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

[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?)?  {Don’t forget to complete your own Anxious Patterns Record.}

 

[Behavioral Exposure] – Watch PDA-7: Behavioral Techniques – Relaxation – Diaphragm Breathing.  Answer the following: (1) Do you think the client learned how to breathe through her diaphragm?!

 

[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?

 

Your original post should be posted by 11/11.  Have your two replies posted no later than 11/13.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

31 Comments (+add yours?)

  1. Jennifer Vear
    Nov 09, 2021 @ 18:31:56

    [Behavioral Exposure] – PDA-6

    1. Lindsey’s primary negative automatic thought in response to the event is “I cannot escape”. She felt as if everyone was noticing her struggling, and felt like she was losing control and could not get out. Once she was out of the store and in the safety of her car and in the presence of her husband, she was able to relax and feel better. Lindsey exhibits dichotomous thinking where she performs all or nothing thinking. Because she couldn’t complete her goal in making it through the store by buying her groceries, she considered the whole event to be a failure. However, she did not recognize that it was not a total failure because she attempted to actually go in the store in the first place, which is something that she has not done in a long time.

    2. Along with performing dichotomous thinking in her inability to go shopping alone, Lindsey also exhibits safety behaviors with her husband. She admits to feeling calmer when she was able to exit the store and see him in the car waiting for her. Once she realizes that she will eventually have to phase this safety behavior out through in-vivo exposure, she becomes uncomfortable and anxious. She recognizes that he is what makes her feel better in these situations, but is apprehensive for the time to come where she will have to experience these events alone and without that safety net.

    [Behavioral Exposure] – PDA-7

    1. I believe that Lindsey was able to effectively learn diaphragm breathing. It did take her a bit to learn, but once she learned it, I could tell that she appreciated how much that it could actually help her. I could see this as something that she could effectively use in anxious situations, but in a more discrete way, as she does not like to draw attention to herself when she is experiencing a panic attack.

    [Behavioral Exposure] – PDA-9

    1. With the decatastrophizing worksheet, I thought it was really helpful to start with the worst-case scenario and then going onto the most realistic case at the end. When I catastrophize situations, I am already thinking about the worst-case scenario happening. So when I was completing the worksheet, that was the easiest to come up with. Then I went to the best case scenario, then to the most realistic.

    2. The probability portion helped me to realize that rationality of my worst-case scenario thought. When it came to the probability of the realistic case scenario, I realized that the most realistic was what has happened 100% of the time, since I have experienced my fear before (popping a tire while driving). But, since the worst-case scenario was a serious car accident, I realized that it was the least-likely to actually happen.

    3. This technique was really helpful to create an alternative thought that I will most likely not pop my tire randomly on the highway. It helped me to realize that even if I did pop a tire, I probably would not get in an accident and die. However, I would probably end up having to slow down, put on my flashers, get over to the side of the road, and call someone in my family to come help me out. But overall, this exercise did help me to realize that my alternative thought is the most realistic evidence and it would not be the end of the world if it happened.

    [Case Formulation & Treatment Plan]

    1. CBT case formulation is extremely important and effective for treatment because it is a working and malleable process that considers the clients’ presenting problems, symptoms, and contributing factors. By considering these various aspects of the clients’ thoughts, emotions, and behaviors, the clinician will be able to then make an effective treatment plan. The malleability of this case formulation is important because it takes into account where the client is at in each stage of treatment and the therapist will adjust it accordingly to meet the needs of the client. Then finally, with support through evidence-based practice, the overall process helps the client to get better.

    2. It is important to have specific, concrete, and measurable treatment goals whenever possible so that the therapist is able to measure the progress of the client. If they were not able to measure any of these important factors, then the therapist would not be able to see how well a particular treatment is working for the client. It is also proof to the client in that they can see areas where they are improving in their life and it can motivate them to continue the treatment. If something is not working for the client, then the therapist can measure the treatment progress and make adjustments as needed for the client, based on these specific, concrete, and measurable goals.

    Reply

    • Valerie Graveline
      Nov 10, 2021 @ 23:13:22

      Hi Jenn,

      I appreciate you mentioning that while doing the catastrophizing worksheet, it was easiest for you to think of the worst-case scenario. I also felt that thinking of this scenario was easiest because it almost seemed reflexive to me. I think it is valuable to evaluate the worst case scenario and then the realistic scenario in this order as it allows for the client to take their time and really think deeply about each. It also may help clients break that reflex of immediately thinking of the worst-case scenario for any given situation. With this, I thought you made a good point about how evaluating the realistic scenario allowed you to realize that the worst-case scenario was actually the least-likely to occur. I think this shows that the deliberate order in which the decatastrophizing worksheet assesses each scenario is extremely helpful in leading clients to come to these conclusions.

      Valerie

      Reply

    • Lindsay O'Meara
      Nov 13, 2021 @ 08:26:56

      Hi Jennifer!

      Once you are catastrophizing, you are so focused on the event that it really is hard to think about anything else. It was also easier for me to start with the worst case scenario and move to the alternatives as well. I have been in a few pretty terrible car accidents, so u really relate to your post! The probability of a serious car accident is definitely not as high and your mind tells you it is. Sometimes it helps for me to think of all of the times that I have driven and nothing bad has happened.

      Thanks,
      Lindsay

      Reply

  2. Kaitlyn Tonkin
    Nov 10, 2021 @ 13:37:38

    [Behavioral Exposure]: PDA-6

    1. Throughout Lindsay’s experience in the grocery store, she seemed to have a few negative automatic thoughts, which, when coupled with the situation, led to a panic attack. Some of the thoughts she had were, “I’m going to have a heart attack”, “I feel silly”, feeling like she failed at going to the store, and thinking about the other people watching her suffer. I think the primary automatic thought she had during this experience was “I can’t escape”. Lindsay felt trapped in the store and like everyone was watching her struggle, which I think made her feel panicked and led to her having a panic attack.

    2. When Lindsay began to have a panic attack, her response was to flee from the situation. She left her shopping cart and returned to her husband who was waiting in the parking lot. I think that Lindsay displays “safety behaviors” with other people. “Safety behaviors” are ways that individuals try to cope with the uncomfortable situation in the moment by engaging in a behavior that makes the situation end or better. For some people, they use others as their safety behaviors because finding another person who can comfort them allows them to feel better. This is true for Lindsay. Once she gets back to her husband, she says that she feels calmer and less anxious about the situation. She also mentions feeling relieved upon getting out to the car. In previous videos we have seen with Lindsay, she admits to feeling safer when her therapist went into the store with her, again, feeling safe with another person with her who she trusts. Additionally, one of Lindsay’s safety behaviors is to flee. Leaving the grocery store allowed Lindsay to feel like she was no longer trapped and gave her a way out. Fleeing is another common safety behavior that clients exhibit.

