 2022 @ 00:53:14

      Hi Sam,
      I really enjoyed reading your post! You brought up a great point that other people may not find it easy going to the store. When most people are in situations that cause panic, they never realize that their other people share the same feeling. Most clients believe that the problem only affects them and that others are doing better than them. I never thought about how starting with the worst-case scenario can help a client accept the truthful parts of the scenario. Accepting the truthful parts of the worst-case scenario can help clients come up with realistic scenarios. Overall, fantastic post!

      Reply

  12. Tayler Shea
    Nov 10, 2022 @ 14:27:56

    It seems to me that the primary autonomic thought that the client is having in these situations is that she is going to have a heart attack or some sort of physical harm from her panic attack. The client seems to catastrophize every time that she is in the store. She mentally understands what is going on, but her emotions and fear take over during these stressful situations. The client’s safe behavior was to leave her cart and rush out of the store into the parking lot to meet her husband. It seems to me, that the client’s husband is a safety for her, along with leaving the store.

    I think that it was very helpful for the client to start with the worst-case scenario because she was able to understand that the likelihood of that happening is not great. The client has a tendency to overthink and catastrophize situations. I think that starting at the worst-case scenario helped the client understand that the worst-case probably will not happen. When using this technique on myself, I found similar results. I realized that the likelihood of what I was afraid would happen was very small. When evaluating the worst-case scenario, I realized that the worst thing that could possibly happen to me in this situation is that if everything does not work out then I may be embarrassed. I then reassured myself that feeling embarrassed is not deadly and that if the worst-case scenario happened, I would be okay. After that, evaluating the likelihood that it would happen helped me realize that it probably would not. I have hosted many events in the past, and they have all been successful. I realized that the chance that no one would come to my event and that it would fail is small. This helped me focus on what I can do to ensure that the event is successful. I then evaluated the best possible outcome and realized that outcome is more likely than the worst case. After assessing this data based on prior events that I have hosted for work, it did help modify my negative automatic thoughts. I was able to focus much more I was very convinced after

    Having a case formulation is critical in CBT. The case formulation must consist of the client’s mental and psychological health history. These are both essential in aiding the therapist in understanding the problem. The case formulation also helps the client and the therapist work together to understand problems, treatment plans, goals, and topics of discussion. The case formulation also helps the therapist plan how to structure therapy overall as well as each individual session with their client. Having specific, concrete, and measurable treatment goals are crucial to tracking the client’s progress. When the client will also succeed more in therapy knowing that they have measurable goals that they can achieve and succeed with. When the client begins to see success within therapy and that they are achieving their goals, they are going to become motivated to continue.

    Reply

  13. Teresia Maina
    Nov 10, 2022 @ 15:33:17

    [Behavior Exposure] Lindsey’s primary negative automatic thought in response to the grocery store event was that she couldn’t escape if she were to have a heart attack in the store. She was worried that she was not going to be able to receive any help if she did have a heart attack at the store. Lindsey also was scared that she was losing control and others could see it. She then reported feeling like “a failure” for not being able to complete the task. The client experienced physical and psychological anxiety symptoms based on the event. She then left the store, returning to the car where her husband was waiting.

    [Behavior Exposure] I found it helpful to start with the worst-case scenario and end with the most realistic. In distressing situations, most individuals tend to catastrophize and have a difficult time thinking rationally. Making it very easy to come up with worst-case scenarios compared to either most-realistic or best-case scenarios. After going through all the worst-case scenarios, I felt I could focus on other possible scenarios. Assessing each scenario’s probability provided “data” that helped modify my negative automatic thought. I noticed that the “data” I had in support of worst-case scenarios were not valid. It also helped to see the probability of each situation visually which helped modify my automatic thought. I think this is a great technique and did provide “convincing” information to develop an alternative thought. It helps the clients come up with each scenario and helps clients develop adaptive thoughts because they can slowly see that the worst-case scenario is not always valid.

    [Case Formulation & Treatment Plan] CBT case formulation is important for multiple reasons. First, it helps strengthen the therapeutic relationship by creating a collaborative environment. It can show the client they are valued by gathering new information and modifying it throughout treatment. Therapy is also individualized; one treatment may not work for others. A case formulation is effective in treatment planning it lists the clients presenting problems, associated symptoms, and contributing factors. Having a specific, concrete, and measurable treatment goal ensures that the goal is objective and easy to monitor the client’s progress.

    Reply

    • Amanda Bara
      Nov 11, 2022 @ 12:42:23

      Hi Teresia! I enjoyed reading your discussion and thought that you shared some important ideas. I agree that catastrophizing does prevent individuals from thinking rationally which is why the behavioral exposure technique is helpful in breaking down the thoughts. I like how you pointed out how case formulation helps to establish rapport and build a strong relationship with the client. I think that it makes client’s feel secure and that their therapy is going somewhere. Great ideas!

      Reply

    • Tuyen Phung
      Nov 11, 2022 @ 21:02:15

      Hi Teresia,
      It is informative for me when I read your answer that negative automatic thoughts can be revealed in the worst-case scenario before coming to the conclusion of the most realistic scenario. Actually, I usually have the worst-case scenario in mind when I have a negative automatic thought. However, I have not recognized it until I saw the realistic scenario. This can be more serious when people have depression and distress. I think that if the most realistic scenario is mentioned before the worst case, people may have a hard time coming to the conclusion of their negative automatic thought.