    [Behavioral Exposure]: PDA-7

    1. While watching this video, I noticed that Lindsay struggled at first to breathe through her diaphragm. She was inclined to breathe with her chest at first, as we normally do, and especially do when having a panic attack. However, as she became more familiar with diaphragmatic breathing, she got more familiar and was able to do it by the end of the exercise. At first, Lindsay was laughing and seemed almost uncomfortable with the exercise, like she didn’t believe it would be useful. But, by the end, she was able to do so without any problems. As the clinician pointed out, Lindsay is basically learning how to breathe differently, so she is going to take some time to get familiar with it.

    [Behavioral Exposure]: PDA-9

    1. When I completed the decatastrophizing worksheet, it was easier to think about the worst-case scenario because I typically go to the worst first, so I already had that in my mind. Working backward from that was helpful, although it was challenging to come up with the best and realistic scenarios, simply because I tend to think the worst. However, working backward was helpful to make sense out of the outcomes and come to the conclusion of what the most realistic and best scenarios would look like.

    2. Rating the probability of the outcomes happening was useful for me in understanding the likelihood of the worst-case scenario happening, which was quite low. I was also able to see the probability of the most realistic scenario happening, which was higher than the rest and it helped me to feel less anxious and worried about the worst-case scenario. Rating the probability of the best-case scenario did not seem to have much of an effect on me because I was more focused on the other two, and it’s not likely that the best-case scenario would happen, albeit, more likely than the worst-case scenario.

    3. This technique was helpful in creating an alternative thought because I was able to see clearly the probability of the worst-case scenario happening and even trying to figure out how I would cope if it were to happen was helpful. I was able to use this worksheet almost as evidence against my thought and modify it to be more adaptive.

    [Case Formulation & Treatment Plan]

    1. A case formulation is an essential part of CBT because it provides a conceptualization of the client’s presenting problems, associated symptoms, and contributing factors through a cognitive-behavioral lens. Case formulations are typically based on the intake and the first few sessions with a client, since it is important this is created to help therapy progress. A case formulation is important to therapy because it can help both the client and therapist understand where some of their distress comes from and how it manifests for the individual. This is useful for informing treatment and how therapy will progress moving forward. The case formulation also gives the opportunity to give a DSM diagnosis, which is also important for understanding the client’s distress and how to move forward with treatment.

    2. It is necessary to have treatment goals that are concrete, measurable, and specific because it helps the therapist understand the client’s progress or lack thereof. If one of the goals was for the client to “get better” but there was not a definition of what that meant or how it would look like, there would not be a way for the therapist to determine if the client had “gotten better” or not, as this is subjective. Having goals is also helpful for the client to see how they are doing and if they do not meet their goals, then the client can work with the therapist to figure out what got in the way and what needs to be modified to better help the client.

    Reply

    • Valerie Graveline
      Nov 10, 2021 @ 23:22:34

      Hi Kaitlyn,

      I thought you provided a very nice explanation about Lindsay’s response to the distressing situation (being in the grocery store) and her subsequent safety behaviors. With this, prior to reading your response, I was thinking that Lindsay being with only her husband was her most notable safety behavior aside from fleeing (which is characteristic of agoraphobia). However, you made a very good point that in previous videos with Lindsay, we can see that simply being with others such as her clinician instantly makes her feel better. I think it is very important to understand the extent of clients’ safety behaviors so that as clinicians, we know what to specifically target.

      Valerie

      Reply

  3. Valerie Graveline
    Nov 10, 2021 @ 23:00:35

    [Behavioral Exposure- PDA-6]
    1) Lindsay’s primary negative automatic thought in response to being in the grocery store was “I can’t escape”. When in the grocery store, Lindsay found herself getting overwhelmed and anxious while in the aisles, and once these thoughts arose, she immediately felt she needed to leave the situation. This thought was exacerbated by physiological symptoms that she experienced such as feelings of choking, sweating, tightening chest, and an overall feeling that she was “losing control”. Another negative automatic thought regarding this event that Lindsay had was “I failed”. This negative automatic thought arose following the event, as she was disappointed in herself that she was not able to complete the exposure activity. However, it was important that the clinician briefly evaluated this thought with her, as she did not completely “fail” the task considering she made significant improvement simply by being able to go inside the store and begin shopping. Though she was not able to “complete” the task by finishing her shopping, the experience was not a failure and shows she is moving in a positive direction.

    2) Lindsay’s response to her negative automatic thought of “I can’t escape” while in the grocery store included physiological symptoms and safety behaviors. Regarding physiological symptoms, Lindsay said that she noticed her palms getting sweaty, her body getting warm, chest getting tight, and a pit in her stomach. Most notably, she had feelings of choking and felt she was “losing control”. In response to this physiological arousal and her thought of “I can’t escape”, Lindsay immediately decided to leave the store because she began to worry that if she was having a heart attack, she would not be able to seek help. With this said, one of Linday’s safety behaviors was leaving the store, or more generally, leaving the location where she is experiencing a panic attack and feels trapped. Another one of Lindsay’s safety behaviors was going to the store with her husband. Though her husband did not go inside the store with her, he was waiting in the car in the parking lot for when she was ready to leave. Lindsay noted that her husband’s presence tends to immediately make her feel better and reduce her anxious symptoms.

    [Behavioral Exposure- PDA-7]
    1) I do think that Lindsay was able to learn the diaphragmatic breathing technique throughout the session. Initially, it appeared that the technique was a little tricky for her considering she kept laughing while attempting the technique. It was clear, though, after multiple repetitions and continuing to practice the technique that Lindsay became more comfortable utilizing it. Lindsay learning how to effectively breathe through her diaphragm in this session will help her continue to practice the technique on her own, with the ultimate goal of mastering it and utilizing it in day-to-day life.

    [Behavioral Exposure- PDA-9]
    1) It was helpful starting with the worst-case scenario and ending with the most realistic scenario, because it showed me that the worst-case scenario was essentially unreasonable and the realistic scenario is more likely to occur. Normally I tend to continue believing the worst-case scenario, so it was helpful to view the various outcomes on a continuum rather than in a black-and-white fashion, where either the worst or the best scenario will occur.

    2) Assessing the probability for each scenario helped me think about what evidence may support the worst-case scenario versus the realistic scenario. Ultimately, I found that there was more evidence to support the realistic scenario than the worst-case scenario, which allowed me to decatastrophize my negative automatic thought slightly. Furthermore, assessing the probability of each scenario helped me realize that the worst-case scenario may be too unrealistic to occur.

    3) This technique was helpful as it provided some convincing information and evidence to support the potential development of an alternative thought. However, I don’t think it was completely convincing enough for me to stop catastrophizing with the particular negative automatic thought. I think this may be because this is the first time I have done this technique, and I tend to catastrophize all situations so it will take a lot more practice and evidence to work toward modifying these thoughts.

    [Case Formulation & Treatment Plan]
    1) A CBT case formulation is important for effective therapy because it is a conceptualization of the client’s presenting problems, associated symptoms, and contributing factors to their distress. The case formulation essentially helps the client get better as it provides a way for them to be directly involved in deciding how their problems are treated alongside the clinician. By being involved in how their symptoms and problems are addressed and treated, they can hopefully become more motivated for positive change. Further, the case formulation is important for therapy as it allows the clinician and client a way to understand how the client’s thoughts, emotions, and behaviors all interact and affect their presenting problems. It is important to note that the case formulation is reassessed throughout the therapeutic process as new information arises, which allows for different interventions to be introduced depending on the client’s current problems and levels of distress.

    2) It is necessary to have specific, concrete, and measurable treatment goals whenever possible throughout the therapeutic process as they will serve as direct indicators of a client’s progress. With treatment goals being objective and measurable, clinicians are able to accurately monitor progress throughout treatment, thus allowing them to see if the particular interventions being utilized are appropriate and working for the client’s problems. Furthermore, it is important for treatment goals to be measurable as managed care companies will need to be assured that the treatment being offered is truly effective, with the client noticeably making progress. When treatment goals are specific, it also allows for appropriate interventions to be chosen in order to meet such goals. With appropriate interventions being chosen, the therapeutic process will ultimately be more effective.

    Reply

    • Jennifer Vear
      Nov 11, 2021 @ 09:34:54

      Hi Valerie!

      You did a really great job describing how Lindsay uses her safety behaviors in response to her physical panic symptoms. Talking about safety behaviors in class and watching this video helped me location my own safety behaviors during anxious situations. It is interesting that we are not always aware of our safety behaviors as it helps us avoid confronting what is making us anxious. I really enjoy seeing Lindsay attempt new things and realize and come to terms with what is causing her anxiety. I am also excited to see how much progress she will make in the end. It makes you realize how well these techniques can work for many individuals.
      Overall, great job!

      – Jenn

      Reply

  4. Morgan Rafferty
    Nov 10, 2021 @ 23:25:22

    Behavioral exposure
    1.Lindsay’s primary negative automatic thought in response to going to the grocery store was “I can’t escape”. She wondered and worried, “what if I have a heart attack right in this aisle?” Despite recognizing that this was a cognitive distortion, Lindsay was still unable to prevent the oncoming panic attack. Lindsay entered the store thinking, “I got this”. Unfortunately, as she walked around her body started to feel warm and she felt more and more uncomfortable as an increasing number of people were in her aisle. She felt like other people were noticing her struggling and this led her to feeling further that she was losing control.

    2.Lindsay left her grocery cart behind and quickly exited the grocery store as a result of her negative automatic thoughts and physiological arousal. Despite telling herself that she would not have a heart attack, she fled to find her husband in the parking lot. Quickly leaving the store and seeking out her husband for safety and comfort were both safety behaviors. A decision was made to not go to the hospital but to head home instead. Lindsay clearly felt comfort upon being with her husband again. She acknowledges how he is there for her; she knows she can count on him to feel better during a panic attack.

    Behavioral techniques – Relaxation – diaphragm breathing
    1.Lindsay appears to have successfully learned how to breathe through her diaphragm. My only criticism would be that her pace is too quick. She needs to slow down her breaths and increase the length of time holding each breath before exhaling.

    Behavioral techniques – Modifying anxious thoughts
    1.I always resorted to finding comfort in using the worst-case scenario technique. I have found that we can almost always deal with the worst case scenario; making it less horrible than we think it might be. I ran into a stumbling block using this technique when I was asked to return for more images when I went for my first mammogram. Suddenly my old technique of asking myself, “what is the worst thing that could happen?” was death! It was totally not helpful. Thankfully there were absolutely no issues in terms of my mammogram follow-up. I have learned that examining the worst-case scenario is not always helpful for me when it comes to medical concerns.

    2.Assessing the probability of the medical concern turning out to be some serious issue can be helpful but still not a guaranteed solution for me. I prefer instead trying to focus on being in the present and to avoid thinking about the future and “what ifs”.
    3.This technique is helpful for me with worries that are not very serious. It helps me to realize that I am capable of handling even the worst case scenario should it come to fruition. This technique is not as helpful when my worst case scenario is too much to bear and falls within the realm of realistically happening.

    Case formulation & treatment plan
    1.Case formulation is created soon after the intake assessment and first few sessions. It is a cognitive-behavioral conceptualization of a client’s presenting problems, associated symptoms, and contributing factors. The client should be involved in developing his/her case formulation. When a client is involved in this process, it is more likely that he/she will be more motivated and hopeful for change. The case formulation is important for effective therapy because it provides structure as to how clients arrived at their current distress, their presenting problems, a formal DSM diagnosis(es), and development of treatment goals and interventions.

    2.A treatment plan is created with the expectation that modifications will be made as therapeutic progress is achieved. A client needs to have specific, concrete, and measurable treatment goals in place whenever possible as a way to work towards making progress in the therapeutic process. Once certain goals are reached it is the hope the client will enjoy decreased distress and increased positive quality of life. The specific, concrete and measurable treatment goals provide the therapist with a method for tracking treatment progress for the sake of the client and for the benefit of managed care.

    Reply

    • Jennifer Vear
      Nov 11, 2021 @ 09:30:22

      Hi Morgan!

      I noticed that you had really great insight with thinking in terms of the worst-case scenario and how you felt that it did not help when that answer is death! I fully agree and I think in a very similar way. It can be interesting to gauge situations based on how close the worst-case scenario is to reality. For my example with popping a tire on the highway, when I am getting anxious while driving, that worst-case scenario feels like reality at the moment. It can be hard to separate them when you are constantly consumed with thoughts of “what if?” However, when I get home safely or to school safely, I have to remind myself that it is less likely to happen in the way in which I originally think it might.
      I also agree with staying present in the moment. That is why meditation and breathing exercises work so well for me because they force you to pay attention to your breathing instead of the what-if situations or past situations.
      Great job!