      Reply

  14. Kristin Blair
    Nov 10, 2022 @ 15:39:59

    The client’s underlying fear of going into the store is that she will have a severe panic attack in the grocery store. Those physical symptoms can elicit actual physical medical symptoms like a heart attack. This would be considered a cognitive distortion since she habitually has this negative bias whenever even thinking about the idea of potentially entering a grocery store. The client explained her symptoms well and seemed very self-aware of her experience. In response to the event of going into the grocery store, the client shared that she experienced many physical symptoms that are pretty in line with what one may expect a heart attack to feel like in a way. She had to leave her cart in the aisle and immediately leave the store. She said she kept telling herself that she would not have a heart attack, but she still felt very strongly that she had to get out. She said that when she saw her husband in the car, she felt immediate relief. Regardless of reminding herself of what she learned in therapy and knowing she would not actually have a heart attack, she still felt extremely inclined to leave the store and get to “safety.”Moving forward with gradual exposure to this event and similar scenarios of going into stores alone while offering her appropriate support. Since her husband is a huge safety net for her, part of the exposure therapy should also include slowly removing her husband from the experience. The client seemed very apprehensive and nervous about that change in the future but seemed open to trying. This should ultimately help her be able to endure these experiences on her own in the future.

    It is easier to start decatastrophizing by starting with the worst-case scenario and working backward because the worst-case scenario is the original pressing thought. The reason why someone would need to decatastrophize in the first place is that they cannot see beyond that, therefor they currently do not have the ability to see the other alternatives. The worst-case scenario is why this dilemma exists, to begin with.
    I think using percentages is helpful because they ” give weight” to each scenario. Writing this down then makes the data visualization and much easier to comprehend.
    In terms of this technique bringing myself to an alternative thought made me think that this technique may work better or worse in different scenarios. Don’t get me wrong, it is a great technique and brings some clarity. My personal scenario involved another person. That being said, I think that in situations where the worst-case thought involves another person, there will always be this facet of us not being able to control others (what they do, say, think, feel, etc.…) This makes coming up with percentages of outcomes a little more difficult and convincing because we genuinely have no way of knowing. In the video, she is anxious about failing a test. Failing or not failing a test only involves that person; therefore, they have more control over the situation, and thus, percentages of likely scenarios are easier to quantify and convincing. I’m not sure if that makes any sense, but that was something I found personally when completing the worksheet.

    Case formulation is a very important part of therapy because it focuses on the whole individual instead of just their diagnosis. For example, if there is a manual on how to treat depression and you have 20 clients with depression, there is just no way that that same manual for treating depression will be as effective for everyone. Every person is vastly different. They all have different personalities, different past experiences, different traumas, etc… Additionally, many of the things that people seek therapy for are often comorbid. Case formulations are created for every individual client and are tested and revised throughout the course of treatment. Doing this allows the clinician to hone in on more specific mechanisms involved in the onset and maintenance of the client’s symptoms. Over time this will become a very helpful guide in treatment planning and clinical assessment.
    Specific, concrete and measurable treatment goals are important because it helps streamline the therapeutic process and helps it feel more fulfilling and efficient. Having “fuzzy” goals in therapy is what ends up feeling the more frustrating. I like to think of it like going to the gym; if you just go into the gym and pick a random machine, do a random number of reps for a random amount of time, then maybe use a jump rope for a few mins, and come back on sporadic days. This person may very well not see the results they want that made them go to the gym in the first place. This leads to frustration, and eventually, they stop going to the gym. However, if they knew what they wanted to work on and chose the appropriate machines, diet, reps, and schedule…they would be more likely to see results. Seeing results empowers them to keep going and ultimately reach their fitness goals. I see this the same way with therapy! Once you have a set plan, it is easier to move forward in the most efficient way possible and choose treatment options that best serve the client.

    Reply

    • Rachel Marsh
      Nov 11, 2022 @ 10:08:57

      Hey Kristin,

      I loved reading your post! I like what you said about Lindsey’s safety behaviors. While having a close relationship with a significant other is essential, Lindsey definitely relies on him too much. Having Lindsey phase out having her husband nearby each time she goes out is definitely a great way to cultivate independence as you mentioned.
      Moreover, I liked your example of comparing therapy goals to going to the gym. I love going to the gym and always make a plan before I go. On days that I don’t plan out my workouts, I find I feel discouraged easier and don’t feel as motivated to work out that day. With your example, I can totally see how this same idea could relate to therapy. If you have a goal in mind, but don’t have specific parameters to know how to achieve that goal or indicate progress, you fail to conceptualize how you can go about achieving said goal. Subsequently, you are significantly more likely to become discouraged and not achieve the results you are aiming for.
      Overall, great post!

      Reply

    • Amanda Bara
      Nov 11, 2022 @ 12:39:32

      Hi Kristin! I enjoyed reading your discussion and thought it was an interesting point that the client thinking she was going to have a heart attack was a cognitive distortion. I agree that the client did seem very self-aware of the experience as well as her thoughts and emotions going into the store. I like how you pointed out how having her husband as a safety behavior should be faded out in the exposure therapy. This is really important because she should eventually become completely independent and not rely on others for those feelings of safeness. Great job!

      Reply

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Adam M. Volungis, PhD, LMHC

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