      – Jenn

      Reply

      • Morgan Rafferty
        Nov 14, 2021 @ 17:30:26

        Thanks Jenn! I appreciate your feedback. It is nice to know you find yourself in the same boat. Yes, those “what if” thoughts can take on a cascading effect at times. I appreciate your comment that the worst case scenerio seems like a reality in the moment.
        I also think faith can play a big part in helping calm the mind. Sorry for the morbid topic but if the worst case scenario is death, it can help to think “well, that is inevitable for us all anyway! So be it.” Those who believe in heaven can perhaps find comfort with that notion.
        Yes, the benefits derived from meditation and deep breathing are significant for sure.
        Thanks Jenn!
        – Morgan

        Reply

    • Lindsay O'Meara
      Nov 13, 2021 @ 08:32:44

      Hi Morgan!

      I agree that it can be really scary when faced with a possible health concern! The worst case in that scenario is pretty much as bad as it gets so it makes sense that it would cause more anxiety for you to think of it that way. As we have discussed, I have definitely had trouble with these situations as well. At this point I kind of just think, well what if it does happen? I mean it’s out of your control to a certain extent. So I just try to focus on the present as well and try to do things that are healthy for me and that seems to ease my anxiety a bit.

      Thanks,
      Lindsay

      Reply

      • Morgan Rafferty
        Nov 14, 2021 @ 17:36:25

        Lindsay! Yes! You and I did speak about the struggles of health anxiety. It is so helpful to take on that mindset of paying attention to only what we can control and not worrying about what we can’t control.
        I have gained from this class a clearer understanding of the fact that many individuals who struggle with anxiety feel they are helping the situation by worrying about it. It’s as if you are doing something productive by spending time worrying rather than ignoring the issue. I also appreciate how Dr. V explained to us that people who struggle with anxiety are really good worriers; if they weren’t good at worrying, they wouldn’t have anxiety. I wish I weren’t a good worrier! 🙂

        Reply

  5. Sergio Rodriguez Pineda
    Nov 11, 2021 @ 10:50:19

    [PDA-6: Behavioral Techniques]

    (1) The patient expressed: “what happens if I fall off and I have a heart attack.” She was feeling trapped and that she couldn’t leave. She cognitively knew she was not going to have a heart attack, but the emotion was that intense that she couldn’t process it that way. Lindsay was catastrophizing because if people noticed that she was struggling, she would feel more anxious at the point where she would have a heart attack, and everything would be a disaster. She was also feeling disappointed in herself. “I feel I failed,” which cognitively could have impacted her future behavioral exposure. However, the therapist went over the details and facilitated a different view of her progress, making her feel much better.

    (2) Lindsay reported a 9 as an overall rate, she described feeling “really hot”, “my palms were getting really sweaty”, “my chest getting tight,” and something essential was that the more she started noticing her physical arousal, the more it got worse: “my heart just started completely racing, it was just like pounding out of my chest.” The patient described a moment when she started noticing how other people could see that she was struggling, which made things even worse: “I started to feel like nauseous in the pit of my stomach.” Lindsay’s safety behavior was leaving the place immediately to the car with her husband when she felt the activation (physiological arousal and the cognitive response). That safety response led to a considerable decrease in her emotional distressAnother safety behavior I could identify was going to the hospital. Still, she didn’t use that on that particular event, even though she mentioned she had done that in the past.

    PDA-7: [Behavioral Exposure]
    (1)
    While watching the video, I was thinking how challenging can be to psychoeducate and highlight the diaphragm breathing experience. In the video, there was a moment when there was a fun situation for the therapist and the client. In general, how the therapist handles those situations will make a difference in how the client experience and use the technique. Lindsay was able to learn and seemed interested in practicing diaphragm breathing. She also expressed: “It seemed kind of silly” but definitely agreed that she felt the difference between her usual chest breathing and the new technique she was learning.

    PDA-9: [Behavioral Exposure]

    (1) The best way to start was with the worst-case scenario because once you can tell your mind or take it to a scenario where the worst possible situation is faced, there is no potential other loss after that. So Lindsay expressed all her fear and consequences about failing the exam, accepting that it could be a possibility. However, before getting to that point, there is a range of possibilities that can occur and are more likely to happen, so it facilitates the perspective from the patient’s point of view. So then, presenting the best possible scenario (getting the best grade for her exam) led her to a mindset where she could also recognize that the other extreme was a bit far away from reality. Identifying and verbalizing a more realistic scenario implies being more rational, and perhaps stepping back from the worst possible situation and being more objective to set a real likely scenario.

    (2) Overall, numbers are the best way to measure and provide an actual number to those feelings, sensations, or thoughts that the patients are experiencing. Therefore, considering the percentage implies that, cognitively setting a number for possible situations, the person will have to analyze and compare options using a more realistic and objective approach. Lindsay was magnifying all the potential consequences of her possible future results because of her emotional response. However, the data helped her bring the rationality to play a role in the odds of failing. In fact, she expressed that seeing things from these perspectives, she could modify percentages and be more realistic based on the evidence provided from her past experiences. (i.e., high school, colleges, and other academic situations).

    (3)
    Providing objective and accurate information was essential to see Lindsay’s alternative thoughts. The therapist prompted her and helped her navigate real situations that she knew but overlooked due to the automatic thoughts that the situation was eliciting. Lindsay was able to reevaluate and switch the values she provided initially for the possibility of failing or passing, or getting a decent grade. Once she was able to explore options, she presented those alternative thoughts that reflected how she felt about her physiological response thinking about those possibilities.

    [Case Formulation & Treatment Plan]

    (1)Case formulation has two principal functions. The first is to be able to understand the antecedents and maintainers of the problem behavior. That is to say, it will allow the therapist and the patient to understand why the behavior is maintained, and for the client, it will be easy to understand what behavioral, cognitive, and physiological modifications must take place for the therapy to be effective.
    The second crucial element is the possibility of generating concrete goals and objectives based on the current difficulties. Again, the patient will play a fundamental role since it is expected that once the therapeutic process is completed, the client will have the facility to face challenging situations and measure his progress independently.

    (2) In a case formulation, objectives should be concrete, observable, measurable, and time-bound for effective measurement. The main reason is that measurement is necessary for any analysis of change or process, and therapy can clearly be no exception. Both therapist and client will get a benefit from the fact of having a concrete objective that is measurable. It will guarantee knowing where the therapeutic process is heading and how much progress is being made to reach it. If adjustments and modifications are required according to the needs, they can be made and measured more objectively and compared to reality.

    Reply

    • Katie O'Brien
      Nov 11, 2021 @ 12:19:36

      Sergio,

      I like how you mentioned the “silly” moment between the therapist and the client during the psychoeducation of diaphragm breathing. I think there will be plenty of moments in therapy where we as therapists might ask the clients to do something unnatural and to just trust the process, try it out and see what happens. In order for clients to feel comfortable doing so, they need to feel comfortable with their therapist first. Having a good rapport with clients and knowing when to laugh and joke versus when to be serious or less silly is important.

      Great post!

      Katie

      Reply

    • Kaitlyn Tonkin
      Nov 13, 2021 @ 18:13:09

      Hi Sergio,

      I find it interesting that you identified Lindsay going to the hospital as one of her safety behaviors. This was not something I had thought of prior to reading your post, but after doing so, it makes complete sense. Like you said, she didn’t do it during this particular instance, but, she has gone to the hospital in the past, to make sure she wasn’t having a heart attack. Despite knowing cognitively that she wasn’t having a heart attack, in her moment of heightened distress, she was unable to understand that and to confirm, and flee the situation causing her anxiety, she went to the hospital. This is a great example of a safety behavior. Thank you for bringing this up, I never would have thought about it without your post.

      Great post, thank you for sharing!

      -Kaitlyn

      Reply

  6. Francesca Bellizzi
    Nov 11, 2021 @ 11:31:04

    Behavioral Exposure – PDA-6]

    1. The primary negative automatic thought that Lindsay had in response to beginning to feel panic attack symptoms in the grocery aisle was “I can’t escape”. Coupled with this was the thought that everyone in the aisle was watching her suffer. While Lindsay truly believed that going to the grocery store was something that she could do and was reminding her self “I know I’m not having a heart attack”, this situational automatic thought made her feel like she was trapped – which I believe exacerbated her anxious feelings and acted as a catalyst for her panic attack.

    2. Lindsay seemed to have a handful of responses to her automatic thoughts and anxious physiological arousal. One thing that stands out, in particular, is her safety behaviors of escaping and seeking comfort in her husband. She mentioned that once she had the automatic thought of “I can’t escape” her response was to leave her cart and run out of the grocery store. This act of escaping the situation may present as a safety behavior. Similarly, she mentioned that “once [she] saw [her] husband that [she] immediately started to feel better” and her symptoms were lessening. While her husband is a valuable coping skill because he understands what she is going through, this may develop into a maladaptive behavior as she may become codependent on her husband.

    [Behavioral Exposure – PDA-7]

    1. I would say Linsday definitely learned how to breathe through her diaphragm. I think that initially, it took her a while to grasp the concept (and to not think about it too much) and to get past feeling silly; however, the education and break down of the exercise were helpful in her understanding and learning how to use diaphragmatic breathing appropriately.

    [Behavioral Exposure – PDA-9]

    1. I think starting with the worst-case scenario and ending with the most realistic scenario was very helpful in trying to decatastrophize. By starting with the worst-case scenario and working my way down, it was easier for me to see how unrealistic I was truly being. Similarly, it was really easy for me to start with the worst-case scenario because I already tend to think that way so it was easier to come up with evidence.

    2. Trying to come up with the probability that each of these scenarios would happen was really effective in modifying the negative automatic thought. Although there wasn’t a drastic difference between my ratings, it helps me see that my catastrophic thoughts are not likely to happen.

    3. I think that this technique provided me with a handful of convincing information to begin developing an alternative thought. While I was unable to come up with something initially, I was eventually able to create the foundation for the alternative thought.

    [Case Formulation & Treatment Plan]

    1. A CBT case formulation is important for effective therapy because it can serve as a “blueprint” for the client and clinician to look back on. Case formulations consist of a client’s presenting problems, symptoms, and possible factors that contribute to their distress – making it an ever-evolving compilation of the most current problems that meets the client’s needs. Similarly, due to the content of a case formulation, it is vital for effective treatment planning (which helps the clients get “better”).

    2. When formulating treatment goals with the client, it is necessary for them to be specific, concrete, and measurable goals whenever possible. First, treatment goals should be specific to the client because treatment goals are outcomes that the client desires. Typically, this involves decreased levels of distress and improved quality of life. Treatment goals should also be measurable. It is important to collaboratively create measurable goals because of the ability to track treatment progress. If the goals are unmeasurable, then there is no way to accurately determine if the client is making progress. Lastly, it is necessary for treatment goals to be concrete because they should be goals that can be realistically attained by the client. Not only are concrete goals realistic, but they also provide specific actions for the client to establish a foundation to reach the said goal (i.e. “be more social” = “engage in at least two social engagements a week”). Whenever possible, it is necessary to have goals that are specific, concrete, and measurable because it leads to a more effective therapeutic process.

    Reply

    • Katie O'Brien
      Nov 11, 2021 @ 12:32:25

      Francesca,

      Thanks for sharing your experience with the decatastrophizing worksheet. I had a very similar experience! I think similarly to us, clients will also have an easier time coming up with the worst case scenario and evidence to support it. Like you said, it’s a bit harder to come up with an alternative thought and evidence for it, which is where we’ll come in as the therapists to help clients get there. Like you mentioned, the process is at least helpful in laying the foundation to get to that point, even if we have to help them finish up formulating an alternative thought. It’s also helpful since we’re the outside perspective – since we’re not feeling the distress we’ll be able to help them come up with more realistic scenarios more readily.

      Great response overall!

      Katie

      Reply

  7. Katie O'Brien
    Nov 11, 2021 @ 12:06:43

    Behavioral Exposure: PDA-6

    (1) During Lindsay’s grocery trip, she experienced a handful of automatic thoughts which helped to perpetuate her panic attack symptoms. As her symptoms revved up and she started noticing other people noticing her, she began to feel like she was losing control. She then catastrophized and thought she was having a heart attack. From there, her automatic thoughts sort of centered on “I cannot escape.” She felt more and more the need to leave and get out of there, but due to the crowdedness of the aisle, her thoughts went to her inability to get out of the situation.

    (2) Lindsay’s first reaction to her thoughts and symptoms was to flee the store and the crowds. One of Lindsay’s safety behaviors is to seek reassurances from other people, in this case, her husband waiting in the car. Once she was back in the car with her husband, she was able to calm down and feel less anxious as she had her husband there with her to help her through it.

    Behavioral Exposure: PDA-7

    (1) Compared to Lindsay’s initial attempt at diaphragm breathing, where the movement was mainly in her chest, her later attempts seemed to be much better, with more of the movement being in her belly instead. Her comfort with the technique also seemed to improve. I think even towards the end she was still breathing through her chest somewhat, but much less than when she first started. As it is sort of a “silly” or uncomfortable technique to try with your therapist watching you, I feel she will definitely get the hang of it when she practices more and more on her own in a more comfortable environment. The initial retraining is there, it will just take more practice for it to come more naturally.

    Behavioral Exposure: PDA-9

    (1) I did find it helpful to begin with the worst case scenario and make my way to the most realistic scenario. As I was already feeling anxious about the scenario, my mind was already pretty focused on the worst case. Using that as a starting point, it was easy to figure out the exact opposite – or best case. From there, I was able to both talk myself down from the worst case, modify the best case to be more realistic, and come up with a more realistic, probable scenario. Even by simply thinking through the scenarios like that, I was able to feel slightly less anxious.

    (2) By looking at the probabilities, it really hit home that neither the worst case scenario, or the best case scenario, are all that likely to happen. If that’s the case, I do not have to put so much pressure on myself to force the best case scenario to work, while also not completely stressing out over the worst case scenario taking place, as it is much more likely that the third option, the most realistic one, will likely be the one that happens. Using this, I was able to come up with a better, more realistic automatic thought that helped to reduce my anxiety level when considering my options and subsequent courses of action.

    (3) Yes. I have a tendency to cognitively know I’m catastrophizing and going to the worst case scenario when there is a more likely, less anxiety provoking option that will likely take place. However, the physiological feelings and emotions of being anxious are still present, which then takes my thoughts down the rabbit hole of worst case possibilities. By looking at the “evidence” in front of me, I could convince myself that the worst case is not likely to occur, and see how much more likely it is that the realistic one will. This helped me to feel less anxious and develop a more adaptive thought.

    Case Formulation & Treatment Plan

    (1) A case formulation is incredibly important in conceptualizing the client’s presenting problems, symptoms, maintaining or contributing factors, and their diagnosis through the lens of CBT. As each client’s distress is in part unique to them, this formulation helps inform the therapist on best CBT interventions and treatment plans for the client. It also helps orient the client and therapist to the client’s distress and provides measurable goals in which they can track the client’s progress throughout therapy. As with everything in CBT, the therapist is able to collaborate with the client on the case formulation, ensuring they are truly understanding the client’s problems and setting goals that the client agrees upon and is comfortable working towards.

    (2) Specific, concrete, and measurable goals help both the therapist and client track the client’s progress throughout treatment. This allows for adjustment throughout the process should the client become stuck – the therapist can see which interventions are not working and re-visit the case formulation to see if something was missed or if other interventions might be more helpful for that particular client. On a more logistical note, the therapist needs to be able to back up what they are doing in therapy to insurance companies, and having objective and measurable goals allows the therapist to show that what is occurring within sessions is helping to relieve the client’s distress.

    Reply

    • Giana Faia
      Nov 12, 2021 @ 10:08:36

      Hi Katie,

      Great job on describing the importance of case formulation as it relates to CBT. A case formulation is important for understanding the client as well as enhancing collaboration between the client and the clinician. Along with this, in tracking the clients progress it is helpful to have specific, measurable, and concrete goals. Not only is this beneficial for tracking progress, but also, like you said, seeing what is working for the client and what isn’t. Thanks for sharing!

      Giana

      Reply

  8. Lindsay O'Meara
    Nov 11, 2021 @ 13:44:31

    [Behavioral Exposure] PDA-6

    1. The client’s primary negative automatic thought was “I can’t escape.” She thought maybe she would have a heart attack in front of all the people that were there. This made Lindsey panic and have symptoms that led to a panic attack. After she got home and she was feeling safe, she felt silly and like she was a failure. However, she was able to go into the grocery store and that was a big win for her.

    2. The client ran out of the grocery store to the parking lot. Once she was with her husband and he drove her home she was able to recover from her panic attack. Her husband can support her, and she feels relaxed with him. She does use her husband as a safety behavior, so in the future she will have to try doing things without him. That made Lindsey anxious to think about. It is important in the future for Lindsey to be able to do these things on her own without her therapist or husband present.

    [Behavioral Exposure] PDA-7

    1. At the beginning of the exercise, it seemed that Lindsey was a little uncomfortable with diaphragm breathing. She was laughing and just seemed like it was a little awkward. By the end of the exercise, it seemed as though Lindsey was more comfortable with deep breathing. It’s clear that this is not the way that Lindsey normally breathes, so it will take some practice to get used to. She seemed to get the hang of it by the end and I think if she spends more time practicing it will become more comfortable for her.

    [Behavioral Exposure] PDA-9

    1. It was helpful for me to start with the worst-case scenario and end with the most realistic scenario. By the time I realized the most realistic outcome, the worst-case scenario seemed extreme and unlikely, and I felt a lot more comfortable.
    2. Assessing the probability for each scenario did help me to provide supportive data to change my negative thought.
    3. This technique did provide enough convincing information to develop an alternative thought. The original thought was not helpful, and there was a lot of evidence compiled against the possibility of it happening.

    [Case Formulation & Treatment Plan]

    1. CBT case formulation is important for effective therapy because it helps us to determine the most effective treatment approach. This approach is client centered and helps the client to assist in their treatment goals. Interconnecting parts of the client’s life and experienced are conceptualized including presenting problems, associated symptoms, and contributing factors. The client’s involvement in this process is critical to positive results and helping our clients to feel better. This can help the client to feel motivated and positive about outcome scenarios.
    2. It is necessary to have specific, concrete, and measurable treatment goals because these are the foundation for your CBT treatment plan. Modifications should be made as the client’s case evolves. It benefits both the therapist and client to have a measurable plan. It is also helpful to do this so that there is information to look back at to determine if the client is making progress.

    Reply

    • Giana Faia
      Nov 12, 2021 @ 09:55:29

      Hi Lindsay,

      I like how you pointed out that Lindsay felt like a failure since she wasn’t able to get her items, but didn’t recognize that actually getting in and being in the store was a major success for her. Despite believing she was going to have a heart attack after being in the store, she was still able to make it that far in her exposure therapy which is an accomplishment. Upon leaving the store and retreating back to her husband, she describing feeling more relaxed, demonstrating how she uses him as a safety behavior. Identifying this safety behavior is important for further sessions/ exposure because both her and the clinician now will move toward doing these things on her how without having her husband there. Thanks for sharing!

      Giana

      Reply

  9. Lisa Andrianopoulos
    Nov 11, 2021 @ 14:19:11

    PDA-6: Behavioral Techniques – Assessment of Anxious Patterns.

    Lindsay’s primary negative automatic thought during a panic attack in the grocery store is “what happens if I have a heart attack right here in the aisle? How am I going to get help? When she got home, her negative thought in response to the event was “I failed.”

    As the grocery aisle became more crowded, Lindsay felt her body getting warm, her palms became sweaty, and her chest was getting tight. The more she noticed this as well as others seeing that she was struggling, her heart started racing and she felt nauseous. She felt like she was choking and losing control. Her behavioral response was to “get out of there.” Though she told herself that she was not having a heart attack, her body told her that she needed to get out. She ran out into the parking lot. As soon as she saw her husband sitting in the car she had a sense of relief. She decided not to go to the hospital, and symptoms were gone by the time she gets home. After talking this through with the therapist, Lyndsay learned that her husband was the safety behavior, and the ultimate goal will be for her to try these things alone.

    PDA-7: Behavioral Techniques – Relaxation – Diaphragm Breathing.
    I think Lindsay partially learned how to breathe though her diaphragm. The idea seemed very new to her, especially since she tends to be a chest breather to begin with. She required several repetitions to get her chest to stop moving as much. It got better over time, but she needs more practice with it for it to feel comfortable and natural.

    Watch PDA-9: Behavioral Techniques – Modifying Anxious Thoughts.
    It was very helpful starting with the worst-case scenario and ending with the most realistic. I started feeling better even before I finished it. Assessing the probability definitely provided supportive data (10% worst case scenario vs. 90% best and most realistic scenario – pretty convincing). The thought is still in the back of my mind, but I see it as ridiculous now!

    CBT case formulation and treatment planning
    1) CBT case formulation is important for effective therapy because it is the process for determining the most effective treatment plan. Essentially, it is the driving force for developing and testing hypotheses for understanding and treating client problems and symptoms. In this vein, it helps guide the direction and goals of intervention. Conducting a quality assessment for the case formulation also sets the stage for collaborative work in therapy (i.e., collaborative empiricism). This is important because clients who take an active role in this regard may very likely have increased motivation and hope for change, which is associated with positive outcomes. Further, a detailed and accurate case formulation allows increased likelihood that you will help relieve the client’s distress/presenting problem. A good case formulation also allows for a deeper understanding and insight into the client’s automatic thoughts and associated behavioral responses/coping. Therefore, the therapist is in a better position for helping the client achieve success.
    2) It is necessary to have specific, concrete, and measurable treatment goals whenever possible because the treatment goals are meant to be therapeutic indicators for the therapist, the client, and in many instances, managed care providers. By making the goals as objective and measurable as possible, treatment progress can be tracked more accurately. By wording the goals more specifically and concrete, you are better able to track treatment progress and provide specific feedback to the client. This is particularly important because frequent and accurate assessment of client progress corresponds with treatment effectiveness. This regular assessment also aids in identifying and making needed modifications along the way, which keeps the therapist and client on the right track for successful outcomes. Also, by being specific and concrete, it allows for the goals to be specific to the client and not a generic goal that can be applied to anyone. This provides greater client specificity, which in turn allows you to adapt your treatment plan to the individual.

    Reply

    • Frayah Wilkey
      Nov 13, 2021 @ 11:31:29

      Lisa,
      I think you made a lot of great points in your responses. I think your thoughts on treatment goals were especially helpful. As you noted, frequent and accurate assessments should be an integral part of the treatment process. It is so important for there to be an element of efficacy to the patient’s treatment so I think it’s great that you brought this up.

      Frayah

      Reply

  10. Frayah Wilkey
    Nov 11, 2021 @ 14:32:39

    Behavioral Exposure] – Part I
    1. Based on the video, Lindsay seems to struggle deeply with anxiety, especially around others in public settings. Even trips to the grocery store were a point of difficulty for her due to her automatic thought of “I cannot escape”. Lindsay feels that she’s trapped in these situations and her automatic thought causes distress, leading her to avoid those situations in the past. She experiences very uncomfortable symptoms and removes herself when they arise, causing a cycle of anxiety and distress.

    2. Lindsay noted several responses to her associated automatic thoughts and physiological arousal. She was able to identify bodily responses that she experienced, such as tightness in her chest and sweaty palms. These signs of physical arousal are typical for those experiencing anxiety inducing situations. Her main safety behavior was to get herself away from the perceived threat which was the crowed grocery store. It seems that her husband also provides a great sense of security for Lindsay and she felt much more comfortable being back in the car with him, bringing down her level of distress.

    Behavioral Exposure] – Part II
    1. In the beginning, diaphragmatic breathing was difficult for Lindsay. I think that this may be true for many people though because it’s a concept we don’t focus on very often. Throughout her practice, I think that Lindsay accomplished the breathing technique. She seemed a lot more comfortable with it than she did when she began so I would say she successfully learned how to do it.

    [Behavioral Exposure] – Part III
    1. Beginning with worst-case scenarios and ending with the most realistic is a really helpful technique. I often jump right to the worst case and I find that this method helps ‘bring me down’. It forces you to be thoughtful and insightful rather than jumping to conclusions that cause more distress. It seems like a great calming technique.

    2. Assessing the probability of the scenarios is a good way to modify thoughts. Again, it forces introspection and gave me time to really consider what is most likely to happen. This is useful in tweaking those negative thoughts because I realized that I was thinking on this hyperbolic level. Evidence is really the key for modification for me.

    3. Doing it quickly, I think that I developed some convincing information but I’d need to sit down and really think about it again. Most of my thought patterns are deeply rooted and I’ve always had a catastrophic mindset so I think I could spend more time working on this. I need to get better at slowing down my thinking and just taking a breath before I jump to conclusions.

    [Case Formulation & Treatment Plan]
    1. Case formulation lays the foundation for the therapy sessions and provides insight to treatment goals. Without it, the therapy would largely just be shooting in the dark and mostly unspecified to the client’s distress. It allows the clinician to take a wholistic perspective and allows them to consider what methods will be most effective for the client. Overall, it is an evidence based approach to the therapeutic relationship and will allow the clinician to apply a more successful treatment because it is specific to the client and their presenting problems.

    2. Successful treatment requires specific, concrete, and measurable treatment goals. The clinician should continually evaluate these factors and consider them during each sessions. This will allow them to track progress and effective methods. It will also differentiate what methods are not helpful to meeting goals. These factors all encompass an evidence based method of therapy and will create a more effective environment for the client, compared to other methods that lack and type of goal setting or tracking.

    Reply

    • Francesca Bellizzi
      Nov 12, 2021 @ 14:22:24

      Hi Fraya,

      Awesome post! Thanks for sharing information about your experience with the decatasrophizing worksheet – it is very relatable for me. Personally, I shared a similar experience when it comes to thinking of the worst case scenario from the start. Of course, now that we know this is the easier route to take when approaching this exercise we are able to help set our clients up for success when the time comes. Similarly, I 100% agree when it comes to the amount of convincing information that I got from this exercise. I think that doing this exercise on our own – without the therapy environment and not having another person there to try and convice us – it is hard to digest the new information fully. Something else I think is important to understand from our experience is that most of our clients are going to feel that way as well! Again, great post and thanks for sharing!!

      All the best,
      Francesca

      Reply

    • Sergio Rodriguez Pineda
      Nov 13, 2021 @ 11:33:57

      Hi Frayah,

      When I considered the importance of the case formulation, I thought I had mentioned the most relevant elements. However, you made a great point that I overlooked: the methods, which immediately made me remember how suitable the evidence-based practice intervention would be for a case formulation. Likewise, how the client and the therapist can understand why these elements are being implemented effectively for the therapeutic process.

      Thanks for sharing!
      Sergio Rodriguez

      Reply

  11. Giana Faia
    Nov 11, 2021 @ 14:45:38

    [Behavioral Exposure] –

    (1) During this encounter, the client felt that she was losing complete control and that she needed to get out immediately. The client’s primary negative automatic thought was that “I can’t escape”. She felt as thought she was going to die and that she needed to get out of the situation. I think the client was catastrophizing when she believed she was going to die if she did not get out of the grocery store, despite demonstrating panic attack symptoms she was not going to die.

    (2) Once the client started experiencing panic symptoms in the grocery story, she left her cart and went to her car. She said once she saw her husband, she was instantly relieved, demonstrating safety behaviors. Her husband is someone who helps her cope and be more relaxed. When they got home, she said her symptoms were gone. Something the client needs to work on is fading her husband out during in vivo exposure, so than she can learn to cope on her own rather than relying on him as a coping technique.

    [Behavioral Exposure] –

    (1) Despite having some difficulties in the beginning, I think the client was able to breathe through her diaphragm toward the end. At first, she admitted she felt silly and was unsure of how useful it would be to her. However, after getting used to it, she was able to focus and actually do it. I think the more she does it, the more familiar it will become to her which will make it easier for her each time. One she feels comfortable enough doing it in the comfort of her home, she can apply it to other situations when she starts to feel anxious.

    [Behavioral Exposure] –

    (1) I thought it was helpful starting with the worst-case scenario and ending with the most realistic because I tend to immediately jump right to the worst-case scenario anyway. By starting with the worst-case first, it helped show that these initial thoughts are very unrealistic compared to that of the most realistic scenario. It helped me visualize and narrow down the most realistic scenario step by step.

    (2) I found that assessing the probability for each scenario did help me modify my negative automatic thought. By actually writing out the evidence for the worst-case scenario to the most realistic helped me see and compare the amount of evidence for each. I was able to see that there was a minimal amount of compelling evidence for the worst-case scenario. On the flip-side, there was more evidence that was more accurate that supported the more realistic scenario.

    (3) I think depending on what the scenario is, it could provide enough “convincing” evidence to develop an alternative thought. For me, it definitely helped me work through my thoughts by showing the actual evidence for the worst and best scenarios. I think for some thoughts this technique would work in providing enough “convincing” evidence to modify the thought. However, for more serious/ more believed thought this might be more tricky in developing an alternative thought

    [Case Formulation & Treatment Plan] –

    (1) A case formulation views the presenting problems, associated symptoms, and contributing factors through a CBT lens. A case formulation is important for both the clinician and the client and allows them to work together throughout the therapeutic process. By involving clients in this process, it can help them feel more hopeful about their therapeutic journey. A case formulation helps the clinician better understand the client by identifying patterns the client engages in, coping mechanisms, behaviors/ thoughts/ and emotions, presenting problems/ symptoms, diagnosis among many other factors that are beneficial in treating the client.

    (2) It is important to have specific, concrete, and measurable treatment goals whenever possible because they are meant to be the therapeutic indicators and help in providing feedback to the client. Having specific, concrete, and measurable goals will allow for greater accuracy in treatment tracking and giving feedback to the client. This allows for tracking the progress of the client and also helps in identifying regression or if something is not working in the current plan. Without these qualities, more subjective goals would be harder to track and measure.

    Reply

    • Francesca Bellizzi
      Nov 12, 2021 @ 14:15:40

      Hi Giana,

      Great post! I agree about the importance of a good case formulation. Not only does it help the client and clinician work together and present information about the client’s problem (i.e. diagnosis, symptoms, etc), but the case formulation is also the foundation for creating an effective treatment plan. This is something that is also highly influential when creating goals for the client to strive for during the treatment process. Again, great post and thanks for sharing!

      All the best,
      Francesca

      Reply

    • Frayah Wilkey
      Nov 13, 2021 @ 11:20:09

      Giana,
      I think you made some really great points. In terms of case formulation, I like how you brought up the importance of involving the client throughout the process. I think that a lot of people may get nervous beginning therapy because they are oftentimes not a part of the case formulation. It’s important for the field to stay up to date on best practices and it seems that patient involvement is a key part of the case formulation.

      Frayah

      Reply

    • Sergio Rodriguez Pineda
      Nov 13, 2021 @ 11:41:57

      Hi Giana,

      I haven’t considered how important it is to write down clear evidence for the worst-case scenario. Usually, I just have all those processes going through my mind but definitely, when I put it into words and see it, it makes you realize how you can get to a middle point where you can be more realistic, and those others extremes (worst – better case scenarios) often are less likely to occur.

      Great post
      Thanks for sharing!

      Reply

    • Kaitlyn Tonkin
      Nov 13, 2021 @ 18:09:32

      Hi Giana,

      I had a very similar experience when completing the decatastrophizing worksheet. My mind also tends to go to the worst-case scenario initially, so filling out and starting with that section was actually simple and came naturally to me. I liked that you said it helped you realize that the worst-case scenario was unrealistic compared to the other options, which I think is an important skill for clients, especially those with anxiety disorders.

      Great post, thanks for sharing!

      -Kaitlyn

      Reply

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Adam M. Volungis, PhD, LMHC

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